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DKA
Diabetic Ketoacidosis
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* Ryan is a 5 year old male transferred from the
PICU to the med/surg unit
* Dx: Diabetic ketoacidosis (new diagnosis)
* Hx: Lethargic and decreased LOC this afternoon
with increased appetite and fluid intake x 3 days.
No other hospital admissions/surgeries
*Objective Findings:
*
* Vitals:
*BP 110/56, HR 88, RR 20, Temp 98.5 PO
* Wt:
*36.2kg/79.64lbs
* Percentile on growth chart for Wt: >99%
*Subjective Findings:
* Patient active and playful.
* No c/o pain
*Other:
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* Parents present at bed side; father a RT.
While admitted in PICU, family’s home
burned down along with the loss of two pets
and pt is unaware
*Labs:
* Blood sugar =115-225
* Urine dip sticks=positive for ketones
* Other blood work within normal limits
*
*Humulin-R (sliding scale) SC
*70-130=0 unit
*131-180=2 units
*181-240=4 units…
*Lantus 7 units SC q morning
*Tylenol 360mg PO pain/fever
*Diet: Regular for age, limit
sweets
*Activity: Ad lib (as desired)
*Vitals: Every 4 hours
*BS check ac (TID) and HS
*Daily weight
*Initial diabetic educator
consultation complete - nutrition,
insulin administration, and
location sites reviewed.
*Call physician with any concerns
or change in patient condition
*
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*Patient assessment this
morning:
*BS at 0730 is 142
*Vital signs are stable
*Lungs: clear
*Heart: regular rhythm, no abnormal
sounds
*Patient is alert, playful, and still
afraid of needles
*Patient’s mother is at bedside and
appears exhausted but pleasant.
*
* BS 142 @ 0730
* Blood work within normal limits
* Vital signs stable
* Lung and Heart assessments within normal limits
* Pt is alert and playful
* Pt is fearful of needles
*
* Is there additional data that you would like to obtain before
you notify the physician about this patient?
* The trend of the patients weight since admission
* If Ryan has a change in hunger and thirst since admission
* Any change in LOC
* If there’s ketones in the urine
*
* It is not an emergency, just calling to update the physician
about Ryan’s current status.
* Patient's blood glucose is under control
* Patient is stable and he does not show any signs or symptoms of
DKA
* Vital signs are stable
* Assessment within normal limits
* If any signs and symptoms of hypoglycemia, hyperglycemia and
cerebral adema occur, physician will be notified immediately
*
Nurse: “Hello Dr. Scarlett I’m Emma, the nurse taking care of Ryan, a 5 year old
admitted the other day in the PICU for DKA. Ryan is newly dx with type 1 diabetes.
Ryan is currently stable on the med surg floor. At 07:30AM this morning, Ryan’s BS
was 142, his heart sounds are regular rhythm, no abnormal sounds, lungs are clear,
and he is alert and playful. Vitals and labs are within normal limits with some traces
of ketones. The diabetes educator came in this morning and discussed nutrition,
insulin administration and sites with the family. The patient taking Lantus 7 units SC
q morning and Humlin-R (sliding) SC”is at this time. Nurse: “However, I’m
concerned that because Ryan is afraid of needles it is going to be hard to manage
his diabetes. In order to reduce needle exposure and I want to request removing
Humlin-R and just continue using the long acting insulin or create a mixture. That
way it will cover Ryan throughout the day and reduce getting needle stick. However,
if it is possible to maybe consider putting Ryan on a insulin pump to reduce
injections. Physician: “I will remove Humlin-R from the medication list. When I
make my rounds, I will discuss the changes of insulin with the family and determine
whether the patient should use the insulin pump” I want you to make sure the
family understands this new medication change and for you to monitor the patient’s
blood glucose closely to see how he tolerates the change. Notify me if there are
signs of hypo/hyperglycemia and cerebral edema we will reevaluate the
medication order.”
*
* What orders might you expect or request from the physician if
applicable?
* Ryan is afraid of needles so request a long acting insulin to reduce
needle exposure and cover the pt throughout the day. Or consider a
insulin pump.
*
*Continuous reassessment and monitoring
*Reduce the amount of needle sticks
*Teach patient to cope with finger sticks
*Daily weight
*Food/beverage log (intake and output)
*BS check ac (TID) and at bedtime
*Contact social worker because Ryan’s house was
burned down and he and his family are homeless
*Offer the mom a break
Highest priority is BS check ac (TID) and at bedtime
to monitor pt condition, because the physician
changed the patient's insulin order.
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Hypoglycaemia,
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Kussmaul breathing or deep sighing respiration - A mark of acidosis; these symptoms may be
mistaken for status asthmaticus, pneumonia, and even hysterical hyperventilation
*
Ketone odor - Patient may have a smell of ketones on the breath, although many people cannot
detect this smell
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Impaired consciousness - Occurs in approximately 20% of patients
Hypokalaemia,
Relapses of DKA
Cerebral edema
Blood pressure - Usually normal until terminal stages of illness
Tachycardia - May be present
Capillary refill - Initially maintained, but a combination of increasing acidosis and dehydration
cause poor tissue perfusion
Coma - May be present in 10% of patients
Abdominal tenderness - May occur; tenderness is usually nonspecific or epigastric in location;
bowel sounds may be reduced or absent in severe cases
*
* Carefully monitor potassium status to prevent complications from hypokalemia.
* Hypoglycemia-, continuous insulin infusions are administered together with
dextrose when blood glucose levels fall below 200 mg/dL (11 mmol/L).
* Specifically designed recording charts (measurements of clinical and biochemical
status, fluid balance, and insulin prescription.
* Frequent review of neurologic status—at least hourly (or any time a change in the
level of consciousness is suspected)—is essential during the first 12 hours of
diabetic ketoacidosis treatment.
* Promptly treat any suspected cerebral edema with osmotic diuretic, CT scan and
referral to a neurosurgeon.
* In patients with diabetic ketoacidosis, the first principals of resuscitation apply (ie,
the ABCs [airway, breathing, circulation]).
* Give oxygen, although this has no effect on the respiratory drive of acidosis.
Diagnose by clinical history, physical signs, and elevated blood glucose.
* Continuous subcutaneous insulin infusion therapy
* using an insulin pump should be stopped during the treatment of diabetic
ketoacidosis.
*
* Obtain height and weight.
* Administer and monitor intravenous fluids.
* Cerebral edema- Mannitol 0.5-1 g/kg infused over 30 minutes, which can be repeated
after 1 hour. The usual dose of hypertonic saline is 5-10 mL/kg, again infused over 30
minutes, which can be repeated after 1 hour. (preferred)
* Strictly measure input and output.
* Provide catheter care if necessary.
* Record blood pressure, temperature, pulse
and respiration.
* Record capillary refill time.
* Assist in administration and monitoring
of insulin therapy.
* Provide supportive care to family
* Inquire about culture and health beliefs and how that can be included in the plan of care
* Provide relief for them to care for themselves
* Keep them informed regarding any changes in patients status and orders
* Connect them to the right team member
*
* Dietary regarding dietary guidelines while admitted and
after admission
* Neurosurgeon if cerebral edema is expected
* Social work/case manager to discuss current case of
patient, insurance coverage, resources needed to pay for
insulin pump if needed,
* Resources for temporary housing. How to go through the
insurance process of obtaining new housing
* Reaching out to family members and friends for support
* Asking about spiritual support within the community
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* As often as needed.
* Every 15 mins to an hour for the
first 12 hours especially in regards
to LOC signs of ICP and
respiratory arrest as this can be
fatal.
* V/S every 4 hours
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In the case of hypoglycemic shock rapid replacement of glucose with 15 grams of rapid carbohydrate such as 4
oz. of fruit juice (orange juice) or tablespoon of honey or syrup. Low-fat cheese sandwich Ham, roast beef, or
turkey sandwich
Know when to test for ketones, such as when you are sick
If you use an insulin pump, check often to see that insulin is flowing through the tubing. Make sure the tube is
not blocked, kinked or disconnected from the pump.
Do not skip meals or snacks and always carry a quick source of sugar especially when exercising.
Staying hydrated by drinking plenty of fluids
Check blood sugar before each meal and at bed time and try to take medications at the same time everyday
Seek immediate medical attention if you recognize:
Trouble breathing
Decreased consciousness
Increased hunger and thirst
Dry mouth
High blood glucose
Frequent urination
Fruity breath
Nausea
Vomiting
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Complains of abdominal pain
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Hx of symptoms upon admission
Admission v/s, subjective and objective data
Lab values
Changes in blood pressure
Changes in blood glucose
Ketones trend
Time and date of insulin initiation and administration
Changes in diet
Changes in physical abilities
Changes in LOC
Changes in breath
Changes in energy
Changes in GI
Complains of pain and steps taken to relieve pain
All interventions time date and outcome
Note time and date physician was contacted and any new orders given
Document consultations and the outcome of those consultations
Documenting that discharge teaching was provided along with
resources for patient and family to take home.
*
* Patient was d/c home on day 3 with diabetic
teaching information, medication administration,
when to check blood pressure and glucose, diet and
when to contact the physician/hospital.
* Patient stated that he was starting to get use to the
finger sticks and that he is happy to be going home.
* The family will be staying with the father’s brother
who lives 10 miles away. They hope to find a new
home in the next month or so. They also plan to
find a new family pet with Ryan as soon as his
health is back to being stable.
*
Lamb, W., Corden T., Cantell, P., Barry, E., Windle, M. (2013).
Pediatric Diabetic Ketoacidosis Treatment & Management.
Retrieved from
http://emedicine.medscape.com/article/907111-treatment
Mcfarlane, K. (2011). An overview of diabetic ketoacidosis in
children. Pediatric Care, 23(1), 14-19.
Silverstein, J., Holzmeister, L. A., Clark, N., Anderson, B., Grey,
M., Deeb, L., et al. (2005). Care Of Children And Adolescents
With Type 1 Diabetes: A Statement Of The American Diabetes
Association. Diabetes Care, 28(1), 186-212.