7 Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome Nursing Care Plans

Use this nursing care plan and management guide to provide care for patients with diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals with diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome.

What is diabetic ketoacidosis (DKA)?

Diabetic ketoacidosis (DKA) is a life-threatening emergency caused by a relative or absolute deficiency of insulin. This deficiency in available insulin results in disorders in the metabolism of carbohydrates, fat, and protein. The main clinical features of DKA are hyperglycemia, acidosis, dehydration, and electrolyte losses such as hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, and hypophosphatemia.

DKA occurs when absolute or relative insulin deficiency inhibits the ability of glucose to enter cells for utilization as a metabolic fuel, the result being that the liver rapidly breaks down fat into ketones to employ as a fuel source. The overproduction of ketones ensues, causing them to accumulate in the blood and urine and turn the blood acidic. The most common early symptoms of DKA are the insidious increase in polydipsia and polyuria (Hamdy & Khardori, 2021).

The most common scenarios for DKA are underlying or concomitant infections such as pneumonia and urinary tract infections, missed or disrupted insulin treatments, and newly diagnosed, previously unknown diabetes. Drugs that affect carbohydrate metabolisms, such as corticosteroids, thiazides, sympathomimetic agents, and pentamidine may precipitate DKA (Lizzo et al., 2022). The overall mortality rate for DKA is 0.2 to 2%, with persons at the highest end of the range residing in developing countries (Hamdy & Khardori, 2021).

Fluid resuscitation and maintenance, insulin therapy, electrolyte replacement, and supportive care are the mainstays of management in DKA (Lizzo et al., 2022). Hypoglycemia is the most common complication of DKA, followed by hypokalemia, cerebral edema, acute respiratory failure, and even myocardial infarction and cerebrovascular accident.

What is hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) or hyperosmolar hyperglycemic state (HHS) is a condition characterized by the presence of hyperglycemia, hyperosmolarity, and dehydration. HHS is one of two serious metabolic derangements that occur in clients with diabetes mellitus. There is enough production of insulin to reduce ketosis but not to control hyperglycemia. Persistent hyperglycemia causes osmotic diuresis, which results in fluid and electrolyte imbalances. Clients with HHS may present with symptoms of hypotension, tachycardia, marked dehydration, and neurological manifestation such as seizures, hemiparesis, and alterations in the sensorium. The clinical features of HHS and DKA overlap and are observed simultaneously in up to one-third of cases. However, unlike clients with DKA, most clients with HHS do not develop significant ketoacidosis (Avichal & Blocher, 2021).

Nursing Care Plans and Management

The nursing care plan for clients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome includes the provision of information about the disease process/prognosis, self-care, and treatment needs, monitoring and assistance of cardiovascular, pulmonary, renal, and central nervous system (CNS) function, avoiding dehydration, and correcting hyperglycemia and hyperglycemia complications.

Nursing Problem Priorities

The following are the nursing priorities for patients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome:

• Diagnose and recognize the signs and symptoms of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS).
• Administer intravenous fluids and electrolytes to correct dehydration and restore fluid balance.
• Monitor blood glucose levels regularly and administer insulin as prescribed.
• Assess and manage acid-base imbalances and electrolyte disturbances.
• Monitor vital signs, including blood pressure and heart rate.
• Administer supplemental oxygen if necessary.
• Educate patients and their caregivers about the importance of regular diabetes management, including medication adherence and monitoring blood glucose levels.
• Provide guidance on preventing future episodes of DKA or HHNS through proper diabetes self-care and lifestyle modifications.
• Schedule follow-up appointments to monitor recovery, assess glycemic control, and adjust treatment plans as needed.

Nursing Assessment

Assess for the following subjective and objective data:

• Diabetic Ketoacidosis (DKA):
  • Excessive thirst and frequent urination
  • Abdominal pain, nausea, and vomiting
  • Rapid breathing (Kussmaul breathing)
  • Fruity or acetone breath odor
  • Confusion, lethargy, or altered mental status
  • Dry or flushed skin
  • High blood glucose levels (>250 mg/dL)
  • Ketones in the urine or blood
• Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS):
  • Extreme thirst and dehydration
  • Excessive urination or low urine output
  • Dry mouth and skin
  • Weakness, fatigue, and dizziness
  • Altered mental status or confusion
  • Seizures or coma in severe cases
  • Very high blood glucose levels (>600 mg/dL)
  • Absence of significant ketones in the urine or blood.

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

• The client will remain normovolemic as evidenced by urinary output greater than 30 ml/hr, normal skin turgor, good capillary refill, normal blood pressure, palpable peripheral pulses, and blood glucose levels between 70-200 mg/dL.
• The client will display normal electrolyte levels and stable vital signs.
• The client will be free of infection as evidenced by normothermia, HR of 100 beats/minute or less, BP within the client’s normal range, WBC count of 11,000/mm³ or less, and negative culture results.
• The client will identify interventions to prevent and reduce the risk of infection.
• The client will demonstrate techniques, and lifestyle changes to prevent the development of infection.
• The client will display a normal energy level.
• The client will take appropriate amounts of calories/nutrients.
• The client will demonstrate stabilized weight or gain toward desired range with normal laboratory values.
• The client will maintain a blood glucose level in the satisfactory range.
• The client will acknowledge the factors that lead to unstable blood glucose and DKA.
• The client will verbalize understanding of body and energy needs.
• The client will verbalize a plan for modifying factors to prevent or minimize complications.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome may include:

1. Managing Hyperglycemia

Without insulin, the amount of glucose entering the cells is reduced, and the production and release of glucose by the liver are increased, leading to hyperglycemia. Under normal circumstances, all of the glucose filtered by the kidneys is reabsorbed. When blood glucose levels reach approximately 180 mg/dL, proximal tubular transport of glucose from the tubular lumen into the renal interstitium becomes saturated, and further glucose reabsorption is no longer possible. The glucose that remains in the renal tubules continues to travel, passing into the distal nephron and, eventually, the urine, carrying water and electrolytes with it. Glucose concentration increases due to the loss of circulating volume (Avichal & Blocher, 2021).

Assess individual factors that may have contributed to the current situation.
Occasionally, a client with unknown diabetes will present with DKA, especially a young person with some type of precipitating infection. However, many times DKA is precipitated by the failure of diabetes management, possibly related to dietary factors, activity, or medications. Because DKA presents more frequently in the young client with type 1 diabetes, there may be a failure to account for developmental changes such as an adolescent growth spurt or pregnancy.

Evaluate the client’s and caregiver’s ability to monitor blood glucose levels.
All available blood glucose monitors will provide satisfactory readings if properly used and maintained and routinely calibrated. Unstable blood glucose may occur due to the failure of regular blood glucose monitoring

Check insulin injection sites.
Insulin absorption can vary from day to day in healthy sites and is less absorbable in lipohypertrophy tissues. Repeated insulin injection procedures result in skin thickening. Increased collagen fibers and possibly amyloid deposition in the dermis may be involved. This reaffirms the importance of appropriate site rotation in insulin injection (Murao et al., 2022).

Auscultate bowel sounds.
Hyperglycemia and fluid and electrolyte disturbances decrease gastric motility and function resulting in gastroparesis, affecting the choice of interventions.

Weigh the client regularly.
This assesses the adequacy of nutritional intake; both absorption and utilization. A history of weight loss is a symptom in clients who are newly diagnosed with type 1 diabetes (Hamdy & Khardori, 2021).

Review the client’s dietary program and usual pattern and compare them with recent intake.
This identifies deficits and deviations from the therapeutic plan, which may precipitate unstable glucose and uncontrolled hyperglycemia.

Observe for signs and symptoms of hypoglycemia.
Once carbohydrate metabolism resumes, blood glucose levels will fall, and as insulin is being adjusted, hypoglycemia may occur. If the client is unconscious, hypoglycemia may occur without a notable change in LOC. This potentially life-threatening emergency should be assessed and treated quickly per protocol.

Provide liquids containing nutrients and electrolytes as soon as the client can tolerate oral fluids, then resume intake of solid foods as tolerated.
The oral route is preferred when the client is alert and bowel function is restored. Once the client’s mental status is back to normal and the client is able to eat, starting an oral diet is indicated. Some HHS clients are unable to eat for several days as a consequence of the comorbidities with which they present (Avichal & Blocher, 2021).

Provide a diet of approximately 60% carbohydrates, 20% proteins, and 20% fats in a designated number of meals and snacks.
Complex carbohydrates help maintain more stable blood glucose levels, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics, such as peak effect and individual client response. A snack of complex carbohydrates at bedtime is especially important if insulin is given in divided doses to prevent hypoglycemia during sleep and potentiate the Somogyi response.

Identify the client’s food preferences, including ethnic and cultural needs.
Incorporating as many of the client’s food preferences into the meal plan increases cooperation with dietary guidelines after discharge. A proper culturally oriented nutritional evaluation must take place with all clients with diabetes. Healthcare professionals must identify local and community resources to help clients improve their food choices (Caballero, 2018).

Include caregivers or family members in meal planning, as indicated.
This promotes a sense of involvement and provides information for the caregivers to understand the nutritional needs of the client. There are various methods available for dietary planning, including carbohydrate counting, the exchange list, the point system, or preselected menus. Some reports suggest that family structural togetherness improves the quality of life and satisfaction among clients with diabetes. Family support may in fact contribute to improving diabetes control (Caballero, 2018).

Monitory laboratory studies such as serum glucose, acetone, pH, and HCO3.
See Laboratory and Diagnostic Procedures

Administer rapid-acting insulin such as regular, lispro, or aspart by intermittent or continuous IV infusion.
See Pharmacologic Management

Administer glucose solutions such as 5% dextrose and half-normal saline.
See Pharmacologic Management

Refer the client to a dietitian or nutritionist.
This is useful in calculating and adjusting diet to meet the client’s specific needs. A nutritionist or dietitian may answer questions and assist the client and caregivers in developing meal plans. Once HHS is resolved, for example, dietary counseling for clients must be provided. This will be delivered most effectively by a registered dietitian who has expertise in counseling clients with diabetes (Avichal & Blocher, 2021).

2. Promoting Infection Control and Preventing Infection

Infection is the most common predisposing factor for the development of a hyperglycemic crisis, which is DKA. Among the predisposing factors for DKA, infection is the most common cause of death. Common reported bacterial infections in diabetes clients have included infections of the respiratory system, kidney, urinary tract, skin, and soft tissues. Poor glycemic control is susceptible to severe bacterial infections and complications such as DKA, which may, in turn, further exacerbate the bacterial infection. (Aprilia et al., 2019)

Assess for signs of infection and inflammation.
Infection is a common cause of DKA. Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and arthralgia (Hamdy & Khardori, 2021).

Observe the client’s feet for ulcers, infected toenails, or other medical problems.
Due to impaired circulation in diabetes, foot injuries are predisposed to poor wound healing. The physical exam should include a thorough screening for peripheral vascular disease and sensory neuropathy as well as an evaluation of the depth and severity of the ulcer (Murphy-Lavoie et al., 2022).

Auscultate breath sounds.
Rhonchi indicate accumulation of secretions possibly related to pneumonia or bronchitis that may have precipitated DKA. Lung infections suffered by these clients trigger sepsis, which then increases the risk of DKA (Aprilia et al., 2019).

Observe the aseptic technique during IV insertion and medication administration. Manage invasive lines carefully.
Elevated blood sugar weakens the immune system thus clients are more prone to infection. Peripheral IV sites should be rotated at least every 96 hours and dressings changed, depending on agency policy. Central lines should be discontinued as soon as feasible and when in place should be handled carefully.

Provide conscientious skin care.
An intact skin protects against infection. Keep the skin dry and the linens dry and wrinkle-free. Peripheral circulation may be impaired, placing the client at increased risk for skin irritation and breakdown, and infection.

Provide efficient wound and foot care.
The basic principle of topical wound management is to provide a moist, but not wet, wound bed. Optimal wound coverage requires wet-to-damp dressings, which support autolytic debridement, absorb exudate, and protect surrounding healthy skin (Khan & Khardori, 2020). 

Provide a pressure-relief mattress or pressure redistribution surface on the client’s bed and off-loading devices for ulcer treatment.
These surfaces help prevent skin breakdown, which could lead to infection. For clients with a neuropathic plantar ulcer, a non-removable knee-high offloading device such as a total contact cast or a removable walker that is rendered irremovable by the provider who fits the device is the preferred offloading treatment. In the absence of other forms of biomechanical relief, felted foam, in combination with appropriate footwear can be considered (Khan & Khardori, 2020).

Encourage proper handwashing techniques.
This avoids the risk of cross-contamination. Clients are at increased risk for bacterial infection because of suppressed inflammatory response. The infection spreads from one person to another through direct or indirect contact. Hand hygiene breaks the chain of infection by reducing the number of pathogens that can be transmitted to others.

Encourage adequate oral fluid intake (two to three liters a day unless contraindicated).
This reduces susceptibility to infection. Dehydration can slow down the healing process of wounds, which increases the risk of infection. Adequate fluid intake also promotes the production of urine, which helps eliminate toxic substances from the body and prevent urinary tract infections.

Encourage deep breathing and coughing exercises and the use of incentive spirometry; maintain the client in a semi-Fowler’s position.
Deep inhalations with incentive spirometry along with deep breathing exercises expand alveoli and help mobilize secretions to the airways. Coughing further mobilizes and clears the secretions. These exercises help prevent pulmonary infection. Additionally, a semi-Fowler position facilitates lung expansion and reduces the risk of aspiration.

Obtain a sample for culture and sensitivity as indicated.
See Laboratory and Diagnostic Procedures

Limit the use of indwelling urethral catheters to clients who are unable to void in a bedpan or when a continuous assessment of urine output is required.
There is an increased risk of infection with indwelling catheters. Nationally recognized nurse-sensitive indicators recommend that, if an indwelling catheter is inserted, every effort be made to remove it within 48 hours.

Administer antibiotics as indicated.
See Pharmacologic Management

Refer to a podiatrist and promote the use of properly-fitted shoes.
Of diabetic foot ulcers, 85% are estimated to be preventable with appropriate preventive medicine, including inspection of the shoes to ensure good support and fit. Medicare covers custom shoes with appropriate healthcare provider documentation confirming that the client is at risk for ulceration.  A podiatrist can help the client with appropriate footwear and prophylactic podiatric interventions to correct high-risk foot deformities (Khan & Khardori, 2020).

3. Enhancing Nutritional Balance

DKA and severe hypoglycemia are important medical events that are potentially life-threatening. Although adherence to insulin injections is the most important factor, diet, and lifestyle may also significantly contribute to the risks for DKA and hypoglycemia (Ahola et al., 2021). Nutritional support combined with drug therapy is an important way to treat clients with DKA. Nutritional support not only maintains a good metabolic status, but also avoids the occurrence of complications such as abnormal blood glucose levels, water metabolism disorders, ketosis or hyperosmolar coma, infections, and nerve damage (Yin et al., 2021).

Determine the client’s dietary program and usual pattern.
This recognizes deficits and deviations from therapeutic needs, which may precipitate unstable glucose and uncontrolled hyperglycemia.

Monitor weight daily or as indicated.
This assesses the adequacy of nutritional intake- both absorption and utilization. Eating disorders are a contributing factor in 20% of recurrent DKA in young clients, unfortunately. A history of rapid weight loss is a symptom in clients who are newly diagnosed with type 1 diabetes (Hamdy & Khardori, 2021).

Auscultation bowel sounds and note the presence of abdominal pain/abdominal bloating, nausea, or vomiting. Maintain NPO status, as indicated.
Imbalances in the fluid and electrolytes and hyperglycemia reduce gastric motility resulting in delayed gastric emptying that will influence the selected intervention. Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia (Hamdy & Khardori, 2021).

Identify individual factors that may have contributed to the current situation.
Occasionally, the client with unknown diabetes will present with DKA, especially a young person with some type of precipitating infection. However, many times DKA is precipitated by the failure of diabetes management, possibly related to dietary factors, activity, or medications.

Identify food preferences, including ethnic and cultural needs.
Incorporating as many of the client’s food preferences into the meal plan as possible increases cooperation with dietary guidelines after discharge. For example, clients who participate in Ramadan may be at higher risk of acute diabetic complications (Khardori & Griffing, 2022).

Involve the client’s family in planning as indicated.
Provide information on the family to understand the nutritional needs of the client. Including the family in meal planning promotes a sense of involvement. Various methods available for dietary planning include carbohydrate counting, exchange list, point system, or preselected menus.

Recognize signs of hypoglycemia.
Hypoglycemia can occur because of a reduced carbohydrate metabolism while still given insulin, it can potentially be life-threatening and should be recognized. Hypoglycemia is associated with twofold, or threefold increased mortality, particularly as age increases and among clients who have a history of severe hypoglycemic episodes (Umpierrez & Korytkowski, 2016).

Monitor laboratory studies (serum glucose, pH, HCO₃, acetone).
See Laboratory and Diagnostic Procedures

Perform fingerstick glucose testing and urine ketone checks.
See Laboratory and Diagnostic Procedures

Administer glucose solution, e.g., dextrose and half normal saline.
Solutions containing glucose are added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. When the metabolism of carbohydrates reaches normal, caution must be taken to prevent hypoglycemia. Should blood glucose fall below 14 mmol/L (250 mg/dL), 10% glucose should be added to allow for the continuation of fixed-rate insulin infusion (Hamdy & Khardori, 2021).

Administer regular insulin by intermittent or continuous IV method.
Intravenous (IV) infusion is the chosen route of insulin delivery because the rapid onset and short duration of action associated with IV infusion allow for matching insulin requirements to rapidly change blood glucose levels. Larger volumes of insulin and isotonic sodium chloride solution mixture can be used, provided that the infusion dose of insulin is similar. Larger volumes may be easier in the absence of an IV infusion pump (Hamdy & Khardori, 2021).

Collaborate with a dietitian for initiation of resumption of oral intake.
Dietitians or nutritionists may help in calculating and adjusting diet to meet the nutritional needs of the client; Dietitian assists the client and the family in producing meal plans. Diet management includes education about how to adjust the timing, size, frequency, and composition of meals so as to avoid hypoglycemia or postprandial hyperglycemia. All clients on insulin should have a comprehensive diet plan, created with the help of a professional dietitian (Khardori & Griffing, 2022).

Provide a diet consisting of 60% carbohydrates, 20% fats, and 20% proteins in the designated number of meals.
Complex carbohydrates (peas, beans, whole grains, and vegetables) decrease glucose and cholesterol levels. Food intake is scheduled according to specific insulin characteristics and individual clients’ responses. Caloric distribution is an important aspect of dietary planning for these clients. A recommended distribution consists of 20% of daily calories for breakfast, 35% for lunch,30% for dinner, and 15% for late-evening snacks (Khardori & Griffing, 2022).

Teach the importance of eating three meals a day at regularly scheduled times and a  bedtime snack.
Such a diet affords the best opportunity for maintaining physiologically normal blood glucose levels rather than “roller coaster” values of alternating hyperglycemia and hypoglycemia. Meals and insulin administration must be linked together, especially when insulin analogues such as Humalog, NovoLog, or Apidra are given before meals and in conjunction with snacks. Analogues are quicker acting than regular insulins.

Use a balance of sugar-containing beverages and water.
Intake of carbohydrates must be maintained unless the insulin dose is altered to avoid hypoglycemia. Water must be consumed to maintain intravascular volume. There are too many carbohydrates in juice or soda to use either as a primary source of volume.

Administer prochlorperazine, diphenhydramine, and metoclopramide as prescribed.
These are beneficial in treating symptoms related to affecting the GI tract such as diabetic gastroparesis, to improve oral intake and nutrient absorption. See Pharmacologic Management

4. Managing Fluid Volume

Without insulin, the amount of glucose entering the cells is reduced, and the production and release of glucose by the liver are increased, leading to hyperglycemia. In an attempt to rid the body of excess glucose, the kidneys excrete the glucose along with water and electrolytes. This osmotic diuresis, which is characterized by excessive urination, leads to dehydration and marked electrolyte loss.

Assess precipitating factors such as other illnesses, new-onset diabetes, or poor compliance with the treatment regimen.
These will provide baseline data for education once with resolved hyperglycemia. Urinary tract infection and pneumonia are the most common infections causing DKA among older clients. Poor compliance with insulin through the omission of insulin injections occurs due to a lack of client or guardian education, or as a result of psychological stress, particularly in adolescents (Hamdy & Khardori, 2021).

Assess skin turgor, mucous membranes, and thirst.
This provides baseline data for further comparison. Skin turgor will decrease and tenting may occur. This occurs because the skin relies on hydration to maintain its elasticity and suppleness. The oral mucous membranes will become dry, and the client may experience extreme thirst.

Monitor hourly intake and output.
Oliguria or anuria results from reduced glomerular filtration and renal blood flow. Hyperglycemia usually exceeds the renal threshold of glucose absorption and results in significant glucosuria. Glucosuria leads to osmotic diuresis, dehydration, and hyperosmolarity. Severe dehydration, if not properly compensated, may lead to impaired renal function (Hamdy & Khardori, 2021).

Monitor vital signs, especially for orthostatic hypotension and Kussmaul’s respirations.
Decreased blood volume may be manifested by a drop in systolic blood pressure and orthostatic hypotension. Acetone breath is due to the breakdown of acetoacetic acid. Kussmaul’s respiration (rapid and shallow breathing) represents a compensatory mechanism by the respiratory buffering system to raise arterial pH by exhaling more carbon dioxide. Fever with flushed, dry skin may indicate dehydration. Compensatory mechanism results in peripheral vasoconstriction with a weak, thready pulse that is easily obliterated.

Assess neurological status every two hours.
Decreased level of consciousness results from blood volume depletion, elevated or decreased glucose level, hypoxia, or electrolyte imbalances. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe (Hamdy & Khardori, 2021).

Weigh the client daily.
This provides baseline data on the current fluid status and adequacy of fluid replacement. A weight loss of 2.2 lbs (1 kg) over 24 hours indicates a liter of fluid loss. Typical free water loss in DKA is approximately six liters or nearly 100 mL/kg of body weight. The initial half of this amount is derived from intracellular fluid and precedes signs of dehydration, while the other half is from the extracellular fluid and is responsible for signs of dehydration (Hamdy & Khardori, 2021).

Assess for the presence of nausea and vomiting.
Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. Ketones, in particular, beta-hydroxybutyrate, induce nausea and vomiting that consequently aggravate fluid and electrolyte loss already existing in DKA.

Maintain a fluid intake of at least 2500 liters/day within cardiac tolerance when oral intake is resumed.
This maintains hydration and adequacy of circulating volume. Hydration causes a decline in counter-regulatory hormones, enhances renal glucose clearance following improved renal perfusion, and augments insulin sensitivity. This, in turn, causes a significant reduction in hyperglycemia, hypertonicity, and acidemia. Hydration alone (intravenous and oral) has been shown to reduce glucose concentration by 17 to 80% over a duration of 12 to 15 hours (Javashree et al., 2019).

Be alert to indicators of fluid overload, particularly among older adults or clients with a history of heart or renal failure.
Indicators of fluid overload, such as jugular vein distention, dyspnea, crackles, or CVP of more than 12 mm Hg, can occur with rapid infusion of fluids. Be extremely cautious to avoid cerebral edema and pulmonary edema. Although initial aggressive fluid replacement is necessary in all clients, particular care must be taken in those with comorbidities such as renal failure or congestive heart failure (Hamdy & Khardori, 2021). 

Monitor laboratory studies such as blood glucose levels, serum ketones, potassium, sodium, creatinine, and blood urea nitrogen (BUN).
See Laboratory and Diagnostic Procedures

Monitor ABG for metabolic acidosis.
See Laboratory and Diagnostic Procedures

Insert indwelling urinary catheter as indicated.
This provides accurate measurement of urinary output, especially if autonomic neuropathies result in neurogenic bladder with urinary retention and overflow incontinence. The catheter may be removed when the client is stable to reduce the risk of infection.

Administer isotonic solutions (0.9% NaCl) initially.
The initial goal of therapy is to correct circulatory fluid volume deficit. Isotonic normal saline will rapidly expand extracellular fluid volume without causing a rapid fall in plasma osmolality. Clients typically need one to three liters within the first two hours of treatment. A liter is administered every four hours following the first two hours, depending on the degree of dehydration and central venous pressure readings (Hamdy & Khardori, 2021).

Administer succeeding IV therapy with a hypotonic solution such as 0.45% normal saline.
Continuation of IV administration depends on the degree of fluid deficit, urinary output, and serum electrolyte values. After initial stabilization with isotonic saline, switch to half-normal saline at 200 to 1000 mL/hour. Half-normal saline matches losses due to osmotic diuresis (Hamdy & Khardori, 2021).

Add dextrose to IV fluid when serum blood glucose level is less than 180 mg/dL in DKA.
When blood sugar decreases to less than 180 mg/dL, isotonic sodium chloride solution is replaced with 5 to 10% dextrose with half isotonic sodium chloride solution (Hamdy & Khardori, 2021). Dextrose is added to prevent the occurrence of hypoglycemia and an excessive decline in plasma osmolality that can result in cerebral edema.

Administer IV potassium and other electrolytes as indicated.
See Pharmacologic Management

Administer bicarbonate as indicated.
See Pharmacologic Management

Administer IV insulin by continuous infusion using an infusion pump.
Regular insulin has a rapid onset and therefore immediately helps move glucose intracellularly. A low-dose insulin regimen has the advantage of not inducing the severe hypoglycemia or hypokalemia that may be observed with a high-dose insulin regimen.  The initial insulin dose is a continuous IV insulin infusion using an infusion pump, if available. The incidence of DKA was reduced with the introduction of pumps equipped with sensitive electronic alarm systems that alert users when the infusion catheter is blocked (Hamdy & Khardori, 2021).

Before initiating treatment, flush the tubing with at least 30 mL of the insulin-containing IV solution.
When added to IV solutions, insulin may be absorbed by the container and plastic tubing. Flushing the tubing ensures that maximum adsorption of the insulin by the container and tubing has occurred before it is delivered to the client.

5. Initiating Patient Education and Health Teachings

Diabetic ketoacidosis is an acute complication of diabetes. Around one-third of DKA cases occur in newly diagnosed diabetes mellitus clients. Most deaths are caused by cerebral edema complications. Awareness forms the basis for health-related practices being implemented. Therefore, it is important to assess and update the knowledge and understanding of clients about diabetes and DKA (Thakare & Ankar, 2021).

Assess the client’s level of knowledge about DKA and the prevention of complications.
Findings of a study indicate that 38% of clients diagnosed with DKA had poor awareness of complications, and 67% had poor management knowledge. The bulk of respondents had a low level of understanding (Thakare & Ankar, 2021). This may affect the client’s perception of the disease and participation to care.

Assess the client’s family history of diabetes mellitus or DKA.
Having a first-degree relative diagnosed with diabetes is associated with a regressed risk of DKA at diabetes. Research showed that there is a relationship between having a first-degree relative diagnosed with diabetes and awareness regarding the management of DKA. Health authorities must provide a more effective way to teach society about DKA management to prevent the development of complications (Farran et al., 2020).

Assess the client’s healthcare literacy (language, reading, comprehension). Assess culture and culturally specific information needs.
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate.

Establish rapport and trust.
Create an environment where trust and good rapport facilitates good relationship in the learning process. Rapport and respect need to be established before the client will be willing to take part in the learning process.

Explain the signs and symptoms of diabetic ketoacidosis.
Symptoms of hyperglycemia include polyuria, polydipsia, polyphagia, flushed skin, and body malaise. Gastrointestinal symptoms such as nausea, vomiting, and generalized abdominal pain are reported in >60% of clients. Abdominal pain, sometimes mimicking an acute abdomen, is especially common in children and clients with severe metabolic acidosis (Dhatariya et al., 2020).

Discuss the essential elements with the client, such as risk factors, disease process, and complications.
Baseline knowledge enables the client to make informed lifestyle choices. Explain the normal blood glucose range and how it compares with the client’s level, the type of diabetes the client has, and the relationship between insulin deficiency and a high glucose level. Knowledge of precipitating factors also helps avoid recurrences. Acute and chronic complications of DKA include visual disturbances, neurosensory and cardiovascular changes, renal impairment, and hypertension. Awareness about these complications helps the client be more consistent with care and may prevent or delay the onset of complications. 

Demonstrate proper blood glucose testing using the glucometer. Instruct the client to check the urine for ketones once blood glucose reaches 250 mg/dL or higher.
Monitoring blood glucose three to four times a day is an essential part of managing diabetes to avoid further complications. Blood glucose >250mg/dl and high urine ketones should be reported to the healthcare provider immediately. Frequent blood glucose monitoring at home makes DKA less likely, as it allows them to promptly search for possible reasons for unexpectedly high blood sugar levels before the condition progresses to DKA (Hamdy & Khardori, 2021).

Review the client’s target blood glucose levels.
Although this range varies per person, the ideal range for an adult diabetic is considered 80 to 120 mg/dL. The optimal rate of glucose decline is 100 mg/dL/hour. Do not allow the blood glucose level to fall below 200 mg/dL during the first four to five hours of treatment. Hypoglycemia may develop rapidly with the correction of ketoacidosis due to improved insulin sensitivity (Hamdy & Khardori, 2021).

Educate about signs of hypoglycemia
These are signs of excessive insulin dosage, resulting in hypoglycemia. Early recognition of these symptoms promotes immediate intervention. Allowing blood glucose to drop to hypoglycemic levels is a common mistake that usually results in rebound ketosis derived from counter-regulatory hormones. Rebound ketosis necessitates a longer duration of treatment (Hamdy & Khardori, 2021).

Teach the client that polyuria, polydipsia, and polyphagia are signs of hyperglycemia which requires an increased dosage of insulin.
These are signs of insufficient insulin dosage and hyperglycemia which may lead to coma and death if untreated. The hyperglycemia-induced osmotic diuresis depletes sodium, potassium, phosphates, and water. This incidence of increased water loss results in severe dehydration, thirst, tissue, hypoperfusion, and, possibly, lactic acidosis, or renal impairment (Hamdy & Khardori, 2021).

Discuss “sick day management”, which includes continuing the same insulin regimen; not stopping insulin or skipping doses; and increasing the frequency of blood glucose monitoring for hyperglycemia.
For prevention of DKA related to illness, “sick day rules or management” for managing diabetes when ill should be reviewed with clients. The most important concept in this is to never eliminate insulin doses when nausea and vomiting occur. Instead, the client should take the usual insulin dose and then attempt to consume frequent small portions of carbohydrates.

Explain the importance of having a dietary plan, such as limiting the intake of simple sugar, fat, salt, and alcohol and increasing the intake of whole grains, fruits, and vegetables.
Medical nutrition therapy is important in managing diabetes and preventing the rate of development of diabetes complications. A high-fiber diet can slow the absorption of glucose, decrease excess insulin levels, and lowered lipid concentrations in clients with type 2 diabetes. Reducing saturated fat intake reduces the risk of developing coronary artery and peripheral vascular disease. Typically, clients are put on a consistent carbohydrate diet composed of 69% carbohydrates, 20 to 30% fats, and 12 to 20% proteins.

Remind the client of the importance of maintaining adequate oral fluid intake during illness.
Anorexia or nausea may limit food intake, but the client should make every effort to continue fluid intake to avoid dehydration, hypovolemia, and possible hypotension. Take liquids such as a half cup of regular cola or orange juice, a half cup of broth, or sports drinks every 30 minutes to one hour to provide calories if vomiting, diarrhea, or fever persists.

Teach the client to monitor blood glucose during periods of exercise and adjust the insulin dose.
The insulin dose should be adjusted after increased or decreased food intake and before any exercise. Exercise may increase the usage of glucose. Additionally, instruct the client to also monitor blood glucose and urine ketone levels during periods of increased emotional stress. Exercise and emotional stress may increase the release of glucose from the liver or increase insulin resistance.

Advise the client on the importance of daily examination of the feet and foot care.
Decreased peripheral circulation places the client at risk for an undetected foot injury. The risk of foot ulceration and limb amputation in people diagnosed with diabetes is lessened by client education stressing the importance of routine preventive foot care, a daily self-inspection of feet, appropriate shoes, and avoidance of barefoot walking (Khan & Khardori, 2020).

Advise the client on the importance of routine eye examinations.
Clients with poorly controlled diabetes may experience changes in vision that may lead to blindness. Microvascular changes consistent with diabetic retinopathy have been reported prior to and after treatment of DKA; the blood-retinal barrier does not experience the same degree of perturbation as the blood-brain barrier does, however (Hamdy & Khardori, 2021).

Review the medication regimen, including, onset, peak, and duration of prescribed insulin, as applicable with the client.
A good way to properly use insulin is to learn these aspects of drug usage. This will help in the adjustment of the doses or the food intake to stop unwanted ups and downs in the glucose level. Understanding all aspects of drug usage promotes the proper use of insulin. Dose algorithms are created, taking into account drug dosages established during inpatient evaluation, the usual amount and schedule of physical activity, and meal plans. 

Review self-administration of insulin and care of equipment. Have the client demonstrate the procedure (e.g., drawing up and injecting insulin, insulin pen technique, or pump therapy).
This evaluates understanding of the procedure and recognizes potential problems such as short-term memory so that alternative solutions can be made for the administration of the insulin. Integral components of diabetes education programs include self-care and self-management with a measurable change in the client’s disease control. Active skill development used to overcome barriers to self-management has been related to lowering HbA1c values (Wang et al., 2013).

Discuss the timing of insulin injection and mealtime.
Regular insulin works best if administered 30 minutes before eating. While a product called insulin lispro (Humalog) works best when taken within 15 minutes of eating. With the onset, twice as fast as regular insulin and a duration nearly half as long. If a blood glucose reading is >80 mg/dL, the insulin should be injected after eating rather than before the meal. Rapid-acting insulins have a rapid onset and short duration of action and are associated with less hypoglycemia than regular insulin (Hamdy & Khardori, 2021).

Discuss the use of a medical alert bracelet.
This enables the client to have a quick entry into the health system, and appropriate care will be given immediately. The American Diabetes Association recommends that all people diagnosed with diabetes wear a diabetes medical alert identification bracelet, especially if the client is on a diabetes medication that decreased blood glucose levels and causes hypoglycemia (American Medical ID, 2023).

Stress the importance of strict follow-up care.
This helps maintain tighter control of the disease process and may prevent exacerbations of DM, retarding the development of systemic complications. An endocrinologist also may be consulted to assist with management after the client has been stabilized adequately (Hamdy & Khardori, 2021).

Remind the client about alternative and complementary health strategies that may alter blood glucose levels.
Certain herbal preparations can alter metabolism and may increase or decrease blood glucose. All methods used should be reported to the healthcare provider. Plant-based therapies that have been shown in some studies to have anti-diabetic properties include aloe vera, bitter melon, cinnamon, fenugreek, ginger, and okra. However, these natural therapies could reduce blood glucose to dangerously low levels and increase the risk of other diabetes complications (Diabetes.co.uk, 2023).

Review the effects of smoking on insulin use. Encourage cessation of smoking.
Nicotine constricts the small blood vessels, and insulin absorption is delayed for as long as these vessels remain constricted.

Establish a regular exercise or activity schedule and identify corresponding insulin concerns.
Exercise should not coincide with the peak action of insulin. A snack should be ingested before or during exercise as needed, and the rotation of injection sites should avoid the muscle group that will be used in the activity to prevent accelerated use of insulin.

6. Administer Medications and Provide Pharmacologic Support

The mainstay of treatment for Diabetic Ketoacidosis (DKA) involves intravenous insulin administration to lower blood glucose levels, intravenous fluids to correct dehydration and electrolyte imbalances, and potassium supplementation to address hypokalemia. In Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS), intravenous fluids are given to restore hydration and normalize blood glucose levels, and insulin therapy may be required to lower blood sugar. In some cases, other medications such as antiemetics or antibiotics may be prescribed depending on the individual patient’s condition and any associated complications.

Rapid-acting insulin such as regular, lispro, or aspart by intermittent or continuous IV infusion.
A rapid-acting insulin is used in a hyperglycemic crisis. The IV route is the initial route of choice because absorption through subcutaneous tissues may be erratic. Many believe the continuous method is the optimal way to facilitate the transition to carbohydrate metabolism and reduce the incidence of hypoglycemia.

Glucose solutions such as 5% dextrose and half-normal saline.
Glucose solutions may be added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia. The optimal rate of glucose decline is 100 mg/dL/hour. The glucose level must not fall below 200 mg/dL during the first 4 to 5 hours because hypoglycemia may develop rapidly due to improved insulin sensitivity (Hamdy & Khardori, 2021).

Antibiotics
Early initiation of antibiotics may help to prevent sepsis. In the presence of infection, the administration of proper antibiotics is guided by the results of culture and sensitivity studies. Starting empiric antibiotics on suspicion of infection until culture results are available may be advisable (Hamdy & Khardori, 2021).

Prochlorperazine
It is indicated for nausea and vomiting. One review concluded that prochlorperazine was equally as effective as metoclopramide, ondansetron, promethazine, and droperidol in the emergency department. Side effects for all medications studied were generally mild (Din & Preuss, 2022).

Diphenhydramine
Diphenhydramine is a first-generation antihistamine that is used for motion sickness.

Metoclopramide.
Metoclopramide is FDA-approved for the treatment of nausea and vomiting in clients with diabetic gastroparesis. It acts by increasing gastric motility (Isola et al., 2022).

Potassium IV and other electrolytes
If the potassium level is greater than 6 mEq/L, do not administer a potassium supplement. Instead, monitor until potassium levels are 4,5 to 6 mEq/L, then administer 10 mEq/hour of potassium chloride. The administration of insulin to lower blood glucose promotes the movement of potassium intracellularly. The infusion must be stopped if the potassium level is greater than 5 mEq/L (Hamdy & Khardori, 2021).

Sodium Bicarbonate
Sodium bicarbonate is only infused if decompensated acidosis starts to threaten the client’s life, especially when associated with either sepsis or lactic acidosis. If sodium bicarbonate is indicated, 100 to 150 mL of 1.4% concentration is infused initially. Rapid and early correction of acidosis with sodium bicarbonate may worsen hypokalemia and cause paradoxical cellular acidosis (Hamdy & Khardori, 2021).

7. Monitoring Results of Diagnostic and Laboratory Procedures

In patients with Diabetic Ketoacidosis (DKA), laboratory tests commonly performed include blood glucose levels, arterial blood gas analysis to assess acid-base balance, serum ketones to confirm ketosis, electrolyte levels to evaluate imbalances, and complete blood count to check for infection or dehydration. In Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS), similar laboratory tests are conducted, focusing on blood glucose levels, serum osmolality to assess dehydration severity, electrolyte levels to evaluate imbalances, and renal function tests to monitor kidney function. Blood and urine cultures may also be obtained if an infection is suspected.

Serum glucose, acetone, pH, and HCO3
With controlled fluid replacement and insulin therapy, blood glucose will gradually decrease. With the optimal insulin dosage administration, glucose can then enter the cells and will act as energy. As a result, acetone levels decrease and acidosis is corrected. It is also important to be aware that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to the factitious elevation of creatinine levels (Hamdy & Khardori, 2021).

Urine and blood culture and sensitivity
Urine and blood culture findings help to identify any possible infectious organisms in clients diagnosed with DKA. This will help identify the appropriate treatment regimen or antibiotic therapy (Hamdy & Khardori, 2021).

Fingerstick glucose testing and urine ketone test
Monitoring of blood glucose such as using finger-stick blood samples has helped in diabetes management for effective glycemic control. If the insulin dose is decreased for persistent incidences of hypoglycemia, the blood glucose should increase to the normal range with the proper dosage. The stress associated with illness alters metabolism and glucose uptake.

Arterial blood gas (ABG) analysis
In clients diagnosed with DKA, ABGs frequently show typical manifestations of metabolic acidosis, low bicarbonate, and low pH of less than 7.3. Venous pH may be used for repeat pH measurements. When monitoring the response to treatment, guidelines recommend the use of venous blood rather than arterial blood in blood gas analyzers, except where respiratory problems preclude using arterial blood (Hamdy & Khardori, 2021).

Blood glucose levels, serum ketones, potassium, sodium, creatinine, and blood urea nitrogen (BUN).
DKA occurs when the blood glucose level is greater than 250 mg/dL. Elevated ketones are associated with DKA. Initially, hyperkalemia occurs in response to metabolic acidosis. As the fluid volume deficit progresses, the potassium level decreases. Both DKA result in hypokalemia. Increased blood sugar causes water to shift from intracellular into extracellular, resulting in serum sodium depletion. Elevated BUN and creatinine indicate cellular breakdown from dehydration or a sign of acute renal failure.

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