4 Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome Nursing Care Plans

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 carbohydrate, fat, and protein. Main clinical features of DKA are hyperglycemia, acidosis, dehydration, and electrolyte losses such as hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, and hypophosphatemia.

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) is a condition characterized by the presence of hyperglycemia, hyperosmolarity, and dehydration. There is enough production of insulin to reduce ketosis but not to control hyperglycemia. Persistent hyperglycemia causes osmotic diuresis, which results in the fluid and electrolyte imbalances. The clients with HHNS may present with symptoms of hypotension, tachycardia, marked dehydration, and neurological manifestation such as seizures, hemiparesis, and alterations in the sensorium).

Nursing Care Plans

The nursing care plan for clients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome includes provision of information about 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.

Here are four (4) nursing care plans (NCP) for Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome:

1. Risk For Fluid Volume Deficit

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Risk for Fluid Volume Deficit: At risk for experiencing vascular, cellular, or intracellular dehydration.

Risk Factors

• - Decreased intake of fluids due to diminished thirst sensation or functional inability to drink fluids.
• - Excessive gastric losses due to nausea and vomiting.
• - Hyperglycemia-induced osmotic diuresis.

Possibly evidenced by

• [not applicable].

Desired Outcomes

• - 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.

Nursing Interventions	Rationale
Assess precipitating factors such as other illnesses, new-onset diabetes, or poor compliance with 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 and HHNS among older clients.
Assess skin turgor, mucous membranes, and thirst.	To provide baseline data for further comparison. Skin turgor will decrease and tenting may occur. 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.
Monitor vital signs:
- Monitor BP especially for orthostatic hypotension.	Decreased blood volume may be manifested by a drop in systolic blood pressure and orthostatic hypotension.
- Monitor respirations, e.g., acetone breath, Kussmaul’s respirations.	Acetone breath is due to the breakdown of acetoacetic acid. Kussmaul’s respiration (rapid and shallow breathing) represent a compensatory mechanism by the respiratory buffering system to raise arterial pH by exhaling more carbon dioxide.
- Monitor temperature.	Fever with flushed, dry skin may indicate dehydration.
- Monitor heart rate.	Compensatory mechanism results in peripheral vasoconstriction with a weak, thready pulse that is easily obliterated.
- Assess neurological status every two (2) hours.	Decreased level of consciousness results from blood volume depletion, elevated or decreased glucose level, hypoxia or electrolyte imbalances.
Weigh client daily.	Provides baseline data of current fluid status and adequacy of fluid replacement. A weight loss of 2.2 lbs over 24 hours indicates a 1 liter of fluid loss.
Monitor laboratory studies:
- Blood glucose levels	Diagnostic criteria:DKA: blood glucose level greater than 250 mg/dL. HHNS: blood glucose level greater than 600 mg/dL with serum osmolality >320 mOsm/kg.
- Serum ketones	Elevated ketones is associated with DKA.
- Potassium	Initially, hyperkalemia occurs in response to metabolic acidosis. As the fluid volume deficit progresses, potassium level decreases. Both DKA and HHNS result in hypokalemia.
- Sodium	Increased blood sugar causes water to shift from intracellular into extracellular, resulting in serum sodium depletion.
- Blood urea nitrogen and creatinine.	Elevated BUN and creatinine indicate cellular breakdown from dehydration or a sign of an acute renal failure.
Monitor ABG for metabolic acidosis.	Clients with DKA have metabolic acidosis with arterial a bicarbonate level less than 18 mEq/L, and a pH less than 7.30.
Insert indwelling urinary catheter as indicated.	To provide accurate measurement of urinary output especially for clients with neurogenic bladder.
Administer fluid as indicated: Isotonic solution (0.9% NaCl).	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 2 to 3 liters within the first 2 hours of treatment.
Administer succeeding IV therapy: 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.
Add dextrose to IV fluid when serum blood glucose level is less than 250 mg/dL in DKA or less than 300 mg/dL in HHNS.	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.	Potaasium is added to the IV once serum potassium drops below 5.5 mEq/L to prevent hypokalemia. The administration of insulin to lower blood glucose promotes the movement of potassium intracellularly.
Administer bicarbonate as indicated.	This is given in clients with a severe hyperkalemia and severe acidosis with pH of less than 7.1.
Administer an IV bolus dose of regular insulin, followed by a continuous infusion of regular insulin.	Regular insulin has a rapid onset and therefore immediately helps move glucose intracellularly. IV route is the initial route because subcutaneous injection of insulin may be absorbed unpredictably. While a continuous infusion is an optimal way to consistently administer insulin to prevent hypoglycemia.

2. Risk For Infection

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Risk for Infection: At increased risk for being invaded by pathogenic organisms.

Risk Factors

• - Preexisting respiratory infection, or UTI.
• - High glucose levels.
• - Decreased leukocyte function.
• - Changes in circulation.

Possibly evidenced by

• [not applicable].

Desired Outcomes

• - Preexisting respiratory infection, or UTI.
• - High glucose levels.
• - Decreased leukocyte function.
• - Changes in circulation.

Possibly evidenced by

• [not applicable].

Desired Outcomes

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• - Client will identify interventions to prevent reduce risk of infection.
• - Client will demonstrate techniques, lifestyle changes to prevent the development of infection.

Nursing Interventions	Rationale
Assess for signs of infection and inflammation.	Infection is a common cause of DKA. Signs of infection includes fever, chills, dysuria, and increased WBC count.
Observe 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.
Observe aseptic technique during IV insertion and medication administration.	Elevated blood sugar weakens the immune system thus clients are more prone to infection.
Provide skin care.	An intact skin protects against infection.
Encourage proper handwashing technique.	To avoid the risk of cross-contamination.
Encourage adequate oral fluid intake (2-3 liters a day unless contraindicated).	Reduces susceptibility to infection.
Encourage deep breathing exercise; Maintain client in semi-Fowler’s position.	Helps in mobilizing secretions. And expanding the lung.
Obtain sample for culture and sensitivity as indicated.	Identifies the bacteria/fungus that causes an infection and the appropriate drug for it.
Administer antibiotics as indicated.	Early initiation of antibiotic may help to prevent sepsis.

3. Deficient Knowledge

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Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

• - Unfamiliarity with the risk factors, treatment, and prevention of the disease.
• - Lack of exposure or recall, information misinterpretation.

Possibly evidenced by

• - Inaccurate follow-through of instructions, development of preventable complications.
• - Questions or request for information.

Desired Outcomes

• - Client will verbalize understanding of the disease condition and potential complication.
• - Client will correctly perform necessary procedures and explain rationale on each action.
• - Client will demonstrate lifestyle changes and participate in treatment regimen.

Nursing Interventions	Rationale
Establish rapport and trust.	Create an environment where trust and good rapport facilitates good relationship in the learning process.
Explain the signs and symptoms of diabetic ketoacidosis.	Symptoms of hyperglycemia include polyuria, polydipsia, polyphagia, flushed skin, and body malaise.
Discuss the following with the client: - Normal blood glucose level. - Risk factors. - Client’s type of diabetes. - The relationship between elevated glucose level and insulin deficiency.	Baseline knowledge enables the client to make informed lifestyle choices.
Demonstrate proper blood glucose testing using the glucometer. Instruct client to check the urine for ketones once blood glucose reaches 250 mg/dL or higher.	Monitoring blood glucose 3-4 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 physician immediately.
Teach signs of hypoglycemia: - Dizziness. - Sweating. - Hunger. - Pallor. - Diaphoresis. - Nervousness. - Tremors.	These are signs of excessive insulin dosage, resulting in hypoglycemia. Early recognition of these symptoms promotes immediate intervention.
Teach client that polyuria, polydipsia, and polyphagia are signs of hyperglycemia which requires increased dosage of insulin.	These are signs of insufficient insulin dosage and hyperglycemia which may lead to coma and death if untreated.
Explain the importance of having a dietary plan: - Limit intake of simple sugar, fat, salt and alcohol. - Increase 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, decreased excess insulin levels and lowered lipid concentrations in clients with type 2 diabetes.
Teach client to monitor blood glucose during periods of exercise and adjust insulin dose.	The insulin dose should be adjusted after increased or decreased food intake and before any exercise. Exercise may increase usage of glucose.
Advise the client the importance of daily examination of the feet and foot care.	Decreased peripheral circulation place the client at risk for an undetected foot injury.
Advise the client the importance of routine eye examination.	Clients with a poorly controlled diabetes may experience changes in vision that may lead to blindness.
Review of 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.
Review self-administration of insulin and care of equipment. Have client demonstrate procedure (e.g., drawing up and injecting insulin, insulin pen technique, or pump therapy).	Evaluate understanding of the procedure. Recognizes potential problems such as short-term memory so that alternative solutions can be made for the administration of the insulin.
Discuss timing of insulin injection and mealtime.	Regular insulin works best if administering it 30 minutes before eating. While a product called insulin lispro (Humalog) works best when taking within 15 minutes of eating. With the onset twice as fast as regular insulin and a duration nearly half as long. Hypoglycemia may result more rapidly. If a blood glucose reading is >80 mg/dL, the insulin should be injected after eating rather than before the meal.
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.
Stress the importance of strict follow-up care.	To prevent or delay the development of complications from diabetes.

4. Imbalanced Nutrition: Less Than Body Requirements

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Imbalanced Nutrition: Less Than Body Requirements:Intake of nutrients insufficient to meet metabolic needs.

May be related to

• - Decreased oral intake.
• - Hypermetabolic state: release of stress hormones (e.g., cortisol, growth hormone, and epinephrine).
• - Insufficient insulin.

Possibly evidenced by

• - Increased urinary output, diluted urine.
• - Increased ketones.
• - Nausea; diarrhea.
• - Recent weight loss; weakness, anorexia, fatigue.
• - Reported inadequate food intake, lack of interest in food.

Desired Outcomes

• - Client will display normal energy level.
• - Client will take appropriate amounts of calories/nutrients.
• - Client will demonstrate stabilized weight or gain toward desired range with normal laboratory values.

Nursing Interventions	Rationale
Determine client’s dietary program and usual pattern.	Recognizes deficits and deviations from therapeutic needs.
Monitor weight daily or as indicated.	Assessing sufficiency of food intake, including absorption and utilization.
Auscultation bowel sounds, note the presence of abdominal pain/abdominal bloating, nausea or vomiting. Maintain on NPO status, as indicated.	Imbalances in the fluid and electrolytes and hyperglycemia reduces gastric motility resulting in delayed gastric emptying that will influence the selected intervention.
Involve patients in planning family as indicated.	Provide information on the family to understand the nutritional needs of the patient.
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.
Monitor laboratory studies (Serum glucose, pH, HCO3, acetone).	With a controlled fluid replacement and insulin therapy, blood glucose will gradually decrease. With the optimal insulin dosages administration, glucose can then enter the cells and will act as energy. As a result, acetone levels decrease and acidosis is corrected.
Perform fingerstick glucose testing.	Monitoring of blood glucose such as using finger-stick blood samples has helped in diabetes management for effective glycemic control.
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 carbohydrate reaches normal, caution must be taken to prevent hypoglycemia.
Administer regular insulin by intermittent or continuous IV method.	Intravenous (IV) infusion is the choice route of insulin delivery because the rapid onset and short duration of action associated with IV infusion allow for matching insulin requirements to rapidly changing blood glucose levels.
Collaborate with a dietician for initiation of resumption of oral intake.	Helps in calculating and adjusting diet to meet nutritional needs of the client; Dietician assists the client and the family on producing meal plans.
Provide a diet consisting of 60% Carbohydrates, 20% fats, 20% proteins in designated number of meals.	Complex carbohydrates (peas, beans, whole grains, and vegetables) decreases glucose and cholesterol levels. Food intake is scheduled according to specific insulin characteristics and individual client’s response.
Administer medication as prescribed.	Beneficial in treating symptoms related to affecting GI tract such as diabetic gastroparesis, to improve oral intake and nutrient absorption.
- Prochlorperazine (Compro); diphenhydramine (benadryl).	Medications to control nausea and vomiting.
- Metoclopramide (Reglan); erythromycin (Eryc).	Medications to stimulate the stomach muscles.

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References and Sources : nurseslabs.com