NR 507 Discussion What is the etiology of Diabetic Ketoacidosis?

Diabetic Ketoacidosis seems to be a very common occurrence in the healthcare setting I currently work in. While many of the individuals recognize the symptoms but do not have common occurrences some patients seem to experience this complication frequently. I feel that education is essential when a patient is first diagnosed with diabetes to ensure the signs and symptoms are known and prevention methods are implemented. In some cases, it can be seen that the patients are not aware of the seriousness of DKA or the long-term effects it can cause. According to Smith and Schub (2018, p. 3), “Complications of DKA include electrolyte imbalances, cerebral edema, thrombotic events (e.g., pulmonary embolism, stroke, DVT), and acute kidney injury”. Complications such as these can be very serious and result in long term effects that could cause further debilitation. In order for the best outcome in the present and future quick treatment is essential and correct treatment of elevated glucose levels independently of the patient to prevent future episodes is essential. You included great information in the discussion allowing for a clear understanding of DKA.

Reference

Smith, N. C., & Schub, T. B. (2018). Diabetic Ketoacidosis in Adults. CINAHL Nursing Guide.

What is the etiology of Diabetic Ketoacidosis?

Diabetic ketoacidosis is a severe complication of diabetes that occurs when your body produces high levels of blood acids called ketones. “Diabetic ketoacidosis (DKA) develops when there is an absolute or relative deficiency of insulin and an increase in the levels of counterregulatory insulin hormones” (McCance, 2013). This disease commonly found in patients with type 1 diabetes. However, it can also occur in type 2 diabetes. The most common triggering aspect for DKA is other illness, such as infection, trauma, surgery, or myocardial infarction. Interruption of insulin administration also may result in DKA. (McCance, 2013).

The condition develops when your body can’t produce enough insulin. Insulin usually plays a crucial role in helping sugar (glucose) — a significant source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. (Mayo clinic staff, 2018).

Describe the pathophysiological process of Diabetic Ketoacidosis.

Diabetic ketoacidosis characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration. Insulin deficiency is the main precipitating factor. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases arising in persons older than 70 years, 23 percent in persons 51 to 70 years of age, 27 percent in persons 30 to 50 years of age, and 36 percent in persons younger than 30 years. The case fatality rate is 1 to 5 percent. About one-third of all cases are in persons without a history of diabetes mellitus. (Westerberg, 2013). According to, McCance, 2013. In a state of relative insulin deficiency, there is an increase in the concentrations of insulin counterregulatory hormones including catecholamines, cortisol, glucagon, and GH. “These counterregulatory hormones antagonize insulin by increasing glucose production and decreasing tissue use of glucose. Profound insulin deficiency results in decreased glucose uptake increased fat mobilization with the release of fatty acids and accelerated gluconeogenesis and ketogenesis. “(McCance, 2013).

Identify the hallmark symptoms of Diabetic Ketoacidosis.

Hallmark symptoms include polyuria with polydipsia (98 percent), dehydration, weight loss (81 percent), fatigue (62 percent), dyspnea (57 percent), vomiting (46 percent), preceding febrile illness (40 percent), abdominal pain (32 percent), and polyphagia (23 percent). Other symptoms of diabetic ketoacidosis include Kussmaul respirations (hyperventilation to compensate for the acidosis), postural dizziness, central nervous system depression, ketonuria, anorexia, nausea.

Identify any abnormal lab results provided in the case and explain why these would be abnormal given the patient’s condition.

Sodium (Na+) 156 mEq/L elevated normal range 136-146 mEq/L. The American Diabetes Association criteria for the diagnosis of DKA are: (1) a serum glucose level >250 mg/dl, (2) a serum bicarbonate level <18 mg/dl, (3) a serum pH <7.30, (4) the presence of an anion gap, and (5) the presence of urine and serum ketones. Arterial blood gases (ABGs) Pco2-40; Po2-70; HCO3-20. Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct relationship between end-tidal carbon dioxide (ETCO2), arterial carbon dioxide (PaCO2), and metabolic acidosis, measuring ETCO2 may serve as a surrogate for ABG in the assessment of possible DKA. (Soeimanpour et al., 2013). These labs are abnormal because the body is compensating for the high level of glucose in the renal system and the loss of glucose in the urine. Ms. Blake has not been eating and probably has been taken her insulin as she was before she got sick. When you have diabetes and don’t get enough insulin and get dehydrated, your body burns fat instead of carbs as fuel, and that makes Ketones. Lots of ketones in your blood turn it acidic. People who drink much alcohol for a long time and don’t eat also enough build up ketones. It can happen when you aren’t eating at all, too. This condition can all lead to or be a predictor of existing Ketoacidosis.

NR 507 Discussion What is the etiology of Diabetic Ketoacidosis

What teaching would you provide this patient to avoid Diabetic Ketoacidosis symptoms?

First, I would emphasize the importance of managing her insulin regimen, instruct her that DKA is a life-threatening condition. I would teach Ms. Blake to Monitor her blood sugar levels closely, especially if you have an infection, are stressed, or experience trauma. Check your blood sugar levels often. You may need to check at least three times each day. If your blood sugar level is too high, give yourself insulin as directed by your healthcare provider. Manage your sick days. When you are sick, you may not eat as much as you usually would. You may need to change the amount of insulin you give yourself. You may need to check your blood sugar level more frequently than typical. Strategize with your healthcare provider about how to manage your diabetes when you are sick.

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References

Mayo clinic staff (2018). Diabetic ketoacidosis/ Symptoms & causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551

McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby.

Soleimanpour,H., Taghizadieh, A., Niafar, M., Rahmani, F., Golzari, S.E.J., Estanjani, R.M. (2013). Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876300/

Westerberg, D.P. (2018). Diabetic Ketoacidosis: Evaluation and Treatment. Retrieved fromhttps://www.aafp.org/afp/2013/0301/p337.html

I enjoyed reading your post and agree with the fact that would point out the importance of managing the patient’s insulin regimen and telling her that diabetic ketoacidosis (DKA) is a life threatening emergency. I would like to add that poor insulin regimen adherence is the main cause of (DKA) in most individual. Many lifestyle behaviors, social economic, psychosocial and educational determinants impact to low adherence (Halepian, Saleh, Hallit & Khabbaz, 2018). According to a study based on the Kaiser Permanente hospital population, the study found that a high percentage of patients who did not start their insulin regimen felt that their medical providers ineffectively disclosed the risks and advantages of insulin (Halepian et al., 2018). More counseling by medical providers is required to educate the patient about the probable aftereffects that may result with insulin regimen and most imperatively about the potency of insulin (Halepian et al., 2018). Emphasizing the benefits of insulin regimen at the time of prescribing, as well as clarifying the possibility of an adverse aftereffects occurring and its significance can enhance how patients comprehend information from different sources (Halepian et al., 2018). Second level of schooling was negatively linked with less trust in physician scores (Halepian et al., 2018). This may clarify why the patients with higher education accomplishment are more involved in the health decision making process and confirm reliability of information offered by their providers (Halepian et al., 2018). As advanced practice nurses it is important to recognize these factors and institute culturally competent intervention and patient education may reduce the reoccurrence of DKA.

References

Halepian, L., Saleh, M.B., Hallit, S., & Khabbaz, L. R. (2018). Adherence to insulin, emotional distress and trust in physician among patients with diabetes. Diabetes Therapy, 9(2), 713-726. doi: 10.1007/s1333000-018-0389-1

What is the etiology of Diabetic Ketoacidosis?

Nice job!

Describe the pathophysiological process of Diabetic Ketoacidosis.

That’s right!

Identify the hallmark symptoms of Diabetic Ketoacidosis.

You got it!

Identify any abnormal lab results provided in the case and explain why these would be abnormal given the patient’s condition.

Excellent job with this section!

What teaching would you provide this patient to avoid Diabetic Ketoacidosis symptoms?

You did a great job explaining the etiology and pathophysiology of Diabetic Ketoacidosis. I would like to touch upon the patient teaching component of this week’s topic discussion. You make a good point about teaching diabetes patients to test their glucose levels more often. Glucose monitoring is a big topic among diabetes researchers and clinicians, even more so is the topic of self-monitoring blood glucose (SMBG) levels. Schnell, Hanefeld, & Monnier (2014) state SMBG is a critical for the optimization of diabetes treatment in insulin-treated diabetes patients. SMBG is beneficial because it helps diabetes patients hit their hemoglobin A1c (HbA1c) targets, minimizes glucose variability, and helps to predict and prevent hypoglycemia (Schnell, Hanefeld, & Monnier, 2014). SMBG also positively influences lower morbidity and all-cause mortality rates among Type I and II diabetes patients (Schnell, Hanefeld, & Monnier, 2014). Those who check their blood glucose levels often are proactively changing their lifestyles for the better. SMBG prompts patients to eat healthier meals, exercise lightly more often, minimize stress, stay hydrated, and follow their medication regimen. Checking glucose levels at least 4 to 5 times a day will heighten patients’ awareness to avoid the type of lifestyle that advance DK symptoms.

Effectively managing blood glucose levels and maintaining glycemic control includes monitoring ketones levels. FNPs can encourage their diabetes patients to add this action after checking their blood glucose levels. FNPs can help educate diabetes patients on ketones, proper ketone levels, how ketones level get too high (above 3.0 mmol/L) or too low (below 1.5 mmol/L), and what actions to take to avoid hypoglycemia if ketone levels get too low. Patients at risk for DK may be interested in adopting a ketogenic diet, a low-carbohydrate, high-fat, adequate-protein diet that reduces one’s chances of inducing DK (Urbain & Bertz, 2016).

References

Schnell, O., Hanefeld, M., & Monnier, L. (2014). Self-Monitoring of Blood Glucose: A Prerequisite for Diabetes Management in Outcome Trials. Journal of Diabetes Science and Technology, 8(3), 609–614. http://doi.org/10.1177/1932296814528134

Urbain, P., & Bertz, H. (2016). Monitoring for compliance with a ketogenic diet: what is the best time of day to test for urinary ketosis? Nutrition & Metabolism, 13, 77. http://doi.org/10.1186/s12986-016-0136-4

Great post and thank you for sharing you made some very informative points. Timely management of diabetic ketoacidosis (DKA) is essential to avoid lengthy hospitalizations and poor clinical outcomes (Joyner-Blair, Hamilton & Spurlock, 2018). There is often an absence of ownership for glycemic management in hospitalized patients, most notably in those with a diagnosis other than diabetes. This lack of ownership supports the use of evidence-based DKA protocols. Joyner-Blair, Hamilton & Spurlock (2018) conducted a project to determine whether utilization of an evidence-based order set versus an individualized provider approach for the treatment and management of DKA decreases resolution time and occurrences of hypoglycemia and improves clinical outcomes.

They retrospectively reviewed electronic medical record of 150 non-pregnant adult patients diagnosed with DKA, pre and post-interventions, for retrieval of relevant outcome data. They concluded that implementation of the institutionally approved evidence-based order set affirmed anticipated outcomes (Joyner-Blair, Hamilton & Spurlock, 2018). Results showed improvements (Joyner-Blair, Hamilton & Spurlock, 2018) in the (a) total length of stay, (b) arrival to intravenous fluid time, (c) intravenous insulin initiation to discontinuation (resolution) time, (d) arrival to subcutaneous insulin administration time, (e) time from initial to sequential laboratory testing, (f) use of a basal, prandial, and correction insulin approach (physiological mimic), and (g) the incidence of hypoglycemia. Outcomes substantiate the importance and need for maintaining an evidence-based and systems approach for the management of DKA. Although hyperosmolar hyperglycemic state can be confused with DKA, ketone levels are low or absent in persons with hyperosmolar hyperglycemic state. Other causes of high anion gap metabolic acidosis, such as alcoholic ketoacidosis and lactic acidosis, must be ruled out.

Reference

Joyner Blair, A. M., Hamilton, B. K., & Spurlock, A. (2018). Evaluating an Order Set for Improvement of

Quality Outcomes in Diabetic Ketoacidosis. Advanced Emergency Nursing Journal, 40(1), 59-72. doi:10.1097/TME.0000000000000178

NR 507 Discussion What is the etiology of Diabetic Ketoacidosis?