DIABETES MELLITUS/DIABETIC KETOACIDOSIS
Diabetes affects 18% of people over the age of 65, and approximately 625,000 new cases of diabetes are diagnosed annually in the general population. Conditions or situations known to exacerbate glucose/insulin imbalance include (1) previously undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in excess of available insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5) stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a life-threatening emergency caused by a relative or absolute deficiency of insulin.
CARE SETTING
Although DKA may be encountered in any setting and mild DKA may be managed at the community level, severe metabolic imbalance requires inpatient acute care on a medical unit.
RELATED CONCERNS
Amputation
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficit)
Psychosocial aspects of care
Patient Assessment Database
Data depend on the severity and duration of metabolic imbalance, length/stage of diabetic process, and effects on other organ function.
ACTIVITY/REST
May report:
Sleep/rest disturbances
Weakness, fatigue, difficulty walking/moving
Muscle cramps, decreased muscle strength
May exhibit:
Tachycardia and tachypnea at rest or with activity
Lethargy/disorientation, coma
Decreased muscle strength/tone
CIRCULATION
May report:
History of hypertension; acute myocardial infarction (MI)
Claudication, numbness, tingling of extremities (long-term effects)
Leg ulcers, slow healing
May exhibit:
Tachycardia
Postural BP changes; hypertension
Decreased/absent pulses
Dysrhythmias
Crackles; jugular venous distension (JVD) (if heart failure [HF] present)
Hot, dry, flushed skin; sunken eyeballs
EGO INTEGRITY
May report:
Stress; dependence on others
Life stressors including financial concerns related to condition
May exhibit:
Anxiety, irritability
ELIMINATION
May report:
Change in usual voiding pattern (polyuria), nocturia
Pain/burning, difficulty voiding (infection), recent/recurrent urinary tract infection (UTI)
Abdominal tenderness, bloating
Diarrhea
May exhibit:
Pale, yellow, dilute urine; polyuria (may progress to oliguria/anuria if severe hypovolemia occurs)
Cloudy, odorous urine (infection)
Abdomen firm, distented
Bowel sounds diminished or hyperactive (diarrhea)
FOOD/FLUID
May report:
Loss of appetite; nausea/vomiting
Not following diet; increased intake of glucose/carbohydrates
Weight loss over a period of days/weeks
Thirst
Use of medications exacerbating dehydration, such as diuretics
May exhibit:
Dry/cracked skin, poor skin turgor
Abdominal rigidity/distension
Thyroid may be enlarged (increased metabolic needs with increased blood sugar)
Halitosis/sweet, fruity odor (acetone breath)
NEUROSENSORY
May report:
Fainting spells/dizziness
Headaches
Tingling, numbness, weakness in muscles
Visual disturbances
May exhibit:
Confusion/disorientation; drowsiness, lethargy, stupor/coma (later stages)
Memory impairment (recent, remote)
Deep tendon reflexes (DTRs) decreased (coma)
Seizure activity (late stages of DKA or hypoglycemia)
PAIN/DISCOMFORT
May report:
Abdominal bloating/pain (mild/severe)
May exhibit:
Facial grimacing with palpation; guarding
RESPIRATION
May report:
Air hunger (late stages of DKA)
Cough, with/without purulent sputum (infection)
May exhibit:
Increased respiratory rate (tachypnea); deep, rapid (Kussmaul’s) respirations (metabolic acidosis)
Rhonchi, wheezes
Yellow or green sputum (infection)
SAFETY
May report:
Dry, itching skin; skin ulcerations
Paresthesia (diabetic neuropathy)
May exhibit:
Fever, diaphoresis
Skin breakdown, lesions/ulcerations
Decreased general strength/ROM
Weakness/paralysis of muscles, including respiratory musculature (if potassium levels are markedly decreased)
SEXUALITY
May report:
Vaginal discharge (prone to infection)
Problems with impotence (men); orgasmic difficulty (women)
TEACHING/LEARNING
May report:
Familial risk factors: diabetes mellitus (DM), heart disease, strokes, hypertension
Slow/delayed healing
Use of drugs, e.g., steroids, thiazide diuretics, phenytoin (Dilantin), and phenobarbital (can increase glucose levels)
May/may not be taking diabetic medications as ordered
Discharge plan considerations:
DRG projected mean length of inpatient stay: 5.9 days
May need assistance with dietary regimen, medication administration/supplies, self-care, glucose monitoring
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Serum glucose: Increased 200–1000 mg/dL or more.
Serum acetone (ketones): Strongly positive.
Fatty acids: Lipids, triglycerides, and cholesterol level elevated.
Serum osmolality: Elevated but usually less than 330 mOsm/L.
Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia.
Glycosylated hemoglobin (HbA1C): Evaluates glucose control during past 8–12 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment.
Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies.
Electrolytes:
Sodium: May be normal, elevated, or decreased.
Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased.
Phosphorus: Frequently decreased.
Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO3 (metabolic acidosis) with compensatory respiratory alkalosis.
CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.
BUN: May be normal or elevated (dehydration/decreased renal perfusion).
Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA.
Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs.
Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated.
Cultures and sensitivities: Possible UTI, respiratory or wound infections.
NURSING PRIORITIES
1. Restore fluid/electrolyte and acid-base balance.
2. Correct/reverse metabolic abnormalities.
3. Identify/assist with management of underlying cause/disease process.
4. Prevent complications.
5. Provide information about disease process/prognosis, self-care, and treatment needs.
DISCHARGE GOALS
1. Homeostasis achieved.
2. Causative/precipitating factors corrected/controlled.
3. Complications prevented/minimized.
4. Disease process/prognosis, self-care needs, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
Diabetes affects 18% of people over the age of 65, and approximately 625,000 new cases of diabetes are diagnosed annually in the general population. Conditions or situations known to exacerbate glucose/insulin imbalance include (1) previously undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in excess of available insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5) stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a life-threatening emergency caused by a relative or absolute deficiency of insulin.
CARE SETTING
Although DKA may be encountered in any setting and mild DKA may be managed at the community level, severe metabolic imbalance requires inpatient acute care on a medical unit.
RELATED CONCERNS
Amputation
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficit)
Psychosocial aspects of care
Patient Assessment Database
Data depend on the severity and duration of metabolic imbalance, length/stage of diabetic process, and effects on other organ function.
ACTIVITY/REST
May report:
Sleep/rest disturbances
Weakness, fatigue, difficulty walking/moving
Muscle cramps, decreased muscle strength
May exhibit:
Tachycardia and tachypnea at rest or with activity
Lethargy/disorientation, coma
Decreased muscle strength/tone
CIRCULATION
May report:
History of hypertension; acute myocardial infarction (MI)
Claudication, numbness, tingling of extremities (long-term effects)
Leg ulcers, slow healing
May exhibit:
Tachycardia
Postural BP changes; hypertension
Decreased/absent pulses
Dysrhythmias
Crackles; jugular venous distension (JVD) (if heart failure [HF] present)
Hot, dry, flushed skin; sunken eyeballs
EGO INTEGRITY
May report:
Stress; dependence on others
Life stressors including financial concerns related to condition
May exhibit:
Anxiety, irritability
ELIMINATION
May report:
Change in usual voiding pattern (polyuria), nocturia
Pain/burning, difficulty voiding (infection), recent/recurrent urinary tract infection (UTI)
Abdominal tenderness, bloating
Diarrhea
May exhibit:
Pale, yellow, dilute urine; polyuria (may progress to oliguria/anuria if severe hypovolemia occurs)
Cloudy, odorous urine (infection)
Abdomen firm, distented
Bowel sounds diminished or hyperactive (diarrhea)
FOOD/FLUID
May report:
Loss of appetite; nausea/vomiting
Not following diet; increased intake of glucose/carbohydrates
Weight loss over a period of days/weeks
Thirst
Use of medications exacerbating dehydration, such as diuretics
May exhibit:
Dry/cracked skin, poor skin turgor
Abdominal rigidity/distension
Thyroid may be enlarged (increased metabolic needs with increased blood sugar)
Halitosis/sweet, fruity odor (acetone breath)
NEUROSENSORY
May report:
Fainting spells/dizziness
Headaches
Tingling, numbness, weakness in muscles
Visual disturbances
May exhibit:
Confusion/disorientation; drowsiness, lethargy, stupor/coma (later stages)
Memory impairment (recent, remote)
Deep tendon reflexes (DTRs) decreased (coma)
Seizure activity (late stages of DKA or hypoglycemia)
PAIN/DISCOMFORT
May report:
Abdominal bloating/pain (mild/severe)
May exhibit:
Facial grimacing with palpation; guarding
RESPIRATION
May report:
Air hunger (late stages of DKA)
Cough, with/without purulent sputum (infection)
May exhibit:
Increased respiratory rate (tachypnea); deep, rapid (Kussmaul’s) respirations (metabolic acidosis)
Rhonchi, wheezes
Yellow or green sputum (infection)
SAFETY
May report:
Dry, itching skin; skin ulcerations
Paresthesia (diabetic neuropathy)
May exhibit:
Fever, diaphoresis
Skin breakdown, lesions/ulcerations
Decreased general strength/ROM
Weakness/paralysis of muscles, including respiratory musculature (if potassium levels are markedly decreased)
SEXUALITY
May report:
Vaginal discharge (prone to infection)
Problems with impotence (men); orgasmic difficulty (women)
TEACHING/LEARNING
May report:
Familial risk factors: diabetes mellitus (DM), heart disease, strokes, hypertension
Slow/delayed healing
Use of drugs, e.g., steroids, thiazide diuretics, phenytoin (Dilantin), and phenobarbital (can increase glucose levels)
May/may not be taking diabetic medications as ordered
Discharge plan considerations:
DRG projected mean length of inpatient stay: 5.9 days
May need assistance with dietary regimen, medication administration/supplies, self-care, glucose monitoring
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Serum glucose: Increased 200–1000 mg/dL or more.
Serum acetone (ketones): Strongly positive.
Fatty acids: Lipids, triglycerides, and cholesterol level elevated.
Serum osmolality: Elevated but usually less than 330 mOsm/L.
Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia.
Glycosylated hemoglobin (HbA1C): Evaluates glucose control during past 8–12 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment.
Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies.
Electrolytes:
Sodium: May be normal, elevated, or decreased.
Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased.
Phosphorus: Frequently decreased.
Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO3 (metabolic acidosis) with compensatory respiratory alkalosis.
CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.
BUN: May be normal or elevated (dehydration/decreased renal perfusion).
Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA.
Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs.
Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated.
Cultures and sensitivities: Possible UTI, respiratory or wound infections.
NURSING PRIORITIES
1. Restore fluid/electrolyte and acid-base balance.
2. Correct/reverse metabolic abnormalities.
3. Identify/assist with management of underlying cause/disease process.
4. Prevent complications.
5. Provide information about disease process/prognosis, self-care, and treatment needs.
DISCHARGE GOALS
1. Homeostasis achieved.
2. Causative/precipitating factors corrected/controlled.
3. Complications prevented/minimized.
4. Disease process/prognosis, self-care needs, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
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