Diabetic Ketoacidosis (DKA): Management of pH and Water Deficits (Nursing)

00:01 So what if this patient is in a severe state? How do you manage it? What are the things you could expect to see? Well, first of all, we're going to have to stabilize the patient's airway, breathing, and circulation.

00:11 Depending on where they are, you'll provide support.

00:13 If they're able to maintain their saturations, then they may not need um oxygen, but they may, particularly if they're in a really severe state.

00:21 Now, you're going to start a large bore IV because we know we're going to be giving them lots of fluids, right? We know they're severely dehydrated, they're peeing out lots of extra urine.

00:30 So we want a big IV, greater than or equal to 16 gauge so we can throw a lot of fluid in there quickly.

00:37 We're going to have them on a heart monitor because we know that their electrolytes can be way off, and we certainly want to watch for any dysrhythmias.

00:44 We're have them on capnography and pulse oximetry because we want to know how they're doing with their breathing and how their body is receiving tissues.

00:52 That'll give us an indication.

00:54 As a nurse, I'm also going to monitor their blood glucose every hour when they're in this state.

00:58 Also going to watch basic electrolytes, BUN, creatinine, phosphorus, serum ketones, and a venous pH or bicarbonate every two to four hours until this patient is stable.

01:09 Things can change so quickly with a client with DKA.

01:12 As a nurse, these are the things I'm going to be watching that closely.

01:16 Now also, I want to be on the lookout for any underlying causes of DKA.

01:21 What might have thrown the patient into it? Well, I know that infection is one.

01:25 So I'm going to be thinking, is there any place I think this patient could be developing an infection? Is it pneumonia? Is it a UTI? Have they had or have they had a heart attack? Which we know a patient can be at increased risk for DKA after a heart attack, and they may not even know they had a heart attack.

01:41 Also know if they haven't been receiving their insulin for whatever reason, that could be the underlying reason of DKA and all of those problems need to be addressed.

01:50 If it's an if it's an infection, they need an appropriate antibiotic treatment.

01:54 If it's an MI, they've got a whole plan of treatment.

01:57 And if they're not getting the appropriate level of insulin, it's our job to figure out why and see how we can help them make the next choice.

02:05 At the end of the day, the patient has the right to choose whatever they want to do about their health.

02:10 But oftentimes, it's not because the patient just doesn't want to access the insulin, it's because they may not have the resources to do so.

02:20 Now I want to talk about the venous pH because this might be something different that you haven't been exposed to.

02:24 This is a blood gas test, but it's not drawn from an artery.

02:29 So you're probably familiar with arterial blood gases, but this is a venous blood gas.

02:34 So the sample is drawn from the vein.

02:36 Now, it will also measure the oxygen and carbon dioxide, but it's in the venous blood, right? So when you think about that, what's the difference? Well, arterial blood is coming out of that left side of your heart going through the aorta, and it's going out to all the tissues to deliver oxygen and pick up waste.

02:53 Once it becomes venous blood, that's going back to the heart.

02:57 So it's already delivered its oxygen and picked up its waste.

03:00 So when we say venous blood, that's the type of blood that you're using for the sample.

03:05 So we can see the oxygen, the carbon dioxide, but remember it's going to be different than if it was arterial blood.

03:10 You can also see a pH.

03:13 That's going to tell you the blood's acidity.

03:15 So that's the difference, a little bit about the difference between venous pH and arterial.

03:19 Now, we know that we're going to be able to look at this venous sample and see the pH, the PCO2, which is the partial pressure of carbon dioxide, the PO2, which is the partial pressure of oxygen in this sample.

03:31 We'll see the bicarbonate concentration, and these are all used primarily to assess the body's acid-base balance.

03:37 Now it can't really tell us how well the body's doing with oxygenation, it's just not as accurate as an ABG, but it can still give us some good indications of where the patient is and what's going on.

03:49 Now, because this patient in DKA loses so much fluid volume, right? They're peeing out so much because they've got that high level of glucose in their bloodstream and the body's trying to come back to homeostasis so it's dumping a bunch of fluid into the intravascular space and it's all being peed out.

04:04 This puts the patient at risk for shock.

04:07 Remember, shock is that the body cells are not receiving the level and amount of oxygen that they need.

04:14 Lots of causes for shock, and in DKA it may be just hypovolemia is what caused the patient to be in shock.

04:21 Remember, shock isn't a disease.

04:23 It's kind of a state.

04:25 And we have to figure out, oh, we know this is not good, this is life-threatening.

04:28 But we need to fix what the underlying problem was.

04:32 What caused them to go into shock? If we fix that, then we're going to be able to make some grounds.

04:37 So, for patients who are showing us signs of shock, they may be going into shock or may already be in shock, we're going to give several liters of IV isotonic fluid, right? So the physician or healthcare provider will order specifically what should be given, but usually it's an isotonic fluid and we give it as rapidly as possible, which is why you have that really big bore IV.

04:59 Now, if patients are hypovolemic, they have low volume in their intravascular space, but they're not showing us signs of shock and they don't have any signs of cardiac or kidney compromise, then we're also going to give IV isotonic fluid, but we're going to give it at a rate that's lower.

05:13 We're going to give it about one-half to one liter per hour for the first hours and just watch how they're doing.

05:19 Remember, a key component, anybody receiving IV fluids, particularly if they're rapid, keep an eye on their lungs.

05:27 You want to be alert to listen for any signs of pulmonary edema, which would be an indication that the amount of fluid we're giving the patient is overwhelming them to the point that fluid is building up in the lungs.

05:38 Now if a patient just has the mild hypovolemia, right? It's not an intense low volume or hypovolemia.

05:44 You're going to individualize the fluid replacement.

05:47 So it's going to be based on what you see.

05:49 You'll work with the healthcare provider.