Diabetic Ketoacidosis (DKA): Nursing Assessment and Diagnostic Findings

00:00 So, let's now talk about what you're going to do when you put your hands on the patients.

00:05 What are you going to do as a nurse who receives this patient, they've come in with these signs and symptoms, what do you do? Well, the same thing you do with any other client, assess their vital signs.

00:16 That's the best place to start.

00:18 Look at their cardiorespiratory status.

00:19 How are they breathing? Do they see that they're in distress? And also their mental status.

00:25 Are they clear? Are they oriented? Or do they seem like they're getting a little confused? Are they slow to answer your questions? Those are all key cues you want to be looking for as you're putting these cues together to analyze and figure out what is going on with this patient.

00:41 Now with any patient, but particularly with someone you suspect DKA, we need to take a look at their volume status.

00:47 Why? Because we know that someone in DKA is going to be peeing out a lot, they're going to be putting out a lot of extra fluid that they normally wouldn't, and that would likely impact their vital signs.

00:59 That will cause their blood pressure to be lower than their normal.

01:03 Remember, blood pressure is all about that client's normal, not the textbook normal.

01:08 So it's helpful if they know what their blood pressure normally runs.

01:12 So with fluid volume status, we're going to look at their vital signs.

01:15 We're going to look at skin turgor.

01:17 Now we always list that, but keep in mind, skin turgor is a really late response.

01:21 When we say skin turgor, you look for tenting, right? You pinch the skin and watch it and see if it just stays up.

01:28 That's called tenting.

01:29 That's a very, very late sign of dehydration.

01:32 If you see that, the tenting, wow, we've really missed some other signs.

01:37 So just keep that in mind.

01:38 Yes, it is appropriate to do it, but it's a very late sign.

01:42 It's helpful that we can catch clients before they get to that state.

01:46 Also look at their oral mucosa and their urine output.

01:49 All of these things, their vital signs, skin turgor, how their oral mucosa looks, and their urine output, are going to be cues that are going to help you identify if this patient is in DKA.

02:00 Now, if you're an output, patients are not going to come in and tell you, yeah, I believe I've put out X number of milliliters per day.

02:07 They don't really know that, so you could ask them different questions.

02:10 Put it in a normal people's language, like, have you noticed that you're going to the bathroom a lot more than you normally do? Do you notice that you're thirstier than you normally are? Are you drinking more? Those are all key questions that you can ask them that would make sense to a normal person.

02:26 Now that you've done your assessment, you can expect at the same time, lab work is going to be ordered.

02:31 So you're going to get several studies.

02:33 So let's walk through them together of the types of lab work that will be done to evaluate this client for if they have DKA and where they are on that spectrum.

02:42 So first, we're going to want to know what their blood sugar is, right? We're going to get a serum glucose.

02:47 And a lot of these labs are going to be on different panels, but I'm just wanting to know what are the specific things we're looking for on these panels.

02:54 So we're going to get a serum glucose to know what their blood sugar is.

02:57 You're going to do a urine analysis and looking for urine ketones.

03:01 Now we might discover other things on that urine analysis, but what we're really looking for are ketones.

03:06 Because when someone's in ketoacidosis, they're going to be spilling out ketones into their urine.

03:13 So that's another cue we look for to see if they're in DKA.

03:16 Of course, we're going to look at serum electrolytes, which we do on most clients when they come into an ER.

03:21 But we're doing that in relation to DKA because if their electrolytes are off, that might help us explain their neuro status.

03:27 But we also know that the electrolytes are off in DKA because the client has put out so much fluid volume.

03:34 Now BUN and creatinine are going to give us a clue on how the kidneys are doing.

03:39 It'll also let us know about how dehydrated they are.

03:43 So plasma osmolality is another indication of how dehydrated your patient is.

03:50 Now we can look at some mixed venous blood gases so we can get a pH.

03:54 Remember, DKA is diabetic ketoacidosis, so we're going to want to take a look at what the pH is of the blood by doing ECG, see how it's going on cardiac wise.

04:04 And we may also draw serum ketones, if that's available.

04:08 It may be measured initially or if the urine ketones are present, they may order that.

04:13 And here's an idea of some examples of the key lab that could be ordered for this client that we suspect DKA.

04:19 Now we talked about what you're going to look at lab, we talked about your vital signs.

04:23 Now let's look at some other studies.

04:27 So let's look at what you would expect to find if a client is in DKA.

04:32 First of all, they're going to have that hyperglycemia we've been talking about, that high blood sugar or glucose.

04:38 They're also going to have a test that we haven't talked about yet.

04:41 It's an elevated anion gap.

04:43 Now this indicates metabolic acidosis.

04:46 And finally, ketonemia, meaning they have ketones in their bloodstream.

04:51 Now can you pause for a minute and remember why do they have ketones in their bloodstream? Okay, welcome back.

05:02 Hopefully you were able to remember and if you're not, don't beat up on yourself.

05:05 They're going to have ketones in their blood because they don't have enough insulin to handle the glucose in the bloodstream to get that energy source into the cell.

05:14 And when the body can't use glucose, it turns to fat.

05:18 And a byproduct of breaking down that fat for energy are ketones.

05:22 And that's why they'll have ketones in their bloodstream.

05:25 So DKA, really high blood sugar, hyperglycemia, they're going to have an elevated anion gap, which indicates metabolic acidosis that indicates the pH of their blood and ketonemia, ketones in their bloodstream.

05:39 Now let's talk about that high blood glucose, how high it is.

05:42 The serum glucose is usually greater than 200 and less than 800.

05:46 Okay, that's a pretty big range, but those are scary numbers.

05:50 It's also really helpful if you know what the patient's regular or consistent normal blood sugar is that can also help you gauge.

05:57 Now in some instances, like insulin was given before they came to the emergency department or the patient is on SGLT2 inhibitors, this might be impacted.

06:06 In fact, their glucose might be normal or only mildly elevated.

06:11 So you have someone come in having all the signs and symptoms of DKA, but their blood sugar doesn't seem to be that elevated.

06:18 Is it DKA? That's why it's really important that you ask what medications did they take or receive before they came to see you? And are they on an SGLT2 inhibitor? That medication we'll talk about a little bit more, but it causes you to dump out a lot of glucose in your urine.

06:36 So you can be euglycemic.

06:38 You can have a relatively normal blood sugar, but still be in DKA.

06:44 So that's what you're looking for when we're looking at the glucose.

06:47 And you know that you can be on the lookout for a relatively normal blood sugar and the patient could still be in DKA.

06:54 Now volume contraction is the other thing we're going to assess with the lab work that we discussed.

06:58 And you're also going to be on the lookout for potassium deficits.

07:02 These might be extremely severe.

07:05 We know if the patient is too low in potassium, we can have all kinds of issue with their cardiovascular system.

07:09 So you want to watch that closely.

07:12 Now if we get additional testing, it's going to be based on what's going on with this particular patient, what's going on in their clinical circumstances, what happened before.

07:21 So there's all types of cultures we may consider, blood or urine.

07:25 Remember that might be for infection.

07:27 We might look at a lipase level, what's going on with the pancreas, and also get a chest x-ray.

07:33 So that's what you should be prepared for, the healthcare provider, to order for this client in order to get a good clinical picture about what is going on.