Diabetic Ketoacidosis (DKA): Pathophysiology and Symptoms (Nursing)

00:00 Hi, I'm Dr. Rhonda Laws, and in this series, I want to take a look at diabetic ketoacidosis.

00:07 Now, sometimes nursing videos have really boring titles.

00:11 So this one, I wanted to have just a little bit of fun with it.

00:14 So think of this as how your cells starve in a sea of glucose.

00:19 Now, DKA is a life-threatening emergency, but before we dive into that and what you need to know in order to care for someone that has DKA, I want to talk about the pathophysiology of how they got there.

00:32 So diabetic ketoacidosis develops through this incredible cascade of metabolic events.

00:38 Now don't worry, we're not going to stop there.

00:40 I'm going to explain it to you what that means.

00:43 Now these metabolic events happen when the insulin is not there or is just severely lacking in a person's body.

00:51 Now here's how this dangerous condition unfolds.

00:54 See, the normal process, we're going to start with that.

00:57 So in a normal process, think about the last meal that you ate.

01:01 So were there carbohydrates in it? Probably.

01:04 And when you eat those carbohydrates, they break down into glucose that then entered your bloodstream.

01:09 Now, when the insulin that's stimulated by the glucose that's in your bloodstream is produced by the pancreas, it acts like this key.

01:17 So think about insulin as a key that unlocks the cells so that glucose can get from in the bloodstream into the cell where it can be used for energy.

01:27 DKA is what develops through this cascade of metabolic events.

01:31 Now this happens when there isn't enough insulin in the body, it's severely lacking, and you don't have enough insulin to help get that glucose out of the bloodstream and into the cell.

01:42 Now this is what's really dangerous.

01:44 We know what the normal process is.

01:46 You eat carbohydrates, then they break down into glucose in your bloodstream, and then the insulin that's produced by your pancreas is what acts like a key that unlocks your cells so glucose can enter the cells and be used for energy.

02:00 Remember, glucose that leaves the bloodstream and enters the cells won't show up in a glucose level that you get from the blood, like for a finger stick blood sugar.

02:10 Now when insulin is missing, this is when we start to get into the problems with DKA.

02:15 Because if you don't have sufficient insulin, either you don't have enough or more likely the person hasn't been able to get their insulin medication, this is when you head into DKA.

02:27 The glucose is going to build up in the bloodstream, but it can't get into the cells.

02:31 That's why we titled this, How Your Cells Essentially Starve for Energy, despite them being surrounded by a sea of glucose in their bloodstream.

02:40 See the body believes it's in a starvation state, and it has to find an alternative fuel.

02:46 Glucose is the largest factor for fuel delivery in your body, but when you don't have the insulin to use that glucose, that's why the body believes it's being in a starvation state.

02:57 So this is a desperate situation for your body.

03:00 When cells can't access the glucose for energy, the body turns to plan B.

03:06 Now what do you think that is? Let's break it down.

03:10 The liver begins breaking down fat stores into fatty acids.

03:14 When it can't get to glucose, it's going to turn to fat.

03:17 Now these fatty acids are converted to ketone bodies.

03:21 That's the K in DKA.

03:24 So the fatty acids are converted to ketone bodies, acetoacetate, beta-hydroxybutyrate, and acetone.

03:31 That's the K in DKA.

03:34 Now these ketones can provide energy without insulin, but so the body produces more and more.

03:40 Okay, so normally the body would use glucose.

03:42 If they don't have enough insulin or they don't have any insulin, the body will switch from using glucose for energy to using fat for energy.

03:50 We talked about how that happens.

03:52 The liver begins breaking down those fat stores.

03:55 Those fatty acids are converted to ketone bodies, and the ketone bodies are what provides energy.

04:02 Now we talked about that cascade.

04:04 Let's talk about where it gets really dangerous, because this process can quickly become dangerous.

04:10 Now you might be asking, what about the keto diet? I know people that do this all the time.

04:14 That's different.

04:16 We're talking about a situation where the client doesn't have insulin or has barely enough insulin.

04:21 So that's different than what clients do when they try a keto diet who are not diabetic.

04:26 See ketones are acidic, and as they accumulate, they lower the blood pH.

04:32 Normal blood pH is 7.35 to 7.45, but if it's a diabetic client who can't get the glucose into their cells for energy, they turn to fat stores.

04:42 They end up having these ketones build up that will lower the blood pH because ketones are acidic.

04:48 You'll also end up with this really high blood glucose, hyperglycemia.

04:53 This is what's going to cause some shifting of fluids.

04:57 When the blood glucose is really high, hyperglycemia, it's going to cause osmotic diuresis.

05:03 They're going to end up peeing out a lot.

05:06 Why is that? Well, all of a sudden this bloodstream is highly concentrated because you have these super high levels of blood glucose in there.

05:14 So the body starts trying to move fluid to try and get back to homeostasis.

05:18 It dumps more and more fluid into the intravascular space, and that's why they end up peeing out and peeing a lot.

05:25 They are peeing so much that this leads to severe dehydration and some electrolyte imbalances.

05:31 Now we've got more to talk about, but start thinking about this.

05:35 If you even know the symptoms of DKA, this should begin to make sense.

05:39 If you're brand new to DKA, don't worry.

05:41 We're going to help you be able to remember all the signs and symptoms of DKA.

05:46 But before we go on, make sure you know, why are ketones acidic? Well, you don't really need to know that.

05:53 You just need to know that they are.

05:56 But what happens when ketones accumulate? What happens to your pH? Beautiful, he said, it becomes more acidic, or it gets lower.

06:05 Now high blood glucose, what does that do to my fluid volume status? What's it going to do to my output of fluids? It's going to make you pee a lot because the body's trying to get back to homeostasis.

06:17 All right, that's all that leads to really severe dehydration and electrolyte imbalances.

06:24 Now when you have the dehydration, imagine what happens to your vital signs.

06:29 When you have less volume on board, right, less volume in your intravascular space, you could see a change in your blood pressure.

06:37 Do you think it will be higher or lower? Well, with less volume in your intravascular space, your blood pressure, if you see a change, will likely be lower.

06:47 Now when you have all this acidic things going on in your blood, right, you've got this buildup of ketones, and now your blood pH is becoming more and more acidic.

06:57 Your body tries to compensate.

06:59 If you haven't studied DBGs yet, it's okay, but think about what we call Kussmaul's breathing, right? They're breathing really fast.

07:07 Do you know why they are? Because they're trying to blow off CO2.

07:11 See, the lungs control the level of CO2 in our bodies.

07:15 So if we got something going on with a metabolic issue, because DKA is a cause of metabolic acidosis, the opposite system has to try and compensate.

07:25 So that would be the lungs, and that's why somebody who's in DKA, if you look closely at their respiratory rate, if their body's compensating, it's going to be fast and deep, and even their breath might smell a little different.

07:39 Might be this really unusual, they call it fruity breath, but once you smell it, you will never forget it.

07:46 And that's coming from the client's acetone when they're in DKA.

07:50 So we've already given you some key signs.

07:53 Pause for just a minute.

07:55 See if you can create a patient in your head that would exhibit signs that you would expect to see for somebody in DKA, just based on what we've talked about.

08:05 Pause the video, try and do that, and then come back and join us.

08:09 Okay, how'd you do? Well, I know not everybody probably did that, and that's okay.

08:16 I get it.

08:17 You do what you need to do for where you are in nursing school.

08:20 But what I want to encourage you with is that this is like you and I hanging out and studying together.

08:26 If you'll try and do these exercises, it will help you study as we go.

08:30 It will also increase your ability to retain this information and to recall it when you need it.

08:36 Most important with patient care, but the other thing that's really important is on your exam scores.

08:41 So stick with us, try and do that as much as you can.

08:45 Now we've got the initial things about what happened with DKA, but as it progresses, let's talk about some of the things your patient might experience.

08:52 They're going to be extremely thirsty and they're going to the bathroom a lot.

08:58 Now why is that? If you got, it's because their glucose level is very high in their bloodstream.

09:03 Bing, bing, bing.

09:05 You got the right answer.

09:06 Perfect.

09:07 They're going to feel tired and kind of confused.

09:10 Why? Well, DKA causes them to be really dehydrated.

09:15 That doesn't help with your energy.

09:16 And your electrolytes are going to be off, which also doesn't help with your ability to think clearly.

09:23 They may also be nauseated and vomiting and have abdominal pain.

09:26 That's going to come from that severe dehydration.

09:29 We talked about they could be breathing really, really fast.

09:31 They might have that fruity smelling breath and without treatment, coma and death can occur.

09:37 Now take a minute.

09:39 Think about the patient that you tried to create in your head.

09:42 How many of those symptoms did you get? Did you picture them as thirsty and that they're having to go to the bathroom a lot? Did you picture them as being tired and maybe not completely oriented, a little confused? Did you catch the nausea, vomiting and abdominal pain? That would have been a hard one.

09:57 What about them breathing fast with the fruity, smelly breath? Hopefully you got that one.

10:03 Now the key point, without treatment, coma and death can occur.

10:08 So before you go on, make sure you finish that picture in your brain.

10:13 Make sure you've hit all of these signs and symptoms of DKA as it progresses, and you're going to be able to recognize this in real life patients and when you see it in questions on your exams.