DKA: Signs, Symptoms, and Diagnosis (Nursing)

00:01 So, what does it look like? How does DKA manifest? There are several ways to think about DKA and when we are trying to figure out how bad it is, how severe this DKA is, there are some defining features. And, this first defining feature that we're going to talk about here really kind of concentrates on the acidosis Ps. And if you remember from previous learnings in your nursing program, when we are trying to figure out if our patients are acidotic, we use a blood gas. So, we're going to look at the venous pH and the serum bicarb of our patients to figure out how bad this DKA really is. So, for a severe case of DKA, you're going to see a pH that's less than 7.1 and your bicarb might be less than 5.

00:59 Now, that's pretty low and you know in many cases this is going to cause people to get very excited about the degree of acidosis that this patient is exhibiting. Usually, patients are still walking and talking at this point, but this level of acidosis really means you're getting into trouble. Now, a moderate DKA is anywhere from a pH of 7.1 to 7.2 and that serum bicarb is going to be from 5-9. The more mild version of DKA, maybe we caught it a little bit earlier, is going to be a pH of 7.2 to 7.3 and that bicarb is going to be a little bit higher so it's going to be 10 to less than 15.

01:43 When we talk about clinical presentation, we talk about the 3 Ps and we touched a little bit on this in a previous presentation, but let's go over these again. So, your first P is going to be the polyuria. So, patients that are in DKA have just a copious, huge amount of urine output and this is due to glucose-induced osmotic diuresis.

02:09 So they are just going to be peeing a lot. Polyphagia is your second P, this is usually due to an inability of the body to use glucose so the body feels like it needs more fuel. It really stimulates that hunger reflex and so patients keep eating. The last P is the polydipsia, and this is because your body is having increased urinary water losses because of that first P, remember the polyuria, so they're having increased water loss through the urine and your body responds to that with an increased thirst reflex. So patients are drinking a ton, they're drinking anything they can get their hands on, they're drinking a lot of water or any other liquid that they can find. So, they're drinking a lot, they're eating a lot, and they're urinating a lot. That's the 3 Ps. So, additionally, you might notice if this condition has gone on for a while, you might notice some weight loss and eventually you'll notice anorexia. So anorexia means that the patient doesn't want to eat and in the previous slide I just said they wanted to eat a lot. Right? So, we know that things change over time and if the DKA is going on for a long period of time, it really causes a lot of stomach upset. So eventually, the patients get to the point where they might not want to eat as much and there's some weight loss experienced mostly because the body can't use the fuel that you're taking in and then eventually because patients quit eating because of that stomach upset. Additionally, you might notice nocturia and enuresis. So, getting up in the middle of the night to go to the bathroom often multiple times, because remember they're drinking a lot because they're increasingly thirsty and they have to get up and they're peeing a lot. So, all night overnight. Additionally, they might have bedwetting and especially in children who have been potty trained or for whom bedwetting has never been a problem before, if they all of the sudden start having bedwetting along with a few of these other symptoms, then that is classic for DKA. We talked a little bit about the fact that patients eventually start to have a lot of stomach upset. So, that clinical presentation includes that nausea, the abdominal pain, and then eventually vomiting. There are some respiratory manifestations of DKA so you're going to notice what we call Kussmaul's respirations and what does that look like. So, Kussmaul's respirations are fast, deep breathing. So, the patient is actually hyperventilating a little bit and this is because they have this acidosis. Their body is trying to compensate for that. So patients are going to be breathing very deeply and they're going to be breathing very quickly. Additionally, you'll notice a fruity breath. In some patients especially teenagers who come into the emergency department that might be experiencing their first DKA episode, some people think they've been imbibing alcohol because that breath starts to smell a little bit strange, but it turns out it's the DKA that's causing that and it's that kind of fruity breath that you'll notice. What are some other clinical signs you're going to notice? Eventually, you're going to see signs of dehydration because patients really just cannot keep up with the amount that they are urinating. So, that heart rate is going to go up, you're going to see that tachycardia. You are a probably eventually going to see poor peripheral perfusion so that cap refill is not going to look as good, you might notice some decrease in the skin turgor. If you remember, skin turgor means that when you pinch that skin, you want it to go right back to where it started from.

06:24 If it stays tented, then you are dehydrated. You might notice tachy mucous membranes. That spit just gets really extra thick and that mouth looks dry, maybe their lips look a little bit cracked, and if you have a younger child who is crying you're not going to see any tears. It is also really important to note that in patients with DKA who are becoming dehydrated, they are still going to have a lot of urine output. And I know this seems strange because one of the biggest signs of dehydration normally is that urine output will drop off. We just don't pee as much when we're dehydrated. But in DKA since that blood sugar is so high and we have osmotic diuresis happening, even though the patient is dehydrated they're still going to have a lot of urine output. So, don't use that as your sign of dehydration.

07:27 There is some more laboratory abnormalities that you're going to be looking for in DKA. The clear one is the blood glucose. So, blood glucose is generally going to be greater than 200. You're looking for that acidosis. We talked a little bit about that earlier when we were talking about severity. So that venous pH is going to be less than 7.3 and that bicarb less than 15. That ketosis. So your serum beta- hydroxybutyrate is going to be greater than 3 millimoles/liter. So, anything less than that and you're probably doing okay but when you get greater than 3 your body is going into that ketosis state. Additionally, you might not be able to get a serum beta-hydroxybutyrate and so if you have a urine dipstick, you can see if you just have positive urine ketones. And then one of the other things that you look at is the anion gap. So, there's going to be an elevation in the anion gap. A normal gap is between 12 and 14. So, if it's higher than that, then you have to suspect DKA.