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Long-term Management and Resolution of DKA (Nursing)

by Amy Howells, PhD, CPNP-AC/PC

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    00:01 It's really important to note that as long as your patient still meets the criteria for being in DKA, meaning they still have acidosis and ketosis, we continue that insulin drip. We are also continuing fluid therapy through that two-bag system and the patient is not having anything by mouth. We don't want them to be eating or drinking anything else because we're keeping such close control over both their glucose levels and their fluid.

    00:33 Additionally, we're going to be sending labs per guidelines. Those will start to space out as that insulin therapy starts working and the blood sugar starts to get better. Your hospital will likely have an algorithm for how often you're going to be sending those labs, but know that at the beginning it's going to be pretty frequent.

    00:54 We're going to be doing strict I's and O's. These patients are very severely dehydrated. We need to stay on top of those I's and O's because as we mentioned in the beginning of the presentation even though they're severely dehydrated, they are having a ton of urine output. So, we need to make sure that we are getting enough fluid in to really account for that urine output that they're having.

    01:19 And that urine output should start to slow down as those glucose levels come down to a more normal level. And then don't forget your neuro checks. We're checking neuro checks every hour. Pediatric patients in particular are at higher risk for cerebral edema and remember cerebral edema can cause death in these patients so you do not want to miss any changes in your patient's neurological status. So, how do we know that the DKA is done? How do we know that we're not in DKA anymore? It is the resolution of the acidosis and ketosis. It actually has nothing to do with the levels of the blood glucose and I know that this can be a little bit confusing because when we think about diabetes we all think about blood sugar. But for DKA, we have to make sure that the acidosis is resolved.

    02:18 So we know that the DKA has been resolved when that beta-hydroxybutyrate is less than 1 or you have no ketones in your urine. So if you have to check the urine dipstick and there's no ketones in your urine and the metabolic acidosis has resolved. So, if your pH level is normal now and your CO2 level, your carbon dioxide level in your blood is 20 or greater, we are not acidotic anymore and that means the DKA has resolved. Interestingly, your blood sugar might still be a little bit on the high side and if your beta-hydroxybutyrate is less than 1 and you don't have acidosis anymore, your DKA is resolved regardless of what the blood sugar is. So what happens when the DKA is resolved when we're done with the DKA? We are now going to transition our patient into their more normal management of their diabetes if they already had diabetes. We're going to be teaching the patient to manage diabetes if this was their initial presentation.

    03:29 This is going to include a carbohydrate-controlled diet. So can't go crazy on the carbohydrates. You have to pay attention to how many they're taking in so that they can account for that with insulin. They're going to start subcutaneous insulin.

    03:43 So we have stopped the continuous insulin now because we're not in DKA anymore. So we'll start a subcutaneous insulin regimen. And they are going to be followed up by the healthcare team. They will be followed up by endocrinology for management of diabetes. Remember this is a lifelong issue so it doesn't end with the DKA.


    About the Lecture

    The lecture Long-term Management and Resolution of DKA (Nursing) by Amy Howells, PhD, CPNP-AC/PC is from the course Endocrine Disorders – Pediatric Nursing.


    Included Quiz Questions

    1. Send labs per guidelines.
    2. Strict intake and output monitoring.
    3. Neurological checks every hour.
    4. Neurological checks every 3 hours.
    5. Pain assessment every hour.
    1. Carb controlled diet
    2. Subcutaneous insulin
    3. Endocrinology consult
    4. IV insulin
    5. Low sodium diet
    1. BHOB < 1 mmol/L and metabolic acidosis is resolved.
    2. BHOB < 2 mmol/L and metabolic acidosis is resolved.
    3. BHOB < 3 mmol/L and metabolic acidosis is resolved.
    4. BHOB < 4 mmol/L and metabolic acidosis is resolved.

    Author of lecture Long-term Management and Resolution of DKA (Nursing)

     Amy Howells, PhD, CPNP-AC/PC

    Amy Howells, PhD, CPNP-AC/PC


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