Management of DKA: Monitoring (Nursing)

00:01 Now, we're going to talk a little bit about the management of DKA once these patients come in to us. Pretty immediately, you're going to start some initial laboratory monitoring. You're going to be getting a point of care blood glucose and a point of care beta-hydroxybutyrate or urine ketones. And what does point of care mean? It means that we actually have a way to measure this without having to send the samples down all the way to the lab. So, in your unit, you'll have a device where you can actually check that glucose right away, you can check the beta- hydroxybutyrate at the keytones right away. Eventually, you're going to start sending samples down to the lab, but initially we want to get these results as quickly as we possibly can. While you're doing this, we are going to send some additional things to the lab. So, we'll send the blood glucose to the lab and that will give us a good reference point. We're also going to send electrolytes and we're going to include the serum bicarbonate in that. We're going to send a BUN and a creatinine. So, the blood urea nitrogen and a creatinine level and this is going to give us an indication of how dehydrated our patient might be and is going to help us determine how much fluid we need to give our patient as we progress forward.

01:22 You're going to send off that pH level. We talked about we need that pH level to kind of figure out how bad this DKA is so we're going to send a venous blood gas and we're going to be checking that pH and the carbon dioxide. We're also going to be looking at the calcium, phosphorus, and magnesium. So, while you're checking your point of care blood glucose and your ketones, you're going to also be sending these additional laboratory specimens down so that we can start figuring out how bad the DKA is and where we need to go from here. So, the other thing that we might be considering is if a serum beta-hydroxybutyrate isn't available, then we can use the urine ketones as a substitute. We might want to send a blood lactate level if the patient appears very ill when they come in and if this is an established patient we might send a hemoglobin A1c and that can kind of give us an idea if this is a patient that is well controlled or not well controlled in their diabetes kind of on a daily basis. So, if this is the first time the patient is presenting, then we are going to send some diabetes-associated antibodies. These will include insulin auto antibodies, islet cell antibodies, zinc transporter antibodies. You don't need to remember those, but just know that when we're having an initial diagnosis and pediatric patients often show up in DKA for their initial diagnosis, we need to send these antibodies off to determine whether we have a type 1 or a type 2 diabetes.

03:14 Additionally, we'll send off the C-peptide levels and that is another way to figure out if we have a type 1 or a type 2. So, this helps us figure out if there's any endogenous insulin production, meaning is the pancreas actually producing any of its own insulin and then again if the pancreas is producing some of its own insulin then we probably have type 2 diabetes and if there's no insulin being produced, then it's more likely a type 1. So we are going to be doing ongoing laboratory monitoring while our patient is in DKA. So, really requires close monitoring of these laboratory values. We are daily going to be looking at those dehydration labs so the BUN and creatinine. And then every hour we're checking the blood glucose.

04:12 So, every hour, every 2 hours for the initial DKA treatment we're going to be checking that beta-hydroxybutyrate. So again, that's the blood ketone level and electrolytes. Because we talked before that those electrolytes are kind of being wonky, they're going up, they're going down so we need to keep track of what those are doing. So, we're going to check those every 2 hours usually for at least 2 checks and then we might space that out to every 4 hours. Every 4 hours we're going to be checking that venous blood gas and we're going to check that at least twice and that's going to give us that indication of how bad the DKA is. And then we're also going to be checking that magnesium, calcium, and phosphorus. So, as you can see, this is very very time intensive. You are sending multiple laboratory specimens off and you are doing that at a really frequent rate. This is an example just to kind of give you a feel for what you might be doing for a DKA patient. This is an example laboratory schedule for a DKA patient for those first hours. Often when you are taking care of a DKA patient, your hospital may have something like this to help you keep track of the laboratory values that you're supposed to be sending and how often you need to send them.