FAKULTAS KEPERAWATAN UNIVERSITAS JEMBER

DOKUMENTASI ASUHAN KEPERAWATAN

Nama Mahasiswa : Durrotul Qomariyah

NIM : 202311101150
Tempat Pengkajian : India

PENGKAJIAN KEPERAWATAN

I. Identitas Klien
Nama : Tn. X No. RM :-
Umur : 30 tahun Pekerjaan :-
Jenis Kelamin : Laki-laki Status Perkawinan :-
Agama :- Tanggal MRS : 25 Juli 2020
Pendidikan :- Tanggal Pengkajian : 13/04/21 Jam : 07;00
Alamat : india Sumber Informasi : Artikel Studi Kasus

II. Riwayat Kesehatan

1. Diagnosis Medis:
Pneumonia COVID-19
2. Keluhan Utama:
Pasien datang dengan keluhan demam lebih dari 6 hari dengan lemah dan sesak napas
progresif.
3. Riwayat penyakit sekarang:
Pasien mengalami sesak napas progresif dan demam yang tidak terselesaikan. Pasien
mengatakan lemas sejak beberapa hari yang lalu
4. Riwayat kesehatan terdahulu:
a. Penyakit yang pernah dialami:
Pasien mengatakan tidak memiliki riwayat DM.
b. Alergi (obat, makanan, plester, dll): pasien mengatakan tidak memiliki alergi terhadap
obat-obatan dan makanan
c. Imunisasi: pasien mengatakan tidak ingat mengenai imunisasi apa yang dia dapatkan
d. Kebiasaan/pola hidup/life style: pasien mengatakan memiliki kebiasaan kopi dan rokok
e. Obat-obat yang digunakan: pasien mengatakan tidak mengkonsumsi obat

5. Riwayat penyakit keluarga:

Pasien mengatakan keluarganya tidak ada yang memiliki riwayat DM.
Genogram:

FKEP UNEJ 2021 1

 Tidak terkaji

III. Pengkajian Keperawatan

1. Persepsi kesehatan & pemeliharaan kesehatan
2. Pola nutrisi/ metabolik (ABCD) (saat sebelum sakit dan saat di rumah sakit)
Antropometry
BB = 80 kg
Tinggi = 160 cm
IMT/ BMI = BB/TB2= 80/(1,6)2 = 31.2
Interpretasi : Saat ini, IMT klien Overweight
Biomedical sign :
- Glukosa darah plasma : 555 mg / dL
- HbA1c : 13,0%
- Urea Darah : 130 mg/dl
- Kreatinin serum : 5,3 mEq/L
- Analisis urin : + keton
- Analisis gas darah arteri (AGD) menunjukkan asidosis metabolic (pH-7.07 dan HCO3-
6.1mmol / L).
Clinical Sign : -
Diet Pattern (intake makanan dan cairan):
Pola makan Sebelum MRS Saat MRS
Frekuensi makan 3 kali sehari 3 kali/hari
Porsi makan 1 porsi 3 sendok makan
Varian makanan Nasi putih dan lauk pauk Nasi putih dan lauk pauk
Nafsu makan Normal menurun
Minum 3-4 kali/hari 3-4 kali/hari
Jumlah minuman 3-4 gelas/hari 3-4 gelas/hari

3. Pola eliminasi: (saat sebelum sakit dan saat di rumah sakit)

BAK Sebelum MRS Saat MRS
Frekuensi 4-6x/sehari 4-6x/sehari
Jumlah -x/ -
Warna - warna kuning
Bau - -
Karakter - Encer kuning
BJ - -
Alat bantu - Terpasang kateter
Kemandirian Mandiri dibantu
(mandiri/dibantu)

FKEP UNEJ 2021 2

 Lainnya
Interpretasi:
Pasien mengalami gangguan pada pola eliminasi urine
BAB Sebelum sakit Saat sakit
Frekuensi Sehari 1 kali 2 kali sehari
Jumlah - -
Warna Kuning kecoklatan Kuning kecoklatan
Bau
Karakter lembut -
Alat bantu - -
Kemandirian mandiri dibantu
(mandiri/dibantu)
Lainnya - -
Interpretasi:
Klien tidak mengalami gangguan pada eliminasi alvi namun membutuhkan bantuan karena
terpasang kateter

4. Pola aktivitas & latihan (saat sebelum sakit dan saat di rumah sakit)
Klien dapat melakukan aktivitas dan latihan seperti biasa
Aktivitas harian (Activity Daily Living)
Kemampuan perawatan diri 0 1 2 3 4
Makan / minum √
Toileting √
Berpakaian √
Mobilitas di tempat tidur √
Berpindah √
Ambulasi / ROM √
Ket: 0: tergantung total, 1: dibantu petugas dan alat, 2: dibantu petugas, 3: dibantu alat, 4:
mandiri
Status Skor ADL : 15
Status Oksigenasi : status oksigen mengalami gangguan
Fungsi kardiovaskuler : -
Terapi oksigen : klien terpasang oksigen

5. Pola tidur & istirahat (saat sebelum sakit dan saat di rumah sakit)
Istirahat dan Tidur Sebelum MRS Saat MRS
Durasi 5-6 jam 5-6 jam
Gangguan tidur - Pasien merasa gelisah
Keadaan bangun Pasien merasa tidak segar, lelah Pasien merasa lelah dan lemas
tidur dan lemas
Lain-lain
Interpretasi : pola tidur dan istirahat mengalami gangguan

6. Pola kognitif & perceptual

Fungsi Kognitif dan Memori :

FKEP UNEJ 2021 3

 Pasien dapat berkomunikasi dengan baik saat dilakukan proses pengkajian, berbicara dan
memahami kata-kata dengan baik, pasien juka memiliki ingatan yang baik.
Fungsi dan keadaan indera :
1) Penglihatan: fungsi penglihatan pasien masih baik dan jelas saat melihat
2) Penciuman: pasien tidak dapat mencium aroma disekitarnya
3) Perasa: fungsi perasa pasien menurun
4) Pendengaran: fungsi pendengaran pasien masih baik, dapat menddengar dengan jelas
5) Peraba: fungsi peraba pasien masih baik, ditunjukkan tidak ada keluhan terkait perabannya
dan masih bisa merasakan sensasi sentuhan dengan baik
Interpretasi : Pola kognitif dan perceptual klien baik

7. Pola persepsi diri

Gambaran diri : klien mengatakan dirinya sebagai seorang pria
Ideal diri : klien mengatakan dia merasa ideal saat dirinya bisa melakukan kewajiban dan
aktivitasnya dengan baik
Harga diri : klien mengatan sangat menjunjung harga diri
Peran Diri : klien mengatakan peran diri sebagai seorang tulangpunggung keluarga
Identitas Diri : klien mengatakan dirinya sebagai seorang orang anak
Interpretasi : pola persepsi pasien baik

8. Pola seksualitas & reproduksi

Tidak terkaji

9. Pola peran & hubungan

Klien mengatakan hubungan dengan keluarga terjalin dengan baik dan selalu terjalin
interaksi
Interpretasi : Pola peran & hubungan pasien baik

10. Pola manajemen koping-stress

Klien mengatakan jika terjadi masalah klien akan menceritakan pada orang terdekat dan
meminta pendapat dan saran
Interpretasi : Pola manajemen koping-stress klien baik

11. Sistem nilai & keyakinan

Klien mengatakan jika klien rajin beribadah, klien juga yakin jika sakit dan sehat adalah
ketentuan dari Allah
Interpretasi : Sistem nilai & keyakinan klien baik

IV. Pemeriksaan Fisik

Keadaan umum:
Kesadaran komposmentis, GCS : (E4V5M6)
Tanda vital:
- TD : 152/84 mmHg

FKEP UNEJ 2021 4

 - Nadi : 122x/menit
- RR : 24 xmenit
- Suhu : 37,7 C
- SpO2 : 90%
Interpretasi :

Pengkajian Fisik Head to toe (Inspeksi, Palpasi, Perkusi, Auskultasi)

1. Kepala
Inspeksi : bentuk kepala normal, rambut hitam, lebat, kulit kepala bersih, bentuk wajah oval.
Palpasi : tidak ada nyeri tekan dan tidak ada benjolan

2. Mata
Inspeksi : Sklera mata tampak ikterik, konjungtiva normal, tidak ada bintil dibagian kelopak
mata, alis mata tidak simetris, pupil isokor
Palpasi : tidak ada nyeri tekan, tidak ada benjolan diarea mata, dan tidak ada lesi

3. Telinga
Inspeksi : telinga simetris kiri dan kanan, tidak ada lesi dan luka
Palpasi : tidak ada nyeri tekan dan tidak ada benjolan

4. Hidung
Inpeksi : tidak terlihat luka, lesi dan benjolan, tidak ada odem
Palpasi : tidak ada nyeri tekan dan tidak terdapat benjolan

5. Mulut
Inspeksi : mukosa bibir terlihat lembab, gigi terdapat karang dan kekuningan

6. Leher
Inspeksi: bentuk leher simetris, tidak ada benjolan
Palpasi: tidak ada nyeri tekan

7. Dada
Jantung
Inspeksi : Bentuk dada simetris kanan dan kiri, tidak terdapat odem,tidak terdapat
peradangan.
Palpasi : tidak ada nyeri tekan
Perkusi : pekak
Auskultasi: Terdapat suara S1 dan S2 dan tidak ada suara tambahan

Paru
Inspeksi: bentuk dada normal, dada simetris, gerakan napas normal
Palpasi : tidak ada benjolan, tidak terdapat nyeri tekan
Perkusi : pekak
Auskultasi: terdapat suara tambahan rhonki

FKEP UNEJ 2021 5

 Payudara dan Ketiak
Inspeksi: tidak ada pembengkakan pada ketiak dan klavikula.
Palpasi : tidak terdapat nyeri tekan

8. Abdomen
Inspeks : Bentuk abdomen simetris
Auskultasi : Bising usus 7x/menit
Palpasi : tidak terdapat benjolan
Perkusi : timpani

9. Genetalia dan Anus

Terpasang kateter urine

10. Ekstremitas
Tidak terkaji
11. Kulit dan kuku
Kulit
Inspeksi : sawo matang, kebersihan kulit terjaga
Palpasi : Turgor kulit lembab
Kuku
Inspeksi : kebersihan kuku terjaga, warna kuku merah muda
Palpasi : CRT <2 detik

12. Keadaan lokal

Pasien nampak lelah dan lemas

VI. Pemeriksaan Penunjang & Laboratorium :-

- Glukosa darah plasma : 555 mg / dL
- HbA1c : 13,0%
- Urea Darah : 130 mg/dl
- Kreatinin serum : 5,3 mEq/L
- Analisis urin : + keton
- Analisis gas darah arteri (AGD) menunjukkan asidosis metabolic (pH-7.07 dan HCO3-
6.1mmol / L).
- uji RT-PCR : positif

Pemeriksaan Radiologi:
- X-Ray : kekeruhan ruang udara di bidang paru bilateral

FKEP UNEJ 2021 6

- HRCT menunjukkan kekeruhan ground-glass di lobus atas bilateral dan kekeruhan kaca tanah
bersama dengan konsolidasi awal masuk lobus bawah bilateral dan segmen lingular dari lobus
kiri atas

Gambar 1. Gambar aksial (A) dan koronal (B) dada HRCT (pasien 1) menunjukkan
kekeruhan kaca dasar dan perubahan konsolidasi awal pada bidang paru-paru bawah bilateral.

Bondowoso, 13 April 2021

Pengambil Data,

( Durrotul Qomariyah)
NIM. 202311101150

FKEP UNEJ 2021 7

 ANALISIS DATA

No Data Etiologi Problem

1 DO : Proses Penyakit Bersihan Jalan
- Pasien mengalami
Napas Tidak
sesak napas progresif
Gangguan jalan Efektif
dan demam yang tidak napas
terselesaikan
- X-Ray : kekeruhan SpO2 meningkat
ruang udara di bidang
paru bilateral Pernapasan
meningkat
- Covid-19 : Positif
- SpO2 : 90%
Bersihan Jalan
napas tidak efektif
2 DO : Proses Penyakit Gangguan
- Pasien mengalami
Pertukaran Gas
sesak napas progresif
Gangguan jalan
dan demam yang tidak napas
terselesaikan
- Lemah SpO2 meningkat
- Batuk non produktif
- X-Ray : kekeruhan Pernapasan
meningkat
ruang udara di bidang
paru bilateral
Gangguan
- Covid-19 : Positif pertukaran Gas
- SpO2 : 90%

3 DO : Proses Penyakit Pola Napas Tidak

- RR : 24x/menit
Efektif
- Nadi : 112x/menit
Gangguan jalan
- SpO2 : 90% napas
- Lelah
- Sesak napas Pernapasan
meningkat
- Covid19 : Positif

FKEP UNEJ 2021 8

 Pola napas tidak
efektif

4 DO : Proses Penyakit Hipertermia

- TD : 152/84 mmHg
- Nadi : 122x/menit
Suhu diatas
- RR : 24 xmenit normal
- Suhu : 37,7 C
- SpO2 : 90% Tubuh terasa
hangat

DS :
Dehidrasi
- Klien mengatakan demam
lebih dari 6 hari
Hipertermia

5 DO : Retensi Insulin Ketidakstabilan

Kadar Glukosa
- Glukosa darah 555 mg/dL
Kadar glukosa
- Urin : + Keton
meningkat
- Polydipsia
- Polyuria Hiperglikemia
- Nokturia

Ketidakstabilan
kadar glukosa
darah

FKEP UNEJ 2021 9

 DIAGNOSIS KEPERAWATAN
(Berdasarkan Prioritas)

1. Bersihan Jalan Napas Tidak Efektif b.d Obstruktif Jalan Napas d.d kekeruhan ruang udara di
bidang paru bilateral, positif Covid19, SpO2 90%, RR : 24x/menit, Nadi : 112x/menit.
2. Gangguan Pertukaran Gas b.d Pneumonia d.d kekeruhan ruang udara di bidang paru bilateral,
positif Covid19, SpO2 90%, RR : 24x/menit, Nadi : 112x/menit.sesak napas
3. Pola Napas Tidak Efektif b.d Hambatan Upaya Napas d.d kekeruhan ruang udara di bidang
paru bilateral, positif Covid19, SpO2 90%, RR : 24x/menit, Nadi : 112x/menit. kelemahan,
sesak napas
4. Hipertermia b.d Proses Penyakit d.d Demam > 6 hari, Kelemahan, Nadi : 112x/menit.Suhu:
37,7 C
5. Ketidakstabilan Kadar Glukosa b.d Hiperglikemi d.d glukosa darah 555 mg/dL, urin positif
keton, Polydipsia, Polyuria, nokturia.

FKEP UNEJ 2021 10

 PERENCANAAN KEPERAWATAN

No Diagnosa Tujuan Kriteria Hasil Intervensi

Keperawatan
1 Bersihan Jalan Napas Setelah dilakukan Bersihan Jalan Napas Pemantauan Respirasi (1.01014)
( L.01001) 1. Monitor frekuensi, irama,
Tidak Efektif (D.0001) tindakan keperawatan
Kriteria Hasil : kedalaman dan upaya napas
3x24 jam, Bersihan 1. Batuk Efektif meningkat 2. Monitor Saturasi oksigen
2. Frekuensi Napas Membaik 3. Monitor nilai AGD
jalan napas meningkat
3. Pola Napas Membaik 4. Monitor hasil x–ray thoraks

Manajemen Jalan Napas (1.01011)

1. Monitor Pola napas (frekuensi,
kedalaman, usaha napas)
2. Monitor bunyi napas tambahan
3. Posisikan semi-fowler

Terapi Oksigen (1.01026)

1. Siapkan dan atur peralatan
pemberian oksigen
2. Berikan oksigen tambahan

2 Gangguan Pertukaran Setelah dilakukan Pertukaran Gas Pemantauan Respirasi (1.01014)

( L.01003) 1. Monitor frekuensi, irama,
Gas tindakan keperawatan
Kriteria Hasil : kedalaman dan upaya napas
(D.0003) 3x24 jam, pertukaran 1. Takikardia membaik 2. Monitor Saturasi oksigen
2. Pola napas membaik 3. Monitor nilai AGD
gas meningkat.
4. Monitor hasil x–ray thoraks

Terapi Oksigen (1.01026)

1. Siapkan dan atur peralatan
pemberian oksigen

FKEP UNEJ 2021 11

 2. Berikan oksigen tambahan

3 Pola Napas Tidak Setelah dilakukan Pola Napas Pemantauan Respirasi (1.01014)
( L.01004) 1. Monitor frekuensi, irama,
Efektif tindakan keperawatan
Kriteria Hasil : kedalaman dan upaya napas
(D.0005) 3x24 jam, Pola napas 1. Frekuensi napas membaik 2. Monitor Saturasi oksigen
2. Kedalaman napas 3. Monitor nilai AGD
membaik
membaik 4. Monitor hasil x–ray thoraks
3. Keluhan sesak nafas
berkurang Manajemen Jalan Napas (1.01011)
1. Monitor Pola napas (frekuensi,
kedalaman, usaha napas)
2. Monitor bunyi napas tambahan
3. Posisikan semi-fowler

Pengaturan Posisi (1.01019

1. Atur posisi semi fowler untuk
mengurangi sesak napas
2. Monitor status oksigen sebelum
dan sesudah mengubah posisi
3. Ubah posisi setiap 2 jam

4 Hipertermia Setelah dilakukan termoregulasi Manajemen Hipertermia (1.15506)

( L.14134) 1. Identifikasi penyebab hipertermia
(D.0130) tindakan keperawatan
Kriteria Hasil : 2. Monitor suhu tubuuh
3x24 jam, Pola napas 1. Takikardi menuruun 3. Monitor komplikasi akibat
2. Takipnea menuruun Hipertermia
membaik
3. Suhu tubuh membaik 4. Kolaborasi pemberian cairan dan
4. Kadar glukosa elektrolit intravena
membaik
5. Tekanan darah Regulasi Temperatur (1.14578)
membaik 1. Monitor TD,frekuensi napas, dan
nadi

FKEP UNEJ 2021 12

 2. Kolaborasi pemberian antipiretik

5 Ketidakstabilan Kadar Setelah dilakukan Kestabilan Kadar Glukosa Manajemen Hiperglikemia (1.03115)
Darah 1. Monitor kadar glukosa darah
Glukosa Darah, tindakan keperawatan
( L.03022) 2. Monitor tanda dan gejala
(D.0027) 3x24 jam, Pola napas Kriteria Hasil : hiperglikemia (poli)
1. Lelah menurun 3. Monitor keton urin, kadar
membaik
2. Rasa haus menuruun AGD,TD,nadi
3. Kadar glukosa dalam 4. Kolaborasi pemberian insulin
darah membaik 5. Kolaborasi pemberian cairan IV

FKEP UNEJ 2021 13

 IMPLEMENTASI KEPERAWATAN

Tgl/Jam Diagnosa Implementasi Evaluasi Tanda

Keperawatan Tangan
14 April Bersihan Jalan 1. Memonitor frekuensi, irama, 1. Klien merasakan sesak napas
2021/ kedalaman dan upaya napas 2. SpO2 : 91%
Napas Tidak
08;00 2. Memonitor Saturasi oksigen 3. Analisis gas darah arteri (AGD)
Efektif (D.0001) 3. Memonitor nilai AGD menunjukkan asidosis metabolic
4. Memonitor hasil x–ray thoraks terkompensasi dengan anion
5. Memonitor Pola napas 4. Menunjukkan konsolidasi ruang Durrotul
(frekuensi, kedalaman, usaha udara bilateral yang lebih
napas) menonjol di susu kiri yang
6. Memonitor bunyi napas melibatkan hampir semua zona
tambahan 5. RR: 24x/menit
7. Memposisikan semi-fowler 6. Konsolidasi ruang udara
8. Menyiapkan dan atur peralatan bilateral
pemberian oksigen 7. Klien kooperatif melakukan
9. Memberikan oksigen tambahan posisi semi-fowler
8. Alat siap digunakan
9. Klien kooperatif menggunakan
alat bantu tambahan
14 April Hipertermi 1. Mengidentifikasi penyebab 1. Klien mampu menjawab saat
2021/ hipertermia
ditanya
09;00 2. Memonitor suhu tubuh
3. Memonitor komplikasi akibat 2. Klien kooperatif saat dilakukan
Hipertermia
pemeriksaan Durrotul
4. Melakukan kolaborasi pemberian
cairan dan elektrolit intravena

FKEP UNEJ 2021 14

 5. Memonitor TD,frekuensi napas, 3. Klien kooperatif saat diberikan
dan nadi
cairan dan elektrolit
4. TD: 120/90 mmHg, RR
22x/menit, Nadi 100x/menit

15 April Gangguan 1. Memonitor frekuensi, irama, 1. Klien mengatakan sesak napas

2021/ pertukaran Gas kedalaman dan upaya napas mulai berkurang
08;00 2. Memonitor Saturasi oksigen 2. Nilai Spo2 meningkat

Durrotul
15 April Ketidakstabilan 1. Memonitor kadar glukosa darah 1. Klien kooperatif dalam
2021/ Kadar Glukosa 2. Memonitor tanda dan gejala
pemeriksaan kadar glukosa
10;00 Darah, (D.0027) hiperglikemia
3. Memonitor keton urin, kadar darah
AGD,TD,nadi
2. Klien kooperatif saat ditanya
4. Melakukan kolaborasi
pemberian insulin tanda dan gejala yang dirasakan
5. Melakukan kolaborasi Durrotul
3. Klien kooperatif saat dilakukan
pemberian cairan IV
pemeriksaan lanjutan
4. Klien kooperatif saat diberikan
terapi insulin dan cairan IV

16 April Pola napas tidak 1. Memonitor frekuensi, irama, 1. Klien mengatan sudah bernapas
2021/ efektif kedalaman dan upaya napas
seperti biasanya
08;00 2. Memonitor Saturasi oksigen
3. Memonitor Pola napas 2. Saturasi oksigen sudah baik
(frekuensi, kedalaman, usaha

FKEP UNEJ 2021 15

 napas) 3. Tidak ada bunyi tambahan Durrotul
4. Memonitor bunyi napas
4. Klien dalam posisi semi fowler
tambahan
5. Memposisikan semi-fowler 5. Klien mengatakan mengubah
6. Mengatur posisi semi fowler
posisi setiap 2 jam
untuk mengurangi sesak napas
7. Memonitor status oksigen
sebelum dan sesudah mengubah
posisi
8. Mengubah posisi setiap 2 jam

FKEP UNEJ 2021 16

 CATATAN PERKEMBANGAN/EVALUASI

No Tanggal/Jam Diagnosa Evaluasi Sumatif Paraf

1 14 April 2021/ Bersihan Jalan Napas S:
08;00 Tidak Efektif - Klien mengatakan napas lebih cepat dari biasanya
O:
- SpO2 : 91 % Durrotul
- RR : 24/menit
A : Masalah belum teratasi
P : intervensi dilanjuttkan
2 14 April 2021/ Hipertermi S : Klien mengatakan sudah lebih baik
09;00 O : T : 36,6 C
A : Masalah teratasi
P : Hentikan Intervensi Durrotul
3 15 April 2021/ Gangguan pertukaran S : Klien mengatakan sesak napas berkurang
08;00 Gas O : - RR : 20x/menit
- SpO2 : 98 %
A : Masalah teratasi sebagian
P : lanjutkan intervensi Durrotul

FKEP UNEJ 2021 17

 4 14 April 2021/ Ketidakstabilan Kadar S : Klien mengatakan lebih enakan
10;00 Glukosa Darah, O : kadar glukosa darah menurun
Klien tampak tidak lemah
A : masalah teratasi sebagian Durrotul
P : Intervensi dilanjutkan
5 15 April 2021/ Pola napas tidak efektif S : Klien mengatakan sudah bernafas seperti biasanya
08;00 O : RR:18x/menit
SpO2 : 99%
A : masalah teratasi Durrotul
P : hentikan intervensi

FKEP UNEJ 2021 18

Since January 2020 Elsevier has created a COVID-19 resource centre with
free information in English and Mandarin on the novel coronavirus COVID-
19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this
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remains active.
 Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1459e1462

Contents lists available at ScienceDirect

Diabetes & Metabolic Syndrome: Clinical Research & Reviews

journal homepage: www.elsevier.com/locate/dsx

Diabetic ketoacidosis precipitated by COVID-19: A report of two cases

and review of literature
Pavan Kumar Reddy a, Mohammad Shafi Kuchay a, *, Yatin Mehta b, Sunil Kumar Mishra a
a
Division of Endocrinology and Diabetes, Medanta the Medicity Hospital, Gurugram, 122001, Haryana, India
b
Institute of Critical Care and Anesthesia, Medanta the Medicity Hospital, Gurugram, 122001, Haryana, India

a r t i c l e i n f o a b s t r a c t

Article history: Background and aims: The relationship between severe acute respiratory syndrome coronavirus 2 (SARS-
Received 25 July 2020 CoV-2) disease (COVID-19) and diabetes mellitus is bidirectional. On one hand, diabetes mellitus is
Accepted 29 July 2020 associated with an increased risk of severe COVID-19. On the other hand, new onset diabetes and severe
metabolic complications of pre-existing diabetes, including diabetic ketoacidosis (DKA) have been
Keywords: observed in patients with COVID-19. In this report, we describe two patient with diabetes mellitus who
COVID-19
presented to our hospital with DKA. We also reviewed almost all published cases of DKA that had been
Diabetic ketoacidosis
precipitated by COVID-19.
Coronavirus
Metabolic complications
Methods: Two patients were admitted with DKA, who were diagnosed to have COVID-19 on the basis of
real time reverse transcription-polymerase chain reaction (RT-PCR) assay. Detailed history, anthro-
pometry, laboratory investigations, imaging studies, clinical course and management outcomes were
documented.
Results: First patient (30-year-male) had undiagnosed diabetes and no other comorbidities, and COVID-
19 precipitated DKA. He also had COVID-19-associated pneumonia. Second patient (60-year-male) had
long duration hypertension with no prior history of diabetes and developed cerebrovascular accident
(CVA). He was also diagnosed with COVID-19 (RT-PCR assay) and DKA in the hospital. CVA and COVID-19
could have precipitated DKA. Both patients responded well to treatment and were discharged in a stable
condition.
Conclusions: These cases show that COVID-19 can precipitate DKA in a significant number of patients.
DKA can occur in patients with pre-existing diabetes or newly diagnosed diabetes. As COVID-19 and
diabetes are prevalent conditions, high degree of suspicion is required to diagnose DKA timely in order to
improve the prognosis of COVID-19-related diabetic ketoacidosis.
© 2020 Published by Elsevier Ltd on behalf of Diabetes India.

1. Introduction medical comorbidities, such as cardiovascular disease, diabetes

In December 2019, unexplained severe viral pneumonia
occurred in Wuhan, Hubei province, in China [1,2]. A novel coro-
navirus, severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2), was isolated from patients with this pneumonia [3]. Since
the COVID-19 pandemic began in China, more than 1.28 million
confirmed cases and around 30,645 COVID-19-related deaths have
been reported in India (as of July 23, 2020). Individuals with dia-
betes are more likely to suffer severe consequences, including
death. Recent studies have shown that advanced age or underlying
* Corresponding author.
E-mail address: drshafikuchay@gmail.com (M.S. Kuchay).
mellitus, hypertension, and obesity are risk factors for severe illness
and mortality among patients with COVID-19 [4].
Acute hyperglycemic crises e diabetic ketoacidosis (DKA) and
hyperosmolar hyperglycemic state (HHS), are the serious acute
metabolic complications of diabetes, and commonly precipitated
by infection. In a retrospective study from China, 42 (6.4%) patients
admitted with COVID-19 had ketosis out of which 15 (35.7%) had
diabetes. Three (20%) out of 15 patients with diabetes had DKA [4].
A few case reports also were published that COVID-19 may trigger
acute hyperglycemic crises (DKA/HHS) in patients with inade-
quately controlled diabetes, as well as newly diagnosed diabetes
[5,6]. Here, we describe two patients with confirmed COVID-19
who presented to our emergency department (ED) with DKA. We
also reviewed almost all published cases of COVID-19-related DKA.

https://doi.org/10.1016/j.dsx.2020.07.050
1871-4021/© 2020 Published by Elsevier Ltd on behalf of Diabetes India.
1460 P.K. Reddy et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1459e1462

Table 1 temperature was 100  F, and oxygen saturation of 90% by pulse

Laboratory investigations of the two patients at admission. oximetry on room air. His investigations (Table 1) revealed random
Parameter Case 1 Case 2 Reference range plasma glucose of 555 mg/dL with venous blood gas analysis on
pH 7.07 7.30 7.25e7.35
room air indicating metabolic acidosis (pH-7.07 and HCO3-
HCO3 (mmol/L) 6.1 13 22e28 6.1mmol/L). Urine ketones were present. His glycosylated hemo-
Hemoglobin (g/dL) 14.5 15.2 13.0e17.0 globin (HbA1c) was 9.6%. He was diagnosed to have moderate-
Total leucocyte count (x103/mL) 13.6 21.0 4.0e10.0 severe DKA and management was initiated with initial intrave-
ESR (mm/hr) 16 10 0e14
nous fluid replacement followed by intravenous insulin infusion.
Sodium (mmol/L) 131 134 135e145
Potassium (mmol/L) 3.9 3.7 3.5e5.1 Serum electrolytes were closely monitored. The chest imaging (X
Chloride (mmol/L) 110 96 95e110 ray) revealed patchy airspace opacities in bilateral lung fields and
Creatinine (mg/dL) 0.7 0.8 0.8e1.5 HRCT chest showed ground-glass opacities in bilateral upper lobes
Anion Gap (mmol/L) 11.9 16.2 12e18
and ground-glass opacities along with early consolidation in
Lactate (mmol/L) 1.22 1.13 0.5e1.5
Glycated hemoglobin (%) 9.6 12.6 5.6
bilateral lower lobes and lingular segment of left upper lobe (Fig. 1).
SGPT (U/L) 61 24 21e72 His laboratory investigations and imaging characteristics were
CRP (mg/L) 156.6 13.7 0e10 consistent with moderately severe COVID-19 as per the criteria set
IL-6 60 12 <6 by Ministry of Health and Family Welfare, Government of India.
Ferritin (ng/mL) 817 135 17.9e464
Therefore, anti-viral agent (Inj. Remdesivir), empirical antibiotics,
D-dimer (mg/L) 1.86 0.88 0.00e0.50
steroids and other symptomatic respiratory treatment for COVID-
ESR, erythrocyte sedimentation rate; SGPT, serum glutamyl pyruvate transaminase;
19 was instituted. He was also started on Inj. Enoxaparin in view
CRP, C-reactive protein, IL-6, interleukin-6.
of elevated D-dimer levels. Patient was admitted in intensive care
setting for close monitoring of the clinical status and inflammatory
2. Methods markers. He improved well with the above management (his
metabolic acidosis improved, blood glucose levels stabilized, and
Demography, detailed medical history, physical examination, blood parameters returned to normal). DKA resolved on the second
laboratory investigations including real time RT-PCR test, day. Once patient stabilized, subcutaneous insulin was initiated. He
computed tomography (CT) imaging studies, treatment given, was discharged in a stable condition with adequate education
clinical course and management outcomes were documented regarding the management of diabetes at home.
prospectively. Informed consent was obtained from both patients
for the study. Diabetic ketoacidosis was defined as plasma glucose
>250 mg/dL, a positive test for urine or serum ketones, and arterial 3.2. Case 2
pH < 7.35 and/or serum HCo3 <18 mmol/L.
Our second patient was a 60-year-old man, who had a long
duration hypertension. He had no personal history of diabetes. He
3. Results presented to our emergency department with sudden onset un-
easiness and inability to move the left upper limb associated with
3.1. Case 1 weakness of left lower limb. He was not able to walk. His initial
blood pressure was 220/180 mm Hg, heart rate 126 beats/min,
Our first patient was a 30-year-old man who presented with respiratory rate 26 breaths/min, and body temperature 99  F. His
general weakness, fever, loss of taste and mild dyspnea of 6 days’ oxygen saturation was 92% by pulse oximetry on room air. Upon
duration. He had a history of contact with a COVID-19 patient. He admission, random blood glucose was 582 mg/dL and HbA1c was
tested positive for SARS COV-2 on RT-PCR assay. He was initially 12.6%. Venous blood gas analysis on room air revealed a compen-
managed at home. However, his condition worsened and presented sated metabolic acidosis (pH-7.30 and HCO3-13 mmol/L), urine
to our emergency department with progressive breathlessness and ketones were present (Table 1). He was managed with intravenous
unresolved fever. The patient reported no prior history of diabetes fluid, intravenous insulin infusion with monitoring of serum elec-
or other comorbidities. There was no family history of diabetes. At trolytes. Due to the high prevalence of COVID-19 and atypical
admission, his blood pressure was 152/84 mmHg, heart rate of 122 clinical presentations that are known to occur with COVID-19,
beats/min and respiratory rate of 24 breaths/min. His body throat swab was sent for testing and was confirmed to have

Fig. 1. Axial (A) and coronal (B) images of HRCT chest (patient 1) showing ground glass opacities and early consolidation changes in bilateral lower lung fields.
 P.K. Reddy et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1459e1462 1461

Table 2
Summary of the previous published cases of DKA in COVID-19.

Case report Age (years) Presenting features Initial HbA1c at Comorbidities Outcome
RBS admission

Chee et al. (2020) (11) 37/male Fever, vomiting, polyuria, polydipsia 714 14.2 None Discharge
Kim et al. (2020) (12) 59/male General weakness, polyuria, polydipsia, mild 655 11.4 T2D, hypertension Death
dyspnoea
Goldman et al. (2020) 4 patients Age 40- Fever, dyspnoea 342 9.5e12.8 One-none Three- Two-deaths Two-
(16) 82 e468 T2D improved
Li et al. (2020) (5) 3 patients Age 26- General weakness, fever, dyspnoea, polyuria, 298 6.8e7.3 e One-death Two-
54 polydipsia e406 Improved
Current study (2020) 30/male General weakness, fever, loss of taste and mild 555 9.6 None Discharge
dyspnoea
60/male Cerebrovascular accident 582 12.6 Hypertension Discharge

COVID-19 on the basis of RT-PCR assay. HRCT chest did not reveal
any significant lung pathology. CT head and CT angiography of brain
and neck revealed hypoperfusion of right MCA territory, consistent
with acute cerebrovascular accident. He was managed as per
neurology guidance (thrombolysed with intravenous Alteplase).
His laboratory investigations were consistent with mild-moderate
COVID-19. Therefore, anti-viral agent (Inj. Remdesivir), empirical
antibiotics and other symptomatic respiratory treatment for
COVID-19 was instituted. He was also started on Inj. Enoxaparin in
view of elevated D-dimer levels. Patient was admitted in intensive
care setting for close monitoring of the clinical, and neurological
status. He improved well with the above management and was
discharged in stable condition with adequate education regarding
the management of stroke and diabetes at home.
4. Discussion
Herein we report two patients with DKA precipitated by COVID-
19 in patients with underlying undiagnosed diabetes. The impact of
diabetes on the severity of COVID-19 and occurrence of new onset
diabetes and severe metabolic complications of pre-existing dia-
betes, including DKA and HHS in patients with COVID-19 pose
challenges in clinical management [6]. DKA occurs as a result of
insulin deficiency and increased counterregulatory responses,
which favour the production of ketones. Interleukin-6 (IL-6) levels
have been shown to be elevated in both DKA and COVID-19, and
may be an important prognostic factor [7]. Both of our cases had
elevated IL-6 levels (Table 1). In our cases, there was no previous
history of diabetes and the severe DKA episode that occurred
leading to hospitalisation in an intensive care setting might be due
to the triggering effect of COVID-19 on diabetes. The exact patho-
genic mechanisms involved are yet to be determined. However, the
role of the inflammatory cytokines released during the viral illness
have been implicated.
The interactions between SARS-CoV-2 and the renin
angiotensin-aldosterone system (RAAS) might provide another
mechanism in the pathophysiology of DKA [8]. Angiotensin-
converting enzyme 2 (ACE2) is a crucial enzyme in the RAAS sys-
tem. It catalyzes the conversion of angiotensin II to angiotensin.
ACE2 is highly expressed in the lungs and pancreas. It serves as the
entry point for SARS-CoV-2. Expression of ACE2 is downregulated
after endocytosis of the virus complex [8,9]. The possible implica-
tions of these interactions are twofold. Firstly, entry of SARS-CoV-2
into pancreatic islet cells may directly aggravate beta cell injury
[10]. Secondly, downregulation of ACE2 after viral entry can lead to
unopposed angiotensin II, which may impede insulin secretion [11].
These 2 factors might have contributed to the acute worsening of
pancreatic beta cell function and precipitated DKA in our patients.
In addition, the relationship between SARS-CoV-2 and the RAAS
can complicate DKA management. Excessive fluid resuscitation
may potentiate acute respiratory distress. Therefore, proper fluid
management is vital in these patients. Furthermore, angiotensin II
stimulates aldosterone secretion, potentiating the risk of hypoka-
lemia, which may necessitate more potassium supplementation in
order to continue intravenous insulin to suppress ketogenesis. To
our knowledge few reports of DKA in COVID-19 have been pub-
lished. Table 2 shows the summary of all the previous published
reports [5,11,12,16].
Emerging information suggests that individuals with diabetes
are at increased risk for complications including death among
COVID-19 patients [13]. According to a clinical report in China
involving 1099 confirmed COVID-19 patients, diabetes was the
second most common comorbidity (16.2%) among severe 173 cases
[14]. There are not enough evidences to determine the risk of dia-
betes for poor outcomes in COVID-19 patients yet, a small study
showed that COVID-19 patients with diabetes were not only at
higher risk of severe pneumonia but also release excessive in-
flammatory biomarkers [15]. Our patient 1 also had severe pneu-
monia based on the HRCT grading. These results suggest that
people with comorbidities, especially with diabetes, are susceptible
to COVID-19. It is well known that acute hyperglycemic crises are
significantly related to morbidity or death in people with diabetes
[16].
5. Conclusions
COVID-19 may aggravate pancreatic beta cell function and pre-
cipitate DKA in patients with pre-existing or newly onset diabetes,
as demonstrated by our cases. We also highlight that aggressive
management with close monitoring in an ICU setting and timely
intervention with the available treatment may lead to improved
prognosis. As both conditions (diabetes mellitus and COVID-19) are
highly prevalent in our country, high degree of suspicion is required
to diagnose DKA timely in order to improve the prognosis of COVID-
19-related acute hyperglycemic complications.
Author contributions
PKR was involved in patient management, revised manuscript,
approved manuscript. MSK wrote manuscript, revised and
approved manuscript. YM was involved in patient management,
approved manuscript, SKM was involved in patient management,
revised and approved the manuscript.
Declaration of competing interest
The authors declare no competing interests.
1462 P.K. Reddy et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1459e1462

References 297e8.
[9] Yang JK, Lin SS, Ji XJ, Guo LM. Binding of SARS coronavirus to its receptor
damages islets and causes acute diabetes. Acta Diabetol 2010;47(3):193e9.
[1] Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients
[10] Carlsson PO, Berne C, Jansson L. Angiotensin II and the endocrine pancreas:
with 2019 novel coronavirus-infected pneumonia in Wuhan, China. J Am Med
effects on islet blood flow and insulin secretion in rats. Diabetologia
Assoc 2020;323(11):1061e9.
1998;41(2):127e33.
[2] Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019
[11] Chee YJ, Ng SJH, Yeoh E. Diabetic ketoacidosis precipitated by Covid-19 in a
novel coronavirus in Wuhan, China. Lancet 2020;395(10223):497e506.
patient with newly diagnosed diabetes mellitus. Diabetes Res Clin Pract
[3] Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019
2020;164:108166.
in China. N Engl J Med 2020;382(18):1708e20.
[12] Kim NY, Ha E, Moon JS, Lee YH, Choi EY. Acute hyperglycemic crises with
[4] Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult
coronavirus disease-19: case reports. Diabetes Metab J 2020;44(2):349e53.
inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
[13] Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients
Lancet 2020;395(10229):1054e62.
with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retro-
[5] Li J, Wang X, Chen J, Zuo X, Zhang H, Deng A. COVID-19 infection may cause
spective, observational study. Lancet Respir Med 2020;8(5):475e81.
ketosis and ketoacidosis. Diabetes Obes Metabol 2020. https://doi.org/
[14] Guo W, Li M, Dong Y, et al. Diabetes is a risk factor for the progression and
10.1111/dom.14057.
prognosis of COVID-19. Diabetes Metab Res Rev 2020:e3319. https://doi.org/
[6] Palermo NE, Sadhu AR, McDonnell ME. Diabetic ketoacidosis in COVID-19:
10.1002/dmrr.3319.
unique concerns and considerations. J Clin Endocrinol Metab 2020;105(8).
[15] Kim KJ, Kwon TY, Yu S, et al. Ten-year mortality trends for adults with and
dgaa360.
without diabetes mellitus in South Korea, 2003 to 2013. Diabetes Metab J
[7] Vaduganathan M, Vardeny O, Michel T, McMurray JJV, Pfeffer MA,
2018;42(5):394e401.
Solomon SD. Renin-angiotensin-aldosterone system inhibitors in patients
[16] Goldman N, Fink D, Cai J, Lee YN, Davies Z. High prevalence of COVID-19-
with Covid-19. N Engl J Med 2020;382(17):1653e9.
associated diabetic ketoacidosis in UK secondary care. Diabetes Res Clin
[8] Bornstein SR, Dalan R, Hopkins D, Mingrone G, Boehm BO. Endocrine and
Pract 2020;166:108291.
metabolic link to coronavirus infection. Nat Rev Endocrinol 2020;16(6):