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categoriesFeaturedRecentPeopleAuthorsStudentsResearchersPublishersGovernment & NonprofitsBusinessesMusiciansArtists & DesignersTeachers+ all categoriesMost FollowedPopularSign Up Log In 1First Page Previous Page Next Page / 5Sections not available Zoom Out Zoom In Fullscreen Exit FullscreenSelect View Mode View ModeSlideshowScroll Readcast Add a Comment Embed & Share Reading should be social! Post a message on your social networks to let others know what you're reading. Select the sites below and start sharing.Readcast this Document Login to Add a Comment Share & EmbedAdd to Collections Download this Document for FreeAuto-hide: on 1. Describe the pathophysiologic changes in DKA.a. Why do blood glucose levels increase?DKA is caused when the body has little or no insulin to use. The blood glucose level keepsrising to dangerous levels. This is called hyperglycemia. DKA most often starts frominfection. Hormonal changes lead to increased liver and renal glucose production anddecreased glucose use in peripheral tissues. Increased production of counterregularyhormones leads to the production of ketoacids and resultant ketonemia and metabolicacidosis. DKA most commonly occurs in a person with type 1 diabetes. The lack of insulinleads to mobilization of fatty acids from adipose tissue because of the unsuppressedadipose cell lipase activity that breaks down triglycerides into fatty acids and glycerol.b. What are commonly seen blood glucose levels?The definitive diagnosis of DKA consists of blood glucose levels >250 mg/d, but is usuallymuch higher.c. What fluid and electrolyte disturbances commonly occur?Typical overall electrolyte loss includes 200-500 mEq/L of potassium, 300-700 mEq/L of sodium, and 350-500 mEq/L of chloride. The combined effects of serumhyperosmolarity,dehydration, and acidosis result in increased osmolarity in brain cells that clinicallymanifests as an alteration in the level of consciousness.d. What causes the fluid and electrolyte disturbances?Hyperglycemia leads to osmotic diuresis, dehydration, and a critical loss of electrolytes.Hyperosmolality of extracellular fluids from hyperglycemia leads to a shift of water andpotassium from the intracellular to the extracellular compartment. Extracellular sodiumconcentration frequently is low or normal despite enteric water losses because of theintracellular-extracellular fluid shift. Serum potassium levels may be normal or elevated,despite total potassium depletion resulting from protracted polyuria and vomiting.Metabolic acidosis is caused by the excess ketoacids that require buffering by bicarbonateions; this leads to a marked decrease in serum bicarbonate levels.e. What acid-base disturbances are commonly seen?Serum pH

<7.35.f. Why do the acid-base disturbances occur?When the accumulated ketones exceed the body's capacity of extracting them, theyoverflow into urine (ie, ketonuria). If the situation is not treated promptly, moreaccumulation of organic acids leads to frank clinical metabolic acidosis (ie, ketoacidosis),with a drop in pH and bicarbonate1 serum levels. Respiratory compensation of this acidoticcondition results in rapid shallow breathing (Kussmaul respirations). 2. Describe the medical management of a patient in DKA.a. How is the fluid status monitored in the acute stage of DKA?The dehydrated patient s lips and mouth may be dry and the tongue furrowed. Temperaturemay be elevated. In patients with poor renal function and excess fluid volume, assess foredema around the eyes and in the limbs, increasing abdominal girth, increasing bloodpressure and pulse volume, jugular venous distention, and orthostatic hypotension. Edemaoccurs with excess interstitial fluid and often is not apparent until interstitial volumeincreases by 2 to 3 L. Daily weights are good indicators of fluid status because 1 kg of bodyweight equals 1 L of fluid. Check the clinical indicators of fluid imbalance. Fluid overload cancause hypertension. Jugular venous pressure increases with volume overload. Orthostatichypotension may indicate volume depletion. In severe volume depletion, the jugular venouspulsation may not be visible even with the patient lying flat.b. How is hypovolemia corrected? How rapidly is fluid volume replaced? Why?The first goal of fluid therapy is to restore volume and maintain perfusion to the brain,heart, and kidneys. Infuse 1 L of isotonic saline over 30 to 60 minutes. Usually, a second literis given in the next hour. The second goal of fluid therapy, replacing total body fluid losses,is achieved more slowly, usually 0.45% saline. When blood glucose levels reach 250 mg/dLgive 5% dextrose in 0.45% saline. This solution prevents hypoglycemia and cerebral edema,which can occur when serum osmolarity declines too rapidly. During the first 24 hours of treatment, the patient needs enough fluids to replace the actual volume deficit and ongoinglosses. This may be as much as 6 to 10 L. Watch for signs of fluid replacement by monitoringblood pressure and urinary intake and output.c. How are blood glucose levels monitored? How often?Hourly blood glucose measurements using a blood glucose meter. If a patient exhibitsclinical symptoms of hyperglycemia that do not reflect the bedside blood glucosemeasurement, a lab glucose measurement is obtained. For the patient receiving acontinuous IV insulin infusion, bedside blood glucose is measured hourly for first 8 hoursafter initiation, then at least every 2 hours thereafter.d. How are elevated blood glucose levels corrected?The outcome of insulin therapy is to lower serum glucose by about 75 to 150 mg/dL/hr.Unless the episode of DKA is mild, regular insulin by continuous IV infusion is the treatmentof choice. Effective blood insulin levels are reached quickly when an IV bolus dose is given atthe start of the infusion. An initial IV bolus dose of 0.1 unit/kg is followed by an IV drip of 0.1unit/kg/hr. Continuous insulin infusion is used because of the 4-minute half-life of IV insulin.Subcutaneous insulin is started when the patient can take oral fluids and ketosis hasstopped. e. How quickly is blood glucose corrected? Why?Slowly lower blood glucose to prevent hypokalemia.3. What electrolytes are monitored in the acute stage of DKA? Why?Na, K Hyper/Hypokalemia a. How are electrolyte imbalances corrected? How rapidly is this accomplished? Why?Hypokalemia prevention requires replacement of 20 to 30 mEq K in each liter of IV fluid tokeep serum K between 4 and 5 mEq/L. If serum K is < 3.3 mEq/L, insulin should be withheldand K given at 40 mEq/h until serum K is 3.3 mEq/L; if serum K is > 5 mEq/L, Ksupplementation

can be withheld. Use of electrolyte replacement solutions based on labfindings.b. How are acid-base disturbances monitored? How often?Arterial blood gas measurement is usually performed to demonstrate the acidosis; thisrequires taking a blood sample from an artery. Subsequent measurements (to ensuretreatment is effective), may be taken from a normal blood test taken from a vein, as there islittle difference between the arterial and the venous pH. The serum CO2 test is performedto determine metabolic acid-base abnormalities. Every one hour.c. How are acid-base disturbances corrected? How quickly is this accomplished? Why?The administration of sodium bicarbonate solution to rapidly improve the acid levels in theblood is controversial. There is little evidence that it improves outcomes beyond standardtherapy, and indeed some evidence that while it may improve the acidity of the blood, itmay actually worsen acidity inside the body's cells and increase the risk of certaincomplications. Its use is therefore discouraged, although some guidelines recommend it forextreme acidosis (pH<6.9), and smaller amounts for severe acidosis (pH 6.9 7.0)4. Describe the nursing management of a patient in DKA.a. How is fluid status assessed?Daily weights are good indicators of fluid status. Check the clinical indicators of fluidimbalance. Assess vitals. Assess urine concentration. Assess mucous membrane and skinturgor. Assess for edema around eyes and in the limbs, increasing abdominal girth,increasing blood pressure and pulse volume.b. What are the complications of fluid replacement and how are they prevented?Fluid overload can cause hypertension, especially in patients with kidney failure. It can alsocause pulmonary edema and edema in extremities. Monitor for fluid imbalance. c. How are blood glucose levels assessed? How often?Hourly blood glucose measurements using a blood glucose meter. If a patient exhibitsclinical symptoms of hyperglycemia that do not reflect the bedside blood glucosemeasurement, a lab glucose measurement is obtained. For the patient receiving acontinuous IV insulin infusion, bedside blood glucose is measured hourly for first 8 hoursafter initiation, then at least every 2 hours thereafter. Urinalysis.d. What are the complications of lowering blood glucose levels and how are they prevented?Hypoglycemia can be avoided by assessing therapy effectiveness with hourly blood glucosemeasurements.e. How are electrolyte disturbances assessed? How often?Every one hour. Anion gap. Vital signs.f. What are the complications of electrolyte replacement and how are they prevented?Hyperkalemia. High potassium levels greater than 5.0 mEq/L should be reported. 7.0 mEq/Lor higher can cause cardiac arrest. Monitor ECG for QRS spread and peaked T waves, a signof hyperkalemia. Assess renal function. Check specific gravity of urine to assess forhypernatremia. Observe for edema and overhydration resulting from an elevated serumsodium level. Keep accurate intake and output record.g. How are acid-base disturbances assessed? How often?Arterial blood gases are usually ordered to assess disturbances of acid-base balance. Aniongap measures cations (sodium and potassium) and anions (chloride and bicarbonate).h. What are the complications of acid-base correction and how are they prevented?If a bicarbonate excess is present, then metabolic alkalosis results. Respiratory alkalosis tocompensate.i. Define anion gap, serum osmolality and venous CO2.Anion gap is the difference between the electrolytes, measured cations (sodium andpotassium), and measured anions (chloride and bicarbonate to determine the unmeasuredcations and anions in the serum. The formula used is: Anion gap = (sodium + potassium) (chloride + bicarbonate). An elevated anion gap greater than 17 mEq/l indicates metabolicacidosis, a decreased anion gap less than 10 mEq/l indicates metabolic alkalosis.A serum osmolality test measures the amount of chemicals dissolved in the liquid part(serum) of the blood. Chemicals that affect serum osmolality include sodium, chloride,bicarbonate, proteins, and sugar (glucose). A serum osmolality test is done on a bloodsample taken from a vein. Serum osmolality is measured to check

the balance between the water and the chemicals dissolved in blood and Find out if severe dehydration oroverhydration is present.Venous CO2 is the amount of carbon dioxide in the blood. The serum CO2 test is performedto determine metabolic acid-base abnormalities.j. How are serial anion gaps, serum osmolalities and venous CO2 results used?The serum CO2 test is performed to determine metabolic acid-base abnormalities. Aniongap indicates metabolic acidosis/alkalosis. Serum osmolalities indicates dehydration oroverhydration.DKA Download this Document for FreePrintMobileCollectionsReport DocumentReport this document?Please tell us reason(s) for reporting this document Spam or junk Porn adult content Hateful or offensiveIf you are the copyright owner of this document and want to report it, please follow these directions to submit a copyright infringement notice.Report Cancel This is a private document. Info and Rating Reads:236Uploaded:04/04/2011Category:Uncategorized.Rated:Copyright:Attribution Non-commercial FollowMorgan MitchellShare & Embed More from this user PreviousNext 5 p.Add a Comment SubmitCharacters: 400 Print this documentHigh QualityOpen the downloaded document, and select print from the file menu (PDF reader required).Download and Print Sign upUse your Facebook login and see what your friends are reading and sharing.Other login optionsLogin with FacebookSignupI don't have a Facebook account email address (required) create username (required) password (required) Send me the Scribd Newsletter, and occasional account related communications. Sign Up Privacy policy You will receive email notifications regarding your account activity. You can manage these notifications in your account settings. We promise to respect your privacy. Why Sign up?Discover and connect with people of similar interests. Publish your documents quickly and easily. Share your reading interests on Scribd and social sites. Already have a Scribd account?email address or username password Log In Trouble logging in? Login SuccessfulNow bringing you back... Back to LoginReset your passwordPlease enter your email address below to reset your password. We will send you an email with instructions on how to continue.Email address: You need to provide a login for this account as well. Login: Submit Upload a Document Search Documents Follow Us!scribd.com/scribdtwitter.com/scribdfacebook.com/scribdAboutPressBlogPartner sScribd 101Web StuffScribd StoreSupportFAQDevelopers / APIJobsTermsCopyrightPrivacyCopyright 2011 Scribd Inc.Language:EnglishChoose the language in which you want to experience Scribd:EnglishEspaolPortugus (Brasil)