Definition
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Severe, uncontrolled diabetes characterized by hyperglycemia, ketoacidosis and ketonuria
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Severe, uncontrolled diabetes characterized by hyperglycemia, hyperosmolarity and dehydration
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Plasma glucose |
Greater than 250 mg/dL; often in the 350 to 500 mg/dL (19.4 to 27.8 mmol/L) range |
Greater than 600 mg/dL; frequently exceed 1000 mg/dL (56 mmol/L) |
Arterial pH |
Less than 7.30 |
Greater than 7.30 |
Serum bicarbonate
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Less than 18 |
Greater than 18 |
Urine ketones |
Positive |
Small/None |
Serum ketones |
Positive |
Small/None |
Serum osmolality
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Variable |
Greater than 320 mOsm/kg |
Anion gap |
Greater than 12 |
Variable |
Mental status |
Drowsy, stupor/coma |
Stupor/coma |
BUN/Creatinine |
Elevated |
Elevated |
Onset |
Rapid (Less than 24 hours) |
Slow, over days |
Affects |
Both type 1 and 2 DM, but occurs most often in type 1
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Both type 1 and 2 DM, but occurs most often in type 2 and elderly
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Precipitating factors |
- Decreased or missed dose of insulin
- Physiologic stress (infection, surgery, myocardial infarction)
- Undiagnosed or untreated diabetes
- Excess alcohol intake
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- Illness
- Medications that cause hyperglycemia (steroids, thiazide diuretics, beta blockers)
- Dialysis
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Signs & symptom |
- Kussmaul respirations (rapid, shallow breathing)
- “Fruity”, acetone breath
- Malaise, weakness, fatigue
- Nausea, vomiting, abdominal pain
- Cardiac arrhythmias, tachycardia
- Hypotension
- Mild disorientation, confusion
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- Similar signs and symptoms as DKA
- Dehydration, extreme thirst
- Tachycardia
- Hypotension
- Mental status changes, lethargy
- Fever
- Loss of vision
- Hallucinations
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Treatment, as ordered |
- Correct fluid deficit per prescriber orders based on degree of hypovolemia and serum Na+
- Replace electrolytes, particularly potassium (K+)
- Reverse acidosis and ketosis (sodium bicarbonate IV for pH less than 6.9)
- Administer insulin to reduce glucose level to 150-200 mg/dL
- Identify underlying cause
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- Correct fluid deficit per prescriber orders based on degree of hypovolemia and serum Na+
- Replace electrolytes (K+) based on adequate renal function
- Administer insulin to reduce glucose level to 250-300 mg/dL (0.1 units/kg bolus followed by continuous IV infusion @ 0.1 units/kg/hour)
- Identify underlying cause
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Signs of resolution |
- Blood glucose level less than 200 mg/dL
- Presence of two of the following:
- Serum bicarbonate level 15 mEq/L or higher
- pH greater than 7.3
- Anion gap 12 mEq/L or lower
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- Osmolality is normal
- When mental status is back to baseline, patient may start clear liquid diet and transition to subcutaneous insulin.
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Potential complications of treatment |
- Fluid overload due to aggressive fluid replacement
- Hypokalemia due to inadequate potassium replacement, or administration of bicarbonate
- Hypoglycemia due to aggressive insulin treatment
- Cerebral edema due to excessive hydration and rapid intracellular fluid shifts
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Nursing considerations |
- Monitor hemodynamics, intake/output, serum osmolality, BUN and creatinine.
- Assess cardiac, renal, and mental status.
- Monitor blood glucose every hour if on IV insulin infusion.
- Monitor electrolytes (Na+, K+, Mg+, PO4), BUN, creatinine every 2-4 hours until stable, per policy.
- If hypokalemic, delay insulin treatment until serum K+ is greater than 3.3 mEq/L.
- Monitor arterial blood gas (ABG) to determine if acidosis is resolving.
- IV insulin should continue for 2 to 4 hours after the first dose of subcutaneous insulin administration to avoid hyperglycemia.
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