Lecture By Sr.Shiny Mathew MMW Head Nurse

1. PRESENTED BY:
SHINY MATHEW
HEAD NURSE MMW

2. DIABETES MELLITES
 Diabetes mellitus is a group of metabolic disease
results from the production of insufficient amount
of insulin by the pancreas. Without insulin the
body cannot utilize glucose. So creating high level
of glucose in the blood and a low level of glucose
absorption by the tissue.
 Type 1 diabetes -- insulin dependant diabetes
 Type2 diabetes-- Non insulin dependant diabetes

3. DIABETIC KETOACIDOSIS
Diabetic keto acidosis is an acute state of severe
uncontrolled diabetic that requires emergency
treatment with insulin and intravenous fluids.bio
chemically DKA is defined as an increase in the
serum concentration of ketons greater than 5
meq/l a blood glucose level of greater than 250
mg/l,blood PH less than 7.2 and HCO3 is 18meq/l
or less.

4. PRECIPITATING FACTORS
 Infections
 Acute stroke
 Pancreatitis
 Myocardial infarction
 Interruption of insulin
 Pregnancy
 Dietery indiscretion
 Trauma and stress

5. INFECTION MISSED INSULIN DOSE
STRESS NEW-ONSET DIABETES
EXCESS SECRETION OF
INADEQUATE
GLYCOGEN AND OTHER
INSULIN
COUNTER REGULATORY
HORMONES
DCREASE
INCREASED LIPOLYSIS GLYCOGENENOLYSIS GLUCOSE UPTAKE
OF ADIPOSE TISSUE AND
GLUCONEOGENESIS
BY THE LIVER HYPERGLYCEMIA
KETOGENESIS
OSMOTIC
KETOSIS DIURESIS
VOMITING
ACIDOSIS POTASSIUM
LOSS
DEHYDRATION

6. LACK OF INSULIN
DECREASED UTILIZATION INCREASED
OF GLUCOSE BY MUSCLE, BREAKDOWN
FAT AND LIVER OF FAT
INCREASED PRODUCTION •ACETONE
OF GLUCOSE BY LIVER BREATH INCREASED
•POOR APPETITE FATTY ACIDS
•NAUSEA
HYPERGLYCEMIA INCREASED
KETONE
•NAUSEA BODIES
BLURRED POLYURIA •VOMITING
VISION •ABDOMINAL PAIN ACIDOSIS
WEAKNESS DEHYDRATION
HEADACHE
INCREASINGLY
INCREASED THIRST RAPID
(POLYDIPSIA) RESPIRATIONS

7. COMMON CLINICAL FEATURES
 Poly urea ,poly dipsia,poly phagia
 Weight loss
 Nausea and vomiting
 weakness
 Abdominal pain
 Clouding of sensorium
 Coma
 Hyper ventillation –kuss mual pattern
 Dehydration and shock
 s

8. LABORATORY FINDINGS
 Blood glucose greater than 14mmol/L[250 mg/l]
 Arterial pH less than 7.3
 Anion gap less than 10
 Ketone urea
 Arterial bicarbonate less than 15
 Hyper magnesimia
 Hypokalemia
 Cardiac enzymes
 Pco2-35it reflects respiratory compensation .

9. NURSING ASSESSMENT
 Assess skin for dehydration like poor turgour,flushing,and dry
mucus membrances.
 Observe for cardiac changes reflecting dehydration,metabolic
and electrolyte imbalance,tachycardia,hypotension,weak
pulse,ECG changes including elevated P wave flattendT wave
or inverted and prolonged QT intervals
 Assess respiratory status kussmual breathing,acctone breaths
characteritic of metabolic acidosis
 Assess gastro intestinal symptoms like nausea vomiting
extreme thirst,abdominal bloating,cramping,and diarrhoea
 Genito urinary symptoms-nocturia and polyuria
 Neurologic signs-
crying,restlessness,twitching,tremers,drowsiness,lethargy,hea
dache.

10. NURSING MANAGEMENT
 Stabilize the patient’s airway,breathing,circulation
 Obtain 16 gauge iv line on both site and assess cardiac
monitoring and pulse oxymetry.
 Monitor serum glucose hourly and urine ketone
 Monitor basic electrolyte,osmolarity and venousPHevery 4
hourly until pt is stable.
 Determine and treat any underlyingcausesof DKAeg;;
pneumonia,UTIand MI

11. 1.FLUID REPLACEMENT[ADULT]
 Give 1 litre of normal saline[0.9%]rapidly via No I8 gauge
cannula if cardiac function is normal.
 Then one litre of normal saline/ hour, for 1st3 hrs for those
individuals who are in shock .
 Then 250-500ml /hr of normal saline depending on hydration
status until blood sugar is 14 mmol/L[250 mg/L]. blood sugar
level<14 mmol/L 0.9%should be switched toD51/2NS or DNS
at 125 to 250ml/hour.
 Assess blood pressure & heart rate frequently.
 Monitor intake and out put for signs of fluid overload.
 Monitor urine specific gravity to assess fluid changes.

12. INSULIN TREATMENT
 Regular insulin 0.1 units/kg. as an IV bolus.
 Then regular insulin infusion IV 0.14 units /kg./hour until
blood sugar reaches 14mmol/litre ( 250mg/dl) & follow IV
infusion protocol
 1ml regular insulin = 100units
 Start insulin infusion 6units/hr.
 Doctor’s order x solution in volume 6units x 50
____________________________ = ____________
Strength of solution 100 units
300
_____ = 3ml/hr. ( 6units/hr.)
100

13. RATE OF INFUSION ACCORDING TO SLIDING SCALE OF
REGULAR INSULIN
CAPILLARY BLOOD GLUCOSE IN UNITS OF INSULIN / HOUR
MG/DL
<99 0.5ml/hr.
100______ 149 (5.6—8.2mmol) 1ml/hr.
150 ______ 199 ( 8.3_____11 ) 2ml/hr.
200 ______ 249 ( 11.1 ____13.8 ) 3ml/hr.
250_______299 (13.9____ 16.6) 4ml/hr.
300_______349 ( 16.7____19.4) 5ml/hr.
350_______399 ( 19.5_____22.2) 6ml/hr.
400_______450 ( 22.3_____24.9) 8ml/hr.
>450 ( > 24.9) 10ml/hr.

14. ANION GAP- Substract the major measured anion from
the major measured Cations (Cl +Hco3- Na)
• IV insulin infusion can be switched to subcutaneous
insulin according to sliding scale.
• Arterial bicarbonate rises 18.
• Anion gap 10 up to 12 + or- 2
• Urine aceton 3times negative
• Oral intake has resumed
• It is important to give the first subcutaneous insulin
approximately two hours before stopping the infusion
• Flush the entire IV infusion set with solution containing
insulin & dicard the solution ,then refill it again
• Keep separate IV line for insulin infusion and electrolyte
replacement

15. POTASSIUM REPLACEMENT
 Aims to keep serum k+ between 4 to 5meq/ L to prevent
hyper or hypokalemea.
 If initial potassium is <3.3 Hold insulin & replace K+
 Do not give K+ direct IV, must be added to IV fluids
 If K+ is >5 do not give Kcl recheck within hour
 If k+ is 4__ 5 give Inj.kcl 20meq in each liter of fluid
 If K+ is 3__4 give Inj.kcl 30meq in each liter of fluid
 If K+ is <3 give Inj.kcl40meq in two hour & recheck
 Follow sliding scale of K+ every 6th hourly until stable

16. BICARBONATE REPLACEMENT
 If arterial PH <7 give 50ml of bicarbonate in 250ml of
0.45% NSS over one hour
 Bicarbonate infusion to correct acidosis is avoided,during
the treatment of DKA because it precipitates further
sudden decrease in serum potassium .
 INVESTIGATION AND OUTCOME BASED EVALUATION
 Serum glucose initially and hrly until acctone disappear
 Serum potassium initially and hrly if K+ < 3 or > 5
 Electrolyte and renal function initially and then 6 hrly ..
 Serum osmolarity , VBG,cardiac enzymes ,CBC
 Urine analysis and urine culture if needed

17. COMPLICATION
 Premature discontinuation of Ivinsulin can result in
prolonged DKA
 Too rapid infusion of IVF in case of severe dehydration
can cause cerebral edema and death
 If blood glucose level falls too fast or too slow,before
the brain has time to equilibrate,the water is pulled
from the cerebrospinal fluid and the brain causing
cerebraloedema and death
 Hypoxiaand leads to ARDS
 Hypoglycemia,venous and arterial thrombosis

18. PATIENT EDUCATION
 Instruct to take insulin or oral diabetic agent as usual
 Check blood sugar and urine sugar every 4 hrly
 Report elevated glucose and urine acctone to physician
 Usual meal plan cannot be followed substitute soft foods 6-
8 times /day
 If any symptoms like vomiting and diarrhoe or fever
consume liquid diet every half to one hour to prevent
dehydration and provide calories
 Inform physician about extreme fluid loss maybe
dangerous.
 For type 1 diabetic, iniability to retain oral fluid needs
hospitallization to avoid DKA and possible coma

19. SHINY MATHEW
MALE
MEDICAL WARD