A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory results show glucose 540 mg/dL, pH 7.18, HCO3 12 mEq/L, and anion gap 22. Which interventions should the nurse anticipate as part of evidence-based DKA management? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
DKA management begins with isotonic IV fluid resuscitation (Choice 6), with adjustments for clients at high risk of fluid overload. Continuous IV short-acting insulin at 0.1 unit/kg/hr is standard for DKA (Choice 2), whereas subcutaneous sliding-scale insulin alone does not treat the ketoacidosis (Choice 4). Because insulin and correction of acidosis lower serum potassium, measure potassium 2 hours after insulin begins and every 4 hours thereafter; start potassium replacement when the level falls below 5.0 mEq/L to maintain 4–5 mEq/L (Choice 5). When glucose falls below about 250 mg/dL, add 5–10% dextrose to the IV fluid and continue insulin until ketoacidosis resolves (Choice 3). Withholding IV fluid until glucose normalizes (Choice 1) is unsafe.
DKA Management Order 1. Fluids first: 0.9% NS bolus, then 0.45% NS once perfusion restored 2. Insulin infusion: 0.1 unit/kg/hr IV regular (no SC sliding scale) 3. Potassium: hourly check, replace if K < 5.0 (insulin drives K into cells) 4. Add dextrose when glucose 200-250 to continue insulin without hypoglycemia 5. Monitor: glucose hourly, BMP q2-4h, anion gap, mentation
When to Stop the Insulin Drip When anion gap closes, HCO3 ≥ 18, pH ≥ 7.30, AND client tolerates oral intake. Overlap SC long-acting insulin 1-2 hr BEFORE stopping IV (otherwise rebound DKA).
Memory Tip — "FIPD" Fluids first, Insulin drip, Potassium watch, Dextrose at 200-250.
Caution Do NOT give insulin if K < 3.3 mEq/L — replace K first. Cerebral edema is the deadliest pediatric DKA complication; avoid overly rapid glucose correction.
Initial Order Set- 1 L NS bolus over 1 hr; reassess- Insulin regular drip 0.1 unit/kg/hr after bolus started- Hourly fingerstick glucose- BMP q2h with K replacement- Strict I&O, foley if obtunded- Search for trigger: infection, missed insulin, MI, pancreatitis
Resolution CriteriaGlucose < 200 + 2 of: HCO3 ≥ 15, venous pH ≥ 7.30, anion gap ≤ 12. Then transition to SC insulin with overlap.
DKA diagnostic triad — Hyperglycemia (glucose ≥ 250 mg/dL), anion gap metabolic acidosis (pH < 7.30, HCO3 < 18, AG > 12), and ketosis (positive serum/urine ketones). Common triggers: infection, missed insulin, new-onset T1DM, MI, pancreatitis, surgery.
Insulin and potassium relationship — Insulin drives extracellular potassium into cells. DKA clients usually have total-body K depletion despite normal or elevated serum K (acidosis pushes K out). Once insulin starts, serum K can drop rapidly and cause life-threatening dysrhythmias. Replace K early; never start insulin if K < 3.3.
Dextrose addition during DKA — When glucose falls to 200-250 mg/dL during insulin therapy, add D5W or D5-0.45% NS to maintain glucose around 150-200 while continuing the insulin infusion. This allows continued correction of the underlying acidosis (the goal) without inducing hypoglycemia.