Last updated on December 28th, 2023

In this post, you will find 12 NANDA-I nursing diagnosis for Diabetic Keto Acidosis (DKA). These include actual and risk nursing diagnoses.

DKA nursing assessment, interventions, priorities, and patient teaching are all included.

List of NANDA-I nursing diagnosis for Diabetic Keto Acidosis (DKA)

1. Deficient fluid volume
2. Acute confusion
3. Imbalanced nutrition: less than body requirements
4. Nausea
5. Ineffective breathing pattern
6. Ineffective health maintenance
7. Powerlessness
8. Deficient knowledge
9. Risk for unstable blood glucose level
10. Risk for injury
11. Risk for infection
12. Risk for disturbed sensory perception

Sample nursing care plan for DKA

Actual NANDA nursing diagnosis for DKA

#1 Deficient fluid volume

May be related to	As evidenced by
Osmotic diuresis, excessive gastric losses	Polyuria, nausea and vomiting, diaphoresis, kussmaul respirations

#2 Acute confusion

May be related to	As evidenced by
Acidosis, dehydration	Patient not oriented, agitation, lethargy, increased intracranial pressure, headache, dry skin and mucous membranes, loss of skin turgor

#3 Imbalanced nutrition: less than body requirements

May be related to	As evidenced by
Inability to utilize glucose (insulin dependence), decreased oral intake, altered consciousness level, infectious process, anorexia, abdominal pain	Hyperglycemia of above 250mg/dl, inadequate food intake, increased ketones, increased urinary output, diarrhea

#4 Nausea

May be related to	As evidenced by
Bad, sour taste in the mouth	Vomiting, uremia, presence of ketones in urine, gagging sensation and frequent urination

#5 Ineffective breathing pattern

May be related to	As evidenced by
Excessive ketone bodies in the blood	presence of kussmaul breathing pattern, restlessness, oxygen saturation <90%

#6 Ineffective health maintenance

May be related to	As evidenced by
Complex medical regimen, lack of knowledge on diabetes, new/unfamiliar disease process	Development of preventable complications

#7 Powerlessness

May be related to	As evidenced by
Dependence on others, chronic illness,	Non-participation in care and decision making, social withdrawal, anger, expression of having no control over the situation, depression over complications despite following through with regimen

#8 Deficient knowledge

May be related to	As evidenced by
New/unfamiliar disease process, inadequate knowledge about dietary restrictions	Verbalization of incorrect statements, asking for information, development of preventable complications

Risk nursing diagnosis for Diabetic Ketoacidosis (DKA)

#1 Risk for unstable blood glucose level

Associated risk factors

• Excessive physiological or psychological stress

• Non-adherence to the treatment regimen
• Poor diabetic self-management
• Undiagnosed diabetes mellitus
• Alcohol or drug use
• Inadequate knowledge of disease process, management, and complications

#2 Risk for infection

Associated risk factors

• Peripheral nerve damage
• Reduced peripheral tissue perfusion
• Invasive procedures

#3 Risk for injury

Associated risk factors

• confusion
• hypoglycemia
• vascular insufficiency
• blurred vision

#4 Risk for disturbed sensory perception

Associated risk factors

• Electrolyte imbalance
• Glucose/insulin imbalance

Nursing Priorities for a patient with DKA

• Rehydration therapy
• Insulin therapy
• Correction of acid-base imbalance
• Correction of electrolyte imbalance
• Treatment of cerebral edema and underlying comorbidities

Nursing management for Diabetic Ketoacidosis (DKA)

Nursing assessment for DKA

• Monitor blood glucose levels
• Assess vital signs
• Monitor electrolytes and blood gasses
• Monitor ketones
• Asses kidney function and urine output
• Assess mental status
• Asses understanding of diabetes diagnosis
• Check for underlying infections
• Take a comprehensive history once the patient is stable

Nursing interventions for diabetic ketoacidosis (DKA)

• Start two large bore IV cannulas
• Administer aggressive isotonic solutions initially (0.9% Normal saline) as prescribed.
• Continue fluid therapy as advised.
• Replace electrolytes
• Give oral fluids if tolerable
• Closely observe for the signs of fluid overload (such as presence of rales and crackles).
• Monitor and maintain intake and output chart
• Reassure patient and family
• Orient patient to surrounding if confused

Patient teaching for Diabetic Ketoacidosis

• Educate the patient on the importance of compliance with medication and insulin therapy
• Educate on warning signs of hyperglycemia.
• Educate the patient on the importance of follow up
• Educate on insulin injection self-administration
• Encourage the patient to quit smoking and abstain from alcohol
• Encourage a healthy diet; high fiber, low in carbs, fats, and sugars
• Advice the patient to wear an ID bracelet signifying that he or she has had a DKA episode
• Carry out a family teaching session to enforce first aid and prevention measures for DKA episodes.

Sample nursing care plan for Diabetic Ketoacidosis (DKA)

Conclusion

To sum up, you now know 12 NANDA-I nursing diagnosis for diabetic ketoacidosis that you can use in your nursing care plans.

Additionally, you have also learned about nursing assessment, nursing interventions, nursing priorities, and patient teaching for DKA.

Reference

Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences.

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

Swearingen, P. (2016). ALL-IN-ONE Nursing Care Planning Resource (4th ed.). Elsevier/Mosby.