Last updated on December 28th, 2023
Here we will formulate sample Diabetic Ketoacidosis (DKA) nursing care plans based on a hypothetical case scenario.
It will include three Diabetic Ketoacidosis (DKA) nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, and nursing interventions with rationales.
DKA Case Scenario
A 56-year-old male presents to the ED with complaints of nausea, vomiting, excessive thirst, and excessive urination.
The patient has a past medical history of hypertension and type 2 diabetes. The patient says that 2 days ago he ran out of insulin and didn’t have enough money to pay for the new prescription.
The patient states: “I thought if I just cut back on eating sweets, I would be fine.” He reports experiencing abdominal pain, blurred vision, fatigue, and most recently, shortness of breath.
Upon examination, the patient appears flushed. He is alert and oriented but says he feels “foggy.” The nurse notes fruity, acetone-scented breath when the patient speaks.
His temperature is 37.5 ˚C, heart rate is 124 BPM, blood pressure is 117/69 mmHg, respirations 37 breaths per minute, and oxygen saturation of 97% on room air.
The patient is taking deep, rapid breaths and his breathing appears labored. No adventitious lung sounds are heard. Significant dry skin is noted.
Upon fingerstick, the patient’s blood sugar is found to be 472 mg/dL. His urine is positive for ketones.
Further blood work reveals an anion gap of 12 mEq/L, sodium of 145 mmol/L, and potassium of 5.9 mmol/L. His BUN and creatinine are slightly elevated at 34 mg/dL and 1.6 mg/dL respectively.
An ABG is drawn revealing pH is 7.23, paCO2 is 32 mmHg, paO2 is 85 mmHg, and HCO3 is 15 mEq/L, confirming metabolic acidosis.
The patient is admitted for Diabetic Ketoacidosis (DKA).
#1 Sample DKA Nursing Care Plan – Risk for unstable blood glucose level
Nursing Assessment
Subjective Data:
- The patient reports recently running out of insulin.
Objective Data:
- The patient’s blood sugar is 472 mg/dL.
- His urine is positive for ketones.
Nursing Diagnosis
Risk for unstable blood glucose level related to insulin deficiency as evidenced by elevated blood sugar and positive ketones in the urine.
Goal/Desired Outcome
Short-term goal: The patient’s blood sugar will be below 150 mg/dL by the end of the shift.
Long-term goal: The patient will have sufficient access to insulin at home, with no further episodes of hyperglycemia.
DKA Nursing Interventions with Rationales – Risk for unstable blood glucose level
| Nursing Interventions | Rationales |
| Administer a regular insulin IV bolus of 0.15 units/kg, then start an insulin infusion of 0.1 units/kg/hr. | An IV insulin infusion is necessary to bring the patient’s blood sugar to a safe level. |
| Check blood sugar every hour, titrating the insulin infusion per facility protocol. | Once the blood sugar is < 250 mg/dL and there’s no change of > 10% for 3 hours, the blood sugar can be checked every 2 hours. |
| Draw serum chemistry every 4 hours, monitoring electrolytes and anion gap. | DKA can cause significant shifts in electrolytes which must be closely monitored. A closed anion gap signifies an improvement in the acid-base balance of the blood. |
| Monitor ABGs. | Monitor ABGs for improving metabolic acidosis which signifies a resolution of DKA. |
| Once the blood sugar is 150-200 mg/dL and the anion gap resolves, begin weaning off insulin per facility protocol. | Once these parameters are met, the patient can begin eating. A subcutaneous insulin dose may be given before discontinuing the insulin infusion. |
#2 Sample DKA Nursing Care Plan – Deficient fluid volume
Nursing Assessment
Subjective Data:
- The patient reports polyuria and polydipsia.
Objective Data:
- The patient’s skin is dry.
- His sodium is slightly elevated at 145 mmol/L.
- His BUN and creatinine are slightly elevated at 34 mg/dL and 1.6 mg/dL respectively.
Nursing Diagnosis
Deficient fluid volume related to diuresis secondary to hyperglycemia as evidenced by dry skin and elevated sodium, BUN, and creatinine.
Goal/Desired Outcome
Short-term goal: By the end of the shift the patient will receive adequate IV hydration and return to a euvolemic state as evidenced by sufficient urine output, moist mucous membranes, and normal skin turgor.
Long-term goal: The patient’s BUN and creatinine will return to normal with no long-term kidney dysfunction.
DKA Nursing Interventions with Rationales – Deficient fluid volume
| Nursing Interventions | Rationales |
| Administer a 1L bolus of 0.9 NS or LR, then start an infusion at 250-500 ml/hr. | DKA causes severe dehydration, a bolus of isotonic fluids must be given to correct the volume depletion. |
| Following the bolus, recheck a sodium level and administer appropriate fluids depending on the result. | If Na > 140 mmol/L, switch fluids to 0.45 NS @ 100-250 ml/hr. If Na < 140 mmol/L, decrease rate of 0.9 NS to 100-250 ml/hr. These fluids should be given concurrently with IV insulin infusion. |
| Once blood sugar reaches 250 mg/dL, administer fluids containing dextrose. | D5/0.45 NS or D5/NS should be administered at a rate of 150-250 ml/hr, while simultaneously receiving IV insulin. |
| Continue to assess for signs of dehydration. | Signs of dehydration are elevated sodium, elevated BUN/creatinine, dry skin, thirst, and low urine output. |
#3 Sample DKA Nursing Care Plan – Deficient knowledge
Nursing Assessment
Subjective Data:
- The patient thought eating fewer sweets would be a substitute for insulin administration.
Objective Data:
- The patient’s blood sugar is 472 mg/dL.
- His urine is positive for ketones.
Nursing Diagnosis
Deficient knowledge related to the role of insulin in diabetes as evidenced by blood sugar of 472 mg/dL and the statement that eating fewer sweets would be a substitute for insulin administration.
Goal/Desired Outcome
Short-term goal: By the end of the shift the patient will be able to explain the function of insulin in the body.
Long-term goal: The patient will successfully manage his diabetes at home, administering insulin as prescribed and checking blood sugar as ordered.
DKA Nursing Interventions with Rationales – Deficient knowledge
| Nursing Interventions | Rationales |
| Educate the patient about the function of insulin and why it’s required in type-2 diabetes. | Type 2 diabetes occurs when the pancreas doesn’t produce enough insulin and/or the cells are resistant to insulin. Without insulin, it is difficult or impossible for glucose to enter the cells. |
| Familiarize the patient with signs and symptoms of hypo and hyperglycemia. | Symptoms of hypoglycemia are lightheadedness, shakiness, headache, irritability, and heart palpitations. Symptoms of hyperglycemia are fruity-smelling breath, dry mouth, excessive thirst, and excessive urination. The blood sugar should be kept above 80 and less than 180 mg/dL. |
| Educate the patient about when to test for ketones at home. | The patient should check for ketones when blood sugar is > 240 mg/dL or when sick. If ketones are positive, the patient should be advised to seek medical attention. |
| Explain the causes of DKA. | Without insulin, an excess amount of glucose circulates in the blood. Cells normally receive energy from glucose, but without glucose, the cells start to break down fat, which releases ketones. Ketones in the blood cause acidosis, which can be deadly. |
| Educate the patient about insulin administration. | Insulin should be administered 15-30 minutes before meals depending on the type of insulin prescribed. |
Conclusion
To sum up, we’ve created scenario-based three sample nursing care plans for Diabetic Ketoacidosis (DKA). These nursing care plans include nursing assessment, NANDA nursing diagnosis, expected outcome, and nursing interventions with rationales 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.
Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.
Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.
