in the peripheral tissues _ Occurs most in DM I, but seen in DM 2 – severe stress, surgery, trauma and most common cause INFECTION _ Hyperglycemia leads to osmotic diuresis with dehydration and electrolyte loss. _ Manifestations: _ 3 Ps, vomiting, abdominal pain, dehydration, weakness, confusion, shock, coma _ Mental Status can vary – alert to profound coma _ as ketones rise – pH of blood decreases – acidosis occurs _ Kussmaul respirations (very deep and rapid respirations) cause respiratory alkalosis to correct metabolic acidosis by exhaling carbon dioxide. _ Na – low or normal – depending on severity _ K – depend on how long DKA existed before treatment. After therapy, K levels drop off quickly. Interventions: _ Assess: Airway, LOC, hydration status, electrolytes, and blood glucose _ Fluid/Electrolyte mgt: assess fluid status; risk for dehydration/shock; fluid overload _ 1st: Provide rapid isotonic fluid (0.9% sodium chloride) replacement to maintain perfusion to vital organs. _ Initial Infusion of 0.9% sodium chloride are 15-20 mL/kg/hr during 1st hr _ 2nd outcome achieved more slowly. fluid replacement depends on BP, electrolytes, urine output. In general 0.45% sodium chloride , infused at 4-14 mL/kg/hr _ when Glucose levels reach 250 mg/dL infuse 5% dextrose in 0.45% sodium chloride to prevent hypoglycemia and cerebral edema. _ Insulin therapy used to lower serum glucose by about 50 to 75 mg/dL/hr by continuous IV infusion _ DKA is considered resolved when BG < 200 mg/dL; pH 7.3 _ mild-moderate hyperkalemia is common initially. _ Insulin therapy, correction of acidosis, and volume expansion = decreased serum K. To prevent hypokalemia: K replacement is initiated after serum levels fall below upper limits of normal. ** Before giving IV POTASSIUM solutions, make sure the urine output is at least 30 mL/hr Teaching: Teach measures to prevent dehydration: _ unless contraindicated: consume 2-3 L/day of water _ if BG levels are low, consume liquids with sugar _ monitor BG every 4 hr when ill, and continue to take insulin! _ teach clients to check urine for ketones if BG is 240 mg/dL _ consume liquids with carbohydrates and electrolytes when unable to eat solid foods KNOW your insulins: rapid acting, short acting. Intermediate acting & long acting Know onset, peak, & durations 
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