Nanda - Nursing Care Plan

7 Nursing Diagnosis for Diabetic Ketoacidosis


Diabetic Ketoacidosis is a medical condition which most likely occurs in patients with Type 1 Diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead.

Diabetic Ketoacidosis is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism. The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes.

Another term for this complication is DKA. Although it is present in Type 1 Diabetes patients, they can also be found in patients who are classified as Type 2 Diabetes. In some instances, this condition is the initial sign that determines people are diabetic.

Symptoms can include:
  • Deep, rapid breathing
  • Nausea and vomiting
  • Dry skin and mouth
  • Stomach pain
  • Flushed face
  • Fruity smelling breath

Other symptoms that can occur include:
  • Breathing difficulty while lying down
  • Abdominal pain
  • Decreased consciousness
  • Decreased appetite
  • Dulled senses that may worsen to a coma
  • Fatigue
  • Muscle stiffness or aches
  • Shortness of breath
  • Frequent urination or thirst that lasts for a day or more
  • Headache

The treatment for Diabetic Ketoacidosis often involves fluid replacement orally or through an IV, electrolyte replacement, and insulin therapy. There are also other instances wherein the patient will need further treatment. When this happens, it is best to follow what the physician recommends.


7 Nursing Diagnosis for Diabetic Ketoacidosis

1. Fluid Volume Deficit
related to:
osmotic diuresis due to hyperglycemia,
excessive discharge: diarrhea, vomiting; restriction intake due to nausea, mental mess.

2. Imbalanced Nutrition: Less Than Body Requirements
related to:
insufficiency of insulin,
decreased oral input,
hipermetabolisme status.

3. Risk for Infection (sepsis)
related to:
increased levels of glucose,
decreased leukocyte function,
changes in the circulation.

4. Risk for Sensory-Perceptual Alterations
related to:
ketidkseimbangan glucose / insulin and / or electrolytes.

5. Fatigue
related to:
decreased metabolic energy production,
insufficiency of insulin,
increasing energy demand: status hypermetabolic / infection.

6. Powerlessness
related to:
long-term illness,
dependence on others.

7. Knowledge Deficit: the disease, prognosis, and treatment
related to:
interpreting the error information,
do not know the source of information.