Diabetic Ketoacidosis & HHNS Nursing Care Plan
Acute hyperglycemic emergencies needing fluids, insulin infusion and potassium replacement.
Quick answer
A Diabetic Ketoacidosis & HHNS nursing care plan centers on restore circulating volume and tissue perfusion with isotonic fluid; correct potassium before and during insulin therapy; give a continuous low-dose iv regular insulin infusion to close the anion gap. Priority nursing diagnoses are Deficient fluid volume, Risk for electrolyte imbalance, Risk for unstable blood glucose. The plan below gives assessment cues, measurable goals, 5 intervention sets with rationales, and patient teaching.
Overview
Diabetic ketoacidosis is an acute, life-threatening complication of an absolute insulin deficiency, most often in type 1 diabetes. Without insulin the cells cannot take up glucose, so the liver breaks down fat for fuel, generating ketoacids. The result is the diagnostic triad: hyperglycemia, ketosis and metabolic acidosis.
The hyperglycemia produces an osmotic diuresis that strips the body of water, sodium, potassium, chloride and phosphate. Patients commonly arrive several liters depleted, with hypotension and tachycardia. Meanwhile the acidosis drives deep, rapid Kussmaul respirations that blow off carbon dioxide as compensation, and gives the breath a fruity acetone odor.
The single most dangerous trap is potassium. Acidosis shifts potassium out of cells, so the serum level may look normal or high even though total body potassium is profoundly depleted. As soon as insulin and fluids are started, potassium moves back into cells and the level can plummet into fatal arrhythmia. Insulin is therefore withheld until potassium is above roughly 3.3 mEq/L, and potassium is replaced continuously during treatment.
Key numbers to know
Diagnostic triad
Glucose usually above 250 mg/dL, arterial pH below 7.30 with bicarbonate under 18 mEq/L, and positive serum or urine ketones.
First intervention
Isotonic IV fluid — usually 0.9% sodium chloride — begun before or alongside insulin; volume replacement alone lowers glucose substantially.
Potassium rule
Hold insulin if potassium is below about 3.3 mEq/L and replace first; check potassium every 1–2 hours during therapy.
Add dextrose
When glucose reaches roughly 200–250 mg/dL, add dextrose to the fluid and continue the insulin infusion until the acidosis and ketones clear.
Common triggers
Infection, missed or insufficient insulin, new-onset diabetes, myocardial infarction, pancreatitis, steroids and pump failure.
Nursing priorities
- Restore circulating volume and tissue perfusion with isotonic fluid.
- Correct potassium before and during insulin therapy.
- Give a continuous low-dose IV regular insulin infusion to close the anion gap.
- Monitor glucose hourly and electrolytes and pH frequently.
- Identify and treat the precipitating cause, especially infection.
- Protect the airway and monitor neurologic status for cerebral edema.
- Prevent hypoglycemia and hypokalemia during correction.
- Teach sick-day rules to prevent recurrence.
Nursing assessment
Subjective data
- Excessive thirst, frequent urination and unrelenting hunger progressing to anorexia
- Nausea, vomiting and diffuse abdominal pain
- Weakness, fatigue, blurred vision and headache
- Recent illness, infection or missed insulin doses
Objective data
- Glucose typically above 250 mg/dL with positive serum or urine ketones
- Arterial pH below 7.30, bicarbonate below 18 mEq/L and an elevated anion gap
- Kussmaul respirations — deep and rapid — with a fruity, acetone breath odor
- Hypotension, tachycardia, weak thready pulse, poor skin turgor, dry mucous membranes
- Decreasing level of consciousness ranging from drowsiness to coma
- Potassium that may be normal or high initially despite total body depletion
- Elevated BUN, creatinine, hematocrit and osmolality from dehydration
- Hourly urine output and continuous cardiac rhythm for potassium-related changes
Related factors
- Absolute insulin deficiency with unopposed counterregulatory hormones
- Osmotic diuresis from hyperglycemia causing profound fluid and electrolyte loss
- Lipolysis producing ketoacids and metabolic acidosis
- Infection or other physiologic stress raising insulin requirements
- Insulin omission, pump malfunction, or undiagnosed type 1 diabetes
Key nursing diagnoses
Goals and expected outcomes
- The client will regain fluid balance with stable blood pressure, heart rate under 100, moist mucous membranes and urine output of at least 30 mL/hr.
- The client will achieve a closing anion gap, pH above 7.30 and bicarbonate above 18 mEq/L.
- The client will maintain serum potassium within normal range with no dysrhythmia.
- The client will have glucose lowered gradually without hypoglycemia or neurologic deterioration.
- The client will return to baseline level of consciousness.
- The client will explain sick-day management, ketone testing and when to seek care before discharge.
Nursing interventions and rationales
1. Fluid resuscitation
- Establish large-bore IV access and begin isotonic 0.9% sodium chloride, often at 15–20 mL/kg in the first hour, adjusted for cardiac and renal status.
- Switch to 0.45% sodium chloride once the patient is hemodynamically stable and corrected sodium is normal or high, to address the free water deficit.
- Measure strict hourly intake and output; urine output is a practical bedside marker of restored perfusion.
- Monitor for fluid overload — crackles, jugular distention, dyspnea — particularly in older adults and those with heart or kidney disease.
- Add dextrose to the infusion when glucose falls to roughly 200–250 mg/dL so the insulin drip can continue clearing ketones without causing hypoglycemia.
2. Insulin therapy
- Use only regular insulin intravenously for DKA; other formulations are not given by IV push or infusion in this setting.
- Confirm serum potassium is above about 3.3 mEq/L before starting insulin — giving insulin first can drive an already low potassium into fatal arrhythmia.
- Administer by continuous low-dose infusion on a pump, typically around 0.1 units/kg/hr, and prime the tubing since insulin adsorbs to plastic.
- Aim for a controlled fall in glucose of roughly 50–75 mg/dL per hour; a faster drop risks cerebral edema.
- Continue the infusion until the anion gap closes and ketones clear, not merely until glucose normalizes — stopping early lets ketoacidosis rebound.
- Overlap subcutaneous insulin with the infusion by one to two hours before discontinuing the drip to avoid a gap in coverage.
- Check capillary glucose hourly during the infusion.
3. Electrolyte and acid–base management
- Recheck potassium every one to two hours during active treatment and keep continuous cardiac monitoring in place.
- Add potassium to IV fluids once the level is below about 5.2 mEq/L and urine output is adequate, since total body stores are always depleted.
- Watch the ECG for the sequence of hypokalemia — flattened T waves, ST depression and U waves — and for peaked T waves of hyperkalemia.
- Monitor sodium, chloride, magnesium and phosphate; correct magnesium when potassium is difficult to replete.
- Reserve bicarbonate for severe acidosis, generally pH under 6.9, because it can worsen hypokalemia and cause paradoxical central nervous system acidosis.
- Follow the anion gap and venous pH as the true markers of resolution rather than glucose alone.
4. Monitoring and preventing complications
- Assess neurologic status frequently; a headache, altered behavior or falling level of consciousness during treatment may signal cerebral edema — a particular risk in children and with rapid correction.
- Protect the airway in an obtunded patient and position to prevent aspiration; insert a nasogastric tube if vomiting persists and consciousness is impaired.
- Recognize that abdominal pain and elevated white count often come from the ketoacidosis itself, but do not assume — evaluate for a surgical cause and infection.
- Search for the precipitant: cultures, chest radiograph, urinalysis and ECG, since infection and myocardial infarction are common triggers and may be painless in diabetes.
- Provide thromboprophylaxis and frequent repositioning during immobility and dehydration.
- Give oral care and reassurance frequently — patients are extremely thirsty and often NPO initially.
5. Preventing recurrence through education
- Teach the sick-day rules explicitly: never omit insulin during illness, check glucose every 3–4 hours, test ketones when glucose exceeds 240 mg/dL, and drink sugar-free fluids to stay hydrated.
- Ensure the patient owns and can use ketone test strips and knows the threshold for calling the provider.
- Review insulin technique, storage, site rotation, and pump troubleshooting; a kinked or dislodged pump catheter can cause DKA within hours.
- Distinguish DKA from hypoglycemia symptoms so the patient responds correctly to each.
- Explore the real reason for omission — cost, needle fear, depression, eating disorder, lack of supplies — and address it, since blaming nonadherence without solving the cause guarantees readmission.
- Arrange diabetes education, follow-up and a written action plan before discharge.
Patient and family teaching
- Never stop taking insulin when you are sick, even if you cannot eat — illness raises your insulin needs.
- During illness check your glucose every 3–4 hours and test for ketones any time glucose is above 240 mg/dL.
- Drink plenty of sugar-free fluids and take small amounts of carbohydrate if you cannot eat a normal meal.
- Call your provider for vomiting you cannot control, moderate or large ketones, glucose above 300 mg/dL that will not come down, or fever.
- Go to the emergency department for deep rapid breathing, fruity breath, severe abdominal pain, or confusion.
- Keep spare insulin, syringes or pump supplies, glucose meter strips and ketone strips on hand at all times.
- Wear medical identification stating you have diabetes.
- Keep regular appointments and bring your glucose log or meter to every visit.
How to build this plan
- 1Assess the patient. Collect subjective and objective data through interview, physical assessment, labs and chart review. Complete, accurate data is the foundation of every later step.
- 2Analyze and cluster the data. Group related cues, compare them with normal findings, and identify patterns that point to actual or potential problems.
- 3Formulate nursing diagnoses. Write the problem statement using a recognized diagnostic label plus related factors and evidence (problem related to cause as evidenced by signs).
- 4Set priorities. Rank diagnoses as high, medium or low using ABCs, Maslow's hierarchy and the patient's own stated priorities. Life-threatening problems come first.
- 5Establish goals and outcomes. Write SMART, patient-centered outcomes: specific, measurable, attainable, realistic and time-bound (short-term and long-term).
- 6Select nursing interventions. Choose independent, dependent and collaborative actions that are safe, evidence-based and matched to the outcome.
- 7Provide rationales. State the scientific reason each intervention works. Rationales are what turn a task list into clinical reasoning.
- 8Evaluate the plan. Compare the patient's actual response with the expected outcome: met, partially met or not met — then continue, revise or discontinue.
- 9Document and communicate. Record the plan and the patient's response in the health record so the whole team works from the same information.
Summarized for study use. Always follow your school's or facility's approved care plan format and current clinical policy.
Practice Diabetic Ketoacidosis & HHNS questions
These concepts are tested on the ATI proctored exams below — every set has answers and rationales.
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Common questions
What are the nursing diagnoses for Diabetic Ketoacidosis & HHNS?
Priority nursing diagnoses for Diabetic Ketoacidosis & HHNS: Deficient fluid volume; Risk for electrolyte imbalance; Risk for unstable blood glucose.
What are the nursing interventions for Diabetic Ketoacidosis & HHNS?
Establish large-bore IV access and begin isotonic 0.9% sodium chloride, often at 15–20 mL/kg in the first hour, adjusted for cardiac and renal status. Switch to 0.45% sodium chloride once the patient is hemodynamically stable and corrected sodium is normal or high, to address the free water deficit. Measure strict hourly intake and output; urine output is a practical bedside marker of restored perfusion. Monitor for fluid overload — crackles, jugular distention, dyspnea — particularly in older adults and those with heart or kidney disease. Add dextrose to the infusion when glucose falls to roughly 200–250 mg/dL so the insulin drip can continue clearing ketones without causing hypoglycemia. Use only regular insulin intravenously for DKA; other formulations are not given by IV push or infusion in this setting.
What are the nursing care goals for Diabetic Ketoacidosis & HHNS?
The client will regain fluid balance with stable blood pressure, heart rate under 100, moist mucous membranes and urine output of at least 30 mL/hr. The client will achieve a closing anion gap, pH above 7.30 and bicarbonate above 18 mEq/L. The client will maintain serum potassium within normal range with no dysrhythmia. The client will have glucose lowered gradually without hypoglycemia or neurologic deterioration. The client will return to baseline level of consciousness. The client will explain sick-day management, ketone testing and when to seek care before discharge.
What should you assess in a patient with Diabetic Ketoacidosis & HHNS?
Excessive thirst, frequent urination and unrelenting hunger progressing to anorexia; Nausea, vomiting and diffuse abdominal pain; Weakness, fatigue, blurred vision and headache; Recent illness, infection or missed insulin doses; Glucose typically above 250 mg/dL with positive serum or urine ketones; Arterial pH below 7.30, bicarbonate below 18 mEq/L and an elevated anion gap; Kussmaul respirations — deep and rapid — with a fruity, acetone breath odor; Hypotension, tachycardia, weak thready pulse, poor skin turgor, dry mucous membranes; Decreasing level of consciousness ranging from drowsiness to coma; Potassium that may be normal or high initially despite total body depletion; Elevated BUN, creatinine, hematocrit and osmolality from dehydration; Hourly urine output and continuous cardiac rhythm for potassium-related changes