A nurse is caring for a client in the emergency department. For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Rationale • Creatinine greater than expected reference range: Elevated creatinine indicates dehydration and potential acute kidney injury, which can occur in both DKA and HHS due to fluid loss. In DKA, osmotic diuresis from hyperglycemia and ketone-induced volume depletion contribute to impaired renal function. In HHS high serum osmolarity from extreme hyperglycemia leads to reduced renal perfusion and elevated creatinine levels. • Skin turgor: Poor skin turgor reflects extracellular fluid volume depletion due to osmotic diuresis. Both DKA and HHS cause significant fluid loss from hyperglycemia, leading to dehydration. Assessment of skin turgor provides an early clinical clue to the severity of volume depletion. • Urine ketones: Presence of ketones in urine is a hallmark of DKA, resulting from fat metabolism due to insulin deficiency. Ketone accumulation leads to metabolic acidosis and distinguishes DKA from HHS, in which ketones are minimal or absent. Monitoring ketones helps guide insulin therapy and acid-base correction. • Blood glucose greater than expected reference range: Hyperglycemia is present in both DKA and HHS, though DKA levels are typically above 250 mg/dL, while HHS often exceeds 600 mg/dL. Elevated glucose contributes to osmotic diuresis, dehydration, and electrolyte imbalance in both conditions. • Blood pH: Metabolic acidosis with low pH occurs in DKA due to accumulation of ketone bodies. The pH usually falls below 7.35. In contrast, HHS generally does not cause significant acidosis, making low pH a distinguishing feature for DKA.