Diabetic Ketoacidosis (DKA) Nursing Care Plan

Nursing Diagnosis 1: Fluid Volume Deficit

Fluid Volume Deficit related to Diabetic ketoacidosis (DKA): hyperglycemia (≥ 250 mg/dL), metabolic acidosis (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 12), and ketosis (serum/urine ketones) as evidenced by Hyperglycemia (≥ 250 mg/dL) with osmotic diuresis; Tachycardia (HR > 110) and orthostatic hypotension; Dry mucous membranes, poor skin turgor, sunken eyes; Urine output < 0.5 mL/kg/hr; Weight loss > 5% from baseline.

Interventions

• Obtain baseline weight and reweigh daily on the same scale, time, and garments when clinical state allows.
• Monitor vital signs (HR, BP, MAP) at intervals matched to clinical acuity and facility protocol; document trend.
• Assess skin turgor, mucous membranes, axillary moisture, and capillary refill at intervals matched to acuity.
• Maintain strict hourly intake and output; calculate running net balance per facility protocol.
• Monitor serum osmolality, Na⁺, BUN, and Cr per provider order during the cardiopulmonary phase of resuscitation.
• Insert a Foley catheter for hourly UOP measurement per provider order in unstable or obtunded patients.
• Administer ordered 0.9% NaCl 15–20 mL/kg over the first hour and continue ordered crystalloid per provider direction and facility protocol.
• Administer ordered 0.45% NaCl at the rate directed by the provider once volume is restored and corrected Na⁺ is normal or high.
• Administer ordered D5-containing maintenance fluid when bedside glucose falls below 250 mg/dL.
• Establish two large-bore peripheral IVs (16–18 g); assist with central access when ordered for hemodynamic instability.
• Elevate head of bed 30° when not contraindicated; avoid Trendelenburg.
• When the patient is alert, teach the patient and family the signs of dehydration (thirst, dizziness, dry mouth, low UOP) and when to seek care early.
• Educate on sick-day rules: continue insulin during illness per provider guidance, check glucose and ketones every 4 hours, and use sugar-free fluids.
• Teach the patient and family the importance of carrying glucose-lowering meds and a medical-ID identifying diabetes for emergency responders.
• Notify the provider for UOP < 0.5 mL/kg/hr for 2 consecutive hours, persistent MAP below ordered parameters, or rising lactate despite ordered resuscitation.
• Coordinate transfer to ICU or step-down per facility DKA protocol for ongoing gtt management.

Outcome: Perfusion indicators are monitored and reported within ordered parameters (MAP, HR); Urine output is monitored and reported per facility protocol; Mucous membranes and capillary refill are assessed and findings documented.

Nursing Diagnosis 2: Spiritual Distress

Electrolyte Imbalance related to Diabetic ketoacidosis (DKA): hyperglycemia (≥ 250 mg/dL), metabolic acidosis (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 12), and ketosis (serum/urine ketones) as evidenced by Total-body potassium deficit (3–5 mEq/kg) masked by acidosis; Insulin therapy will drive K⁺ intracellularly; Ongoing osmotic diuresis with K⁺, Mg²⁺, and PO₄³⁻ losses; Acid-base shift can lower serum K⁺ as pH normalizes; Risk of arrhythmia with K⁺ < 3.3 or > 5.5.

Interventions

• Verify K⁺ before initiating the ordered insulin gtt; recheck every 2 hours initially, then q4h once stable, per facility protocol.
• Maintain continuous cardiac monitoring per facility protocol; document rhythm strip per shift and with electrolyte changes.
• Assess for symptoms of hypokalemia: muscle weakness, leg cramps, diminished reflexes, paralytic ileus.
• Monitor Mg²⁺, PO₄³⁻, and corrected Na⁺ per provider order during the gtt.
• Verify adequate urine output (> 0.5 mL/kg/hr) before administering ordered K⁺ replacement.
• Hold the ordered insulin gtt if K⁺ < 3.3 mEq/L per ADA 2024 and facility protocol; resume per provider order after ordered replacement raises the level to ≥ 3.3.
• Administer ordered KCl 20–30 mEq/L in maintenance fluid when K⁺ is 3.3–5.3 mEq/L with adequate UOP, per provider direction.
• Administer ordered KCl up to 40 mEq/L (central line typically preferred per facility protocol) when K⁺ < 3.3 mEq/L.
• Administer ordered IV magnesium sulfate when Mg²⁺ falls below provider-ordered parameters.
• Administer ordered phosphate replacement only when ordered (typically reserved for PO₄³⁻ < 1.0 mg/dL with symptoms per ADA 2024).
• When the patient is alert, teach the patient and family the symptoms of hypokalemia (weakness, palpitations, fatigue) and hyperkalemia.
• Educate on dietary sources of K⁺ and Mg²⁺ (bananas, potatoes, leafy greens, nuts) for post-discharge care.
• Reinforce continued insulin use during illness per provider guidance to support prevention of recurrent electrolyte crises.
• Notify the provider for K⁺ < 3.3 or > 5.5, new arrhythmia, or ECG changes (peaked T, U-wave, prolonged QT).
• Coordinate with pharmacy for ordered replacement and verify rate-limited K⁺ infusion (typically max 10 mEq/hr peripheral, up to 20–40 mEq/hr central with continuous telemetry per facility protocol). Note: concentration (mEq/L) × rate (mL/hr) determines delivered mEq/hr.
• Escalate symptomatic hypokalemia that persists despite ordered replacement; coordinate central access and continuous telemetry per facility protocol.

Outcome: Serum K⁺ is monitored and reported within ordered parameters throughout treatment; Cardiac rhythm is monitored and changes are reported; Mg²⁺ and PO₄³⁻ are trended and reported per facility protocol.

Nursing Diagnosis 3: Fluid Imbalance

Endocrine Alteration related to Diabetic ketoacidosis (DKA): hyperglycemia (≥ 250 mg/dL), metabolic acidosis (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 12), and ketosis (serum/urine ketones) as evidenced by Absolute or relative insulin deficiency; Counter-regulatory hormone excess (glucagon, cortisol, catecholamines); Hepatic gluconeogenesis and glycogenolysis; Anion gap > 10 mEq/L with positive ketones; Home regimen variability (insulin pump, basal/bolus, or SGLT2 inhibitor).

Interventions

• Check bedside fingerstick glucose every hour while on the ordered IV insulin gtt per facility protocol.
• Perform neuro checks (GCS, headache, new vomiting, bradycardia with hypertension) every 1–2 hours per facility protocol, especially in patients younger than 21 or with rapid glucose or osmolality correction.
• Monitor anion gap and HCO₃⁻ per provider order during the gtt.
• Trend serum or capillary β-hydroxybutyrate per provider order when available.
• Review home insulin regimen and verify last-dose timing on admission.
• Assess for precipitating cause: infection symptoms, MI symptoms, recent steroid use, SGLT2 inhibitor use.
• Administer the ordered regular insulin gtt at 0.1 unit/kg/hr (or 0.05 unit/kg/hr for mild or SGLT2-related euglycemic DKA per provider order) after K⁺ is verified per facility protocol.
• Support the provider’s ordered glucose drop of 50–75 mg/dL/hr; report a faster rate so the provider can adjust the gtt per facility protocol.
• Administer ordered D5-containing fluids when glucose falls below 250 mg/dL; the insulin gtt typically continues per ADA 2024. Pediatric protocols commonly add dextrose earlier (glucose < 300 mg/dL) to support cerebral-edema prevention — refer to the institutional pediatric DKA protocol.
• Support glucose maintenance within ordered parameters (commonly 150–200 mg/dL) until AG closes by adjusting the ordered dextrose-containing fluid, not by stopping the gtt.
• Coordinate ordered SQ transition when the provider documents resolution criteria (pH > 7.3, HCO₃⁻ > 18, AG ≤ 12, tolerating PO).
• Overlap ordered SQ basal insulin with the IV gtt for 1–2 hours before discontinuation per ADA 2024 and facility protocol.
• Teach sick-day rules: continue insulin during illness per provider guidance; check glucose and ketones every 2–4 hours; use sugar-free fluids; call the provider for ketones large or vomiting > 4 hours.
• Reinforce technique: rotation of injection sites, dosing, syringe vs pen vs pump, and storage of insulin.
• Educate on continuous glucose monitor (CGM) use and alarm thresholds when the patient has one.
• Provide a written DKA action plan and sick-day card the patient can keep at home.
• Notify the provider once AG closes so the ordered SQ transition can be initiated and the IV gtt overlapped per facility protocol.
• Coordinate diabetes-educator and endocrinology consultation prior to discharge per facility protocol.

Outcome: Hourly bedside glucose is documented and trends are reported within ordered parameters; Glucose is supported within ordered parameters (commonly 150–200 mg/dL) until anion gap closes; Anion gap and HCO₃⁻ trend are monitored and reported per facility protocol.

Nursing Diagnosis 4: Risk For Infection

Infection Risk related to Diabetic ketoacidosis (DKA): hyperglycemia (≥ 250 mg/dL), metabolic acidosis (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 12), and ketosis (serum/urine ketones) as evidenced by Hyperglycemia can impair neutrophil function; Indwelling lines and Foley catheter typically required for treatment; Possible undiagnosed precipitating infection (UTI, pneumonia, cellulitis); Leukocytosis may be stress-related and obscure source; Diabetic foot ulcer or skin breakdown can be a source of infection.

Interventions

• Obtain a focused infection-source history: dysuria, cough, abdominal pain, foot wound, recent procedure.
• Inspect skin, between toes, perineum, and IV sites on admission and every shift.
• Monitor temperature every 4 hours; report new fever or hypothermia.
• Trend WBC, lactate, and procalcitonin (when available) over the first 24 hours.
• Review urinalysis, chest X-ray, blood and urine cultures from admission.
• Obtain blood, urine, and (when indicated) sputum or wound cultures before ordered antibiotics are administered when feasible per facility protocol.
• Administer ordered empiric antibiotics within 1 hour of suspected sepsis per provider order and facility sepsis protocol.
• Maintain sterile technique with all line insertions, dressing changes, and Foley care per facility protocol.
• Provide meticulous mouth care every 4 hours; oral chlorhexidine per facility VAP-prevention protocol when intubated.
• Reposition and inspect dependent skin every 2 hours; offload pressure points per facility protocol.
• Teach foot inspection, daily skin checks, and prompt provider notification for any new wound.
• Educate on the vaccination schedule per CDC and ACIP guidance: annual influenza, pneumococcal, and COVID boosters.
• Reinforce hand hygiene and avoidance of sick contacts when possible.
• Notify the provider for new fever, rising lactate, hypotension despite ordered fluids, or worsening WBC.
• Coordinate infectious-disease consultation per facility protocol for refractory cases or unusual organisms.

Outcome: Temperature is monitored and reported within ordered parameters; Culture results are reviewed with the provider team and ordered antibiotics are administered as directed; WBC trend is documented and reported after resuscitation.

Nursing Diagnosis 5: Knowledge Deficit

Knowledge Deficit related to Diabetic ketoacidosis (DKA): hyperglycemia (≥ 250 mg/dL), metabolic acidosis (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 12), and ketosis (serum/urine ketones) as evidenced by First DKA episode in newly diagnosed diabetes; Recurrent DKA — more than one admission in 12 months; Patient verbalizes uncertainty about insulin dosing during illness; Misconception that insulin should be held when not eating; Limited health literacy or language barrier.

Interventions

• Assess baseline diabetes knowledge, prior DKA episodes, and self-management capacity.
• Assess health literacy, language preference, and need for interpreter services.
• Assess social determinants: insulin cost, transportation, food security, housing stability.
• Identify the primary caregiver or support person and include them in teaching with patient consent.
• Use teach-back for every key concept (sick-day rules, dosing, ketone checks) per facility protocol.
• Provide written, language-appropriate sick-day plan and DKA action card.
• Demonstrate insulin draw-up, injection sites, pen use, and glucose-meter operation; have the patient demonstrate back per facility protocol.
• Coordinate connection with manufacturer patient-assistance programs or low-cost insulin options before discharge per facility social-work workflow.
• Sick-day rule #1: Continue basal insulin per provider guidance even when not eating; dose changes are made with the provider, not independently.
• Sick-day rule #2: Check glucose every 2–4 hours during illness; check ketones when glucose is above 240 mg/dL or symptomatic.
• Sick-day rule #3: Drink sugar-free fluids (water, broth, diet soda) to support hydration.
• Sick-day rule #4: Call the provider for ketones large or moderate, vomiting > 4 hours, glucose > 300 on two checks, or inability to keep fluids down.
• Educate on DKA warning signs requiring 911 or ED evaluation: severe abdominal pain, rapid deep breathing, confusion, fruity breath, vomiting with high glucose.
• Review correction-factor and carb-counting basics when the patient is on a basal/bolus regimen.
• Teach proper insulin storage: refrigerate unopened, room temperature once in use, and discard after the manufacturer-labeled in-use period.
• Coordinate endocrinology and diabetes-educator follow-up within 7–14 days of discharge per facility protocol.
• Refer to social work for insulin affordability, transportation, or food-insecurity issues identified during admission.
• Document teach-back completion and remaining knowledge gaps in the discharge summary.

Outcome: Patient verbalizes sick-day rules before discharge when ready for teaching; Patient demonstrates insulin technique and glucose monitoring per facility teach-back protocol; Patient identifies signs of DKA and when to seek emergency care.

Diabetic ketoacidosis (DKA) is an acute, life-threatening hyperglycemic crisis defined by the triad of hyperglycemia (≥ 250 mg/dL), metabolic acidosis (pH < 7.30, HCO₃⁻ < 18 mEq/L, anion gap > 12), and ketosis. Historically a complication of type 1 diabetes (T1DM), DKA is increasingly recognized in T2DM and in euglycemic DKA precipitated by SGLT2 inhibitors. Common precipitants include infection (the most frequent trigger), missed or inadequate insulin, acute MI, pancreatitis, alcohol, pregnancy, and new-onset diabetes. Pathophysiologically, an absolute or relative insulin deficiency combined with excess counter-regulatory hormones (glucagon, catecholamines, cortisol, growth hormone) drives unrestrained lipolysis, releasing free fatty acids (FFAs) that the liver converts to ketoacids (β-hydroxybutyrate, acetoacetate). The resulting metabolic acidosis is partially compensated by Kussmaul respirations. Simultaneous hyperglycemia produces osmotic diuresis, causing severe volume depletion (typical deficit 5–9 L) and large losses of Na⁺, K⁺, Mg²⁺, and phosphate. DKA is distinguished from hyperosmolar hyperglycemic state (HHS), which presents with higher glucose (> 600 mg/dL), higher osmolality (> 320 mOsm/kg), minimal ketosis, and no significant acidosis (pH > 7.30, HCO₃⁻ > 18 mEq/L, minimal ketonuria). Per ADA Standards of Care 2024, treatment centers on fluid resuscitation, IV insulin infusion (no bolus), aggressive K⁺ replacement, and identification of the precipitant; nurses support these ordered therapies through assessment, administration as ordered, monitoring, and escalation per facility protocol.

• Glucose drop (ordered): 50–75 mg/dL/hr; add dextrose when < 250
• Initial fluids (ordered): NS 15–20 mL/kg first hour
• Insulin gtt (ordered): 0.1 unit/kg/hr after K⁺ check
• K⁺ replacement: Typically started when K⁺ < 5.3 with adequate UOP
• Bicarbonate (ordered): Typically reserved for pH < 6.9

• Makic, M. B. F., & Martinez-Kratz, M. R. (Eds.). (2023). Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier.
• American Diabetes Association. (2024). Standards of Care in Diabetes—2024. Diabetes Care, 47(Suppl. 1), S1–S322.
• Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 32(7), 1335–1343.
• Umpierrez, G., & Korytkowski, M. (2016). Diabetic emergencies — ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nature Reviews Endocrinology, 12(4), 222–232.