Diabetic ketoacidosis is a fluid, electrolyte, and insulin problem, and the order matters. The nurse runs the resuscitation while trending the labs that tell you it is working.
Fluids first
Start with the ordered isotonic IV fluid resuscitation to restore volume before insulin does its work. Track intake and output closely, and watch a patient with heart or kidney disease for overload.
Check potassium before insulin
This is the one that catches people. Insulin drives potassium into the cells, so a level that looks normal or high will fall once the drip starts. Do not start the insulin infusion until potassium is above 3.3 mEq/L, and expect to replace potassium as the level drops. Starting insulin on a low potassium can trigger dangerous arrhythmias, so keep the patient on a monitor.
Run the insulin drip and trend the gap
- Give the insulin infusion at the ordered, usually weight-based, rate.
- Check point-of-care glucose hourly.
- Follow the anion gap and ketones, not just the glucose. The drip continues until the gap closes, even after glucose normalizes.
- When glucose reaches the ordered threshold, expect dextrose to be added so the insulin can keep running without going low.
Monitor
- Hourly glucose, and electrolytes on the ordered schedule.
- Cardiac rhythm for the potassium shifts.
- Neuro status. A new headache or drop in alertness during treatment, especially in a young patient, can signal cerebral edema.
- Intake, output, and signs of overload or ongoing dehydration.
When to escalate
New confusion or headache during treatment, a potassium that will not stay in range, a rhythm change, or an anion gap that is not closing. Any of these gets the provider back to the bedside.
For the full clinical picture, see the free DKA nursing care plan, and keep your hourly glucose and electrolytes organized on a free brain sheet.
Sources: American Diabetes Association guidance on holding insulin until potassium is above 3.3 mEq/L in DKA, and standard nursing management references. Follow your facility protocol.