a. Hyperglycemia and ketoacidosis (also referred to as diabetic coma) result from too much sugar in the blood (in relation to the amount of insulin).

This situation can be caused by eating more food than allowed, taking too little or no insulin, illness, or infection.

Remember that insulin regulates glucose metabolism and that insufficient insulin will cause an inability to utilize the glucose. Glucose accumulates in the blood (hyperglycemia) and is unable to be used as a source of energy due to the lack of insulin. When glucose cannot be utilized, the body must break down fats and proteins for energy. If too many by-products of fat and protein metabolism (ketones) accumulate in the body, an acid-base imbalance will occur. This condition is called acidosis, or ketoacidosis. If this condition is left undetected or untreated, coma and death will result.

b. Signs and symptoms of diabetic ketoacidosis include the following. Onset is gradual, occurring over several hours to several days.

(1) Hot, dry, flushed skin.

(2) Absence of sweating.

(3) “Fruity” odor to breath (acetone).

(4) Slow and labored respirations, air hunger.

(5) Anorexia and nausea.

(6) Tachycardia.

(7) Hypotension.

(8) Polydipsia (excessive thirst).

(9) Large and frequent urine output (polyuria).

(10) Presence of sugar and acetone in the urine.

(11) High blood sugar level.

c. Pathophysiology.

(1) As mentioned above, when glucose cannot be utilized, fats and proteins are broken down for energy. Their by-products (ketones) accumulate in the blood. Ketone bodies are strong acids that can lower blood pH, producing metabolic acidosis (ketoacidosis).

(2) Electrolyte disturbances occur as a result of polyuria, dehydration, and the alteration in pH.

(3) Hypothermia and a lack of pyrexial response (fever) to infection may occur.

(4) Level of consciousness will begin to alter (probably due to diminished brain perfusion of oxygen), resulting in coma and death if the condition is left untreated.

d. Nursing management.

(1) Administer insulin. (The physician will usually order administration of a low dose of regular insulin intravenously.)

(2) Draw blood for a glucose level.

(3) Monitor vital signs and level of consciousness carefully.

(4) Force fluids (usually IV).

(5) Insert a retention catheter to monitor urine output.

(6) Observe for respiratory changes.

(7) Observe accurate I & O.

(8) Document all information in the patient’s clinical record.