Recognising Diabetic Ketoacidosis for Student Nurses
Learn how to recognise the clinical pattern of diabetic ketoacidosis, assess deterioration systematically and understand why prompt clinical escalation is essential.
What is diabetic ketoacidosis?
DKA occurs when there is insufficient effective insulin and the body begins producing ketones as an alternative source of energy. This can result in hyperglycaemia, metabolic acidosis, dehydration and significant physiological deterioration.
Blood glucose may be raised
A high glucose result can form part of the DKA picture, although it must always be interpreted with other findings.
Ketones may be elevated
Blood ketone testing may form part of the clinical assessment when DKA is suspected.
The patient may deteriorate
Dehydration, vomiting, abnormal breathing and altered consciousness may indicate increasing severity.
What might you notice?
| Finding | Possible presentation | Why it matters |
|---|---|---|
| Thirst | Marked thirst or dry mouth. | Hyperglycaemia may contribute to significant fluid loss. |
| Frequent urination | Passing larger amounts of urine or urinating more often. | Osmotic fluid loss can contribute to dehydration. |
| Nausea and vomiting | Persistent nausea or episodes of vomiting. | These symptoms can worsen dehydration and accompany DKA. |
| Abdominal pain | New abdominal discomfort or pain. | Abdominal symptoms can occur as part of the DKA presentation. |
| Altered breathing | Deep, rapid or otherwise unusual breathing. | Respiratory compensation may occur in metabolic acidosis. |
| Neurological change | Drowsiness, confusion or reduced responsiveness. | Altered consciousness indicates significant deterioration. |
Look for a cluster of findings
Hyperglycaemia becomes particularly concerning when it occurs alongside dehydration, vomiting, abdominal symptoms, unusual breathing or a change in consciousness.
Build the clinical picture quickly
Check blood glucose
Measure glucose when indicated and within your competence and local procedure.
Consider ketone testing
Ketone assessment may be required according to local diabetes guidance and the patient's clinical condition.
Assess hydration
Ask about thirst, urinary frequency, vomiting and fluid intake and look for signs of dehydration.
Observe breathing
Measure respiratory rate and identify deep, rapid or otherwise abnormal breathing.
Assess consciousness
Look for new confusion, drowsiness, difficulty concentrating or reduced responsiveness.
Escalate promptly
Obtain registered or emergency clinical support according to local DKA and deterioration procedures.
Assess significant deterioration systematically
Airway
Confirm that the airway is patent, particularly if consciousness has deteriorated.
Breathing
Assess respiratory rate, depth, pattern, oxygen saturation and work of breathing.
Circulation
Assess pulse, blood pressure, peripheral perfusion and signs of dehydration.
Disability
Assess blood glucose, consciousness and any new neurological changes.
Exposure
Consider temperature, infection, vomiting, fluid loss and other possible clinical triggers.
Emergency escalation
Significant metabolic or physiological deterioration requires prompt registered and medical review.
What may contribute to DKA?
DKA may occur when insulin availability becomes inadequate relative to the body's needs. Understanding the clinical context can support recognition and communication.
Infection or acute stress
Acute illness can increase insulin requirements and contribute to metabolic deterioration.
Interrupted treatment
Missed, reduced or interrupted insulin treatment may contribute to DKA.
Previously unrecognised diabetes
DKA can sometimes be part of the first presentation of diabetes.
When should DKA enter your thinking?
- Significant hyperglycaemia alongside acute illness.
- Marked thirst and increased urinary frequency.
- Signs of dehydration or poor fluid intake.
- Persistent nausea or vomiting.
- New abdominal pain.
- Deep, rapid or otherwise abnormal breathing.
- Increasing pulse or falling blood pressure.
- New drowsiness, confusion or reduced consciousness.
- Raised ketones where testing has been performed.
- Known diabetes with interruption to insulin treatment.
Think metabolic emergency, not simply βhigh sugarβ
The important change is the combination of abnormal glucose, dehydration, ketone production and systemic deterioration.
The patient may deteriorate progressively
Raised glucose
The patient's glucose is elevated but they remain alert and observations are relatively stable.
Symptoms develop
They become increasingly thirsty, begin vomiting and report abdominal discomfort.
Significant deterioration
Respiratory rate increases, breathing becomes deep and the patient appears dehydrated and increasingly drowsy.
The trajectory is important
A worsening clinical pattern over several hours can be a critical clue that apparently simple hyperglycaemia is becoming a serious metabolic emergency.
Putting the findings together
Example
A patient with diabetes has had persistently raised glucose readings during the day.
They now report intense thirst, abdominal discomfort and repeated vomiting.
Their pulse has increased and they appear dehydrated. Their breathing has become noticeably deeper and faster, and they seem increasingly drowsy.
The concern is the combined pattern of hyperglycaemia, dehydration, gastrointestinal symptoms, altered breathing and neurological deterioration.
As a student nurse, recognise the possibility of a serious metabolic emergency, continue an appropriate ABCDE assessment within your competence and obtain prompt registered and medical support according to local procedures.
DKA recognition errors to avoid
- Treating it as βjust high glucose.β Assess for systemic deterioration.
- Ignoring vomiting or abdominal pain. These may be important associated symptoms.
- Missing altered breathing. Deep or rapid breathing can be clinically significant.
- Ignoring dehydration. Review fluid loss, thirst and circulatory observations.
- Failing to consider ketones. Follow local diabetes guidance when DKA is suspected.
- Waiting for reduced consciousness. Deterioration should be escalated earlier.
- Trying to manage independently. DKA requires registered and medical assessment.
Communicate why you are concerned
Example escalation
βI'm concerned about Mr Evans. His glucose has remained high and he has now developed repeated vomiting and abdominal pain. He looks dehydrated, his respiratory rate has increased and his breathing is unusually deep. He is also becoming drowsy.β
This communicates the metabolic concern, symptoms, respiratory change and neurological deterioration.
Recognise β assess β communicate β escalate
Spot the metabolic pattern
Look beyond hyperglycaemia to dehydration, vomiting, abnormal breathing and consciousness.
Use ABCDE
Assess breathing, circulation, glucose, consciousness and the wider physiological picture.
Seek prompt review
Report the glucose trend, symptoms, observations and reason for concern clearly.
Build your metabolic-emergency recognition skills
Continue developing your ability to recognise deterioration, assess patients systematically and communicate urgent concerns through the NurseNet Clinical Confidence pathway.
Explore Clinical Confidence β