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COMPREHENSIVE NOTES

1. Core Difference: DKA vs HHS
   DKA (Type 1 diabetic, absolute insulin deficiency)

No insulin → body burns fat → ketones formed → metabolic acidosis

Deep, rapid Kussmaul respirations

Total body potassium depleted though serum may appear high

State of starvation + dehydration

HHS (Type 2 diabetic, relative insulin deficiency)

Some insulin remains → prevents ketones → no significant acidosis

Extreme hyperglycemia (often 600–1200+)

Severe dehydration + high serum osmolality

Slow onset, often in older adults

1. Diagnostic Markers
   DKA Diagnostic Triad

Hyperglycemia > 250

Metabolic acidosis

pH < 7.30

Bicarb < 18

Anion gap elevated

Ketones moderate to large (blood or urine)

HHS Diagnostic Markers

Extreme hyperglycemia > 600 (often > 1000)

Serum osmolality > 320

Minimal or no ketones, pH > 7.3

1. DKA Treatment Priorities (FIK Sequence)

This is a major NCLEX priority sequence.

F – Fluids first

Severe dehydration: 4–6 liters lost

Start aggressive normal saline

About 1 liter in the first hour

Goal: restore perfusion and blood pressure quickly

I – Insulin second

Only after fluids have begun

Regular insulin IV bolus → insulin infusion

Critical NCLEX rule: Check potassium FIRST

K – Potassium last

Insulin drives potassium into cells → serum potassium drops fast

If potassium < 3.3 → HOLD insulin and replace potassium immediately

Begin potassium replacement once potassium < 5.2 AND urine output is present

When glucose reaches 200–250

Switch to D5 ½ NS

Purpose: prevent hypoglycemia while continuing insulin to clear ketones and acidosis

1. HHS Treatment Priorities
2. Fluids (most critical)

Fluid loss often 9–12 liters

More aggressive initial resuscitation than DKA

Start 0.9% normal saline, often 1–2 liters in the first hour

1. Slow, careful insulin

Lower dose: ~0.05–0.1 units/kg/hr

Begin only after fluid resuscitation

Target glucose drop: 50–70 per hour

Purpose: prevent cerebral edema, caused by rapid osmotic shifts

1. Prevent thrombosis (HHS-specific)

Hyperosmolar blood → massive thrombosis risk

Early low molecular weight heparin unless contraindicated

Fluid transition

Switch fluids when glucose reaches 250–300

Use 0.45% sodium chloride

1. High-Yield Scenarios
   Scenario 1: DKA with potassium 3.0

Priority:

Start normal saline

Hold insulin

Immediate aggressive potassium replacement

Once potassium rises above 3.3 → start insulin infusion

NCLEX trap: Giving insulin first.

Scenario 2: HHS elderly patient, glucose 1250, osmolality 400

Priority:

Aggressive normal saline

Insert Foley catheter for hourly urine output

Start LMWH for clot prevention

Delay insulin until hydration improves

Then start low-dose insulin infusion slowly

1. Prevention and Patient Education
   Who is high risk for DKA?

Type 1 diabetics

Young adults

Those experiencing diabetes burnout

Patients omitting insulin doses

Any illness that increases metabolic demand

Discharge teaching essentials

Sick-day rules: Never skip insulin

Check blood glucose 4–10 times/day

Check ketones when glucose > 250

1. Evolving Role of Technology

Continuous glucose monitors (e.g., Eversense 365)

Automated insulin delivery systems

Omnipod 5

iLet / Twist system

These systems significantly reduce DKA admissions (40–60%)

Nurses increasingly become educators and system managers rather than crisis responders

Need to reach out? Send an email to Brooke at [email protected]