9.5 Diabetic Emergencies (Hypoglycemia and DKA)

NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

9.5 Diabetic Emergencies (Hypoglycemia and DKA)

Key Takeaways Explain This Topic AI

Hypoglycemia (blood glucose < 70 mg/dL) presents with cold, clammy skin, tremors, confusion, and tachycardia

Rule of 15 for conscious hypoglycemia: Give 15 g fast-acting carbs, wait 15 minutes, recheck glucose

Unconscious hypoglycemia requires IV D50W (25-50 mL) or IM glucagon

DKA (2024 adult consensus) requires glucose ≥ 200 mg/dL or known diabetes, plus elevated ketones and metabolic acidosis; Kussmaul respirations and fruity breath are classic signs

DKA treatment: IV fluids, insulin and potassium; if K+ is below 3.5 mEq/L, replace potassium first and delay insulin until K+ is above 3.5, and start replacement once K+ falls below 5.0

Last updated: October 2026

Diabetic Emergencies

Diabetic emergencies can be rapidly fatal if not recognized and treated promptly. Nurses must differentiate between hypoglycemia (too little glucose) and hyperglycemic crises (too much glucose) to provide appropriate intervention.

Hypoglycemia (Low Blood Sugar)
Definition: Blood glucose < 70 mg/dL

Hypoglycemia is the most immediately dangerous diabetic emergency because the brain depends on glucose for function.

Causes of Hypoglycemia

Category Examples
Medication-Related Too much insulin, sulfonylureas, skipping meals after insulin
Activity Excessive exercise without carbohydrate adjustment
Dietary Missed meals, inadequate food intake, alcohol
Illness Vomiting, diarrhea, malabsorption
Signs and Symptoms
Think "Cold and Clammy" for hypoglycemia

Mild Hypoglycemia (50-70 mg/dL):

Tremors, shakiness
Sweating (diaphoresis)
Tachycardia, palpitations
Anxiety, irritability
Hunger
Pallor

Moderate Hypoglycemia (40-50 mg/dL):

Confusion
Difficulty concentrating
Slurred speech
Blurred vision
Drowsiness
Mood changes

Severe Hypoglycemia (< 40 mg/dL):

Loss of consciousness
Seizures
Coma
Death (if untreated)
Treatment: The Rule of 15

For Conscious Patients:

Give 15 grams of fast-acting carbohydrates:

4 oz (1/2 cup) fruit juice
4 oz regular soda (not diet)
3-4 glucose tablets
1 tablespoon honey or sugar
Wait 15 minutes
Recheck blood glucose
If still < 70 mg/dL, repeat steps 1-3
Once glucose > 70 mg/dL, eat a snack with protein and complex carbs

For Unconscious Patients:

IV access available: D50W (Dextrose 50%) 25-50 mL IV push
No IV access: Glucagon 1 mg IM or SubQ
Position patient on side (aspiration precaution)
Do NOT give oral glucose (aspiration risk)

Exam Tip: Never give oral glucose to an unconscious patient. If no IV access, give glucagon IM. Once the patient regains consciousness, follow with oral carbohydrates.

Diabetic Ketoacidosis (DKA)

Definition (2024 adult consensus report on hyperglycemic crises): all three must be present:

D iabetes: blood glucose ≥ 200 mg/dL or a known history of diabetes, whatever the glucose (about 10% of patients present with euglycemic DKA, glucose < 200 mg/dL)

K etones: elevated (blood β-hydroxybutyrate ≥ 3.0 mmol/L is the preferred test)
A cidosis: pH < 7.30 or serum bicarbonate < 18 mEq/L

DKA occurs primarily in Type 1 diabetes but can occur in Type 2 under stress.

Pathophysiology
Absolute or relative insulin deficiency
Body cannot use glucose for energy
Fat breakdown produces ketone bodies (acids)
Ketoacidosis develops
Osmotic diuresis causes severe dehydration
Electrolyte imbalances occur
Causes (The I's)
I nfection (one of the two most frequent triggers, especially urinary tract infection and pneumonia)
I nsulin missed or inadequate (the other most frequent trigger)
I nfarction (MI, stroke)
I llness or stress
I nitial presentation of Type 1 diabetes
Signs and Symptoms
Think "Hot and Dry" for DKA

System Findings
Metabolic Hyperglycemia (usually ≥ 200 mg/dL; about 10% present with glucose < 200 mg/dL)
Respiratory Kussmaul respirations (deep, rapid), fruity/acetone breath
Neurological Altered mental status, confusion, lethargy
GI Nausea, vomiting, abdominal pain
Cardiovascular Tachycardia, hypotension, dehydration
Skin Warm, dry, flushed, poor turgor
Urinary Polyuria (until dehydrated), ketones in urine
Laboratory Findings in DKA

Lab Finding
Blood glucose ≥ 200 mg/dL, or any level with known diabetes (euglycemic DKA < 200 mg/dL)
pH < 7.30 (acidosis)
HCO3 < 18 mEq/L (low bicarbonate)
Serum ketones Elevated (β-hydroxybutyrate ≥ 3.0 mmol/L)
Potassium May be high, normal, or low (total body depleted)
Anion gap Elevated (> 12)
BUN/Creatinine Elevated (dehydration)
Treatment of DKA

Mainstays (2024 adult consensus): fluid replacement, insulin, electrolyte (potassium) repletion, and treatment of the precipitating cause. Check potassium before the insulin starts.

1. Fluid Resuscitation

Initial (adults without kidney or heart compromise): isotonic saline or a balanced crystalloid at 500-1,000 mL/hour for the first 2-4 hours

Older adults, heart failure, or dialysis-dependent kidney disease: smaller boluses (for example, 250 mL) with frequent hemodynamic checks

Afterward: fluid choice and rate follow hydration status (blood pressure, heart rate, intake and output) and sodium

When glucose falls below 250 mg/dL: add 5-10% dextrose to the saline (prevents hypoglycemia while insulin continues until the ketoacidosis resolves)

2. Insulin Therapy

Preferred: short-acting (Regular) insulin by continuous IV infusion, usually a fixed rate of 0.1 units/kg/hour or a nurse-driven variable-rate protocol

Bolus: 0.1 units/kg IV or IM when a delay in IV access is anticipated

Uncomplicated mild or moderate DKA: subcutaneous rapid-acting insulin analogs every 1-2 hours are an effective alternative

Once glucose is below 250 mg/dL, the infusion is usually reduced (about 0.05 units/kg/hour) to keep glucose near 200 mg/dL until the ketoacidosis resolves

Cerebral edema is rare in adults; rapid shifts in osmolality may contribute, so watch for mental status changes

3. Potassium Replacement

Critical: Always check potassium BEFORE starting insulin!

Serum K+ (adults, 2024 consensus) Action
< 3.5 mEq/L Start potassium replacement (about 10 mEq/hour) and delay insulin until K+ is above 3.5

3.5-5.0 mEq/L Give insulin and replace potassium to keep K+ at 4-5 (20-30 mEq per liter of IV fluid is usually enough)

> 5.0 mEq/L Give insulin; start potassium replacement once K+ falls below 5.0

Recheck potassium 2 hours after insulin starts, then every 4 hours until the DKA resolves.

Why potassium is critical: Insulin drives potassium INTO cells. Starting insulin when K+ is low can cause life-threatening cardiac arrhythmias and respiratory muscle weakness.

4. Treat Underlying Cause
Antibiotics for infection
Address medication non-compliance
Patient education
Comparing Hypoglycemia and DKA

Feature Hypoglycemia DKA
Onset Rapid (minutes) Gradual (hours to days)
Glucose < 70 mg/dL ≥ 200 mg/dL or known diabetes (can be < 200)
Skin Cold, clammy, pale Warm, dry, flushed
Breathing Normal or rapid Kussmaul (deep, rapid)
Breath Odor Normal Fruity, acetone
Mental Status Confused → unconscious Confusion → coma
Treatment Glucose (oral or IV) Fluids, insulin, K+
Quick Memory Aid
Hypoglycemia = Cold and Clammy, need some Candy
DKA = Hot and Dry, Sugar High
Hyperosmolar Hyperglycemic State (HHS)

Brief mention for comparison:

More often seen in older adults with type 2 diabetes (it can occur with any type)
Blood glucose often > 600 mg/dL

No significant ketoacidosis, though mild ketonemia may be present; DKA and HHS overlap in more than a third of hyperglycemic crises

Severe dehydration and hyperosmolarity
Treatment similar to DKA but may need less insulin
Nursing Considerations
For Hypoglycemia
Check blood glucose before treating if possible (but do not delay treatment)
Teach patients to always carry fast-acting glucose
Review medication and meal timing
Educate on symptoms and self-treatment
For DKA
Capillary blood glucose checks every 1-2 hours during treatment
Strict intake and output
Telemetry monitoring (potassium affects heart)
Neurological checks (report any change in mental status)

Electrolytes, phosphate, creatinine, β-hydroxybutyrate and venous pH about every 4 hours; potassium 2 hours after insulin starts, then every 4 hours

Key Points for the NCLEX
Hypoglycemia is an immediate emergency - treat first, verify later if needed
Rule of 15: 15g carbs, wait 15 minutes, recheck
Unconscious patient: IV D50W or IM glucagon - never oral glucose
DKA: Fluids FIRST, then insulin
Check potassium before starting insulin in DKA
Kussmaul respirations and fruity breath = DKA
Add 5-10% dextrose once glucose falls below 250 mg/dL during DKA treatment