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Diabetic ketoacidosis and the hyperosmolar state on the ward: monitoring, fluids, potassium and insulin-infusion checks

  • Assessment

On the ward the nurse recognises a hyperglycaemic crisis, starts the first checks, calls early and watches fluids, potassium and mental status.

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What it is

Diabetic ketoacidosis (DKA) is high glucose with ketones and metabolic acidosis; it is more common in younger people with type 1 diabetes and develops over hours to days. The hyperosmolar hyperglycaemic state (HHS) is very high glucose with severe dehydration and high osmolality but little ketosis; it is more common in older people with type 2 diabetes and develops over days to weeks. Infection is the most common trigger. Treatment rests on IV fluids, insulin and electrolytes, plus treating the cause. On the ward the nurse recognises the crisis, starts the first checks, escalates and monitors. Severe DKA, HHS, reduced consciousness or a critical trigger need ICU or high-dependency care; the ICU insulin infusion has its own page.

Reference values

  • DKA: hyperglycaemia + ketones in blood or urine + metabolic acidosis. HHS: very high glucose + high serum osmolality, with little ketosis or acidosis.
  • First tests usually include glucose, electrolytes, venous blood gas, blood count, ketones and an ECG; osmolality is added in HHS.
  • Monitoring during treatment: glucose every 1–2 hours; electrolytes, ketones and venous pH about every 4 hours, as the protocol states.
  • Resolution is judged on ketones and venous pH or bicarbonate (in HHS, on osmolality, urine output and mental status), not on urine ketones.

What you need

  • Glucose meter and, if available, a blood ketone meter.
  • ECG and, as the protocol states, a cardiac monitor; IV access and the infusion pump; intake and output chart.
  • The institutional DKA/HHS protocol and the rapid response or early-warning system.

How to measure it (and why)

  1. Suspect a crisis with thirst, polyuria, vomiting, abdominal pain, deep breathing or confusion: check glucose and ketones at once.
  2. Take full vital signs and an early-warning score, and assess mental status: tachycardia and low blood pressure suggest severe fluid loss.
  3. Call the doctor or rapid response team early: severity decides whether the patient stays on the ward or goes to ICU.
  4. Help with IV access, blood samples and the ECG: potassium must be known before insulin starts.
  5. Start fluids as ordered and reassess often in older adults, heart or kidney disease and pregnancy: they are at risk of fluid overload.
  6. If an insulin infusion is started, follow the protocol with an independent double check: it is a high-alert infusion.
  7. Check glucose every 1–2 hours and report a fast fall: fluids are adjusted as glucose falls to prevent a low.
  8. Record intake and output and mental status every check: falling consciousness or a new headache can mean cerebral oedema.
  9. Look for the trigger (infection, missed insulin, infarction, new medicines) and give thromboprophylaxis as ordered.

How to read it

  • Abdominal pain that persists after acidosis and dehydration improve needs medical review: it may be the trigger.
  • Hyperchloraemic acidosis can appear after a lot of saline and should not be confused with persistent DKA.
  • Fast correction of sodium, especially in HHS, carries a risk of osmotic demyelination: report big changes.
  • Acute kidney injury and thrombosis are frequent: daily kidney function and prophylaxis as ordered.

Next step: when to call for help

  • Call at once: drowsiness, confusion or any fall in consciousness, a new headache or new neurological signs.
  • Call at once: low or rising potassium on the results, arrhythmia or ECG changes, low blood pressure or poor urine output.
  • Call: glucose falling fast or a low during the infusion, signs of fluid overload (breathlessness, crackles, oedema).
  • Before the infusion stops: confirm that subcutaneous insulin was given with the overlap the protocol sets.

Test yourself

Think of the answer, then tap the question to see it.

Can a patient have DKA with a near-normal glucose?

Yes. It is called euglycaemic DKA and is seen especially with SGLT2 inhibitors, prolonged fasting or a very low-carbohydrate diet; ketones and acidosis confirm it.

Why must potassium be known before insulin is started in DKA?

Insulin moves potassium into the cells and the level falls. If potassium is already low, the protocol replaces it first and delays insulin to avoid arrhythmias and respiratory muscle weakness.

Which features mean the patient needs ICU or high-dependency care?

Severe DKA, HHS or a mixed DKA/HHS, drowsiness or coma, and a critical trigger such as sepsis, myocardial infarction or gastrointestinal bleeding.

Why is subcutaneous insulin started before the IV insulin stops?

IV insulin acts for a very short time. The overlap prevents rebound hyperglycaemia and the return of ketoacidosis.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Hyperglycaemic crises in adults with diabetes: a consensus report (Umpierrez GE et al., Diabetologia (CC BY 4.0, PMC), 2024); 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2025 (American Diabetes Association Professional Practice Committee, Diabetes Care (PMC), 2025); Diabetic Ketoacidosis (Centers for Disease Control and Prevention (CDC), 2024); Nursing Pharmacology, 9.4: Antidiabetics (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2023).

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