NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Monitor blood glucose The hallmark of
 Risk For Fluid  Client will remain levels HHNS is extremely Maintain blood
Subjective Data: Volume Deficit normovolemic as elevated blood glucose glucose levels within
 Risk For Infection evidenced by Encourage optimal levels >600 mg/dL target range for
 Extreme thirst  Deficient urinary output hydration and administer patient, attain optimal
 Drowsiness Knowledge greater than 30 IV fluids (Normal Excessive urination hydration and fluid
 Confusion  Imbalanced ml/hr, normal skin Saline) to maintain fluid can cause dehydration. balance.
Nutrition: Less turgor, good balance. Encourage oral fluids
 Loss of vision
Than Body capillary refill, as tolerated and
 Weakness on one side normal blood Insulin (Regular) administer IV fluids to
Requirements
of the body pressure, palpable infusion to reduce blood re-establish tissue
 Hallucinations peripheral pulses, glucose level. Monitor perfusion and maintain
and blood glucose for hypokalemia. electrolyte balance
Objective Data: levels between 70-
200 mg/dL. Frequently assess level
 Blood glucose level  Client will of consciousness and Monitor blood glucose
>600 mg/dL identify mentation levels and serum
 Dry mucous interventions to potassium. As insulin
Monitor for hyperthermia is administered,
membranes prevent reduce and treat with potassium is lost.
 Warm, dry skin that risk of infection. antipyretics (fever Initiate potassium
does not sweat  Client will reducers), cool supplementation as
 High fever compresses and cooled necessary.
demonstrate
techniques, IV fluids
The brain is an insulin-
lifestyle changes
Thermoregulation is dependent tissue. With
to prevent impaired as urine elevated glucose
the development production decreases; levels, there is not
of infection. sweating decreases and enough insulin to
 electrolytes become normalize and the
imbalanced. patient becomes
confused, dizzy and
Monitor vitals for may have changes in
hypotension and level of consciousness.
tachycardia Patients often
experience drowsiness.
Most likely related to
dehydration and
hypovolemia. Patient is
at risk for hypovolemic
shock.
Collaborative:
 Refer to physical
therapy.