nursing Care Plan

Nursing Diagnosis Fluid Volume Deficit r/t active fluid loss (increased urine output) Long Term Goal: Patient will have adequate fluid balance

Short Term Goals / Outcomes: Patients will maintain urine output >30 ml/hr, BP > 90/60, HR 60-100 and glucose 70-200 mg/dl. Patient will demonstrate elastic skin turgor and moist, pink mucous membranes. Intervention Weigh patient daily. Rationale Changes in weight can provide information on fluid balance and the adequacy of volume replacement. 1lb = 2.2kg. Fluid volume deficit reduces glomerular filtration and renal blood flow causing oliguria. The patient in DKA may also be undergoing osmotic diuresis and have excessive outputs. Poor turgor, dry membranes and excessive thirst are all signs of dehydration. Compensatory mechanisms result in peripheral vasoconstriction with a weak thready pulse, drop in systolic blood pressure, orthostatic hypotension and reduced CVP. Evaluation Patient able to maintain weight.

Measure and record urine output hourly; report urine output less than 30ml for 2 consecutive hours. Assess skin turgor, mucous membranes and complaints of thirst. Measure vital signs, including CVP (central venous pressure).

Intake equal to output.

Membranes pink and moist, no tenting. BP 100/60, HR 80, RR 24, urine output >30ml/hr CVP 6.

Assess neurological status.

Alterations in mental status can omlur Awake, alert and oriented from severe volume depletion and altered X3. sodium levels, Patients are also at risk for seizures. Glucose has a high osmotic pull. Glucose levels needs to be reduced gradually for the fluid balance to omlur. A steady decline of 50 to 75 mg/hr is desirable. Insulin therapy needs to continue until ketoacidosis is resolved. Glucose decreased from 350 to 280 in first hour of treatment.

Monitor serum glucose every 30 to 60 minutes, then hourly as long as insulin infusion continues. Notify physician if glucose does not fall by 50 mg/dl in the initial hour. Monitor for

Because insulin therapy needs to continue No signs of hypoglycemia

hypoglycemia.

until ketoacidosis is resolved and the blood glucose improves faster than the acidosis, hypoglycemia can omlur. Osmotic diuresis causes increased excretion of potassium. Insulin therapy results in shifting of potassium intracellular. Both DKA and HHNS result in a total body deficit for potassium. Serum potassium may be elevated, normal, or low. Goal is to maintain levels between 3 and 4 mEq/L. With insulin therapy and as ketoacidosis resolves potassium levels can shift quickly. Hyperkalemia can develop.

noted.

Assess for signs of hypokalemia: fatigue, malaise, confusion, muscle weakness, cramping, shallow respirations and cardiac abnormalities. Assess for signs of hyperkalemia: irritability, weakness, EKG changes (tall peaked T waves, wide QRS, prolonged PR interval and flattened P wave). Assess for signs of hyponatremia: weakness, headache, malaise, confusion, poor skin turgor, weight loss, decreased CVP, nausea, abdominal cramps. Assess for signs of metabolic acidosis: drowsiness, Kussmaul respirations, nausea, confusion and fruity odor to the breath. Assess serum ketones / acetone levels.

No signs of hypokalemia present.

No signs of hyperkalemia present.

Hyperglycemia can cause water to be No signs of hyponatremia pulled from intracellular fluid and placed present. in the extracellular compartment, causing dilution of serum sodium. Osmotic diuresis contributes to hyponatremia.

Patients with DKA have metabolic acidosis due the build up of ketones in the blood stream.

Patient admitted with fruity breath and Kussmaul respirations, resolving with treatment.

Serum ketones are a more reliable measure than urine ketone tests. DKA is associated with elevated levels of ketone bodies in the blood. Patients with DKA have metabolic acidosis with a pH less than 7.3 and a bicarbonate less than 15 mEq/L. Normal ratio is 10:1 to 15:1. Ratios greater than 20:1 are associated with dehydration.

Serum ketone 3.0 on admission.

Assess arterial blood gases. Assess BUN/ creatine ratio.

pH 7.1 HCO3 18 metabolic acidosis. Ratio 12:1 after fluid replacement.

Assess for changes in hemoglobin, hemoatocrit and white blood cell count.

Elevations in white blood cell count may All levels WNL. indicate infection, a common precursor to DKA. All levels may be elevated due to hemoconcentration. Urine culture positive for UTI.

Assess for abnormalities Pneumonia and urinary tract infections in chest x-ray and are the most frequent infections causing urinalysis. DKA and HHNS.

Monitor for effects of IV Volume replacement is necessary to BP 100/60, HR 80, RR 24, therapy. provide adequate circulation, perfusion urine output >30ml/hr. and oxygenation of the tissues. Replacement is adequate when vital signs are back to baseline. Initiate and administer IV therapy:

0.9% NSS administered X2L. Initial goal is to correct circulatory volume deficit. Isotonic saline will rapidly expand extracellular fluid volume. The secondary goal, correction of water deficit, is usually amlomplished by a hypotonic solution. D5 NSS infusing at 65ml/hr. Vital signs normal, pulses +3, BGM 199, Urine output >30ml/hr.

Isotonic saline (0.9%) initially. Subsequent type of therapy depends, on the state of hydration, serum electrolyte levels and urinary output. Dextrose is added to IV fluids when blood glucose concentrations are less than 250 mg/dl in DKA or less than 300 mg/dl in HHS.

Dextrose is added to prevent hypoglycemia excessive decline in plasma osmolality the leads to cerebral edema.

Initiate and administer Insulin therapy:

IV bolus dose of regular insulin is followed by continuous infusion. Prime the line by

Insulin is necessary to correct the ketoacidosis. Injected forms are inconsistently absorbed when the patient is hypotensive and acidotic. Insulin has an affinity to the tubing. 50ml must be primed through the tubing, to allow the mixture to coat the tubing and make sure the patient is receiving the

Insulin infusing at 2units/hr. Serum positive for ketones.

wasting 50ml of the mixture. Administer potassium IV as ordered: typically 20 to 30 mEq/L. Administer bicarbonate as ordered.

true dose.

Potassium is added to Iv infusions once renal function has been established and serum potassium levels are below 5.5 mEq/L. This recommenced only in lifethreatening hyperkalemia, severe lactic acidosis and severe acidosis in adults with pH less than 6.9

K 3.0 20meq KCL administered over 1 hour.

pH 7.1 no bicarb needed.

Nursing Diagnosis Risk for Ineffective management of the Therapeutic Regimen related to complexity of the medical regimen

Long Term Goal: Patient will be able to selfmanage disease and prevent complications

Short Term Goals / Outcomes: Patient will verbalize dietary needs and restrictions. Patient will be compliant with pharmacological therapy. Hemoglobin A1c will be less than 6.5%. Patient will verbalize measures to prevent complications (i.e. skin/ foot care). Patient will verbalize sick day management. Intervention Determine the patients learning needs, selfmanagement skills and ability and willingness to learn. Teach signs of hyperglycemia: increased thirst, increased hunger, increased urination, fatigue, blurred vision and poor wound healing. Teach causes and prevention of hyperglycemia. Rationale An initial assessment must be done to determine what needs taught and how the patient best learns. Evaluation Patient states needs education on foot care and insulin. Learns best by demonstration. Patient able to state 3 signs of hyperglycemia.

Hyperglycemia results when inadequate insulin is present to use glucose. Excessive glucose results in an osmotic effect that causes the hallmark symptoms. Increased food intake, noncompliance with medications, infection, illness and stress will all elevate glucose levels and insulin needs. The best way to prevent hyperglycemia to be compliant with dietary restriction, medication regimen and blood glucose monitoring.

Patient states the importance of taking medications and proper diet.

Teach symptoms and causes of hypoglycemia.

Symptoms include trembling, shaking, sweating, tingling of extremities, blurred vision, slurred speech and fatigue. All causes are due to excess insulin available in relationship to nutrients. Common causes include missed or delayed meals, irregular carbohydrate content and taking medications at the wrong time.

Patient able to state 3 signs of hypoglycemia.

Teach treatment when hypoglycemia occurs:

Hypoglycemia is considered blood Patient states to drink 4-6 glucose less than 70 mg/dl. 10 to 15 ounces of juice if having grams of carbohydrate should raise the signs of hypoglycemia. 3-4 glucose tablets. glucose levels 30 to 45 mg/dl. Glucose containing products will produce faster 8-10 Lifesaver results. candies. 4-6 ounces of juice. HbA1c measures the blood glucose over the past 2-3 months, so it is a better indicator of the overall management. Noncompliance with dietary regulations can result in hyperglycemia. Regular excise reduces the risk of cardiovascular complications and has an insulin-like effect and helps lower blood glucose levels. Moderate weight loss has been shown to improve hyperglycemia and hypertension. Intensive glucose control should range between 80 and 120 mg/dl fasting. HbA1c should be below 7.0%. Patient should perform 30 minutes of moderate physical activity on most days of the week. HbA1c level 6.0%.

Monitor HbA1c levels.

Assess understanding of the diabetic diet. Assess pattern of physical exercise.

Patient states have trouble at times choosing the best foods. Patient exercises 3 times a week for 30 minutes.

Establish goals with the patient for weight loss, glucose levels, HbA1c levels and exercise regimen.

Patient and nurse agree the patient will attempt to lose 5 pounds, keep glucose between 80-120 and maintain exercise program.

Refer to registered An individualized meal plan should be dietician for individualized developed for each patient. diet instruction. Instruct to take oral hyperglycemia Hypoglycemia occurs less often with oral agents; however episodes of

Patient has appointment set up with dietician. Patient states when to take medications in relationship

medications as ordered. Instruct to take insulin as ordered. Instruct in the type, onset, peak and duration of action of specific insulin.

hypoglycemia can occur in patients who dont eat regularly. Insulin is required for individuals with type 1 diabetes and some with type 2 diabetes. Specific types of insulin vary in the onset, peak and duration. These characteristics of the specific insulin ordered determine when the injection should be administered. Inaccurate technique can result in an elevated glucose level.

to meals. Patient states when to rake insulin in relationship to meals. Patient states when to take insulin in relationship to meals.

Instruct the patient to prepare and administer insulin.

proper procedure rotation of injection sites storage of insulin mixing of insulin

Patient able to demonstrate appropriate technique, stated to rotate sites with Insulin injections should be given in the each injection. Will keep subcutaneous tissue. Injecting over the insulin in refrigerator. same site will result in reduced absorption. Insulin should be refrigerated. Unopened vials may be stored until expiration date. If the patient experiences irritation from the cold insulin, vials may be stored at room temperature for one month and then discarded. Patients should refer to the manufactures guidelines when mixing insulin. A specific routine should be individualized to each patient. In general routines should be 30 to 60 minutes in length 3-4 times a week for good glycemic control. Dehydration can hasten hypoglycemia, especially in a hot environment. Insulin requirements increase with infection. Allows the patient to guide therapy. Patient able to verbalize management during illness. Patient exercises 3 times a week for 30 minutes.

Assist patient to develop an exercise routine. Include methods to maintain hydration and prevent hypoglycemia when exercising. Instruct the patient on diabetes management during illness:

continue to take all diabetes medication self-monitor blood Provides for early detection of DKA. glucose every 2 to 4 hours

Test urine for ketones if blood glucose is consistently higher than 300 mg/dl or nausea or vomiting occur. Sufficient intake is needed to prevent Drink fluid and dehydration. simple carbohydrates: soup, pudding, etc Early treatment of hyperglycemia can prevent the occurrence of DKA or HHNS. Paten able to verbalize when extra insulin needs are necessary.

Instruct the patient to take additional short acting insulin as prescribed when:

blood glucose levels are greater than 300 mg/dl. vomiting for more than 2 to 4 hours. failure of urinary ketones to clear within 12 hours. symptoms of dehydration or developing DKA. Fungal infections in nails (thick, deformed, or ingrown) are a port of bacterial entry. general appearance Neuropathy leads to dryness, fissuring of the skin, muscle weakness and of the foot changes to the shape of the foot. status of nails Pressure over bony prominences leads abnormalities in to callus formation and skin shape of foot breakdown. callus or corn formation.

Assess skin integrity include:

Patient able to state what it is necessary to inspect the feet for.

Teach patients to inspect feet daily. Use a mirror if necessary to examine bottom of feet.

Palpate dorsalis pedis and posterior tibial pulses. Assess for edema.

Atherosclerosis results in gradual decrease in blood supply to the foot. Edema is a major predisposing factor for ulcerations. Neuropathy leads to swelling in the foot. Maceration between the toes can lead to infection. Soaking can cause maceration.

Pulses +3 bilaterally. No edema noted.

Instruct patient to wash feet daily in warm water using mild soap. Dry carefully and gently, especially between toes. Avoid soaking feet. Teach patient to report signs of infection immediately. Instruct in appropriate footwear:

Patient able to verbalize proper foot care.

Early treatment is essential to prevent amputation. To prevent injury to the foot sue to decreased sensation appropriate footwear is essentials. The widest part of the shoe must accommodate the widest part of the foot.

Patient able to verbalize signs of infection.

have foot size measured. inspect shoes daily by feeling for irregularities in lining or foreign objects in shoes. wear clean, wellfitting stockings of cotton, synthetic blend, or wool. never go barefoot.

Patient able to verbalize proper foot care.

Soft cotton or wool will absorb moisture from perspiration and discourage an environment for fungus.

Teach patient to:

Sue to loss of normal pain and temperature sensation from neuropathy test bath water with thermal injuries can occur. Patient able to verbalize wrist or elbow measure to prevent a avoid heating pads, thermal burn. hot water bottle, or electric blankets maintain safe distance form fireplace or space heater.

Instruct patient in nail care:

Avoid injury to the toes. Patient able to verbalize proper nail care.

trim straight across file sharp corners consult a podiatrist of unable to manage by self.

Teach patient to avoid over the counter selftreatment for foot problems. Teach patient to stop smoking.

Many over the counter agents contain Patient able to verbalize. salicylic acid that may cause ulceration in a diabetic foot. The vasoconstriction effects of smoking reduced the ability of the tissues to heal.