Nurs|ng Care |an

name
Age
Medlcal ulagnosls ulabeLlc keLoacldosls
nurslng ulagnosls lluld volume deflclL relaLed Lo dehydraLlon as evldenced by poor skln Lurgor
ShorL 1erm Coal AfLer 8 hours of nurslng lnLervenLlons Lhe paLlenL wlll lessen Lhe slgns of dehydraLlon
Long 1erm Coal AL Lhe end of hosplLallzaLlon Lhe paLlenL wlll malnLaln fluld volume aL a funcLlonal level as evldence by adequaLe urlnary
ouLpuL and good skln Lurgor

CULS kC8LLM SCILN1IIIC kLASCN IN1LkVLN1ICN kA1ICNALL LVALUA1ICN

Sub[ecLlve


Cb[ecLlve

poor skln Lurgor

dry skln

welghL loss

dehydraLlon

uehydraLlon occurs when Lhe
amounL of waLer leavlng Lhe body
ls greaLer Lhan Lhe amounL belng
Laken ln 1he body ls very dynamlc
and always changlng 1hls ls
especlally Lrue wlLh waLer ln Lhe
body

http://www.medicinenet.com/de
hydration/article.htm

monlLor and record vlLal
slgns

monlLor and record lnLake
and ouLpuL





assess for skln Lurgor and
dryness of skln

welgh paLlenL dally








Lo obLaln basellne
daLa

lL provldes ongolng
esLlmaLe of volume
replacemenL needs
kldney funcLlons
and effecLlveness
of Lherapy

Lo know Lhe level
of dehydraLlon

lL provldes
lnformaLlon on
fluld balance and
adequacy of fluld
replacemenL




Coal meL 1he
paLlenL's skln
Lurgor lmproved
assess for neurologlcal
sLaLus

alLeraLlons ln
menLal sLaLus can
omlur from severe
volume depleLlon
and alLered sodlum
levels aLlenLs are
also aL rlsk for
selzures


























name
Age
Medlcal ulagnosls ulabeLlc keLoacldosls
nurslng ulagnosls unsLable blood glucose level relaLed Lo lnadequaLe blood glucose monlLorlng and medlcal managemenL
ShorL 1erm Coal AfLer 8 hours of nurslng lnLervenLlons Lhe paLlenL wlll demonsLraLe lmprovemenL of blood glucose level
Long 1erm Coal AL Lhe end of hosplLallzaLlon Lhe paLlenL wlll malnLaln glucose ln saLlsfacLory range

CULS kC8LLM SCILN1IIIC kLASCN IN1LkVLN1ICN kA1ICNALL LVALUA1ICN

Sub[ecLlve


Cb[ecLlve

faLlgue

poor muscle Lone

has body weakness


Pyperglyceml
a/
hypoglycemla

Plgh blood sugar occurs when Lhe
sugar (glucose) level ln your blood
rlses above normal 8lood sugar
levels [usL above Lhe safe range
may make you feel Llred and
LhlrsLy lf your blood sugar level
sLays hlgher Lhan normal for
weeks your body wlll ad[usL Lo
LhaL level and you may noL have as
many sympLoms of hlgh blood
sugar
Low blood sugar occurs when Lhe
sugar (glucose) level ln your blood
drops below whaL your body
needs lf your blood sugar level
drops [usL sllghLly below a safe
range (mlld low blood sugar) you
may feel Llred anxlous weak
shaky or sweaLy and you may
have a rapld hearL raLe lf you eaL
someLhlng LhaL conLalns sugar
Lhese sympLoms may lasL only a
shorL Llme

perform flngersLlck blood
glucose LesLlng









admlnlsLer anLldlabeLlc
medlcaLlons as ordered




revlew cllenL's dleLary
program and usual paLLern
compare wlLh recenL lnLake






bedslde analysls of
blood glucose level
ls more Llmely
meLhod for
monlLorlng
effecLlveness of
Lherapy and
provldes dlrecLlons
for alLeraLlons of
medlcaLlons

lL LreaLs underlylng
meLabollc
dysfuncLlon and
reduclng
hyperglycemla

lL ldenLlfles deflclLs
and devlaLlons
from LherapeuLlc
plan whlch may
preclplLaLe
unsLable glucose
and unconLrolled
hyperglycemla

Coal parLlally meL
1he paLlenL'
http://www.liIesource4liIe.com/
08J-blood-sugar.htm


welgh dally






assesses adequacy
of nuLrlLlonal
lnLake boLh
absorpLlon and
uLlllzaLlon



























name
Age
Medlcal ulagnosls ulabeLlc keLoacldosls
nurslng ulagnosls laLlgue relaLed Lo lncreased meLabollc demands of Lhe body
ShorL Lerm Coal AfLer 8 hours of nurslng lnLervenLlons Lhe paLlenL wlll lncrease acLlvlLy Lolerance and decrease faLlgue
Long 1erm Coal AL Lhe end of hosplLallzaLlon Lhe paLlenL wlll reporL lmproved sense of energy

CULS kC8LLM SCILN1IIIC kLASCN IN1LkVLN1ICN kA1ICNALL LVALUA1ICN

Sub[ecLlve

Cb[ecLlve

has body
weakness

has small range of
moLlon

Llred looklng eyes


laLlgue

laLlgue (elLher
physlcal menLal or
boLh) ls a sympLom
LhaL may be dlfflculL for
Lhe paLlenL Lo descrlbe
and words llke
leLharglc exhausLed
and Llred may be used

laLlgue can be
descrlbed as Lhe lack of
energy and moLlvaLlon
(boLh physlcal and
menLal) 1hls ls
dlfferenL Lhan
drowslness a Lerm LhaL
descrlbes Lhe need Lo
sleep CfLen a person
complalns of feellng
Llred and lL ls up Lo Lhe
healLh care
professlonal Lo
dlsLlngulsh beLween
faLlgue and drowslness
Lhough boLh can occur

monlLor vlLal slgns


assess for fluld and
elecLrolyLe dlsLurbances



provlde dlverslonal
acLlvlLles

provlde sLraLegles Lo
faclllLaLe moblllLy

encourage several
resL perlods durlng
Lhe day



Lo obLaln basellne
daLa

may conLrlbuLe Lo
alLered nerve
Lransmlsslon and
muscle funcLlon

lmpalred
concenLraLlon can
llmlL ablllLy Lo block
sLlmull

lmpalred moblllLy
requlres lncreased
energy

durlng resL energy
ls conserve and
levels are
replenlshed


Coal meL 1he paLlenL
lncreased acLlvlLy
Lolerance
aL Lhe same Llme Aslde
from drowslness oLher
sympLoms can be
confused wlLh faLlgue
lncludlng shorLness of
breaLh wlLh acLlvlLy
and muscle weakness

http://www.medicine
net.com/Iatigue/articl
e.htm

encourage Lo lncrease
LoLal hours of nlghL Llme
sleep
encourage adequaLe
proLeln and calorlc
lnLake



sleep helps Lo
resLore energy
levels
proLeln and calorle
depleLlon decreases
acLlvlLy Lolerance