NURSING CARE PLAN Deficient fluid volume

NURSING CUES Subjective: Nurse pwede na ba ako uminom uhaw na uhaw na ako as verbalized by the patient DIAGNOSIS Deficient fluid volume related to osmotic dieresis from hyperglycemi a

SCIENTIFIC EXPLANATION
Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic

OBJECTIVE

NURSING INTERVENTION Obtain history from client and significant other (SO) related to duration and intensity of symptoms, such as vomiting and excessive urination.

RATIONALE

EVALUATION

Helps estimate total volume depletion. Symptoms may have been present for varying amounts of time- hours to days. Presence of infectious process results in fever and hypermetab olic state,

Objective: c dry and cracked mucous membrane c thirst c kussmauls breathing

and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.

 c weak and thready pulse c increased urinary output Vital sign as follows: Monitor vital signs: Respiratory pattern, such as Kussmauls respirations , acetone breath

increasing insensible fluid losses.

Lungs remove carbonic acid through respirations, producing a compensato ry respiratory alkalosis or ketoacidosis

 Respiratory rate and quality; use of accessory muscles, periods of apnea, and appearance of cyanosis

Correction of hypoglycem ia and acidosis will cause the respiratory rate and pattern to approach normal. In contrast, increased work of breathingshallow, rapid respirations and presence of cyanosis may

indicate Temperatur e, skin color, and moisture Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes . Monitor intake and output (I&O); note urine specific gravity. Promote Although fever, chills, and diaphoresis are common with infectious process, fever with flushed, dry skin may reflect dehydration. respiratory fatigue and that client is losing ability to compensate for acidosis.

comfortabl e environme nt. Cover client with light sheets.Inve stigate changes in mentation and sensorium Administer fluids, as indicated: isotonic (0.9%) or lactated Ringers solution without additives

Note: Although fever is a common precipitating factor for DKA, clients may be normotherm ic or hypothermic because of peripheral vasodilation . Indicators of level of hydration and adequacy of circulating

volume. Insert and maintain indwelling urinary catheter Monitor laboratory studies, such as fallowing: Hematocrit Blood urea nitrogen (BUN/creat inine (Cr) Serum osmolality Sodium, Potassium Administer Avoids overheating, which could promote further fluid loss. Changes in mentation can be due Provides ongoing estimate of volume replacement needs, kidney function, and effectivenes s of therapy.

potassium , and other electrolytes intravenous ly (IV)

to abnormally high or low glucose, electrolyte abnormalitie s, acidosis, decreased cerebral perfusion or developing hypoxia. Regardless of the cause, impaired consciousne ss can predispose client to aspiration. Type and

amount of fluid depends on degree or deficit and individual client response. Note: client with DKA is often severely dehydrated and commonly needs 5 to 10 L of isotonic saline, 2 to 3 L within first 2 hours of

treatment. Provides for accurate and ongoing measuremen t of urinary output, especially if autonomic neuropathie s result in neurogenic bladder with urinary retention and overflow incontinenc e. May be removed when client

is stable to reduce risk of infection. Assesses level of hydration; Hct is often elevated because of hemoconcen tration associated with osmotic dieresis. Elevated because of hyperglyce mia and dehydration.

 May be decreased, reflecting shift of fluids from the intracellular compartmen t as with osmotic dieresis. High sodium values reflect severe fluid loss and dehydration or sodium reabsorption in response to

aldosterone secretion. Initially, hyperkalemi a occurs in response to metabolic acidosis, but as this potassium is lost in the urine, the absolute potassium level in the body is depleted. As insulin is replaced and acidosis is corrected, serum

potassium deficit becomes apparent. Potassuim should be added to the IV as soon as urinary flow is adequate, to prevent hypokalemi a. Note: Potassium phosphate may be drug of choice when IV fluids contain

sodium chloride in order to prevent chloride overload. Phosphate concentratio ns tend to decrease with insulin therapy.

UNSTABLE GLUCOSE LEVEL

NURSING CUES Subjective: DIAGNOSIS

SCIENTIFIC EXPLANATION

OBJECTIVE

NURSING INTERVENTION Determine individual

RATIONALE

EVALUATION

occasionally client with unknown diabetes will present with DKA, especially a young person with some type of precipitating infection. However, many times DKA is precipitated by failure of diabetes

Objective: Vital sign as follows:

factors that may have contributed to current situation. Note clients age, developme ntal level, and aware of needs.

managemen t, possibly related to dietary factors, activity, or medications. Because DKA presents roore frequently in the young client with type 1 diabetes, there may be a failure to account for developmen tal changes,

such as adolescent growth spurt or pregnancy. Perform fingerstick glucose testing. ascertain whether the client and SO are adept at blood glucose monitoring and are testing according to plan. all available glucose monitors will provide satisfactory readings if properly used and maintained and routinely calibrated. note: unstable blood

glucose is often associated with failure to perform testing on a regular schedule. for client insulin: review types of insulin used, such as rapid, short acting, intermediat e, long acting, premixed, these factors affect timing of effects and provide clues to potential timing of glucose instability.

and the delivery methodsubcutaneo us, inhaled, or pump. note times when shortacting and long-acting insulins are administere d. Check injection sites. Insulin absorption can vary from day to day in healthy sites and is less

absorbable in lypohypertr opic (lumpy) tissues. Review clients dietary program and usual pattern; compare with recent intake. Identifies deficits and deviations from therapeutic plan, which may precipitate unstable glucose and uncontrolled hyperglyce mia. Weigh Assesses

daily or as indicated.

adequacy of nutritional intake-both absorption and utilization. Note: Eating disorders are a contributing factor in 20% of recurrent DKA in young clients.

Auscultate bowel sounds. Note reports of

Hyperglyce mia and fliud and electrolyte disturbances

abdominal pain and bloating, nausea, or vomiting. Maintain nothing by mouth (NPO) status, as indicated.

decrease gastric motility and function resulting in gastroparesi s, affecting choice of intervention s. Note: long-term difficulties with gastroparesi s and poor intestinal motility suggest automic neuropathie s affecting the GI tract

and requiring symptomati c treatment. Provide liquids containing nutrients and electrolytes as soon as client can tolerate oral fluids; progress to more solid food as tolerated. Identify food preferences Incorporatin g as many of the Oral route is preferred when client is alert and bowel function is restored.

, including ethnic and cultural needs.

clients food preferences into the meal plan as possible increases cooperation with dietary guidelines after discharge.

Include SO in meal planning, as indicated.

Promotes sense of involvement ; provides information for SO to understand nutritional needs of client. Note:

various methods available for dietary planning includes carbohydrat es counting, exchange list, point system, or preselected menus. Observe for signs of hypoglyce miachanges in LOC, cool and clammy Once carbohydrat e metabolism resumes, blood glucose level will

skin, rapid pulse, hunger, irritability, anxiety, headache, lighteadedn ess, and shakiness.

fall, and as insulin is being adjusted, hypoglycem ia may occur. If client is comatose, hypoglycem ia may occur without notable change in LOC. This potentially life threatening emergency should be assessed and

treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycem ia because normal response to low blood sugar may be diminished. Monitor laboratory Blood glucose will

studies, such as serum glucose, acetone, pH, anmd HCo3.

decrease slowly with controlled fluid reaplacemen t and insulin therapy. With the administrati on of optimal insulin dosages, glucose can then enter the cells and be used for energy. When this happens acetone levels

decrease and acidosis is corrected. Adminster rapidacting insulin, such as regular (HumulinR), lispro (Humalog), or aspart (Novolog) by intermittent or continous IV method, for example, Rapidacting insulin is used in hyperglyce mia crisis. The IV route is the initial route of choice because absorption from subcutaneou s tissues may be erratic. Many

IV bolus followed by a continous drip via pump of approximat ely 5 to 10 units/hour so that glucose is reduced by 50 to 75 mg/dl/hour.

believe the continuous method is the optimal way to facilitate transition to carbohydrat e metabolism and reduce incidence of hypoglycem ia. Note: intermediate insulin, such as NPH, Humulin N, Lente , and long acting insulin such as

Ultralente, protamine zinc insulin (PZI), and glargine (lantus), may be part of the clients usual or added insulin, but not are part of crisis hyperglyce mic treatment. Administer glucose solutions, for Glucose solutions may be added after

example, 5% dextrose and halfnormal saline.

insulin and fluids have brought the blood glucose to approximate ly 400 mg/dl. As carbohydrat e metabolism approaches normal, care must be taken to avoid hypoglycem ia.

Consult with nutrionist

Useful in calculating and

or dietitian for resumption of oral intake.

adjusting diet to meet clients specific needs; answer questions and assist client and SO in developing meal plans .

Provide diet of approximat ely 60% carbohydra tes, 20% proteins, and 20% fats in

Complex carbohydrat es help to maintain more stable glucose levels, reduces serum

designated number of meals and snacks.

cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristi c such as peak effect, and individual client response. Note: A snack of complex carbohydrat es at bedtime is

especially important if insulin is given in divided doses to prevent hypoglycem ia during sleep and potential somogyi response.