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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

Rationale

Evaluation

Weigh patient daily.

Changes in weight can provide information on fluid balance and the adequacy of volume replacement.  1lb = 2.2kg.

Patient able to maintain weight.

Measure and record urine output hourly; report urine output less than 30ml for 2 consecutive hours.

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.

Intake equal to output.

Assess skin turgor, mucous membranes and complaints of thirst.

Poor turgor, dry membranes and excessive thirst are all signs of dehydration.

Membranes pink and moist, no tenting.

Measure vital signs, including CVP (central venous pressure).

Compensatory mechanisms result in peripheral vasoconstriction with a weak thready pulse, drop in systolic blood pressure, orthostatic hypotension and reduced CVP.

BP 100/60, HR 80, RR 24, urine output >30ml/hr  CVP 6.

Assess neurological status.

Alterations in mental status can omlur from severe volume depletion and altered sodium levels,  Patients are also at risk for seizures.

Awake, alert and oriented X3.

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.

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 for hypoglycemia.

Because insulin therapy needs to continue until ketoacidosis is resolved and the blood glucose improves faster than the acidosis, hypoglycemia can omlur.

No signs of hypoglycemia noted.

Assess for signs of hypokalemia: fatigue, malaise, confusion, muscle weakness, cramping, shallow respirations and cardiac abnormalities.

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.

No signs of hypokalemia present.

Assess for signs of hyperkalemia: irritability, weakness, EKG changes (tall peaked T waves, wide QRS, prolonged PR interval and flattened P wave).

With insulin therapy and as ketoacidosis resolves potassium levels can shift quickly.  Hyperkalemia can develop.

No signs of hyperkalemia present.

Assess for signs of hyponatremia: weakness, headache, malaise, confusion, poor skin turgor, weight loss, decreased CVP, nausea, abdominal cramps.

Hyperglycemia can cause water to be pulled from intracellular fluid and placed in the extracellular compartment, causing dilution of serum sodium.  Osmotic diuresis contributes to hyponatremia.

No signs of hyponatremia present.

Assess for signs of metabolic acidosis: drowsiness, Kussmaul respirations, nausea, confusion and fruity odor to the breath.

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.

Assess serum ketones / acetone levels.

Serum ketones are a more reliable measure than urine ketone tests.  DKA is associated with elevated levels of ketone bodies in the blood.

Serum ketone 3.0 on admission.

Assess arterial blood gases.

Patients with DKA have metabolic acidosis with a pH less than 7.3 and a bicarbonate less than 15 mEq/L.

pH 7.1 HCO3 18 – metabolic acidosis.

Assess BUN/ creatine ratio.

Normal ratio is 10:1 to 15:1.  Ratios greater than 20:1 are associated with dehydration.

Ratio 12:1 after fluid replacement.

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

Elevations in white blood cell count may indicate infection, a common precursor to DKA.  All levels may be elevated due to hemoconcentration.

All levels WNL.

Assess for abnormalities in chest x-ray and urinalysis.

Pneumonia and urinary tract infections are the most frequent infections causing DKA and HHNS.

Urine culture positive for UTI.

Monitor for effects of IV therapy.

Volume replacement is necessary to provide adequate circulation, perfusion and oxygenation of the tissues.  Replacement is adequate when vital signs are back to baseline.

BP 100/60, HR 80, RR 24, urine output >30ml/hr.

Initiate and administer IV therapy:

  • 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.

 

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.

 

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

0.9% NSS administered X2L.

D5 ½ NSS infusing at 65ml/hr.  Vital signs normal, pulses +3, BGM 199, Urine output >30ml/hr.

Initiate and administer Insulin therapy:

  • IV bolus dose of regular insulin is followed by continuous infusion.
  • Prime the line by wasting 50ml of the mixture.

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 true dose.

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

Administer potassium IV as ordered: typically 20 to 30 mEq/L.

Potassium is added to Iv infusions once renal function has been established and serum potassium levels are below 5.5 mEq/L.

K 3.0  20meq KCL administered over 1 hour.

Administer bicarbonate as ordered.

This recommenced only in life-threatening hyperkalemia, severe lactic acidosis and severe acidosis in adults with pH less than 6.9

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 self- manage 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

Rationale

Evaluation

Determine the patient’s learning needs, self-management skills and ability and willingness to learn.

An initial assessment must be done to determine what needs taught and how the patient best learns.

Patient states needs education on foot care and insulin. Learns best by demonstration.

Teach signs of hyperglycemia: increased thirst, increased hunger, increased urination, fatigue, blurred vision and poor wound healing.

Hyperglycemia results when inadequate insulin is present to use glucose.  Excessive glucose results in an osmotic effect that causes the hallmark symptoms.

Patient able to state 3 signs of hyperglycemia.

Teach causes and prevention of hyperglycemia.

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:

  • 3-4 glucose tablets.
  • 8-10 Lifesaver candies.
  • 4-6 ounces of juice.

Hypoglycemia is considered blood glucose less than 70 mg/dl.  10 to 15 grams of carbohydrate should raise the glucose levels 30 to 45 mg/dl.  Glucose containing products will produce faster results.

Patient states to drink 4-6 ounces of juice if having signs of hypoglycemia.

Monitor HbA1c levels.

HbA1c measures the blood glucose over the past 2-3 months, so it is a better indicator of the overall management.

HbA1c level 6.0%.

Assess understanding of the diabetic diet.

Noncompliance with dietary regulations can result in hyperglycemia.

Patient states have trouble at times choosing the best foods.

Assess pattern of physical exercise.

Regular excise reduces the risk of cardiovascular complications and has an insulin-like effect and helps lower blood glucose levels.

Patient exercises 3 times a week for 30 minutes.

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

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.

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

Refer to registered dietician for individualized diet instruction.

An individualized meal plan should be developed for each patient.

Patient has appointment set up with dietician.

Instruct to take oral hyperglycemia medications as ordered.

Hypoglycemia occurs less often with oral agents; however episodes of hypoglycemia can occur in patients who don’t eat regularly.

Patient states when to take medications in relationship to meals.

Instruct to take insulin as ordered.

Insulin is required for individuals with type 1 diabetes and some with type 2 diabetes.

Patient states when to rake insulin in relationship to meals.

Instruct in the type, onset, peak and duration of action of specific insulin.

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.

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

Inaccurate technique can result in an elevated glucose level.

Insulin injections should be given in the subcutaneous tissue.  Injecting over the 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 manufacture’s guidelines when mixing insulin.

Patient able to demonstrate appropriate technique, stated to rotate sites with each injection.  Will keep insulin in refrigerator.

Assist patient to develop an exercise routine.  Include methods to maintain hydration and prevent hypoglycemia when exercising.

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.

Patient exercises 3 times a week for 30 minutes.

Instruct the patient on diabetes management during illness:

  • continue to take all diabetes medication
  • self-monitor blood 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.
  • Drink fluid and simple carbohydrates: soup, pudding, etc

Insulin requirements increase with infection.

Allows the patient to guide therapy.

 

Provides for early detection of DKA.

 

 

 

Sufficient intake is needed to prevent dehydration.

 

Patient able to verbalize management during illness.

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.

Early treatment of hyperglycemia can prevent the occurrence of DKA or HHNS.

Paten able to verbalize when extra insulin needs are necessary.

Assess skin integrity include:

  • general appearance of the foot
  • status of nails
  • abnormalities in shape of foot
  • callus or corn formation.

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

Fungal infections in nails (thick, deformed, or ingrown) are a port of bacterial entry.
Neuropathy leads to dryness, fissuring of the skin, muscle weakness and changes to the shape of the foot.
Pressure over bony prominences leads to callus formation and skin breakdown.

 

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

Palpate dorsalis pedis and posterior tibial pulses.

Atherosclerosis results in gradual decrease in blood supply to the foot.

Pulses +3 bilaterally.

Assess for edema.

Edema is a major predisposing factor for ulcerations.  Neuropathy leads to swelling in the foot.

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.

Maceration between the toes can lead to infection.  Soaking can cause maceration.

Patient able to verbalize proper foot care.

Teach patient to report signs of infection immediately.

Early treatment is essential to prevent amputation.

Patient able to verbalize signs of infection.

Instruct in appropriate footwear:

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

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.

 

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

 

Patient able to verbalize proper foot care.

Teach patient to:

  • test bath water with wrist or elbow
  • avoid heating pads, hot water bottle, or electric blankets
  • maintain safe distance form fireplace or space heater.

Sue to loss of normal pain and temperature sensation from neuropathy thermal injuries can occur.

 

Patient able to verbalize measure to prevent a thermal burn.

Instruct patient in nail care:

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

Avoid injury to the toes.

 

Patient able to verbalize proper nail care.

Teach patient to avoid over the counter self-treatment for foot problems.

Many over the counter agents contain salicylic acid that may cause ulceration in a diabetic foot.

Patient able to verbalize.

Teach patient to stop smoking.

The vasoconstriction effects of smoking reduced the ability of the tissues to heal.

Information given.  Patient willing to enter smoking cessation program.

References:
Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St. Louis






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