SUBJECTIVE DATA: Patient caregiver verbalizes that she didn’t take oral fluids.

OBJECTIVE DATA: patient looks dry lips, dry oral mucous membrane.

NURSING DIAGNOSIS: Deficient fluid volume related to Decreased intake of fluids due to diminished thirst sensation as evidenced by urinary
output greater than 30 ml/hr

GOAL: the patient will maintain normal fluid volume.

PLANNING IMPLEMENTATION RATIONALE EVALUATION

Assess precipitating factors Assessed the patient condition. These will provide baseline data for
such as other illnesses, new- Patient has diabetes for past 10 education once with resolved
onset diabetes, or poor years and has poor compliance hyperglycemia. Urinary tract
compliance with treatment with the treatment regimen. infection and pneumonia are the
regimen. most common infections causing
DKA and HHNS among older
clients.

Assess skin turgor, mucous It provides baseline data for further

Assessed the patient skin turgor, comparison. Skin turgor will
membranes, and thirst.
patient has dry mucous decrease and tenting may occur.
membrane and dry lips. The oral mucous membranes will
become dry, and the client may
experience extreme thirst.
Monitor hourly intake and Monitored hourly intake and Patient will maintain normal
output. Oliguria or anuria results from
output. fluid volume.
reduced glomerular filtration and
Hourly intake:100ml
renal blood flow.
Hourly output:300ml

Monitor vital signs:

Decreased blood volume may be
 Monitor BP especially Monitored Blood pressure
manifested by a drop in systolic
for orthostatic 60/40mm of hg
blood pressure and orthostatic
 hypotension. hypotension.

 Monitor respirations,
e.g., acetone breath, Acetone breath is due to the
Kussmaul’s breakdown of acetoacetic acid.
respirations.
Monitored respiration Kussmaul’s respiration (rapid and
Rate:28breaths/mt shallow breathing) represents a
Patient has acetone breath. compensatory mechanism by the
respiratory buffering system to
raise arterial pH by exhaling more
carbon dioxide.

Fever with flushed, dry skin may

 Monitor temperature.
indicate dehydration.
 Monitor heart rate. Monitored patient temperature
Compensatory mechanism results
100°F
in peripheral vasoconstriction with
a weak, thready pulse that is easily
Monitored patient heart rate
obliterated.
90beats/mt
Decreased level of consciousness
 Assess neurological results from blood volume
status every two depletion elevated or decreased
(2) hours. glucose level, hypoxia or
Neurological assessment done electrolyte imbalances.
E2V2M3 Provides baseline data of current
fluid status and adequacy of fluid
Weigh client daily. replacement.
A weight loss of 2.2 lbs over 24
Checked patient weight. patient hours indicates a 1 liter of fluid
weight is 40kg loss.

DKA: blood glucose level greater

 Monitored patient blood glucose
 Blood glucose levels level. Patient blood glucose level than 250 mg/dL.HHNS: blood
is 350mg/dl glucose level greater than 600
mg/dL with serum osmolality>320
mOsm/kg.

Monitor Serum ketones Elevated ketones are associated

with DKA.
Monitored serum ketone level.
Initially, hyperkalemia occurs in
response to metabolic acidosis. As
Monitor serum Potassium the fluid volume deficit progresses,
Monitored serum potassium level.
potassium level decreases. Both
Patient sr.pottasium is 6 mEq/dl
DKA and HHNS result in
hypokalemia.

Monitor serum Sodium Increased blood sugar causes

Monitored serum sodium level water to shift from intracellular
Patient sr.sodium level is into extracellular, resulting in
135mEq/dl. serum sodium depletion.

Monitor Blood urea nitrogen Elevated BUN and creatinine

and creatinine. indicate cellular breakdown from
Monitored BUN and creatinine. dehydration or a sign of an acute
renal failure.
Monitor ABG for metabolic Clients with DKA have metabolic
acidosis. acidosis with arterial a bicarbonate
- level less than 18 mEq/L, and a
pH less than 7.30.

Insert indwelling urinary

catheter as indicated. To provide accurate measurement
of urinary output especially for
 Catheterization done to the clients with neurogenic bladder.
patient.
Initial goal of therapy is to correct
Administer fluid as indicated: circulatory fluid volume deficit.
Isotonic solution (0.9% Isotonic normal saline will rapidly
NaCl). Administered IV fluids to the expand extracellular fluid volume
patient.
without causing a rapid fall in
IVF.normal saline 200ml/hr
plasma osmolality. Clients
typically need 2 to 3 liters within
the first 2 hours of treatment.

Administer succeeding IV Continuation of IV administration

therapy: Hypotonic solution depends on the degree of
such as 0.45% normal saline. - fluid deficit, urinary output, and
serum electrolyte values.

Dextrose is added to prevent the

Add dextrose to IV fluid occurrence of hypoglycemia and an
when serum blood glucose excessive decline in plasma
level is less than 250 mg/dL - osmolality that can result in
in DKA or less than 300 cerebral edema.
mg/dL in HHNS.
Potaasium is added to the IV once
Administer IV potassium and serum potassium drops below 5.5
other electrolytes as indicated. mEq/L to prevent hypokalemia.
-

This is given in clients with a

Administer bicarbonate as
severe hyperkalemia and severe
indicated.
acidosis with pH of less than 7.1.
Administer an IV bolus dose Administered sodium bicarbonate
of regular insulin, followed by to the patient. The administration of insulin to
a continuous infusion of
lower blood glucose promotes the
 regular insulin. Administerd iv insulin to the movement of potassium
patient intracellularly.

SUBJECTIVE DATA: Patient caregiver verbalizes that she has wound in her right foot.

OBJECTIVE DATA: Patient has right foot ulcer.

NURSING DIAGNOSIS: Risk for infection related to decreased leukocytes function as evidenced by foot ulcer.

GOAL: The patient will get relief from the foot ulcer.

PLANNING IMPLEMENTATION RATIONALE EVALUATION

Assess for signs of infection Assessed the signs for infection Infection is a common cause of
and inflammation. and inflammation. Patient has DKA. Signs of infection
fever and chills. include fever, chills, dysuria,
Patient body temperature is and increased WBC count.
100°F.
Observe client’s feet for Due to impaired circulation in
ulcers, infected toenails, or Observed the foot ulcer. Patient diabetes, foot injuries are
other medical problems. had poor wound healing. predisposed to poor wound
healing.
Observe aseptic technique Followed the aseptic technique. Elevated blood sugar weakens
during IV insertion and
medication administration. the immune system thus clients
are more prone to infection.
The patient will get relief from the
Provide skin care. Provided skin care. foot ulcer.
An intact skin protects against
infection.
Encourage proper hand
To avoid the risk of cross-
washing technique.   Encouraged proper hand washing
contamination.
technique.
Encourage adequate oral fluid
intake (2-3 liters a day unless   Encouraged adequate oral fluids.
Reduces susceptibility to
contraindicated). infection.
Encourage deep breathing
exercise; Maintain client in Encouraged deep breathing
exercise. Maintained client ion Helps in mobilizing secretions.
semi-Fowler’s position. And expanding the lung.
semi- fowler’s position.
Obtain sample for culture and
sensitivity as indicated. - Identifies the bacteria/fungus
that causes an infection and the
appropriate drug for it.

Administer antibiotics as .
 indicated. Administered antibiotics as per Early initiation of antibiotic
doctor order. may help to prevent sepsis
Inj. ceftriaxone 1g iv bid

SUBJECTIVE DATA : The patient caregiver is asking more questions regarding prognosis of disease.

OBJECTIVE DATA : patient looks fearful.

NURSING DIAGNOSIS : Knowledge deficit related to prognosis of disease condition as evidenced by asking more question.

GOAL : The patient will improve knowledge regarding the foot care and prognosis of disease.

PLANNING IMPLEMENTATION RATIONALE EVALUATION

Explain the signs and Explained about the signs and Symptoms of hyperglycemia
symptoms of diabetic symptoms of diabetic ketoacidosis. include polyuria, polydipsia,
ketoacidosis. polyphagia, flushed skin, and
body malaise.

Discuss the following with the Discussed about the normal blood Baseline knowledge enables the
client: glucose level, risk factors, types of client to make informed lifestyle
diabetes and client blood glucose choices.
 Normal blood glucose level and the risk factors.
level.
 Risk factors.
 Client’s type of
diabetes.
 The relationship
between elevated
glucose level and
insulin deficiency.

Demonstrate proper blood Demonstrated the method to use Monitoring blood glucose 3-4
glucose testing using the the glucometer. times a day is an essential part
glucometer. Instruct client to
of managing diabetes to avoid
check the urine for ketones
further complications. Blood
once blood glucose reaches
glucose >250mg/dl and high
250 mg/dL or higher.
urine ketones should be reported
to the physician immediately.
Teach signs of hypoglycemia: Taught the signs of hypoglycemia.
These are signs of excessive
insulin dosage, resulting in
 Dizziness. hypoglycemia.
 Sweating. Early recognition of these
 Hunger. symptoms promotes immediate
 Pallor. intervention.
 Diaphoresis.
 Nervousness.
 Tremors.
Taught the main signs and
Teach client that polyuria, symptoms of hyperglycemia. These are signs of insufficient
polydipsia, and polyphagia are insulin dosage and
signs of hyperglycemia which hyperglycemia which may lead
requires increased dosage of to coma and death if untreated.
insulin.

Explain the importance of Explain the importance of limit Medical nutrition therapy is
having a dietary plan: intake of simple sugar, fat, salt and important in managing diabetes
alcohol. and preventing the rate of
Increase intake of whole grains, development of diabetes
 Limit intake of simple
fruits, and vegetables. complications.
sugar, fat, salt and
alcohol. A high-fiber diet can slow the
 Increase intake absorption of glucose, decreased
of whole grains, fruits, excess insulin levels and
and vegetables. lowered lipid concentrations in
clients with type 2 diabetes.
Teach client to monitor blood
glucose during periods of Explained about the regular
exercise and adjust insulin The insulin dose should be
monitoring of blood glucose level.
dose. adjusted after increased or
decreased food intake and
before any exercise. Exercise
may increase usage of glucose.
Advise the client the
importance of daily Advised about the daily foot care. Decreased peripheral circulation
examination of the feet and place the client at risk for an
foot care. undetected foot injury.

Clients with poorly controlled

Advise the client the Advised the importance of routine diabetes may experience
importance of routine eye eye examination. changes in vision that may lead
examination. to blindness.
A good way to properly use
insulin is to learn these aspects
Review of medication Explained about the insulin of drug usage. This will help in
regimen, including, onset,
peak, and duration of regimen. the adjustment of the doses or
prescribed insulin, as the food intake to stop unwanted
applicable with the client. ups and downs in the glucose
level.

Evaluate understanding of
Review self-administration of the procedure. Recognizes
insulin and care of equipment. potential problems such as short-
Demonstrated the self term memory so that alternative
Have client demonstrate
administration of insulin. solutions can be made for the
procedure (e.g., drawing up
and injecting insulin, insulin administration of the insulin.
pen technique, or pump
therapy). Regular insulin works best if
administering it 30 minutes
Discuss timing of insulin before eating. While a product
injection and mealtime. called insulin lispro (Humalog)
Discussed about the timing of
works best when taking within
insulin administration.
15 minutes of eating. With the
onset twice as fast as regular
insulin and a duration nearly
half as long.

Discuss the use of a medical This enables the client to have a

alert bracelet. quick entry into the health
- system, and appropriate care
will be given immediately.
Stress the importance of strict
.
follow-up care.
Educated the importance of follow To prevent or delay the
up care. development of complications
from diabetes