Nursing Priorities

1. Restore fluid/electrolyte and acid-base balance. 2. Correct/reverse metabolic abnormalities. 3. Identify/assist with management of underlying cause/disease process. 4. Prevent complications. 5. Provide information about disease process/prognosis, self-care, and treatment needs.

Discharge Goals
1. Homeostasis achieved. 2. Causative/precipitating factors corrected/controlled. 3. Complications prevented/minimized. 4. Disease process/prognosis, self-care needs, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge.

Diagnostic Studies

Serum glucose: Increased 2001000 mg/dL or more. Serum acetone (ketones): Strongly positive. Fatty acids: Lipids, triglycerides, and cholesterol level elevated. Serum osmolality: Elevated but usually less than 330 mOsm/L. Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia. Glycosylated hemoglobin (HbA1C): Evaluates glucose control during past 812 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment. Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies. Electrolytes: Sodium: May be normal, elevated, or decreased. Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased. Phosphorus: Frequently decreased. Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO3 (metabolic acidosis) with compensatory respiratory alkalosis. CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.

BUN: May be normal or elevated (dehydration/decreased renal perfusion). Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA. Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs. Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated. Cultures and sensitivities: Possible UTI, respiratory or wound infections.

Nursing Care Plans

This post contains 6 diabetes mellitus Nursing Care Plan (NCP)

Risk for Infection

Nursing Diagnosis: Risk for Infection Risk factors may include: High glucose levels, decreased leukocyte function, alterations in circulation

Preexisting respiratory infection, or UTI

Desired Outcomes: Identify interventions to prevent/reduce risk of infection.

Demonstrate techniques, lifestyle changes to prevent development of infection.

Rationale Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection.

Nursing Interventions Observe for signs of infection and inflammation, e.g., fever, flushed appearance, wound drainage, purulent sputum, cloudy urine. Promote good handwashing by staff and patient. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance/site care. Rotate IV sites as indicated. Provide catheter/perineal care. Teach the female patient to clean from front to back after elimination Provide conscientious skin care; gently massage bony areas. Keep the skin dry, linens dry and wrinkle-free.

Reduces risk of cross-contamination.

High glucose in the blood creates an excellent medium for bacterial growth.

Minimizes risk of UTI. Comatose patient may be at particular risk if urinary retention occurred before hospitalization. Note: Elderly female diabetic patients are especially prone to urinary tract/vaginal yeast infections. Peripheral circulation may be impaired, placing patient at increased risk for skin irritation/breakdown and infection. Rhonchi indicate accumulation of secretions possibly related to pneumonia/bronchitis (may have precipitated the DKA). Pulmonary congestion/edema (crackles) may result

Auscultate breath sounds.

from rapid fluid replacement/HF. Place in semi-Fowlers position. Reposition and encourage coughing/deep breathing if patient is alert and cooperative. Otherwise, suction airway, using sterile technique, as needed. Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct patient in proper handling of secretions. Encourage/assist with oral hygiene. Encourage adequate dietary and fluid intake (approximately3000 mL/day if not contraindicated by cardiac or renal dysfunction), including 8 oz of cranberry juice per day as appropriate. Administer antibiotics as appropriate. Facilitates lung expansion; reduces risk of aspiration. Aids in ventilating all lung areas and mobilizing secretions. Prevents stasis of secretions with increased risk of infection.

Minimizes spread of infection.

Reduces risk of oral/gum disease. Decreases susceptibility to infection. Increased urinary flow prevents stasis and aids in maintaining urine pH/acidity, reducing bacteria growth and flushing organisms out of system. Note: Use of cranberry juice can help prevent bacteria from adhering to the bladder wall, reducing the risk of recurrent UTI. Early treatment may help prevent sepsis.

Risk for Disturbed Sensory Perception

Nursing Diagnosis: Sensory Perception, risk for disturbed (specify) Risk factors may include Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance Desired Outcomes Maintain usual level of mentation.

Recognize and compensate for existing sensory impairments.

Rationale Provides a baseline from which to compare abnormal findings, e.g., fever may affect mentation. Decreases confusion and helps maintain contact with reality. Promotes restful sleep, reduces fatigue, and may improve cognition.

Nursing Interventions

Monitor vital signs and mental status.

Address patient by name; reorient as needed to place, person, and time. Give short explanations, speaking slowly and enunciating clearly. Schedule nursing time to provide for uninterrupted rest periods.

Keep patients routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able. Protect patient from injury (avoid/limit use of restraints as able) when level of consciousness is impaired. Place bed in low position. Pad bed rails and provide soft airway if patient is prone to seizures.

Helps keep patient in touch with reality and maintain orientation to the environment.

Disoriented patient is prone to injury, especially at night, and precautions need to be taken as indicated. Seizure precautions need to be taken as appropriate to prevent physical injury, aspiration. Retinal edema/detachment, hemorrhage, presence of cataracts or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy and/or supportive care. Peripheral neuropathies may result in severe discomfort, lack of/distortion of tactile sensation, potentiating risk of dermal injury and impaired balance. Reduces discomfort and potential for dermal injury. Promotes patient safety, especially when sense of balance is affected. Imbalances can impair mentation. Note: If fluid is replaced too quickly, excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication). Alteration in thought processes/potential for seizure activity is usually alleviated once hyperosmolar state is corrected.

Evaluate visual acuity as indicated.

Investigate reports of hyperesthesia, pain, or sensory loss in the feet/legs. Look for ulcers, reddened areas, pressure points, loss of pedal pulses. Provide bed cradle. Keep hands/feet warm, avoiding exposure to cool drafts/hot water or use of heating pad. Assist with ambulation/position changes.

Monitor laboratory values, e.g., blood glucose, serum osmolality, Hb/Hct, BUN/Cr.

Carry out prescribed regimen for correcting DKA as indicated.

Powerlessness
Nursing Diagnosis: Powerlessness May be related to Long-term/progressive illness that is not curable

Dependence on others

Possibly evidenced by Reluctance to express true feelings; expressions of having no control/influence over situation

Apathy, withdrawal, anger Does not monitor progress, nonparticipation in care/decision making

Depression over physical deterioration/complications despite patient cooperation with regimen

Desired Outcomes: Acknowledge feelings of helplessness.

Identify healthy ways to deal with feelings. Assist in planning own care and independently take responsibility for self-care activities.
Rationale

Nursing Interventions Encourage patient/SO to express feelings about hospitalization and disease in general.

Identifies concerns and facilitates problem solving.

Acknowledge normality of feelings.

Recognition that reactions are normal can help patient problem-solve and seek help as needed. Diabetic control is a full-time job that serves as a constant reminder of both presence of disease and threat to patients health/life. Knowledge of individuals style helps determine needs for treatment goals. Patient whose locus of control is internal usually looks at ways to gain control over own treatment program. Patient who operates with an external locus of control wants to be cared for by others and may project blame for circumstances onto external factors.

Assess how patient has handled problems in the past. Identify locus of control.

Provide opportunity for SO to express concerns and discuss ways in which he or she can be helpful to patient. Ascertain expectations/goals of patient and SO. Determine whether a change in relationship with SO has occurred. Encourage patient to make decisions related to care, e.g., ambulation, time for activities, and so forth. Support participation in selfcare and give positive feedback for efforts.

Enhances sense of being involved and gives SO a chance to problem-solve solutions to help patient prevent recurrence.

Unrealistic expectations/pressure from others or self may result in feelings of frustration/loss of control and may impair coping abilities. Constant energy and thought required for diabetic control often shifts the focus of a relationship. Development of psychological concerns/visceral neuropathies affecting self-concept (especially sexual role function) may add further stress.

Communicates to patient that some control can be exercised over care.

Promotes feeling of control over situation.

Imbalanced Nutrition Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements May be related to: Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism)

Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process

Possibly evidenced by: Increased urinary output, dilute urine

Reported inadequate food intake, lack of interest in food Recent weight loss; weakness, fatigue, poor muscle tone Diarrhea Increased ketones (end product of fat metabolism)

Desired Outcomes: Ingest appropriate amounts of calories/nutrients.

Display usual energy level. Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.
Rationale Assesses adequacy of nutritional intake (absorption and utilization).

Nursing Interventions Weigh daily or as indicated. Ascertain patients dietary program and usual pattern; compare with recent intake. Auscultate bowel sounds. Note reports of abdominal pain/bloating, nausea, vomiting of undigested food. Maintain nothing by mouth (NPO) status as indicated. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids; progress to more solid food as tolerated. Identify food preferences, including ethnic/cultural needs.

Identifies deficits and deviations from therapeutic needs.

Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility/function (distension or ileus), affecting choice of interventions. Note: Long-term difficulties with decreased gastric emptying and poor intestinal motility suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment.

Oral route is preferred when patient is alert and bowel function is restored.

If patients food preferences can be incorporated into the meal plan, cooperation with dietary requirements may be facilitated after discharge.

Include SO in meal planning as indicated.

Promotes sense of involvement; provides information for SO to understand nutritional needs of patient. Note:Various methods available or dietary planning include exchange list, point system, glycemic index, or preselected menus. Once carbohydrate metabolism resumes (blood glucose level reduced) and as insulin is being given, hypoglycemia can occur. If patient is comatose, hypoglycemia may occur without notable change in level of consciousness (LOC). This potentially lifethreatening emergency should be assessed and treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished. Bedside analysis of serum glucose is more accurate (displays current levels) than monitoring urine sugar, which is not sensitive enough to detect fluctuations in serum levels and can be affected by patients individual renal threshold or the presence of urinary retention/renal failure. Note: Some studies have found that a urine glucose of 20% may be correlated to a blood glucose of 140360 mg/dL. Regular insulin has a rapid onset and thus quickly helps move glucose into cells. The IV route is the initial route of choice because absorption from subcutaneous tissues may be erratic. Many believe the continuous method is the optimal way to facilitate transition to carbohydrate metabolism and reduce incidence of hypoglycemia. Glucose solutions may be added after insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia. Complex carbohydrates (e.g., corn, peas, carrots, broccoli, dried beans, oats, apples) decrease glucose levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics (e.g., peak effect) and individual patient response. Note:A snack at bedtime (hs) of complex carbohydrates is especially important (if insulin is given in divided doses) to prevent hypoglycemia during sleep and potential Somogyi response. < May be useful in treating symptoms related to autonomic neuropathies affecting GI tract, thus enhancing oral intake and absorption of nutrients.

Observe for signs of hypoglycemia, e.g., changes in level of consciousness, cool/clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness.

Perform fingerstick glucose testing.

Administer regular insulin by intermittent or continuous IV method, e.g., IV bolus followed by a continuous drip via pump of approximately 510 U/hr so that glucose is reduced by 50 mg/dL/hr.

Administer glucose solutions, e.g., dextrose and half-normal saline.

Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals/snacks.

Administer other medications as indicated, e.g., metoclopramide (Reglan); tetracycline.

Deficient Fluid Volume

Nursing Diagnosis: Deficient Fluid Volume May be related to

Osmotic diuresis (from hyperglycemia) Excessive gastric losses: diarrhea, vomiting Restricted intake: nausea, confusion

Possibly evidenced by: Increased urinary output, dilute urine

Weakness; thirst; sudden weight loss Dry skin/mucous membranes, poor skin turgor Hypotension, tachycardia, delayed capillary refill

Desired Outcomes: Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.
Nursing Interventions Obtain history from patient/SO related to duration/intensity of symptoms such as vomiting, excessive urination. Actions Assists in estimation of total volume depletion. Symptoms may have been present for varying amounts of time (hours to days). Presence of infectious process results in fever and hypermetabolic state, increasing insensible fluid losses. Hypovolemia may be manifested by hypotension and tachycardia. Estimates of severity of hypovolemia may be made when patients systolic BP drops more than 10 mm Hg from a recumbent to a sitting/standing position. Note: Cardiac neuropathy may block reflexes that normally increase heart rate.Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Acetone breath is due to breakdown of acetoacetic acid and should diminish as ketosis is corrected.Correction of hyperglycemia and acidosis will cause the respiratory rate and pattern to approach normal. In contrast, increased work of breathing; shallow, rapid respirations; and presence of cyanosis may indicate respiratory fatigue and/or that patient is losing ability to compensate for acidosis.Although fever, chills, and diaphoresis are common with infectious process, fever with flushed, dry skin may reflect dehydration.

Monitor vital signs: Note orthostatic BP changes; Respiratory pattern, e.g., Kussmauls respirations, acetone breath; Respiratory rate and quality; use of accessory muscles, periods of apnea, and appearance of cyanosis; Temperature, skin color/moisture.

Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes. Monitor I&O; note urine

Indicators of level of hydration, adequacy of circulating volume.

Provides ongoing estimate of volume replacement needs, kidney

specific gravity.

function, and effectiveness of therapy. Provides the best assessment of current fluid status and adequacy of fluid replacement.

Weigh daily.

Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed. Promote comfortable environment. Cover patient with light sheets.

Maintains hydration/circulating volume.

Avoids overheating, which could promote further fluid loss.

Investigate changes in mentation/sensorium.

Changes in mentation can be due to abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Regardless of the cause, impaired consciousness can predispose patient to aspiration. Provides for accurate/ongoing measurement of urinary output, especially if autonomic neuropathies result in neurogenic bladder (urinary retention/overflow incontinence). May be removed when patient is stable to reduce risk of infection.

Insert/maintain indwelling urinary catheter.

Fatigue
Nursing Diagnosis: Fatigue May be related to Decreased metabolic energy production

Altered body chemistry: insufficient insulin Increased energy demands: hypermetabolic state/infection

Possibly evidenced by Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone

Impaired ability to concentrate, listlessness, disinterest in surroundings

Desired Outcomes Verbalize increase in energy level.

Display improved ability to participate in desired activities.

Rationale Education may provide motivation to increase

Nursing Interventions Discuss with patient the need for activity. Plan

schedule with patient and identify activities that lead to fatigue. Alternate activity with periods of rest/uninterrupted sleep. Monitor pulse, respiratory rate, and BP before/after activity. Discuss ways of conserving energy while bathing, transferring, and so on. Increase patient participation in ADLs as tolerated.

activity level even though patient may feel too weak initially. Prevents excessive fatigue.

Indicates physiological levels of tolerance. Patient will be able to accomplish more with a decreased expenditure of energy. Increases confidence level/self-esteem and tolerance level.