Home Chapter 13 Nursing Care Plan

Nursing Care Plan

Nursing Diagnosis Long Term Goal:
Fluid Volume Deficit r/t active fluid loss (increased urine Patient will have adequate
output) 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 Patient able to maintain
information on fluid balance and the weight.
adequacy of volume replacement.  1lb =
2.2kg.
Measure and record Fluid volume deficit reduces glomerular Intake equal to output.
urine output hourly; filtration and renal blood flow causing
report urine output less oliguria.  The patient in DKA may also
than 30ml for 2 be undergoing osmotic diuresis and have
consecutive hours. excessive outputs.
Assess skin turgor, Poor turgor, dry membranes and Membranes pink and
mucous membranes and excessive thirst are all signs of moist, no tenting.
complaints of thirst. dehydration.
Measure vital signs, Compensatory mechanisms result in BP 100/60, HR 80, RR 24,
including CVP (central peripheral vasoconstriction with a weak urine output >30ml/hr 
venous pressure). thready pulse, drop in systolic blood CVP 6.
pressure, orthostatic hypotension and
reduced CVP.
Assess neurological Alterations in mental status can omlur Awake, alert and oriented
status. from severe volume depletion and altered X3.
sodium levels,  Patients are also at risk
for seizures.
Monitor serum glucose Glucose has a high osmotic pull.  Glucose decreased from
every 30 to 60 minutes, Glucose levels needs to be reduced 350 to 280 in first hour of
then hourly as long as gradually for the fluid balance to omlur. treatment.
insulin infusion A steady decline of 50 to 75 mg/hr is
continues.  Notify desirable.  Insulin therapy needs to
physician if glucose continue until ketoacidosis is resolved.
does not fall by 50 mg/dl
in the initial hour.
Monitor for Because insulin therapy needs to No signs of hypoglycemia
hypoglycemia. continue until ketoacidosis is resolved noted.
and the blood glucose improves faster
than the acidosis, hypoglycemia can
omlur.
Assess for signs of Osmotic diuresis causes increased No signs of hypokalemia
hypokalemia: fatigue, excretion of potassium.  Insulin therapy present.
malaise, confusion, results in shifting of potassium
muscle weakness, intracellular.  Both DKA and HHNS
cramping, shallow result in a total body deficit for
respirations and cardiac potassium.  Serum potassium may be
abnormalities. elevated, normal, or low.  Goal is to
maintain levels between 3 and 4 mEq/L.
Assess for signs of With insulin therapy and as ketoacidosis No signs of hyperkalemia
hyperkalemia: resolves potassium levels can shift present.
irritability, weakness, quickly.  Hyperkalemia can develop.
EKG changes (tall
peaked T waves, wide
QRS, prolonged PR
interval and flattened P
wave).
Assess for signs of Hyperglycemia can cause water to be No signs of hyponatremia
hyponatremia: pulled from intracellular fluid and placed present.
weakness, headache, in the extracellular compartment, causing
malaise, confusion, poor dilution of serum sodium.  Osmotic
skin turgor, weight loss, diuresis contributes to hyponatremia.
decreased CVP, nausea,
abdominal cramps.
Assess for signs of Patients with DKA have metabolic Patient admitted with
metabolic acidosis: acidosis due the build up of ketones in fruity breath and
drowsiness, Kussmaul the blood stream. Kussmaul respirations,
respirations, nausea, resolving with treatment.
confusion and fruity
odor to the breath.
Assess serum ketones / Serum ketones are a more reliable Serum ketone 3.0 on
acetone levels. measure than urine ketone tests.  DKA is admission.
associated with elevated levels of ketone
bodies in the blood.
Assess arterial blood Patients with DKA have metabolic pH 7.1 HCO3 18 –
gases. acidosis with a pH less than 7.3 and a metabolic acidosis.
bicarbonate less than 15 mEq/L.
Assess BUN/ creatine Normal ratio is 10:1 to 15:1.  Ratios Ratio 12:1 after fluid
ratio. greater than 20:1 are associated with replacement.
dehydration.
Assess for changes in Elevations in white blood cell count may All levels WNL.
hemoglobin, indicate infection, a common precursor
hemoatocrit and white to DKA.  All levels may be elevated due
blood cell count. to hemoconcentration.
Assess for abnormalities Pneumonia and urinary tract infections Urine culture positive for
in chest x-ray and are the most frequent infections causing UTI.
urinalysis. DKA and HHNS.
Monitor for effects of IV Volume replacement is necessary to BP 100/60, HR 80, RR 24,
therapy. provide adequate circulation, perfusion urine output >30ml/hr.
and oxygenation of the tissues. 
Replacement is adequate when vital
signs are back to baseline.
Initiate and administer   0.9% NSS administered
IV therapy: X2L.
Initial goal is to correct circulatory
 Isotonic saline volume deficit.  Isotonic saline will D5 ½ NSS infusing at
(0.9%) initially. rapidly expand extracellular fluid 65ml/hr.  Vital signs
 Subsequent volume. normal, pulses +3, BGM
type of therapy
199, Urine output
depends, on the
state of The secondary goal, correction of water >30ml/hr.
hydration, deficit, is usually amlomplished by a
serum hypotonic solution.
electrolyte
levels and  
urinary output.
 Dextrose is
Dextrose is added to prevent
added to IV
fluids when hypoglycemia excessive decline in
blood glucose plasma osmolality the leads to cerebral
concentrations edema.
are less than
250 mg/dl in
DKA or less than
300 mg/dl in
HHS.

Initiate and administer Insulin is necessary to correct the Insulin infusing at

Insulin therapy: ketoacidosis.  Injected forms are 2units/hr.  Serum positive
inconsistently absorbed when the patient for ketones.
 is hypotensive and acidotic.
 IV bolus dose of
regular insulin is Insulin has an affinity to the tubing. 
followed by 50ml must be primed through the tubing,
continuous
to allow the mixture to coat the tubing
infusion.
 Prime the line and make sure the patient is receiving the
by wasting 50ml true dose.
of the mixture.

Administer potassium Potassium is added to Iv infusions once K 3.0  20meq KCL

IV as ordered: typically renal function has been established and administered over 1 hour.
20 to 30 mEq/L. serum potassium levels are below 5.5
mEq/L.
Administer bicarbonate This recommenced only in life- pH 7.1 – no bicarb needed.
as ordered. threatening hyperkalemia, severe lactic
acidosis and severe acidosis in adults
with pH less than 6.9
Nursing Diagnosis Long Term Goal:
Risk for Ineffective management of the Therapeutic Regimen Patient will be able to self-
related to complexity of the medical regimen 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 An initial assessment must be done to Patient states needs
learning needs, self- determine what needs taught and how education on foot care and
management skills and the patient best learns. insulin. Learns best by
ability and willingness to demonstration.
learn.
Teach signs of Hyperglycemia results when Patient able to state 3
hyperglycemia: increased inadequate insulin is present to use signs of hyperglycemia.
thirst, increased hunger, glucose.  Excessive glucose results in
increased urination, an osmotic effect that causes the
fatigue, blurred vision and hallmark symptoms.
poor wound healing.
Teach causes and Increased food intake, noncompliance Patient states the
prevention of with medications, infection, illness and importance of taking
hyperglycemia. stress will all elevate glucose levels medications and proper
and insulin needs. diet.
The best way to prevent hyperglycemia
to be compliant with dietary restriction,
medication regimen and blood glucose
monitoring.
Teach symptoms and Symptoms include trembling, shaking, Patient able to state 3
causes of hypoglycemia. sweating, tingling of extremities, signs of hypoglycemia.
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.
Teach treatment when Hypoglycemia is considered blood Patient states to drink 4-6
hypoglycemia occurs: glucose less than 70 mg/dl.  10 to 15 ounces of juice if having
grams of carbohydrate should raise the signs of hypoglycemia.
 3-4 glucose glucose levels 30 to 45 mg/dl.  Glucose
tablets. containing products will produce faster
 8-10 Lifesaver results.
candies.
 4-6 ounces of
juice.

Monitor HbA1c levels. HbA1c measures the blood glucose HbA1c level 6.0%.
over the past 2-3 months, so it is a
better indicator of the overall
management.
Assess understanding of Noncompliance with dietary Patient states have trouble
the diabetic diet. regulations can result in at times choosing the best
hyperglycemia. foods.
Assess pattern of physical Regular excise reduces the risk of Patient exercises 3 times a
exercise. cardiovascular complications and has week for 30 minutes.
an insulin-like effect and helps lower
blood glucose levels.
Establish goals with the Moderate weight loss has been shown Patient and nurse agree the
patient for weight loss, to improve hyperglycemia and patient will attempt to lose
glucose levels, HbA1c hypertension.   Intensive glucose 5 pounds, keep glucose
levels and exercise control should range between 80 and between 80-120 and
regimen. 120 mg/dl fasting.  HbA1c should be maintain exercise
below 7.0%.  Patient should perform program.
30 minutes of moderate physical
 activity on most days of the week.
Refer to registered An individualized meal plan should be Patient has appointment
dietician for developed for each patient. set up with dietician.
individualized diet
instruction.
Instruct to take oral Hypoglycemia occurs less often with Patient states when to take
hyperglycemia oral agents; however episodes of medications in
medications as ordered. hypoglycemia can occur in patients relationship to meals.
who don’t eat regularly.
Instruct to take insulin as Insulin is required for individuals with Patient states when to rake
ordered. type 1 diabetes and some with type 2 insulin in relationship to
diabetes. meals.
Instruct in the type, onset, Specific types of insulin vary in the Patient states when to take
peak and duration of onset, peak and duration.  These insulin in relationship to
action of specific insulin. characteristics of the specific insulin meals.
ordered determine when the injection
should be administered.
Instruct the patient to Inaccurate technique can result in an Patient able to
prepare and administer elevated glucose level. demonstrate appropriate
insulin. technique, stated to rotate
Insulin injections should be given in sites with each injection. 
 proper procedure the subcutaneous tissue.  Injecting over Will keep insulin in
 rotation of the same site will result in reduced refrigerator.
injection sites absorption.
 storage of insulin
Insulin should be refrigerated. 
 mixing of insulin
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.
Assist patient to develop A specific routine should be Patient exercises 3 times a
an exercise routine.  individualized to each patient.  In week for 30 minutes.
Include methods to general routines should be 30 to 60
maintain hydration and minutes in length 3-4 times a week for
prevent hypoglycemia good glycemic control.  Dehydration
when exercising. can hasten hypoglycemia, especially in
a hot environment.
Instruct the patient on Insulin requirements increase with  
diabetes management infection.
during illness:
Allows the patient to guide therapy. Patient able to verbalize
 continue to take management during
all diabetes   illness.
medication
 self-monitor blood
glucose every 2 to
Provides for early detection of DKA.
4 hours
 Test urine for  
ketones if blood
glucose is  
consistently
higher than 300  
mg/dl or nausea
or vomiting occur.
 Drink fluid and Sufficient intake is needed to prevent
simple dehydration.
carbohydrates:
soup, pudding, etc

Instruct the patient to take Early treatment of hyperglycemia can Paten able to verbalize
additional short acting prevent the occurrence of DKA or when extra insulin needs
insulin as prescribed HHNS. are necessary.
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.

Assess skin integrity Fungal infections in nails (thick,  

include: deformed, or ingrown) are a port of
bacterial entry. Patient able to state what it
 general Neuropathy leads to dryness, fissuring is necessary to inspect the
appearance of the of the skin, muscle weakness and feet for.
foot changes to the shape of the foot.
 status of nails
Pressure over bony prominences leads
 abnormalities in
shape of foot to callus formation and skin
 callus or corn breakdown.
formation.
Teach patients to inspect
feet daily.  Use a mirror if
necessary to examine
bottom of feet.
Palpate dorsalis pedis and Atherosclerosis results in gradual Pulses +3 bilaterally.
posterior tibial pulses. decrease in blood supply to the foot.
Assess for edema. Edema is a major predisposing factor No edema noted.
for ulcerations.  Neuropathy leads to
swelling in the foot.
Instruct patient to wash Maceration between the toes can lead Patient able to verbalize
feet daily in warm water to infection.  Soaking can cause proper foot care.
using mild soap.  Dry maceration.
carefully and gently,
especially between toes. 
Avoid soaking feet.
Teach patient to report Early treatment is essential to prevent Patient able to verbalize
signs of infection amputation. signs of infection.
immediately.
Instruct in appropriate To prevent injury to the foot sue to  
footwear: decreased sensation appropriate
footwear is essentials.  Patient able to verbalize
 have foot size proper foot care.
measured. The widest part of the shoe must
 inspect shoes accommodate the widest part of the
daily by feeling for
foot.
irregularities in
lining or foreign
objects in shoes.  
 wear clean, well-
fitting stockings of Soft cotton or wool will absorb
cotton, synthetic moisture from perspiration and
blend, or wool. discourage an environment for fungus.
 never go barefoot.

Teach patient to: Sue to loss of normal pain and  

temperature sensation from neuropathy
 test bath water thermal injuries can occur. Patient able to verbalize
with wrist or measure to prevent a
elbow thermal burn.
 avoid heating
pads, hot water
bottle, or electric
blankets
  maintain safe
distance form
fireplace or space
heater.

Instruct patient in nail Avoid injury to the toes.  

care:
Patient able to verbalize
 trim straight proper nail care.
across
 file sharp corners
 consult a
podiatrist of
unable to manage
by self.

Teach patient to avoid Many over the counter agents contain Patient able to verbalize.
over the counter self- salicylic acid that may cause ulceration
treatment for foot in a diabetic foot.
problems.
Teach patient to stop The vasoconstriction effects of Information given.  Patient
smoking. smoking reduced the ability of the willing to enter smoking
tissues to heal. cessation program.

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