Cues Nursing Diagnosis Background Knowledge Goal and Objectives Nursing Interventions and Rationale Evaluation

Subjective: Deficient Fluid Volume Fluid volume deficit NOC: Hydration NIC: Fluid Management
 Upon interview related to active fluid (FVD) or hypovolemia is a
she mentioned loss due to diarrhea as state or condition where Goal (Long term):
to have passage evidenced by the fluid output exceeds After the nursing
of soft stool for hypotension, the fluid intake. It occurs interventions, the client
3x with slight tachycardia,tachypnea, when the body loses both will be able to:
bloody low temperature water and electrolytes from 1. Maintain fluid
appearance fainting and cold to the ECF in similar volume at a
 Her daughter touch. proportions. Common functional level
mentioned that sources of fluid loss are the as evidenced by
her mother gastrointestinal tract, stable vital
experienced polyuria, and increased signs, good skin
fainting and perspiration. Risk factors turgor, good
cold touch prior for FVD are as follows: capillary refill,
to coming to the vomiting, diarrhea, GI moist mucous
ER. suctioning, sweating, membranes and
 She had tremors, decreased intake, nausea, adequate urinary
sweating and inability to gain access to output with
very weak fluids, adrenal normal specific
insufficiency, osmotic gravity.
Objective: diuresis, hemorrhage, 2. Explains
 Vital signs take coma, third-space fluid measures that
as follows: shifts, burns, ascites, and can be taken to
BP- 90/50 liver dysfunction. treat or prevent
RR-30 (Wayne, 2019) fluid volume
HR- 116 loss
Temp-35.8
Objectives (Short term,
can be achieved
throughout the 8-hour
shift):
After nursing
interventions, the client The nurse will: The patient:
will be able to:
1. Identify factors 1. Monitor for the existence of 1. Identified factors the
the causing the factors causing deficient fluid causing the condition.
condition. volume. Early identification of
risk factors and early
intervention can decrease the
occurrence and severity of
complications from deficient
fluid volume. The
gastrointestinal system is a
common site of abnormal fluid
loss.
2. Obtained vital signs within
2. Obtain vital 2. Monitor vital signs. normal range
signs within Tachycardia is present along
normal range with a varying degree of
hypotension, depending on the
degree of fluid deficit.

3. Exhibit signs of  Administer antidiarrheals. The 3. Exhibit signs of hydrations

hydration gastrointestinal tract is a
common site for fluid loss. The
goal is to stop the loss that
results from or diarrhea

 Institute measures to rest the

 bowel when client is vomiting
or has diarrhoea. Hydrate client
with ordered IV solutions if
prescribed. The most common
cause of deficient fluid volume
is gastrointestinal loss of fluid.
At times it is preferable to
allow the gastrointestinal
system to rest before resuming
oral intake.

 Monitor urine output. Measure

or estimate fluid losses from
all sources such as
diaphoresis, wound drainage,
and gastric losses.
 If client requires IV fluid
replacement, maintain patent
IV access, set an appropriate
IV infusion flow rate, and
administer at a constant flow
rate as ordered. Isotonic IV
fluids such as 0.9% N/S or
lactated ringers allow
replacement of intravascular
volume.
 Cues Nursing Diagnosis Background Knowledge Goals And Objectives Nursing Interventions & Rationale Evaluation

Subjective: Unstable blood glucose NOC: Blood Glucose NIC: Hyperglycemia Management
 Weakness level related to Level
 Fatigue inadequate blood glucose Diabetes Self-
monitoring or medication Management
Objective: management and insulin
 Fainting deficiency evidenced by Goal (Long Term)
 Cold to touch blood glucose levels After effective nursing
 Sweating below or above normal interventions, the client
 Hgt stat upon levels, weakness, fatigue, will be able to maintain
hospitalization – and altered level of glucose in satisfactory
50 mg/dl consciousness range and verbalize
plan for modifying
 Blood glucose
factors to prevent or
monitoring:
minimize
- Day 1: 6 AM+
complications.
195mg/dl;
11AM=167mg/dl;
Objectives:
6PM= 204mg/dl
After nursing
- Day 2: 6 AM+
interventions, the client The nurse will:
1146mg/dl;
will be able to:
11AM=154mg/dl;
6PM= 161mg/dl
1. Assess 1. Determine individual factors that
- Day 3: 6 AM+
risk/contributing may contribute to unstable glucose as
171mg/dl;
factors: listed in risk factors.Client or family
11AM=198mg/dl;
history of diabetes, known diabetic
6PM= 189mg/dl
with poor glucose control, eating
disorders (e.g., morbid obesity),
poor exercise habits, or a failure to
recognize changes in glucose needs
or control due to adolescent growth
spurts or pregnancy can result in
 problems with glucose stability.
Determine the client’s awareness and
ability to be responsible for dealing
with the situation. Age, maturity,
current health status, and
developmental stage all affect a
client’s ability to provide for his or
her own safety.

2. Assist client to 2. Perform fingerstick glucose

develop preventive testing. Ascertain whether client and
strategies to avoid SO(s) are adept at blood glucose
glucose instability: 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

Review medical necessity for

regularly scheduled lab screening
and monitoring tests for diabetes.
Screening tests may include fasting
plasma glucose or oral glucose
tolerance tests. In the known or sick
diabetic, tests can include fasting
and daily (or numerous times in a
day) fi ngerstick glucose levels. Also,
in diabetics, regular testing of
hemoglobin (Hgb) A 1 C and the
 estimated average glucose (eAG)
help determine glucose control over
several months.

Discuss home glucose monitoring

according to individual parameters
(e.g., six times a day for a normal
day and more frequently during
times of stress) to identify and
manage glucose variations.

Discuss how the client’s antidiabetic

medication(s) work. Drugs and
combinations of drugs work in
varying ways with different blood
glucose control and side effects.
Understanding drug actions can help
the client avoid or reduce the risk or
potential for hypoglycemic reactions.

3. Promote wellness 3. Review type(s) of insulin used,

such as rapid, short-acting,
intermediate, long-acting, premixed,
and the delivery method—
subcutaneous, inhaled, or pump.
Note times when short-acting and
long-acting insulins are
administered. These factors affect
timing of effects and provide clues to
potential timing of glucose
instability.

Check injection sites. Insulin

 absorption can vary from day to day
in healthy sites and is less
absorbable in lypohypertrophic
(lumpy) tissues

Review client’s dietary program and

usual pattern; compare with recent
intake. Identifies deficits and
deviations from therapeutic plan,
which may precipitate unstable
glucose and uncontrolled
hyperglycemia.

4. Maintain blood 4. Observe for signs of

glucose levels within hypoglycemia—changes in LOC,
appropriate range cool and clammy skin, rapid pulse,
hunger, irritability, anxiety,
headache, lightheadedness, and
shakiness. Once carbohydrate
metabolism resumes, blood glucose
level will fall, and as insulin is being
adjusted, hypoglycemia may occur.
If client is comatose, hypoglycemia
may occur without notable change in
LOC. This potentially lifethreatening
emergency should be assessed and
treated quickly per protocol.

Monitor laboratory studies, such as

serum glucose, acetone, pH, and
HCO3 – . Blood glucose will
decrease slowly with controlled fluid
replacement and insulin therapy.
With the administration 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

Administer rapid-acting insulin, such

as regular (Humulin R), lispro
(Humalog), or aspart (Novalog) by
intermittent or continuous IV
method, for example, IV bolus
followed by a continuous drip via
pump of approximately 5 to 10
units/hour so that glucose is reduced
by 50 to 75 mg/dL/hour. Rapid-
acting insulin is used in
hyperglycemic crisis. 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.
 Cues Nursing Diagnosis Background Goal and Objectives Nursing Interventions and Evaluation
Knowledge Rationale
Objective: Fatigue r/t unstable An overwhelming NOC: Fatigue: Disruptive Effects NIC: Energy Management
 Extreme weakness blood glucose sustained sense of
 (+) Sleep exhaustion and Goal:
disturbances such as decreased capacity After the nursing interventions, the
administration of for physical and patient will be able to report
insulin and repeated mental work at the improve sense of energy.
medical procedures usual level (Fatigue,
including blood NANDA 15th ed).
glucose monitoring
Objectives: After nursing
 Blood glucose level:
interventions, the patient will be The nurse will:
-@6 AM= 195
able to:
mg/dL
1. Acknowledge the degree of 1. Determine degree of sleep The patient:
-@11 AM= 167
difficulty falling asleep. disturbance. 1. Acknowledged the degree
mg/dL
-@6 PM= 204 mg/dL Fatigue can be exacerbated by of difficulty falling asleep.
sleep deprivation. 2. Described her overall
feeling of tiredness or lack
2. Describe her overall feeling of 2. Ask patient to rate fatigue of energy.
tiredness or lack of energy. (using 0 to 10 scale). 3. Was able to lessen the risk
 Fatigue may vary in intensity of injury.
and often accompanied by lack 4. Acknowledged the need to
of concentration. maintain adequate fluid
intake.
3. Evaluate the need for individual 5. Demonstrated ability to
3. Lessen the risk of injury. assistance or assistive devices. perform pursed-lip
To conserve energy for other breathing and controlled
tasks. breathing.
6. Was able to rest and sleep
4. Encourage to increase fluid better to compensate the
4. Acknowledge the need to intake. energy loss.
maintain adequate fluid intake. To help maintain energy.

5. Encourage deep breathing

5. Demonstrate ability to perform exercises.
pursed-lip breathing and To help turn off the body’s
controlled breathing. stress switch.

6. Rest and sleep better to 6. Discuss measures to promote

compensate the energy loss. restful sleep.
To regain strength and restore
energy.