ASSESSMENT

S:
O:
(+)
kussma
uls
respipr
ation
Letharg
ic
(+) use
of
accesso
ry
muscle
s in
breathi
ng
(+)
nasal
flaring
02 sat:
94%
RR: 48
cpm

NURSING
DIAGNOSIS

SCIENTIFIC
RATIONALE

PLANNING

Ineffective
breathing
pattern:
Hyperventillation
(Kussmauls
respiration)
r/t
severe
ketonemia
2
absence
of
insulin

Dec. glucose
transport
inside the cell

After 1-2
hours of
nursing
Intervention
the patient
will be able to
improve
ventilation
and maintain
patent airway
as evidenced
by:

Cellular
starvation
Use of
reserve fats
(LIPOLYSIS)
Inc. ketoacids
Metabolic
acidosis
Kussmauls
respiration

RR:
(-) use
of
accesso
ry
muscles
in
breathi
ng
(-)
nasal
flaring
(-)
kussma
uls
respirat
ion

INTERVENTION
Assess
pertinent
parameter
of
respiratory
function
such as RR
and
breathing
pattern
Auscultate
breath
sounds

Monitor
oxygen
saturation
Elevate
HOB and

RATIONALE
Ineffective
breathing
pattern
may lead to
muscle
weakness
and or can
develop
respiratory
arrest
To monitor
developme
nt of
atelectasis:
atelectatica
rea will
have no
breath
sounds and
partially
collapsed
areas have
dec. breath
sounds
To evaluate
oxygenatio
n in the
tissue

EVALUATION
After 1 hour
of nursing
intervention
the patient
was able to
improved
ventillation
and
maintained
patent airway
as evidenced:
RR:
(-) use
of
access
ory
muscle
s in
breathi
ng
(-)
nasal
flaring
(-)
kussma
uls
respirat
ion

encouorag
eddeep
breathing
exercise
Provide
oxygen
support at
1-2 Lpm as
ordered
Administer
regular
insulin 16
units
mixed with
PNSS to
make 100
ml solution
run at 10
cc/hr as
ordered

GOAL MET
To promote
maximum
lung
expansion
To maintain
adequate
oxygen
supply in
the body
and
prevent
hypoxia
Dec. blood
glucose
level
thereby
correcting
metabolic
acidosis

ASSESSMENT

NURSING
DIAGNOSIS

SCIENTIFIC
RATIONALE

PLANNING

S: Nauuhaw
ako as
verbalized

Fluid
and
electrolyte
imbalance
r/t
osmotic
dieresis caused
by
extreme
glycosuria
2
hyperglycemic
state

HYPERGLYCEMI
A

After the shift

patient will be
hydrated as
evidenced by:

O:
(+) dry
skin
and
mucous
membr
ane
(+)
sunken
eyeball
Letharg
ic
Laborat
ory
values
K+: 2.3
Na:
135.7
Glucose
: 32.77
v/s

Exceed renal
threshold of
glucose

Glucose
attracts mo re
water
Passes in the
tubules
Increase fluid
and electrolyte
loss

adequa
te
intake
of fluid
in
relation
to
output
LONG TERM
GOAL;

INTERVENTION
Assess
neurologic
and
behavioral
status

Assess
fluid
status:
- VS

After 2-3 days

of nursing
intervention:
Pts electrolyte
( k+ Na+) will
be on normal
range
Pt will be free
from

I&O

RATIONALE
Dehydratio
n usually
reflects
intracellula
r fluid
dedficit as
well as
contraction
of the ECF
volume
leading to
alteration
in
neurologict
atus
Hypovolemi
a state is
reflected
by rapid
and
thready
pulse,
potential
risk of
hypovolemi
c shock

EVALUATION
After the shift
patient was
hydrated as
evidenced by:
I: 270 cc
0: 225 cc
GOAL MET
LONG TERM
GOAL
After 3 days
of nursing
intervention
pts electrolyte
remained on
normal range
as evidenced
by:
K+: 3.8
Na+: 139.5
(-) sunken
eyeball
(-) lethargy

T: 38C
HR: 146
RR: 48
BP:
80/50

dehydration
as evidenced
by:
(-) sunken
eyeball
(-) lethargy
(-) dry skin
and mucous
membrane
Vs within
normal range

must be
anticipated
and
assessed
for
-

Hgt
Provides on
going
estimate of
volume
replacemen
t needs

Monitor
electrolyte
values: K+,
Na

Provide
safety and
security;
raising
siderails

Hyperglyce
mic state
will further
predispose
patient
from
dehydratio
n
Because
potassium
is lost ion
the urine
the
absolute
potassium
is depleted.
Na may
also dec.
d/t fluid

(-) dry skin

and mucous
membrane
GOAL MET

loss
Provide
comfortabl
e and cool
environme
nt
Cover pt.
with light
sheets
Regulate
IVF strictly
as
prescribed
Insert IFC
as ordered

Administer
potassium
replaceme
nt therapy

Dehydratio
n may alter
LOC and
behavioral
status that
may put pt.
at risk for
injury such
as fall
Avoids
overheatin
g which
could
promote
further fluid
loss
Maintains
hydration/
circulating
volume
To
accurately
assess UO
and renal
function
and
determine
fluid and

as
prescribed

electrolyte
therapy

Administer
regular
insulin 16
units
mixed with
PNSS to
make 100
ml solution
run at 10
cc/hr as
ordered

To restore
and
maintain
normal k+
conc
To ensure a
sustained
progressive
reduction /
maintenanc
e of normal
serum
glucose
level

ASSESSMENT

S:

O:
Flushed
skin
Warm to
touch

NURSING
DIAGNOSIS

SCIENTIFIC
RATIONALE

PLANNING

Altered
body
temperatur
e:
Hypertherni
a r/t inc.
fluid loss

Exceed
renal
threshold

After 1-2
hours of
nursing
intervention
patient will
maintain
temp. within
normal as
evidenced
by:

H2o
+glucose
passes to
renal
tubule

T: 38 C
Polyuria

Increase
fluid loss

T:
36.5

37.5
C
(-)

INTERVENTION

RATIONALE

Monitor
patients
temperatur
e

Serves as
baseline data

Provide cool
environmen
t
Loosen
clothing
Cover with
light sheet

Avoid
overheating
which would
promote
further fluid
loss that
contriubutes
to
hyperthermia

EVALUATION

After 1 hour
of nursing
intervention
pt.
maintained
temp within
normal as
evidenced
by:

T:
367C
(-)
flushe
d skin

Provide heat

(-)
skin

Dehydratio
n

Dec.
amount of
h20
available
for cooling

Flush
ed
skin
(-)
skin
warm
to
touch

Provide TSB

Regulate
IVF strictly
as
prescribed

Inc. temp.
Administer
paracetamo
l 200 mg IV
q4 for T >
37.8C as
ordered
Administer
regular
insulin 16
units mixed
with PNSS
to make
100 ml
solution run
at 10 cc/hr
as ordered

loss by
convection

To prevent
further
dehydration
that
precipitate
temp.
Pharmacologic
management
for
hyperthermia

To correct
hyperglycemic
state which is
the underlying
cause of
dehydration
that
precipitates
hyperthermia

warm
to
touch
GOAL MET