ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC RATIONALE

PLANNING INTERVENTION RATIONALE EVALUATION

S:

O: (+)

kussmaul’s respipration

Lethargic (+) use of

accessory muscles in breathing

(+) nasal flaring

02 sat: 94%

RR: 48 cpm

Ineffective breathing pattern: Hyperventillation (Kussmaul’s respiration) r/t severe ketonemia 2 absence of insulin

Dec. glucose transport inside

the cell

Cellular starvation

Use of reserve fats (LIPOLYSIS)

Inc. ketoacids

Metabolic acidosis

Kussmaul’s respiration

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

RR: (-) use of

accessory muscles in breathing

(-) nasal flaring

(-) kussmaul’s respiration

Assess pertinent parameter of respiratory function such as RR and breathing pattern

Auscultate breath sounds

Monitor oxygen saturation

Elevate HOB and encouoraged

Ineffective breathing pattern may lead to muscle weakness and or can develop respiratory arrest

To monitor development of atelectasis: atelectaticarea will have no breath sounds and partially collapsed areas have dec. breath sounds

To evaluate oxygenation in the tissue

To promote maximum lung

After 1 hour of nursing intervention the patient was able to improved ventillation and maintained patent airway as evidenced:

RR: (-) use of

accessory muscles in breathing

(-) nasal flaring

(-) kussmaul’s respiration

GOAL MET

deep 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

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 INTERVENTION RATIONALE EVALUATION

S: “ Nauuhaw ako’ as verbalized

O: (+) dry

skin and mucous membrane

(+) sunken eyeball

Lethargic Laborator

y values

K+: 2.3Na: 135.7Glucose: 32.77

v/sT: 38CHR: 146RR: 48BP: 80/50

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

HYPERGLYCEMIA

Exceed renal threshold of

glucose

Glucose attracts mo re water

Passes in the tubules

Increase fluid and electrolyte loss

After the shift patient will be hydrated as evidenced by:

adequate intake of fluid in relation to output

LONG TERM GOAL;

After 2-3 days of nursing intervention:

Pts electrolyte ( k+ Na+) will be on normal range

Pt will be free from dehydration as evidenced by:

(-) sunken eyeball(-) lethargy(-) dry skin and

Assess neurologic and behavioral status

Assess fluid status:- VS

- I & O

Dehydration usually reflects intracellular fluid dedficit as well as contraction of the ECF volume leading to alteration in neurologictatus

Hypovolemia state is reflected by rapid and thready pulse, potential risk of hypovolemic shock must be anticipated and assessed for

After the shift patient was hydrated as evidenced by:

I: 270 cc0: 225 cc

GOAL MET

LONG TERM GOAL

After 3 days of nursing intervention pts electrolyte remained on normal range as evidenced by:

K+: 3.8Na+: 139.5

(-) sunken eyeball(-) lethargy(-) dry skin and mucous

mucous membraneVs within normal range

- Hgt

Monitor electrolyte values: K+, Na

Provide safety and security; raising siderails

Provides on going estimate of volume replacement needs

Hyperglycemic state will further predispose patient from dehydration

Because potassium is lost ion the urine the absolute potassium is depleted. Na may also dec. d/t fluid loss

Dehydration may alter LOC and behavioral status that may put pt. at risk for injury

membrane

GOAL MET

Provide comfortable and cool environment

Cover pt. with light sheets

Regulate IVF strictly as prescribed

Insert IFC as ordered

Administer potassium replacement therapy as prescribed

Administer regular insulin

such as fall

Avoids overheating which could promote further fluid loss

Maintains hydration/ circulating volume

To accurately assess UO and renal function and determine fluid and electrolyte therapy

To restore and maintain normal k+ conc

To ensure a sustained progressive

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

reduction / maintenance of normal serum glucose level

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC RATIONALE

PLANNING INTERVENTION RATIONALE EVALUATION

S:

O:

Flushed skin

Warm to touch

T: 38 C

Altered body temperature: Hyperthernia r/t inc. fluid loss

Exceed renal threshold

H2o +glucose passes to

renal tubule

Polyuria

Increase fluid loss

Dehydration

Dec. amount of h20

available for cooling

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

T: 36.5 – 37.5 C

(-) Flushed skin

(-) skin warm to touch

Monitor patients temperature

Provide cool environment

Loosen clothing

Cover with light sheet

Provide TSB

Regulate IVF strictly as prescribed

Serves as baseline data

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

Provide heat loss by convection

To prevent further dehydration that precipitate temp.

Pharmacologic management for

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

T: 367C

(-) flushed skin

(-) skin warm to touch

GOAL MET

Inc. temp.

Administer paracetamol 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

hyperthermia

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