Nursing Care Plan for Diabetic Ketoacidosis - Nursing Diagnosis : Deficient Fluid Volume
Diabetic ketoacidosis is a state of emergency or acute Type I diabetes, is caused by the increased acidity of the body of ketone bodies due to deficiency or insulin deficiency, characterized by hyperglycemia, acidosis, and ketones due to a lack of insulin (Stillwell, 1992).
Diabetic ketoacidosis is often the first sign of type 1 diabetes in people who do not yet have other symptoms. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin, or surgery can lead to diabetic ketoacidosis in people with type 1 diabetes.
Most cases of diabetic ketoacidosis occur in people with type 1 diabetes, although it can also be a complication of type 2 diabetes.
Symptoms of diabetic ketoacidosis include:
- Deep, rapid breathing
- Dry skin and mouth
- Flushed face
- Fruity smelling breath
- Nausea and vomiting
- Stomach pain
Deficient Fluid Volume
Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level)
Defining Characteristics:
- Decreased urine output;
- increased urine concentration;
- weakness;
- sudden weight loss (except in third-spacing);
- decreased venous filling;
- increased body temperature;
- decreased pulse volume/pressure;
- change in mental state;
- elevated hematocrit;
- decreased skin/tongue turgor;
- dry skin/mucous membranes;
- thirst;
- increased pulse rate;
- decreased blood pressure
Nursing Diagnosis for Diabetic Ketoacidosis : Deficient Fluid Volume related to excessive secretion of fluid (osmotic diuresis) due to hyperglycemia
Outcomes:
- Vital signs within normal limits
- Peripheral pulse can be palpated
- Skin turgor and capillary refill good
- Balance urine output
- Normal electrolyte levels
Nursing Intervention:
- Observation of input and output of fluids every hour.
- Observation drip infusion.
- Monitor vital signs and level of consciousness every 15 minutes, if stable continue for every hour.
- Observation of skin turgor, mucous membranes, acral, capillary refill
- Monitor results of laboratory tests: hematocrit, BUN / creatinine, blood osmolarity, sodium, potassium.
- EKG monitor.
- CVP monitoring (when used).
- Collaboration with other health team:
- Parenteral fluid administration : Giving insulin therapy, Catheter urine, CVP installation if possible
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