Nursing Diagnosis : Fluid Volume Deficit related to
- osmotic diuresis due to hyperglycemia,
- excessive discharge: diarrhea, vomiting;
- restriction of intake due to nausea
- Increased urine output
- Weakness, thirst, weight loss suddenly
- Dry skin and mucous membranes, poor skin turgor
- Hypotension, tachycardia, decreased capillary refill
- Vital signs are within normal limits
- Peripheral pulse can be palpated
- Skin turgor and capillary refill good
- Balance of urine output
- Normal electrolyte levels
Nursing Care Plan for Diabetic Ketoacidosis
Intervention and Rational:
1. Assess history of duration / intensity of nausea, vomiting and excessive urination.
Rationale: Helps to estimate the total volume reduction. The process of infection that causes fever and hypermetabolic state, increased discharge insensibel.
2. Monitor vital sign and orthostatic blood pressure changes.
Rational: Hypovolemia can be manifested by hypotension and tachycardia. Excessive hypovolemia can be shown to decrease blood pressure greater than 10 mmHg from a lying position to a sitting or standing.
3. Monitor changes in respiration: kussmaul, the smell of acetone.
Rationale: The release of carbonic acid through respiration, resulting in respiratory alkalosis, compensated in ketoacidosis. Acetone breath odor, due to breakdown of amino ketones and will be lost when it is corrected.
4. Observation of breathing quality, accessory muscle use, and cyanosis.
Rationale: The increase in expenses breath showed an inability to compensate for acidosis.
5. Observation urine output and quality.
Rationale: Describe the ability of the kidneys and the effectiveness of therapy.
6. Measure weight
Rationale: Shows the status and adequacy of rehydration fluids.
7. Maintain fluid 2500 ml / day if indicated.
Rationale: Maintaining hydration and circulation volume.
8. Create a comfortable environment, consider the emotional changes.
Rationale: Reduce the temperature increases causing a reduction in fluid, emotional changes showed decreased cerebral perfusion and hypoxia.
9. Write down the things that are reported such as nausea, abdominal pain, vomiting and gastric distention.
Rationale: Lack of fluid and electrolyte alter gastrointestinal motility, often cause vomiting and potentially lead to lack of fluids and electrolytes.
10. Observation increases the feeling of fatigue, edema, weight gain, irregular pulse and the presence of vascular distension.
Rationale: Fluid for quick fixes may be a potential cause fluid load and congestive heart failure.
11. Monitor laboratory tests:
Rationale: Assessing the level of dehydration due to hemoconcentration.
BUN / Creatinine
Rationale: The increase reflects the value of cell damage due to dehydration or the onset of kidney failure.
Rationale: Increase in hyperglycemia and dehydration.
Rationale: Decrease reflects the movement of intracellular fluid (osmotic diuresis), higher mean fluid loss / dehydration or respond to sodium reabsorption in the aldosterone secretion.
Rationale: Potassium occurs in early acidosis and subsequently lost through urine, the absolute levels in the body is reduced.