University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2022
Views:

117

Pages:

1
Author:

Marilyn James

Nursing Diagnosis #1: Risk for Fluid Volume Deficit AEB hypotension and HA r/t polyuria. Nursing Diagnosis #2: Risk for Infection AEB hyperglycemia r/t poor wound healing Date: 3-9-2022 Nursing Interventions w/rationale: Nursing Interventions w/rationale: Nurse will assess skin turgor because it is a sign of dehydration Nurse will administer IV fluids as prescribed by provider to keep patient hydrated. Nurse will assess patient’s feet for presence of ulcers because diabetes causes poor wound healing Nurse will administer antibiotics as prescribed to fight infections. Goals: (Short & Long term) Goals: (Short & Long term) ST: Patient will remain hydrated with urinary output greater than 30ml/hr by end of shift. LT: Patient will be able to recognize signs of dehydration by discharge. ST: Patient will demonstrate proper skin care and hand washing by end of shift. LT: Patient will identify interventions to reduce risk of infection by discharge Evaluation: ST (goal met), LT (working towards goal) E l i ST ( l ) LT ( ki d Assessment: Tachypnea, tachycardia, hypotension, fever, decreased skin turgor, Polydipsia, polyuria, N/V, dyspnea, Kussmaul respirations, fruity breath, abdominal pain, confusion, weakness, fatigue, HA, dehydration Diagnostics: Ketone testing (through a urine or blood test) Arterial blood gas Basic metabolic panel Osmolality blood test Blood glucose test Metabolic acidosis l) Labs: pH ≤ 7.3 HCO₃ ≤ 18 Anion gap > 10 Blood glucose > 250 Creatine (0.5-1.2), sodium (136-145), potassium (3.5-5.5), phosphate (2.84.5), often elevated or normal white blood cells (5000-10000) mildly elevated Disorder: Diabetic Ketoacidosis (DKA) Pathophysiology: Insulin deficiency causes the body to metabolize triglycerides and amino acids instead of glucose causing an increase of ketones in the blood. The formation of ketones causes the pH to decrease creating a state of metabolic acidosis. Insulin deficiency also leads to hyperglycemia which causes excretion of water and electrolytes through the urine. Risk Factors: DM type 1 and 2 (not as common), missed doses of insulin, heart disease, infections, recreational drug use, surgery, trauma, stomach illness with lots of vomiting, difficulty assessing fluids Medications: IV fluids and electrolytes especially potassium Insulin if needed Complications & Actions to Prevent: Hypoglycemia Hypokalemia Cerebral edema Pulmonary edema Damage to kidneys or other organs from fluid loss