Assessment Diagnosis Planning Implementation Rationale Evaluation

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Objective: Risk for Fluid Volume After 8 hours of nursing  Asses the patient’s skin  To determine signs of After 8 hours of nursing
 History of Type 1 Diabetes Deficit as evidenced interventions: turgor, mucous dehydration such as poor interventions the patient:
Mellitus by active fluid loss  The patient will membranes, and thirst. skin turgor, dry mouth and  Maintained fluid
 GCS of 10 (eye opening:3; due to nausea and maintain fluid throat, and extreme thirst. volume with urinary
verbal response:3; motor  Monitor intake and output  Poor glomerular filtration
vomiting, and volume at functional output greater than
response:4;) every 1 hour. and renal blood flow may
hyperglycemic- level as evidence by 30 ml/hr, normal skin
 BP: 102/52 mmHg present oliguria or anuria.
HR: 112 bpm induced osmotic urinary output  Monitor BP closely for  Decrease in systolic blood turgor, good capillary
RR: 36 bmp (rapid and diuresis. greater than 30 orthostatic hypotension. pressure and orthostatic refill, and normal
shallow) ml/hr, normal skin hypotension indicates blood pressure.
T: 36.2 ‘C turgor, good capillary decreased blood volume.  Demonstrate
SpO2: 96% w/o supplemental refill, and normal  Monitor temperature  Dehydration is manifested understanding about
oxygen blood pressure. by fever with flushed and fluid replacement as
BGL: 42.1 mmol/L  Patient will dry skin. evidenced by
Ketone levels: 7.1 mmol/L demonstrate  Monitor heart rate.  Compensatory mechanism cooperation in
 Acetone breath results in peripheral
behaviors changes to treatment regimen.
 Skin is flushed and dry vasoconstriction with a
prevent
 Urinalysis shows glycosuria weak pulse that is easily
and ketonuria with low development of fluid obliterated.
specific gravity. volume deficit  Assess level of  Decreased level of
Subjective consciousness every 2 consciousness results from
 Significant other reported hours. decreased blood volume,
that patient is lethargic and elevated or decreased
unable to make any sense. glucose level, hypoxia and
She has been unwell with flu- dehydration.
like illness for the past week,  Weight the patient.  This will provides baseline
with nausea and vomiting data of current fluid status
over the past 2 days. She did and adequacy of fluid
not take her regular dose of replacement.
insulin last night as she Monitor laboratory
hadn’t been eating and her examination:
BGL was only 8.1 mmol/L. She  Blood glucose and ketone  Hyperglycemia leads to
had gone to toilet several levels high ketone levels, and
times during at night, and blocks water absorption
when she woke up this and triggers kidney to
morning, she had wet bed. excrete the water through
increasing urine
production (diuresis).
 Potassium levels  As fluid volume deficit
progress, potassium levels
decreases.
 Sodium  Increased blood sugar
causes water to shift from
intracellular into
extracellular, resulting in
serum sodium depletion.
 Blood urea nitrogen and  Elevated BUN and
creatinine. creatinine indicate cellular
breakdown from
dehydration or a sign of an
acute renal failure.
 Insert indwelling urinary  This provide accurate
catheter as indicated. measurement of urinary
output
 Administer IV therapy with  Isotonic solution will
2-3L isotonic solution expand extracellular fluid
(0.9% NaCl) as indicated. volume without causing a
rapid fall in plasma
 Administer succeeding IV osmolality.
therapy with hypotonic  It will help hydrate the
solution such as 0.45% cells by allowing the water
normal saline. to shift from extracellular
 Add dextrose to IV fluid space into the cell.
when serum blood glucose  Prevent the hypoglycemia
level is less than 250 and an excessive decline in
mg/dL in DKA as indicated. plasma osmolality that can
 Provide patient and result in cerebral edema.
significant other health
teaching about fluid  To enhance cooperation to
replacement options and the regimen and
schedule and engage them achievement of goals.
in fluid management plan.

Assessment Diagnosis Planning Implementation Rationale Evaluation

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ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

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