Diabetes Mellitus_DM_ Nursing Care Plan

Nursing Diagnosis

Objective

Fluid Volume Deficient (Regulatory Failure)Possible Etiologies: (Related to) Uncontrolled diabetes mellitus  Osmotic dieresis from hyperglycemia

Short term goal: Client will maintain hydration at a functional level as evidenced by adequate urine output, stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, and electrolyte levels within normal range.

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Excessive gastric loss (diarrhea and vomiting) Restricted or low fluid intake due to nausea or confusion

Defining characteristics: (Evidenced by)         

Statements of fatigue and nervousness Increased urinary output Concentrated urine Weakness Thirst Sudden weight loss Poor skin turgor/ dry skin and mucous membranes Hypotension Increased pulse rate

Long term goal: Client will demonstrate behaviours to monitor and correct deficit as indicated.

Nursing Interventions

1. Obtain history for intensity and duration of symptoms such as vomiting and excessive urination.2. Monitor the vital signs like: a. Orthostatic BP changes b. Respiratory changes i.e. Kussmaul’s respiration, acetone breath c. Respiratory rate and quality; use of accessory muscles, periods of apnea, and cyanosis

Rationale

- Helps in making approximation of total volume loss. Symptoms may be present for hours or days and presence of other diseases usually result, too, to increase in sensible fluid losses.Hypovolemia can be manifested by hypotension and tachycardia; Carbonic acid is removed in the lungs through respiration and producing respiratory alkalosis for ketoacidosis; Acetone breath is due to acetoacetic acid and should disappear when condition is corrected; Cyanosis, apnea and increase in respiratory effort may be due to compensation from acidosis; Fever with flushed skin reflects dehydration.

d. Temperature, skin turgor 3. Check peripheral pulses, capillary refill, and for skin turgor.

- These are indicators for the hydration status of a client and so as the circulating volume in the body.

- Gives baseline data of client’s 4. Strictly monitor the intake and hydration status and to know the the output. approximation of fluid replacement; the function of kidney and the effectiveness 5. Encourage client to take at of the fluid replacement therapy. least 2500ml/ day. - It maintains hydration level in the 6. Weigh client daily or as functional state. indicated. - It provides the current fluid status and 7. Investigate changes in adequacy of fluid replacement. mentation.

Evaluation

Client’s hydration status will resume to a functional level through demonstrating a clearcolored urine approximately 100 cc in amount and reflecting the same approximate amount of intake; less occurrence of postural hypotension with BP ranging from 120/80mmHg to 110/70mmHg; palpable peripheral pulses in synchronous with cardiac

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Decreased pulse volume and pressure/ delayed capillary refill Change in mental state

8. Administer fluid replacement measures are prescribed by the physician. 9. Insert and maintain a catheter as indicated. 10. Monitor laboratory results i.e. hematocrit, BUN/ creatinine, sodium, and potassium. 11. Administer medications like potassium intravenously or orally as indicated by the physician.(As soon as urinary flow is present)

- Changes in mentation reflect abnormally high or low glucose level, acidosis, electrolyte imbalances and decreased cerebral perfusion. - The type and amount of fluid depend on the degree of dehydration. - It gives accurate assessment of urinary output. - These parameters reflect fluid shifts and degree of dehydration of client. It may also pertain to how the body reacts to metabolic acidosis. - To prevent hypokalemia.

12. Insert NGT as indicated. - To decompress the stomach and to stop vomiting.

rate of 80 – 95 beats per minute; good skin turgor and capillary refill of less than 2 seconds; and sodium and potassium levels within normal range after one week of nursing care. Client will be able to know and perform activities helpful in controlling diabetes mellitus and maintaining adequate fluid volume like monitoring blood glucose periodically, administering

own medications like insulin injection, increasing fluid intake and monitoring urine for presence of ketones, and other activities like proper diet, exercise and lifestyle.