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4 Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome Nursing Care Plans

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By Paul Martin, BSN, R.N.
Diabetic Ketoacidosis Nursing Care Plans
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Diabetic ketoacidosis (DKA) is a life-threatening emergency caused by a relative or absolute deficiency of insulin. This deficiency in available insulin results in disorders in the metabolism of carbohydrate, fat, and protein. Main clinical features of DKA are hyperglycemia, acidosis, dehydration, and electrolyte losses such as hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, and hypophosphatemia.

Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) is a condition characterized by the presence of hyperglycemia, hyperosmolarity, and dehydration. There is enough production of insulin to reduce ketosis but not to control hyperglycemia. Persistent hyperglycemia causes osmotic diuresis, which results in the fluid and electrolyte imbalances. The clients with HHNS may present with symptoms of hypotension, tachycardia, marked dehydration, and neurological manifestation such as seizures, hemiparesis, and alterations in the sensorium).

Nursing Care Plans

The nursing care plan for clients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome includes provision of information about disease process/prognosis, self-care, and treatment needs, monitoring and assistance of cardiovascular, pulmonary, renal, and central nervous system (CNS) function, avoiding dehydration, and correcting hyperglycemia and hyperglycemia complications.

Here are four (4) nursing care plans (NCP) and nursing diagnosis for patients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Nonketotic Syndrome:

  1. Risk For Fluid Volume Deficit
  2. Risk For Infection
  3. Deficient Knowledge
  4. Imbalanced Nutrition: Less Than Body Requirements

2. Risk For Infection

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Risk For Infection

Nursing Diagnosis

Risk Factors

  • Preexisting respiratory infection, or UTI.
  • High glucose levels.
  • Decreased leukocyte function.
  • Changes in circulation.

Possibly evidenced by

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  • [not applicable].

Desired Outcomes

  • Client will identify interventions to prevent reduce risk of infection.
  • Client will demonstrate techniques, lifestyle changes to prevent the development of infection.
Nursing InterventionsRationale
Assess for signs of infection and inflammation.Infection is a common cause of DKA. Signs of infection includes fever, chills, dysuria, and increased WBC count.
Observe client’s feet for ulcers, infected toenails, or other medical problems.Due to impaired circulation in diabetes, foot injuries are predisposed to poor wound healing.
Observe aseptic technique during IV insertion and medication administration.Elevated blood sugar weakens the immune system thus clients are more prone to infection.
Provide skin care.An intact skin protects against infection.
Encourage proper handwashing technique. To avoid the risk of cross-contamination.
Encourage adequate oral fluid intake (2-3 liters a day unless contraindicated). Reduces susceptibility to infection.
Encourage deep breathing exercise; Maintain client in semi-Fowler’s position.Helps in mobilizing secretions. And expanding the lung.
Obtain sample for culture and sensitivity as indicated.Identifies the bacteria/fungus that causes an infection and the appropriate drug for it.
Administer antibiotics as indicated.Early initiation of antibiotic may help to prevent sepsis.
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2. Risk For Infection

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

Other nursing care plans related to endocrine system and metabolism disorders:

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Paul Martin, BSN, R.N.
Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.
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