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).
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:
- Risk For Fluid Volume Deficit
- Risk For Infection
- Deficient Knowledge
- Imbalanced Nutrition: Less Than Body Requirements
Risk For Infection
Risk for Infection: At increased risk for being invaded by pathogenic organisms.
- Preexisting respiratory infection, or UTI.
- High glucose levels.
- Decreased leukocyte function.
- Changes in circulation.
Possibly evidenced by
- [not applicable].
- Client will identify interventions to prevent reduce risk of infection.
- Client will demonstrate techniques, lifestyle changes to prevent the development of infection.
|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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