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.
- Risk For Fluid Volume Deficit
- Risk For Infection
- Deficient Knowledge
- Imbalanced Nutrition: Less Than Body Requirements
May be related to
- Unfamiliarity with the risk factors, treatment, and prevention of the disease.
- Lack of exposure or recall, information misinterpretation.
Possibly evidenced by
- Inaccurate follow-through of instructions, development of preventable complications.
- Questions or request for information.
- Client will verbalize understanding of the disease condition and potential complication.
- Client will correctly perform necessary procedures and explain rationale on each action.
- Client will demonstrate lifestyle changes and participate in treatment regimen.
|Establish rapport and trust.||Create an environment where trust and good rapport facilitates good relationship in the learning process.|
|Explain the signs and symptoms of diabetic ketoacidosis.||Symptoms of hyperglycemia include polyuria, polydipsia, polyphagia, flushed skin, and body malaise.|
|Discuss the following with the client:
|Baseline knowledge enables the client to make informed lifestyle choices.|
|Demonstrate proper blood glucose testing using the glucometer. Instruct client to check the urine for ketones once blood glucose reaches 250 mg/dL or higher.||Monitoring blood glucose 3-4 times a day is an essential part of managing diabetes to avoid further complications. Blood glucose >250mg/dl and high urine ketones should be reported to the physician immediately.|
|Teach signs of hypoglycemia:
|These are signs of excessive insulin dosage, resulting in hypoglycemia.|
Early recognition of these symptoms promotes immediate intervention.
|Teach client that polyuria, polydipsia, and polyphagia are signs of hyperglycemia which requires increased dosage of insulin.||These are signs of insufficient insulin dosage and hyperglycemia which may lead to coma and death if untreated.|
|Explain the importance of having a dietary plan:
|Medical nutrition therapy is important in managing diabetes and preventing the rate of development of diabetes complications.|
A high-fiber diet can slow the absorption of glucose, decreased excess insulin levels and lowered lipid concentrations in clients with type 2 diabetes.
|Teach client to monitor blood glucose during periods of exercise and adjust insulin dose.||The insulin dose should be adjusted after increased or decreased food intake and before any exercise. Exercise may increase usage of glucose.|
|Advise the client the importance of daily examination of the feet and foot care.||Decreased peripheral circulation place the client at risk for an undetected foot injury.|
|Advise the client the importance of routine eye examination.||Clients with a poorly controlled diabetes may experience changes in vision that may lead to blindness.|
|Review of medication regimen, including, onset, peak, and duration of prescribed insulin, as applicable with the client.||A good way to properly use insulin is to learn these aspects of drug usage. This will help in the adjustment of the doses or the food intake to stop unwanted ups and downs in the glucose level.|
|Review self-administration of insulin and care of equipment. Have client demonstrate procedure (e.g., drawing up and injecting insulin, insulin pen technique, or pump therapy).||Evaluate understanding of the procedure. Recognizes potential problems such as short-term memory so that alternative solutions can be made for the administration of the insulin.|
|Discuss timing of insulin injection and mealtime.||Regular insulin works best if administering it 30 minutes before eating. While a product called insulin lispro (Humalog) works best when taking within 15 minutes of eating. With the onset twice as fast as regular insulin and a duration nearly half as long. Hypoglycemia may result more rapidly. If a blood glucose reading is >80 mg/dL, the insulin should be injected after eating rather than before the meal.|
|Discuss the use of a medical alert bracelet.||This enables the client to have a quick entry into the health system, and appropriate care will be given immediately.|
|Stress the importance of strict follow-up care.||To prevent or delay the development of complications from diabetes.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to endocrine system and metabolism disorders:
- Acid-Base Balance
- – Respiratory Acidosis Nursing Care Plan
- – Respiratory Alkalosis Nursing Care Plan
- – Metabolic Acidosis Nursing Care Plan
- – Metabolic Alkalosis Nursing Care Plan
- Addison’s Disease | 3 Care Plans
- Cushing’s Disease | 6 Care Plans
- Diabetes Mellitus Type 1 (Juvenile Diabetes) | 4 Care Plans
- Diabetes Mellitus Type 2 | 17 Care Plans
- Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) | 4 Care Plans
- Eating Disorders: Anorexia & Bulimia Nervosa | 7 Care Plans
- Fluid and Electrolyte Imbalances | 10 Care Plans
- – Fluid Balance: Hypervolemia & Hypovolemia
- – Potassium (K) Imbalances: Hyperkalemia and Hypokalemia
- – Sodium (Na) Imbalances: Hypernatremia and Hyponatremia
- – Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia
- – Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperthyroidism | 7 Care Plans
- Hypothyroidism | 3 Care Plans
- Obesity | 4 Care Plans
- Thyroidectomy | 5 Care Plans