Nursing Care Plan for Diabetic Ketoacidosis

Nursing Diagnosis for Diabetic Ketoacidosis

Definition

Diabetic Ketoacidosis is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism. The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes.

Diabetic Ketoacidosis is defined clinically as an acute state of severe uncontrolled diabetes associated with ketoacidosis that requires emergency treatment with insulin and intravenous fluids.

Symptoms

A person developing diabetic ketoacidosis may have one or more of these symptoms: excessive thirst or drinking lots of fluid, frequent urination, general weakness, vomiting, loss of appetite, confusion, abdominal pain, shortness of breath, a generally ill appearance, dry skin, dry mouth, increased heart rate, low blood pressure, increased rate of breathing, and a distinctive fruity odor on the breath.

Treatment

The goal of treatment is to correct the high blood sugar level with insulin. Another goal is to replace fluids lost through urination and vomiting.

Most of the time, you will need to go to the hospital, where the following will be done:
  • Insulin replacement
  • Fluid and electrolyte replacement
  • The cause of the condition (such as infection) will be found and treated

You may be able to spot the early warning signs and make changes at home before the condition gets worse. It is important to stay in close touch with your doctor.

Nursing Care Plan for Diabetic Ketoacidosis

Assessment

Anamnesis:
  • History of DM
  • Polyuria, Polidipsi
  • Stop injecting insulin
  • Fever and infection
  • Abdominal pain, nausea, vomiting
  • Blurred vision
  • Weak and headaches

Physical Examination:
  • Orthostatic hypotension (systolic decreased 20 mmHg or more on standing)
  • Hypotension, Shock
  • Breath smelled of acetone (smells sweet like fruit)
  • Hyperventilation: Kusmual (respiration rapid and deep)
  • Awareness can composmentis, lethargy or coma
  • Dehydration

Assessment of Emergency
  • Airways: Assess the patient's airway clearance, presence or absence of sputum or foreign objects blocking the airway.
  • Breathing: Assess frequency of breath, breath sounds, presence or absence of muscle use a respirator.
  • Circulation: Assess pulse, capillary refill.

Objective Data:

Activity / Rest
  • Symptoms: weakness, fatigue, difficulty moving / walking, muscle cramps, decreased muscle tone, impaired resting / sleeping.
  • Signs: Tachycardia and tachypnea in the resting state or activity, lethargy / disorientation, coma.

Circulation
  • Symptoms: A history of hypertension, acute myocardial infarction, claudication, numbness and tingling in the extremities, foot ulcers, healing time, tachycardia.
  • Signs: Changes in postural blood pressure, hypertension, decreased pulse / no, dysrhythmias, cracels, jugular venous distention, skin hot, dry, and red, sunken eyeballs.

Integrity / Ego
  • Symptoms: Stress, dependent on others, financial problems associated with the condition.
  • Signs: Anxiety, sensitive to stimuli.

Elimination
  • Symptoms: Changes in the pattern of urination (polyuria), nocturia, pain / burning, difficulty urinating (infection), UTI new / recurrent abdominal tenderness, diarrhea.
  • Signs: Urine thin, pale, yellow, polyuria (may progress to oliguria / anuria, if there is severe hypovolemia), cloudy urine, odor (infection), hard abdomen, presence of ascites, weakness and decreased bowel sounds, hyperactive (diarrhea).

Nutrition / Fluids
  • Symptoms: Loss of appetite, nausea / vomiting, do not comply with the diet, increased input glucose / carbohydrate, weight loss of more than a few days / weeks, thirst, diuretic use.
  • Signs: Dry skin / scaly, ugly turgor, stiffness / abdominal distension, vomiting, enlargement of the thyroid (increased metabolic demands with increased blood sugar), odor halisitosis / sweet smell of fruit (acetone breath)

Neuro-sensory
  • Symptoms: Dizziness, headache, tingling, numbness, muscle weakness, paresthesia, visual disturbances.
  • Signs: Disorientation, drowsiness, allergies, stupor / coma (stage), memory impairment (new, past), messed up mentally, decreased deep tendon reflexes (coma), seizure activity (stage of Diabetic Ketoacidosis).

Pain / comfort
  • Symptoms: Abdomen tense / pain (moderate / severe)
  • Signs: face grimacing with palpitations, looks to be very careful

Respiratory
  • Symptoms: Feeling a lack of oxygen, cough with / without purulent sputum (depending on the presence of infection / no)
  • Signs: Hungry air, cough with / without purulent sputum, increased respiratory rate.
Security
  • Symptoms: Dry skin, itching, skin ulcers.
  • Symptoms: Fever, diaphoresis, damaged skin, lesions / ulcerations, decreased general strength / range of motion, paresthesias / paralysis of muscles, including the respiratory muscles (if potassium levels declined sharply).
Sexuality
  • Symptoms: vaginal discharge (likely an infection).
  • Problems impotence in men, orgasm difficulties in women.

Guidance / learning
  • Symptoms: family risk factors diabetes, heart disease, stroke, hypertension. Healing is slow, or may not need to order diabetic medication. Repatriation plans: Possibly need help in diet, medication, self-care, monitoring of blood glucose.

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