Use the nursing process as a framework for care of patients who have hyperglycemia with diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome
DIABETES OR HYPERGLYCEMIA
it is a metabolic disorder in which there is insufficient insulin production, no insulin production or both occur which result in increased the blood glucose level in the body.
A few acute complications that arise due to the hyperglycemia or diabetes, that is diabetic ketoacidosis and the hyperglycemic hyperosmolar syndrome, that increases the mortality and the morbidity in the individual if it is not treated properly, death that occurs is due to the other precipitating factors rather than the metabolic changes in diabetes,
if early identification of the precipitating factors and the treatment is done then the positive outcome can be achieved.
this 2 condition is the life-threatening complication in the individual with hyperglycemia.
in DKA three main symptoms are seen that is ACIDOSIS, DEHYDRATION AND THE ELECTROLYTE IMBALANCE
in HHS the main symptoms seen are a fluid imbalance, renal complications, dehydration
NURSING PROCESS
ASSESSMENT.
The nurse monitors the clients ECG to check for dysrhythmias which shows there is an imbalance in the potassium level,
vitals should be monitored especially for a pulse, blood pressure, ABG, emotional and mental status,
check for cerebral edema by the neurological assessment that may result in the death of the patient.
for HHS assess vital signs, the status of fluid, urine output and renal complications, cardiovascular system changes, pulmonary system changes.
NURSING DIAGNOSIS
It is made by reviewing the data from the assessment and the following nursing diagnosis can be made.
1. Risk for fluid volume deficit related to the polyurea and the dehydration.
2. fluid and electrolyte imbalance related to loss of fluid and the shift of fluid.
3. knowledge deficit related to self-care skills.
4. anxiety related to loss of control over the management of diabetes.
PLANNING AND GOALS.
The main aim and the goal is to maintain patients fluid and electrolyte, maintenance of blood glucose level and improve self skill in the management of diabetes.
NURSING IMPLEMENTATION.
1. MAINTAINANCE OF FLUID AND ELECTROLYTE
A. measure clients input and the output chart.
b. maintain fluid and electrolytes by administering fluids intravenously or orally.
c. monitor lab values for sodium and potassium.
d. monitor vital signs and the skin turgor for dehydration, breath sound monitoring, the consciousness of the client, and the presence of edema, and the cardiovascular changes by ECG monitoring.
2. ENHANCING KNOWLEDGE ABOUT DIABETES MANAGEMENT.
1. Discuss regarding the knowledge the patient and the family regarding the management of the DKA and HSS
2. encourage a client to focus his attention on the management of the DKA and HSS by taking regular medication, dietary control, exercise.
3. as it is a life-threatening situation to encourage a client to gain maximum knowledge to prevent himself from any fatal complications in the future.
4. encourage the client not to miss doses of insulin and oral medications.
5. always maintain a normal blood glucose level.
MANAGING AND MONITORING ANY POTENTIAL COMPLICATIONS.
1. overload fluid.
it can occur in a patient with DKA and HSS due to the administration of a large amount of fluid in the treatment of the dehydration, a large amount of fluid in the body can have a deleterious effect on the cardiovascular and the pulmonary system that can lead to heart failure and the pulmonary edema,
continuous CVP monitoring and the maintenance of intake and output chart is done to ensure there is no fluid overload in the body of the patient.
2. Hypokalemia OR low potassium level.
it is one of the complications of the treatment of DKA and due to the rehydration.
3. EDEMA
cerebral edema is seen due to the continuous fluid shifts,
EVALUATION
1. Patient achieves fluids and electrolyte.
a. fluid volume, electrolytes, and the vital signs are monitored.
2. knowledge about DKA and the HSS
give knowledge regarding the sign and the symptoms, treatment and about the long term and the short term management goal.
3. Absence of complications
The patient maintains normal cardiac rhythm and the normal breath sound.
make sure no venous jugular extension is seen.
keep blood glucose and the ketone level in a normal range.
improve mental status without cerebral edema.
prevent the client from developing hyperglycemia and hypoglycemia.
Use the nursing process as a framework for care of patients who have hyperglycemia with diabetic...
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