NURSING CARE PLAN 1

DIAGNOSIS GOAL NURSING INTERVENTIONS RATIONALE

FLUID VOLUME DEFICIT Within 1x24 hours of INDEPENDENT
related to osmotic rendering holistic nursing
diuresis secondary to care, the patient will : 1. Obtain history of illness 1. Assist estimation of total volume
increased blood glucose depletion. Symptoms may have
levels >Achieve/Demonstrate been present for varying amounts
adequate hydration as of time.
evidenced by stable V/S
and increased intake of 2. Monitor BP changes 2. Hypovolemia is manifested by
Inference: fluid. hypotension along with tachycardia
 Increased serum and tachypnea; estimates of the
glucose levels severity the hypovolemia may be
made when BP drops more than
 F & E from cells are 10mmHg
pulled by greater
osmotic power of 3. Assess peripheral pulses, capillary refill, 3. Indicators of level of DHN, and
glucose skin turgor and mucous membranes. circulating volume adequacy

 Cellular dehydration 4. Monitor I & O, calculate 24-hour fluid 4. Provides ongoing estimate of
balance, weight daily and monitor urine volume replacement needs, kidney.
 Kidneys excrete specific gravity.
excess glucose
5. Provide frequent TSB. 5. TSB promotes skin moisture and
 Water is pulled prevents dryness. Also promotes
because of high comfort of patient.
osmotic power of
glucose(osmotic 6. Discourage intake of alcoholic and 6. Alcohol and caffeine exert a diuretic
diuresis) caffeinated beverages. effect increasing fluid loss.

 Increased 7. Provide frequent oral care and eye 7. Fluid losses from body, decreases
urination(polyuria) care. the skin and mucosal moisture
thereby rendering the area
susceptible to injury.
8. Promote patient safety. 8. Patients manifest symptoms of
decreasing LOC with fluid loss
making patient susceptible to
accidents.

9. Keep fluids within clients reach and 9. Encouraging patient to rehydrate

encourage frequent intake not less maintains fluid balance and
than 1500 ml/day. replaces fluid loss from present
condition.

COLLABORATIVE COLLABORATIVE

1. Do IV follow-ups, as ordered. 1. IV therapy promotes rehydration

and restores fluid balance.

2. Monitor indwelling urinary catheter and 2. Monitoring the placement of the

urinary output. catheter and bag ensures
prevention of infection; the urine
output must be monitored for
color, consistency, specific gravity
and composition to determine
degree of renal function.

3. Administer medications as indicated. 3. Insulin injection promotes

utilization of glucose to cells.

4. Monitor and regulate IVF as ordered. 4. This is to prevent over infusion and
under infusion of patient; IVF
therapy replaces fluids and
electrolyte losses.

5. Monitor lab studies, e.g.

Hct; Assesses level of hydration and is often

elevated because of hemoconcentration
that occurs after osmotic diuresis.
BUN/Cr; Elevated values may reflect cellular
breakdown from dehydration or signal the
onset of renal failure.

Serum osmolality; Elevated due to hyperglycemia and

dehydration.

Sodium; May be decreased reflecting shift of fluids

from the intracellular compartment
(osmotic diuresis).

Potassium; Initially, hyperkalemia occurs in response to

acidosis, but as this potassium is lost in the
urine, the absolute potassium level in the
body is depleted. As insulin is replaced and
acidosis is corrected, serum potassium
deficit becomes apparent.
NURSING CARE PLAN
2
DIAGNOSIS GOAL NURSING INTERVENTIONS RATIONALE
ALTERED NUTRITION less Within 1x24 hours of INDEPENDENT
than body requirements rendering holistic nursing
related to decreased care, the patient will: 1. Determine pt ability to chew, swallow 1. Patients with upper GI problems
appetite, painful a. Take in and taste food. may manifest difficulty in chewing
chewing and swallowing, appropriate and swallowing.
insulin deficiency and amounts of
presence of infection. calories and 2. Ascertain client’s dietary program and 2. Identifies deficits and deviations
nutrients as usual pattern; compare with recent from the therapeutic needs.
evidenced by intake.
Inference: increased in food
intake. 3. Provide liquids containing nutrients and 3. Oral route is preferred when client is
Presence of oral thrush + electrolytes. alert
disease state
4. Discuss eating habits, including food 4. To determine appeal to clients likes
Results to lesions which preference and intolerance. and dislikes.
can cause local pain on .
oral cavity
5. Observe for presence of hypoglycemia, 5. Once carbohydrate metabolism
Chewing and swallowing e.g., changes in LOC, cool/clammy skin, begins (blood glucose level reduced),
is affected rapid pulse, hunger, irritability, anxiety, and as insulin is being given,
headache, lightheadedness, shakiness hypoglycemia can occur.
Changes in
appetite(decreased) 6. Observe presence of subcutaneous 6. This may indicate protein-energy
fat/muscle wasting, loss of hair, malnutrition.
Decreased food intake fissuring of nails, delayed healing, gum
bleeding, swollen abdomen.
Nutrition is altered
7. Auscultate bowel sounds, note 7. This is needed to evaluate the
characteristics of stool. degree of deficit.

8. Encourage adequate rest and sleep 8. Adequate rest and sleep periods
periods. decreases caloric demand and
prevents fatigue.
9. Include SO in meal planning, as 9. Promotes sense of involvement,
indicated. provides information for SO to
understand nutritional needs of the
patient.

10. Provide simple health teachings to 10. Simple health teachings promote
patient and SO regarding management client and SO education and So
of DM type 2. involvement. Promotes
independence of client as well.

COLLABORATIVE COLLABORATIVE

1. Monitor and regulate IVF and do 1. Monitoring IVF regularly prevents

follow-ups as ordered. overinfusion and underinfusion of
client. IV follow-ups are for fluid
replacement.