Scribd
Upload
1K views

NCP Risk

The patient was at risk for fluid volume deficit due to osmotic diuresis from hyperglycemia. Nursing interventions included monitoring vital signs, hydration levels, and signs of dehydration. After 8 hours, the patient showed adequate hydration with stable vitals and no signs of dehydration, demonstrating the interventions were effective.

Uploaded by

Maricar Azolae Mascual
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
1K views

NCP Risk

The patient was at risk for fluid volume deficit due to osmotic diuresis from hyperglycemia. Nursing interventions included monitoring vital signs, hydration levels, and signs of dehydration. After 8 hours, the patient showed adequate hydration with stable vitals and no signs of dehydration, demonstrating the interventions were effective.

Uploaded by

Maricar Azolae Mascual
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 3

ASSESSMENT

NURSING DIAGNOSIS Risk for fluid volume deficit related to osmotic diuresis from hyperglycemia

RATIONALE In diabetes, there is extracellular hyperglycemia. Glucose in the blood exceeds the renal threshold thus having glucosuria this will result to osmotic diuresis and will manifest polyuria or frequent urination. Type 1 diabetes mellitus can occur at any age and is characterized by the marked and progressive inability of the pancreas to secrete insulin because of autoimmune destruction of the beta cells. It commonly occurs in children, with a fairly abrupt onset;

PLANNING

INTERVENTI ON After 3 days Independent: of nursing Monitor interventions, orthostatic the patient blood will pressure demonstrate changes. adequate Monitor hydration. respiratory pattern like Objectives: Kussmauls After 8 hours respirations and of nursing acetone breath. intervention Monitor patient will temperature, manifest no skin signs of color and dehydration moisture. Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane. Monitor input and output. Note urine specific gravity. Weigh daily.

RATIONALE Hypovolemia may be manifested by hypotension and tachycardia. Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration. Indicators of level of dehydration, adequacy of circulating volume. Provides

EVALUATION After 8 hours of nursing interventions, the patient was able to demonstrate adequate hydration and no signs of dehydration evidenced by stable vital signs, palpable peri pheral pulses, good skin turgor and capillary refill.

however, newer antibody tests have allowed for the identification of more people with the newonset adult form of type 1 diabetes mellitus called latent autoimmune diabetes of the adult (LADA). The distinguishing characteristic of a patient with type 1 diabetes is that, if his or her insulin is withdrawn, ketosis and eventually ketoacidosis develop. Therefore, these patients are dependent on exogenous insulin.

Maintain fluid intake at least 2500 ml / day within cardiac tolerance with oral intake is resumed. Promote comfortable environment. Cover patient with light sheets. Collaborative: Administer fluids as indicated.

ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. Provides the best assessment of current fluid status and adequacy of fluid replacement. Maintains hydration and circulating volume. Avoids overheating, which could promote further fluid loss. Type and amount of fluid depend on the degree of deficit and individual patient response.

You might also like