Me dic at io ns St udent

Name: Lab Value s /Diagno s t ic T e s t Re s ult s

Home: BMP
Patient Initials: Room #: Admit Date: CODE S tatus: T oday's
50 U/day of insulin daily: Dat e :
H.D.
5 U of lispro insulin (Humalog) with
breakfast N N N
Age: Gender: Weight: Height: Braden 40.5
5 U with lunch S c ore:
34 M
10 U with dinner ↑
30 U of insulin glargine (Lantus) at
Diet: Ac tivity:
N N N
bedtime

Religion: Allergies: CBC

Admit t ing Diagno s is /Chie f Co mplaint N

Diagnosis: Diabetic Ketoacidosis
Admitted to the emergency department after he was found unconscious by his wife in their N N
apartment
N

As s e s s me nt Dat a

Mis c Lab Value s /Diagno s t ic T e s t

IV Sit e s /Fluids /Rat e :
Re s ult s
Blood pH 7.26
Subject ive Dat a (Provided by wif e)
Has history of gastroenteritis for 1 wk with vomiting and
anorexia
Stopped taking insulin 2 days ago when he was unable to eat
Missed last 2 follow up appointments with his diabetes team

Object ive Dat a

Physical Examination T r e at me nt s
Breathing is deep and rapid
Acetone smell on breath
Skin flushed and dry
Pas t Me dic al/Sur gic al His t o r y
Type 1 diabetes mellitus for 12 months

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

 Pr imar y Nur s ing Diagno s is Nur s ing Diagno s is 2 Nur s ing Diagno s is 3
Risk for unstable blood glucose levels as evidenced by Deficient fluid volume related to excessive fluid loss through Ineffective health management related to insufficient
insufficient diabetes management (infrequent blood glucose normal route (hyperglycemic-induced diuresis), and knowledge of therapeutic regimen (the ability to prevent,
monitoring and lack of following diabetes management plan) insufficient fluid intake identify, and manage ketoacidosis)

Suppo r t ing Dat a Suppo r t ing Dat a Suppo r t ing Dat a

Blood glucose 40.5 mmol/L Deep and rapid breathing Found unconscious
Blood pH 7.26 Flushed and dry skin Blood glucose 40.5 mmol/L
Acetone smell on breath Blood pH 7.26 Lack of adherence to diabetes management plan
Lack of adherence to diabetes management plan

ST G/NOC ST G/NOC ST G/NOC

Expect ed Pat ient Out comes: Expect ed Pat ient Out comes: Expect ed Pat ient Out comes:

P atient's blood glucose level will be stabilized within normal P atient will achieve normovolemia by discharge. P atient will state signs and symptoms of ketoacidosis and
range prior to discharge. describe actions for its' prevention prior to discharge.

Int e r ve nt io ns /NIC wit h Rat io nale Int e r ve nt io ns /NIC wit h Rat io nale Int e r ve nt io ns /NIC wit h Rat io nale
Monitor blood glucose levels every 1 to 2 hours to monitor Observe for indications of hypovolemia to detect fluid Assess level of knowledge of disease and treatment to
the patient's response to treatment. imbalances and determine the need for therapy. determine scope and extent of required teaching.
Administer insulin as prescribed to promote normal blood Monitor fluid status, including intake and output and weight Anticipate situations in which insulin requirements will
glucose levels. to document fluid losses and gains. increase (e.g., flu) to allow patient to adjust insulin dosage
apprpriately.
Facilitate adherence to diet and exercise regimen to promote Monitor vital signs to detect fluid imbalances and plan
diabetes control. appropriate interventions. Instruct patient on measures to prevent or minimiz e
Maintain a steady IV infusion flow rate to replace fluids and symptoms to promote management of the disease.
electrolytes. Instruct as to which signs and symptoms to report to health
Monitor laboratory results to detect the presence of fluid and care provider to ensure prompt treatment.
electrolyte imbalance and determine need for replacement. Restrict exercise when blood glucose level is higher than 13.9
mmol/L to decrease the body's requirement for unavailable
glucose.

Rat io nale Cit at io n/EBP Rat io nale Cit at io n/EBP Rat io nale Cit at io n/EBP
Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M.,
Lok, J., Tyerman, J., & Goldsworthy, S. (eds.). (2019). Lok, J., Tyerman, J., & Goldsworthy, S. (eds.). (2019). Lok, J., Tyerman, J., & Goldsworthy, S. (eds.). (2019).
Medical-surgical nursing in Canada: Assessment and Medical-surgical nursing in Canada: Assessment and Medical-surgical nursing in Canada: Assessment and
management of clinical problems (4th ed.). Toronto, ON: management of clinical problems (4th ed.). Toronto, ON: management of clinical problems (4th ed.). Toronto, ON:
Elsevier. Elsevier. Elsevier.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

 Evaluat io n Evaluat io n Evaluat io n
Maintains a balance of nutrition, activity, and insulin Maintains fluid and electrolyte balance required for metabolic 1. Verbalizes key elements of the therapeutic regimen,
availability that results in stable, normal blood glucose levels. needs. including knowledge of treatment plan.
2. Decreases self-care measures that may prevent
complications.

Addit io nal Inf o r mat io n

Other potential nursing diagnoses:
Nursing diagnoses: Risk for injury, risk for infection, deficient knowledge, imbalanced nutrition: less than body requirements
C ollaborative problems: Hyperglycemia, coma, electrolyte disturbances

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.