Nursing Care Plan for Diabetes Mellitus (Diabetic Ketoacidosis/DKA)| Diabetes Overview;
Diabetes Mellitus/Diabetic Ketoacidosis Overview
Diabetes affects 18% of people over the age of 65, and approximately 625,000 new cases of diabetes are diagnosed annually in the general population.
Conditions or situations known to exacerbate glucose/insulin imbalance include:
- Previously undiagnosed or newly diagnosed type 1 diabetes
- Food intake in excess of available insulin
- Adolescence and puberty
- Exercise in uncontrolled diabetes
- Stress associated with illness, infection, trauma, or emotional distress.
Type 1 diabetes can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a life-threatening emergency caused by a relative or absolute deficiency of insulin.
Care Setting
Although DKA may be encountered in any setting and mild DKA may be managed at the community level, severe metabolic imbalance requires inpatient acute care on a medical unit.
Related Concerns
- Amputation
- Fluid and electrolyte imbalances
- Metabolic acidosis (primary base bicarbonate deficit)
- Psychosocial aspects of care
Here is an example of nursing care plan for diabetes mellitus (DKA).
Nursing Care Plan for Diabetes Mellitus (Diabetic Ketoacidosis/DKA) | Nursing Priorities; Discharge Goals
Nursing Priorities | Nursing Care Plan for Diabetes
- Restore fluid/electrolyte and acid-base balance.
- Correct/reverse metabolic abnormalities.
- Identify/assist with management of underlying cause/disease process.
- Prevent complications.
- Provide information about disease process/prognosis, self-care, and treatment needs.
Discharge Goals| Nursing Care Plan for Diabetes
- Homeostasis achieved.
- Causative/precipitating factors corrected/controlled.
- Complications prevented/minimized.
- Disease process/prognosis, self-care needs, and therapeutic regimen understood.
- Plan in place to meet needs after discharge.
Nursing Care Plan for Diabetes Mellitus (Diabetic Ketoacidosis/DKA) | Nursing Diagnosis for Diabetes
Nursing Care Plan for Diabetes Mellitus (Diabetic Ketoacidosis/DKA) | Nursing Diagnosis for Diabetes; Risk factors; Desired Outcomes
Nursing Diagnosis for Diabetes Mellitus (Diabetic Ketoacidosis/DKA): Fluid Volume deficient [specify]
May be related to
- Osmotic diuresis (from hyperglycemia)
- Excessive gastric losses: diarrhea, vomiting
- Restricted intake: nausea, confusion
Possibly evidenced by
- Increased urinary output, dilute urine
- Weakness; thirst; sudden weight loss
- Dry skin/mucous membranes, poor skin turgor
- Hypotension, tachycardia, delayed capillary refill
Desired Outcomes/Evaluation Criteria | Nursing Care Plan for Diabetes Mellitus (Diabetic Ketoacidosis/DKA)
Patient Will:
Fluid Balance (NOC)
- Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.
Nursing Care Plan for Diabetes Mellitus (DKA) | Nursing Interventions for Diabetes
Nursing Care Plan for Diabetes | Nursing Interventions for Diabetes and Rationale;
Nursing Interventions for Diabetes and Rationale
Fluid/Electrolyte Management (NIC)
Nursing Interventions for Diabetes (Independent) | Nursing Care Plan for Diabetes
- Obtain history from patient/SO related to duration/intensity of symptoms such as vomiting, excessive urination. Rationale: Assists in estimation of total volume depletion. Symptoms may have been present for varying amounts of time (hours to days). Presence of infectious process results in fever and hypermetabolic state, increasing insensible fluid losses.
- Monitor vital signs:
- Note orthostatic BP changes; Rationale: Hypovolemia may be manifested by hypotension and tachycardia. Estimates of severity of hypovolemia may be made when patient’s systolic BP drops more than 10 mm Hg from a recumbent to a sitting/standing position. Note: Cardiac neuropathy may block reflexes that normally increase heart rate.
- Respiratory pattern, e.g., Kussmaul’s respirations, acetone breath; Rationale: Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Acetone breath is due to breakdown of acetoacetic acid and should diminish as ketosis is corrected.
- Respiratory rate and quality; use of accessory muscles, periods of apnea, and appearance of cyanosis; Rationale: Correction of hyperglycemia and acidosis will cause the respiratory rate and pattern to approach normal. In contrast, increased work of breathing; shallow, rapid respirations; and presence of cyanosis may indicate respiratory fatigue and/or that patient is losing ability to compensate for acidosis.
- Temperature, skin color/moisture. Rationale: Although fever, chills, and diaphoresis are common with infectious process, fever with flushed, dry skin may reflect dehydration.
Nursing Interventions for Diabetes and Rationale
Fluid/Electrolyte Management (NIC)
Nursing Interventions for Diabetes (Independent) - continue| Nursing Care Plan for Diabetes
- Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes. Rationale: Indicators of level of hydration, adequacy of circulating volume.
- Monitor I&O; note urine specific gravity. Rationale: Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy.
- Weigh daily. Rationale: Provides the best assessment of current fluid status and adequacy of fluid replacement.
- Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed. Rationale: Maintains hydration/circulating volume.
- Promote comfortable environment. Cover patient with light sheets. Rationale: Avoids overheating, which could promote further fluid loss.
- Investigate changes in mentation/sensorium. Rationale: Changes in mentation can be due to abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Regardless of the cause, impaired consciousness can predispose patient to aspiration.
Nursing Interventions for Diabetes and Rationale
Fluid/Electrolyte Management (NIC)
Nursing Interventions for Diabetes (Collaborative) | Nursing Care Plan for Diabetes
- Administer fluids as indicated:
- Isotonic (0.9%) or lactated Ringer’s solution without additives; Rationale: Type and amount of fluid depend on degree of deficit and individual patient response. Note: Patients with DKA often severely dehydrated and commonly need 5–10 L of isotonic saline (2–3 L within first 2 hr of treatment).
- Albumin, plasma, dextran. Rationale: Plasma expanders may occasionally be needed if the deficit is life-threatening/BP does not normalize with rehydration efforts.
- Insert/maintain indwelling urinary catheter. Rationale: Provides for accurate/ongoing measurement of urinary output, especially if autonomic neuropathies result in neurogenic bladder (urinary retention/overflow incontinence). May be removed when patient is stable to reduce risk of infection.
Monitor laboratory studies, e.g.:- Hct; Rationale: Assesses level of hydration and is often elevated because of hemoconcentration associated with osmotic diuresis.
- BUN/creatinine (Cr); Rationale: Elevated values may reflect cellular breakdown from dehydration or signal the onset of renal failure.
- Serum osmolality; Rationale: Elevated because of hyperglycemia and dehydration.
- Sodium; Rationale: May be decreased, reflecting shift of fluids from the intracellular compartment (osmotic diuresis). High sodium values reflect severe fluid loss/dehydration or sodium reabsorption in response to aldosterone secretion.
- Potassium. Rationale: Initially, hyperkalemia occurs in response to metabolic 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 Interventions for Diabetes and Rationale
Fluid/Electrolyte Management (NIC)
Nursing Interventions for Diabetes (Collaborative) - continue | Nursing Care Plan for Diabetes
- Administer potassium and other electrolytes via IV and/or by oral route as indicated. Rationale: Potassium should be added to the IV (as soon as urinary flow is adequate) to prevent hypokalemia. Note: Potassium phosphate may be drug of choice when IV fluids contain sodium chloride in order to prevent chloride overload.
- Administer bicarbonate if pH is less than 7.1. Rationale: Given with caution to help correct acidosis in the presence of hypotension or shock, lactic acidosis, or severe hyperkalemia.
- Insert NG tube and attach to suction as indicated. Rationale: Decompresses stomach and may relieve vomiting.
This is a sample of Nursing Care Plan for Diabetes Mellitus (Diabetic Ketoacidosis/DKA).
