Mrs. Ballenger, age 78, is hospitalized in the intensive care unit (ICU) with complications of type 1 diabetes mellitus. Most recently, she is experiencing diabetic ketoacidosis with a blood glucose of 320 mg/dL. In addition, she has coronary heart disease (CHD) from the microvascular complications of her diabetes; she has a pulmonary artery catheter to monitor her hemodynamic status. Her primary clinical manifestations from the CHD are hypertension, tachycardia, and occasional arrhythmias. At present, her level of consciousness (LOC) is impaired, she is breathing with Kussmaul respirations, her breath is sweet in nature, and she is extremely fatigued.
ASSESSMENT
A 78-year-old female with complications associated with type 1 diabetes mellitus. Specifically, she has a primary diagnosis of diabetic ketoacidosis ([DKA] blood glucose = 320 mg/dL). In addition, she has hypertension, atrial cardiac arrhythmias, and a decreased LOC. She is being monitored in an intensive care unit.
NURSING DIAGNOSIS #1
Deficient fluid volume related to osmotic diuresis associated with hyperglycemia.
NOC: Electrolyte and acid-base imbalance; Fluid balance; Hydration; Nutritional status; Food and fluid intake
NIC: Fluid management; Hypovolemia management; Shock management: Volume
EXPECTED OUTCOMES
The patient will:
1. Maintain a blood glucose level in the 150–180 mg/dL range within 72 hours.
2. Demonstrate no signs or symptoms of dehydration during her admission in the ICU.
3. Maintain a cardiac output in the normal range of 4–6 L/min during her admission to the ICU.
PLANNING/INTERVENTIONS/RATIONALE
1. Measure blood glucose levels every hour and administer insulin per sliding scale orders. Blood glucose levels are at a crisis level, and close monitoring prevents further complications of DKA.
2. Evaluate cardiac output by assessing the cardiac system with vital signs, hemodynamic monitor (pulmonary artery catheter), and electrophysiology. Allows for close cardiac monitoring, which is necessary for the patient’s critical condition.
3. Assess hydration status every hour by monitoring: urine specific gravity, intake and output (hourly urine output), skin turgor, and vital signs. Frequent assessment detects subtle changes in hydration status during the critical complication of DKA.
EVALUATION
The patient has a blood glucose within a controlled range, stable hemodynamic readings of the pulmonary artery catheter, and no clinical manifestations of dehydration during her admission to the ICU.
NURSING DIAGNOSIS #2
Ineffective breathing pattern of Kussmaul respirations related to metabolic acidosis associated with DKA.
NOC: Respiratory status: Ventilation; Vital signs status; Respiratory status; Airway patency
NIC: Airway management; Respiratory monitoring
EXPECTED OUTCOMES
The patient will:
1. Demonstrate an effective respiratory rate of 12–16 breaths per minute with an oxygen saturation level of at least 94% within 24 hours.
2. Progressively regain level of consciousness within 24 to 48 hours.
3. Decrease energy expenditures and experience less generalized fatigue within 24 to 48 hours.
PLANNING/INTERVENTIONS/RATIONALE
1. Monitor oxygen saturation levels and assess depth or rhythm of respirations every hour. Detects respiratory compensation during a time of the respiratory crisis of Kussmaul breathing (caused by the DKA).
2. Assess LOC by evaluating neurological responses and patient’s ability to effectively answer questions every hour. Provides constant monitoring of neurological status.
3. Ask patient questions regarding her level of energy and ask patient to quantify from 1–10 the level of her fatigue every hour. Evaluates fatigue levels on constant basis.
EVALUATION
The patient has a progressive decrease in the Kussmaul breathing pattern, an increasing LOC, and an increasing level of energy.