Fluid volume deficient related to osmotic diuresis from hyperglycemia
Planning
After 8 hours of nursing interventions, the patient will demonstrate adequate hydration.
Intervention
- Monitor orthostatic blood pressure changes.
Rational : Hypovolemia may be manifested by hypotension and tachycardia. - Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane.
Rational : Indicators of level of dehydration, adequacy of circulating volume. - Monitor respiratory pattern like Kussmaul’s respirations and acetone breath.
Rational : Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. - Monitor input and output. Note urine specific gravity.
Rational : Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. - Promote comfortable environment. Cover patient with light sheets.
Rational : Avoids overheating, which could promote further fluid loss. - Monitor temperature, skin color and moisture.
Rational : Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration.
Diabetes Mellitus Nursing Diagnosis Fluid Volume Deficient