- Acute Confusion related to Cerebral edema and Metabolic encephalopathy as evidenced by Confusion and Increased intracranial pressure
- Decreased Cardiac Output related to Hyperglycaemia and Hypokalaemia as evidenced by Hypotension and elevated cardiac biomarkers
- Ineffective Tissue Perfusion related to Hyperglycaemia and Cerebral edema as evidenced by Oliguria and Poor skin turgor
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Hallucinations -Paranoia Objective data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to Cerebral edema and Metabolic encephalopathy as evidenced by Confusion and Increased intracranial pressure | Patient will remain alert and oriented to person, place, and time. Patient will not experience seizures, cerebral edema, or coma from DKA. | 1. Administer insulin. IV insulin is the standard treatment for DKA as the patient needs insulin rapidly to decrease glucose and ketone levels. 2. Avoid overhydration. Fluid replacement is another priority intervention though overhydration can lead to cerebral edema so nurses must carefully rehydrate. 3. Consider magnesium. Magnesium deficits can contribute to cognitive symptoms such as tremors, agitation, and seizures. Magnesium levels should be checked and corrected. 4. Wear a medical alert bracelet. In the event that DKA occurs when no one is around or the patient is too confused to verbalize, a medical alert bracelet can be lifesaving. | Patient remained alert and oriented to person, place, and time. Patient relieved from experiences like seizures, cerebral edema, or coma from DKA. |
| Subjective data: Verbalizes tiredness Objective data: -Decreased central venous pressure (CVP) -Increased pulmonary artery pressure (PAP) -Chest pain -Abnormal heart sounds -Dysrhythmia Fatigue -Change in level of consciousness -Anxiety/Restlessness -Abnormal electrolyte levels -Abnormal ABGs -Elevated cardiac biomarkers | Decreased Cardiac Output related to Hyperglycaemia and Hypokalaemia as evidenced by Hypotension and elevated cardiac biomarkers | Patient will manifest adequate cardiac output as evidenced by the following: Systolic BP within 20 mmHg of baseline Heart rate: 60 to 100 beats/min with a regular rhythm Respiratory rate: 12 to 20 breaths/min Patient will demonstrate potassium levels within a range of 4.0-5.0 mEq/L. | 1. Correct electrolyte imbalances. With DKA, insulin causes potassium to shift into cells which can cause rebound hypokalaemia. If potassium levels are low, potassium should be replaced before administering insulin to prevent cardiac arrest and dysrhythmias. 2. Administer supplemental oxygen as needed. Some patients with a history of congestive heart failure may be at risk for fluid overload since DKA requires aggressive fluid resuscitation. Provide supplemental oxygen to manage symptoms of pulmonary edema and to prevent hypoxia. 3. Consider sodium bicarbonate for acidosis. If sepsis or lactic acidosis is observed, sodium bicarbonate can be infused to correct acidosis and prevent dysrhythmias. 4. Consult with cardiology. Patients who continue to display dysrhythmias despite proper treatment should receive a cardiology consult. | Patient manifested adequate cardiac output as evidenced by the following: Systolic BP within 20 mmHg of baseline Patient demonstrated potassium levels within a range of 4.0-5.0 mEq/L. |
| Subjective data: -Nausea -Abdominal pain -Bloating Objective data: -Hypoactive or absent bowel sounds -Distended abdomen -Vomiting -Electrolyte imbalance | Ineffective Tissue Perfusion related to Hyperglycaemia and Cerebral edema as evidenced by Oliguria and Poor skin turgor | Patient will maintain optimal perfusion as evidenced by the following: Temperature: 36.5 to 37.4C HR: 60 to 90 bpm RR: 12-20 breaths per min BP: SBP>90 to <140 mmHg / DBP >60 to <90 mmHg Urine output 0.5 to 1.5 cc/kg/hour WBC 4,000 to 12,000/mm3 Capillary refill time <2 secs Patient will not experience any alterations in consciousness or orientation. | 1. Administer IV fluid as ordered. Fluid resuscitation is crucial in the management of patients with DKA. IV fluids replace extravascular and intravascular fluids and electrolyte losses. High glucose levels and counterregulatory hormones become diluted. 0.9% normal saline is the IV fluid of choice. 2. Prevent cerebral Edema. Rare and most common in children, cerebral edema is a serious complication often associated with ongoing hyponatremia. Monitor closely for alterations in cognition, posturing, and lethargy as signs of cerebral hypoperfusion. Mannitol or a hypertonic saline solution is the suggested treatment. 3. Monitor urine output. Patients with DKA are also prone to acute renal failure due to hypovolemia and sepsis. Urine output is a helpful tool in assessing renal function. 4. Administer medications as ordered. Infections are a common cause of DKA. Broad-spectrum antibiotics aid in controlling the source of infection until the pathogen is identified to prevent worsening perfusion. | Patient maintained optimal perfusion as evidenced by the following: Temperature: 36.5 to 37.4C Patient relieved from experiences like alterations in consciousness or orientation. |