You are on page 1of 58

1.

Acute Pain
May be related to

Decreased myocardial blood flow

Increased cardiac workload/oxygen consumption

Possibly evidenced by

Reports of pain varying in frequency, duration, and intensity (especially as


condition worsens)

Narrowed focus

Distraction behaviors (moaning, crying, pacing, restlessness)

Autonomic responses, e.g., diaphoresis, blood pressure and pulse rate


changes, pupillary dilation, increased/decreased respiratory rate

Desired Outcomes

Report anginal episodes decreased in frequency, duration, and severity.

Demonstrate relief of pain as evidenced by stable vital signs, absence of


muscle tension and restlessness

Nursing Interventions

Rationale
Pain and decreased cardiac output may
stimulate the sympathetic nervous system
to release excessive amounts of
norepinephrine, which increases platelet

Instruct patient to notify nurse


immediately when chest pain occurs.

aggregation and release of thromboxane


A2. This potent vasoconstrictor causes
coronary artery spasm, which can
precipitate, complicate, and/or prolong an
anginal attack. Unbearable pain may cause
vasovagal response, decreasing BP and
heart rate.

Assess and document patient response to

Provides information about disease

medication.

progression. Aids in evaluating


effectiveness of interventions, and may

Nursing Interventions

Rationale
indicate need for change in therapeutic
regimen.

Identify precipitating event, if any:

Helps differentiate this chest pain, and

frequency, duration, intensity, and location

aids in evaluating possible progression to

of pain.

unstable angina.
Decreased cardiac output (which may
occur during ischemic myocardial episode)

Observe for associated symptoms:

stimulates sympathetic and

dyspnea, nausea and vomiting, dizziness,

parasympathetic nervous system, causing

palpitations, desire to micturate.

a variety of vague sensations that patient


may not identify as related to anginal
episode.

Evaluate reports of pain in jaw, neck,

Cardiac pain may radiate. Pain is often

shoulder, arm, or hand (typically on left

referred to more superficial sites served by

side).

the same spinal cord nerve level.

Place patient at complete rest during

Reduces myocardial oxygen demand to

anginal episodes.

minimize risk of tissue injury.

Elevate head of bed if patient is short of

Facilitates gas exchange to decrease

breath.

hypoxia and resultant shortness of breath.


Patients with unstable angina have an

Monitor heart rate and rhythm.

increased risk of acute life-threatening


dysrhythmias, which occur in response to
ischemic changes and/or stress.
Blood pressure may initially rise because
of sympathetic stimulation, then fall if

Monitor vital signs every 5 min during


initial anginal attack.

cardiac output is compromised.


Tachycardia also develops in response to
sympathetic stimulation and may be
sustained as a compensatory response if
cardiac output falls.

Stay with patient who is experiencing pain

Anxiety releases catecholamines, which

or appears anxious.

increase myocardial workload and can

Nursing Interventions

Rationale
escalate and/or prolong ischemic pain.
Presence of nurse can reduce feelings of
fear and helplessness.

Maintain quiet, comfortable environment.

Mental/emotional stress increases

Restrict visitors as necessary.

myocardial workload.

Provide light meals. Have patient rest for 1


hr after meals.

Provide supplemental oxygen as indicated.

Decreases myocardial workload associated


with work of digestion, reducing risk of
anginal attack.
Increases oxygen available for myocardial
uptake and reversal of ischemia.

Administer antianginal medication(s) promptly as indicated:


Nitroglycerin has been the standard for
Nitroglycerin: sublingual (Nitrostat),

treating and preventing anginal pain for

buccal, or oral tablets, metered-dose

more than 100 yr. Today it is available in

spray.

many forms and is still the cornerstone of


antianginal therapy.
Rapid vasodilator effect lasts 1030 min

sublingual isosorbide dinitrate (Isordil)

and can be used prophylactically to


prevent, as well as abort, anginal attacks.
Long-acting preparations are used to
prevent recurrences by reducing coronary
vasospasms and reducing cardiac

Sustained-release tablets, caplets:


(Nitrong, Nitrocap T.D.), chewable tablets
(Isordil, Sorbitrate), patches,
transmucosal ointment (Nitro-Dur,
Transderm-Nitro)

workload. May cause headache, dizziness,


light-headedness, symptoms that usually
pass quickly. If headache is intolerable,
alteration of dose or discontinuation of
drug may be necessary. Note: Isordil may
be more effective for patients with variant
form of angina. Reduces frequency and
severity of attack by producing continuous
vasodilation.

Beta-blockers: acebutolol (Sectral),

Reduces angina by reducing the hearts

Nursing Interventions

Rationale

atenolol (Tenormin), nadolol (Corgard),

workload. Note: Often these drugs alone

metoprolol (Lopressor), propranolol

are sufficient to relieve angina in less

(Inderal)

severe conditions.

Calcium channel blockers: bepridil


(Vascor), amlodipine (Norvasc), nifedipine
(Procardia), felodipine (Plendil), isradipine
(DynaCirc), diltiazem (Cardizem)

Produces relaxation of coronary vascular


smooth muscle; dilates coronary arteries;
decreases peripheral vascular resistance.
Usually sufficient analgesia for relief of

Analgesics: acetaminophen (Tylenol)

headache caused by dilation of cerebral


vessels in response to nitrates.
Potent narcotic analgesic may be used in
acute onset because of its several
beneficial effects, e.g., causes peripheral
vasodilation and reduces myocardial
workload; has a sedative effect to produce

Morphine sulphate (MS)

relaxation; interrupts the flow of


vasoconstricting catecholamines and
thereby effectively relieves severe chest
pain. MS is given IV for rapid action and
because decreased cardiac output
compromises peripheral tissue absorption.
Ischemia during anginal attack may cause
transient ST segment depression or
elevation and T wave inversion. Serial

Monitor serial ECG changes.

tracings verify ischemic changes, which


may disappear when patient is pain-free.
They also provide a baseline against which
to compare later pattern changes.

2. Knowledge Deficit
May be related to

Lack of exposure

Inaccurate/misinterpretation of information

Unfamiliarity with information resources

Possibly evidenced by

Questions; statement of concerns

Request for information

Inaccurate follow-through of instructions

Desired Outcomes

Participate in learning process.

Assume responsibility for own learning, looking for information and asking
questions.

Verbalize understanding of condition/disease process and potential


complications.

Verbalize understanding of /participate in therapeutic regimen.

Initiate necessary lifestyle changes.

Nursing Interventions

Rationale
Patients with angina need to learn why it

Discuss pathophysiology of condition.


Stress need for preventing and managing
anginal attacks.

occurs and what they can do to control it.


This is the focus of therapeutic
management to reduce likelihood of
myocardial infarction and promote healthy
heart lifestyle.
Although recommended LDL is 160
mg/dL, patients with two or more risk

Review significance of cholesterol levels


and differentiate between LDL and HDL
factors. Emphasize importance of periodic
laboratory measurements.

factors (smoking, hypertension, diabetes


mellitus, positive family history) should
keep LDL 130 mg/dL, and those with
diagnosis of CAD need to keep LDL below
100 mg/dL. HDL below 3545 is
considered a risk factor; a level above 60
mg/dL is considered an advantage.

Encourage avoidance of situations that

Doing so would reduce the incidence or

may precipitate anginal episode (stress,

severity of ischemic episodes.

Nursing Interventions

Rationale

intense physical exertion, large heavy


meals especially during bedtime, exposure
to extreme temperatures).
Assist patient and/or SO to identify
sources of physical and emotional stress

This is a crucial step in preventing anginal

and discuss ways that they can be

attacks.

avoided.
Knowledge of the significance of risk
Review importance of weight control,
cessation of smoking, dietary changes,
and exercise.

factors provides patient with opportunity


to make needed changes. Patients with
high cholesterol who do not respond to 6month program of low-fat diet and regular
exercise will require medication.
Fear of triggering attacks may cause

Encourage patient to follow prescribed

patient to avoid participation in activity

reconditioning program; caution to avoid

that has been prescribed to enhance

exhaustion.

recovery (increase myocardial strength


and form collateral circulation).

Discuss impact of illness on desired

Patient may be reluctant to resume usual

lifestyle and activities, including work,

activities because of fear of anginal attack

driving, sexual activity, and hobbies.

or death. Patient should take nitroglycerin

Provide information, privacy, or

prophylactically before any activity that is

consultation, as indicated.

known to precipitate angina.

Demonstrate how to monitor own pulse

Allows patient to identify those activities

and BP during and after activities, and to

that can be modified to avoid cardiac

schedule activities, avoid strain and take

stress and stay below the anginal

rest periods.

threshold.

Discuss steps to take when anginal attacks


occur, (cessation of activity, keeping

Being prepared for an event takes away

rescue NTG on hand, administration of

the fear that patient will not know what to

prn medication, use of relaxation

do if attack occurs.

techniques).
Review prescribed medications for

Angina is a complicated condition that

Nursing Interventions

Rationale
often requires the use of many drugs

prevention of anginal attacks:

given to decrease myocardial workload,


improve coronary circulation, and control
the occurrence of attacks.
These drugs are considered first-line

Lipid-lowering agents: bile acid


sequestrants, cholestyramine (Questran),
colestipol (Colestid);

agents for lowering serum cholesterol


levels. Note: Questran and Colestid may
inhibit absorption of fat-soluble vitamins
and some drugs such as Coumadin,
Lanoxin, and Inderal.

nicotinic acid, and HMG-CoA reductase


inhibitors: lovastatin (Mevacor),
simvastatin (Zocor)

The HMG-CoA reductase inhibitors may


cause photosensitivity.

Stress importance of checking with

OTC drugs may potentiate or negate

physician before taking OTC drugs.

effects of prescribed medications.

Discuss ASA and other antiplatelet agents


as indicated.

Review symptoms to be reported to


physician: increase in frequency of
attacks, changes in response to
medications.

May be given prophylactically on a daily


basis to decrease platelet aggregation and
improve coronary circulation.
May prolong survival rate of patients with
unstable angina. Knowledge of
expectations can avoid undue concern for
insignificant reasons or delay in treatment
of important symptoms.
Angina is a symptom of progressive

Discuss importance of follow-up

coronary artery disease that should be

appointments.

monitored and may require occasional


adjustment of treatment regimen.

3. Anxiety
May be related to

Situational crises

Threat to self-concept (altered image/abilities)

Underlying pathophysiological response

Threat to or change in health status (disease course that can lead to further
compromise, debility, even death)

Negative self-talk

Possibly evidenced by

Expressed concern regarding changes in life events

Increased tension/helplessness

Apprehension, uncertainty, restlessness

Association of diagnosis with loss of healthy body image, loss of


place/influence

View of self as noncontributing member of family/society

Fear of death as an imminent reality

Desired Outcomes

Verbalize awareness of feelings of anxiety and healthy ways to deal with


them.

Report anxiety is reduced to a manageable level.

Express concerns about effect of disease on lifestyle, position within family


and society.

Demonstrate effective coping strategies/problem-solving skills.

Nursing Interventions

Rationale

Explain purpose of tests and procedures:

Reduces anxiety attributable to fear of

stress testing.

unknown diagnosis and prognosis.


Unexpressed feelings may create internal
turmoil and affect self-image.

Promote expression of feelings and fears.


Let patient/SO know these are normal
reactions.

Verbalization of concerns reduces tension,


verifies level of coping, and facilitates
dealing with feelings. Presence of negative
self-talk can increase level of anxiety and
may contribute to exacerbation of angina
attacks.

Encourage family and friends to treat

Reassures patient that role in the family

patient as before.

and business has not been altered.

Nursing Interventions
Tell patient the medical regimen has been
designed to limit future attacks and
increase cardiac stability.

Administer sedatives, tranquilizers, as


indicated.

Rationale
Encourages patient to test symptom
control, to increase confidence in medical
program, and to integrate abilities into
perceptions of self.
May be desired to help patient relax until
physically able to reestablish adequate
coping strategies.

1. Excess Fluid Volume


Nursing Diagnosis

Excess fluid volume

May be relate to

Compromised regulatory mechanism (renal failure)

Possibly evidenced by

Intake greater than output, oliguria; changes in urine specific gravity

Venous distension; blood pressure (BP)/central venous pressure (CVP)


changes

Generalized tissue edema, weight gain

Changes in mental status, restlessness

Decreased Hb/hematocrit (Hct), altered electrolytes; pulmonary congestion


on x-ray

Desired Outcomes

Display appropriate urinary output with specific gravity/laboratory studies


near normal; stable weight, vital signs within patients normal range; and
absence of edema.

Nursing Interventions

Rationale

Accurately record intake and output (I&O)

Decrease in output (to less than 400 ml

Nursing Interventions

noting to include hidden fluids such as IV


antibiotic additives, liquid medications,
frozen treats, ice chips. Religiously
measure gastrointestinal losses and
estimate insensible losses (sweating),
including wound drainage, nasogastric
outputs, and diarrhea.

Rationale
per 24 hours) may indicate acute failure,
especially in high-risk patients. Accurate
monitoring of I&O is necessary for
determining renal function and fluid
replacement needs and reducing risk of
fluid overload. Do note that hypervolemia
usually occurs in anuric phase of ARF and
may mask the symptoms.
Measures the kidneys ability to
concentrate urine. In intrarenal failure,

Monitor urine specific gravity.

specific gravity is usually equal to or less


than 1.010, indicating loss of ability to
concentrate the urine.

Weigh daily at same time of day, on same


scale, with same equipment and clothing.

Daily body weight is best monitor of fluid


status. A weight gain of more than 0.5
kg/day suggests fluid retention.
Edema occurs primarily in dependent
tissues of the body, (hands, feet,

Assess skin, face, dependent areas for


edema. Evaluate degree of edema (on
scale of +1+4).

lumbosacral area). Patient can gain up to


10 lb (4.5 kg) of fluid before pitting edema
is detected. Periorbital edema may be a
presenting sign of this fluid shift because
these fragile tissues are easily distended
by even minimal fluid accumulation.

Monitor heart rate (HR), BP, and JVD/CVP.

Tachycardia and hypertension can occur


because of: (1) failure of the kidneys to
excrete urine, (2) excess fluid
resuscitation during efforts to treat
hypovolemia and/or hypotension or
convert oliguric phase of renal failure, (3)

Nursing Interventions

Rationale
changes in the renin-angiotensin system.
Invasive monitoring may be needed for
assessing intravascular volume, especially
in patients with poor cardiac function.
Fluid overload may lead to pulmonary

Auscultate lung and heart sounds.

edema and HF evidenced by development


of adventitious breath sounds, extra heart
sounds.

Assess level of consciousness. Investigate

May reflect fluid shifts, accumulation of

changes in mentation, presence of

toxins, acidosis, electrolyte imbalances, or

restlessness.

developing hypoxia.

Scatter desired beverages throughout the

Helps avoid periods without fluids,

24-hour period and give various offering

minimizes boredom of limited choices, and

(hot, cold, frozen).

reduces sense of deprivation and thirst.

Correct any reversible cause of ARF:


replace blood loss, maximize cardiac
output, discontinue nephrotoxic drug,
relieve obstruction via surgery.

Kidneys may be able to return to normal


functioning, preventing or limiting residual
effects.

Use appropriate safety measures (raising

Patient with CNS involvement may be

side rails and restraints.

dizzy and/or confused.

Monitor diagnostic studies:


Blood urea nitrogen (BUN), creatinine (cr)

BUN assess management of renal


dysfunction. Both values may increase but
creatinine is a better indicator of renal
function because it is not affected by
hydration, diet, and tissue catabolism.
Dialysis is usually indicated if ratio is
higher than 10:1 or if therapy fails to

Nursing Interventions

Rationale
indicate fluid overload or metabolic
acidosis.
In ATN, tubular functional integrity is lost
and sodium resorption is impaired,

Urine sodium and Cr.

resulting in increased sodium excretion.


Urine creatinine is usually decreased as
serum creatinine elevates.
Hyponatremia may result from fluid

Serum sodium.

overload (dilutional) or kidneys inability to


conserve sodium. Hypernatremia indicates
total body water deficit.
Lack of renal excretion and/or selective

Serum potassium.

retention of potassium to excrete excess


hydrogen ions leads to hyperkalemia,
requiring prompt intervention.
Decreased values may indicate
hemodilution (hypervolemia) however,
during prolonged failure, anemia

Hb/Hct.

frequently develops as a result of RBC


loss. Other possible causes (active or
occult hemorrhage) should also be
evaluated.
Increased cardiac size, prominent
pulmonary vascular markings, pleural

Serial chest x-rays.

effusion, congestion indicate acute


responses to fluid overload or chronic
changes associated with renal and heart
failure.

Administer and/or restrict fluids as

Fluid management is usually calculated to

Nursing Interventions

Rationale
replace output from all sources plus
estimated insensible losses (metabolism,
diaphoresis). Prerenal failure (azotemia) is
treated with volume replacement and/or
vasopressors. The oliguric patient with

indicated.

adequate circulating volume or fluid


overload who is unresponsive to fluid
restriction and diuretics requires dialysis.
Note: During oliguric phase, push/pull
therapy (push IV fluids and diurese with
diuretics) may be tried to stimulate kidney
function.

Administer medication as indicated:


Given early in oliguric phase of ARF in an
Diuretics: furosemide (Lasix),

effort to convert to non-oliguric phase,

bumetanide (Bumex), torsemide

flush the tubular lumen of debris, reduce

(Demadex), mannitol (Osmitrol).

hyperkalemia, and promote adequate


urine volume.

Antihypertensives: clonidine (Catapres),


methyldopa (Aldomet), prazosin
(Minipress).

May be given to treat hypertension by


counteracting effects of decreased renal
blood flow and/or circulating volume
overload.
Given early in nephrotoxic ATN to reduce

Calcium channel blockers.

influx of calcium into kidney cells, thereby


helping to maintain cell integrity and
improve GFR.

Prostaglandins.

Vasodilatory effect may improve


circulating volume and reestablish renal
blood flow to aid in clearing nephrotoxic

Nursing Interventions

Rationale
agents from nephrons.
Catheterization excludes lower tract
obstruction and provides means of

Insert indwelling catheter, as indicated.

accurate monitoring of urine output during


acute phase; however, indwelling
catheterization may be contraindicated
because of increased risk of infection.
Done to correct volume overload,

Prepare for dialysis as indicated:

electrolyte and acid-base imbalances, and

hemodialysis, peritoneal dialysis, or

to remove toxins. The type of dialysis

continuous renal replacement therapy

chosen for ARF depends on the degree of

(CRRT).

hemodynamic compromise and patients


ability to withstand the procedure.

During peritoneal dialysis, position the


patient carefully: elevate the head of the
bed.
Watch out for complications such as
peritonitis, atelectasis, hypokalemia,
pneumonia and/or shock.

Doing so would reduce the pressure on the


diaphragm and can aid in respiration.

These complications are common for


patients undergoing peritoneal dialysis.

2. Risk for Decreased Cardiac Output


Nursing Diagnosis

Risk for decreased cardiac output

Risk factors may include

Fluid overload (kidney dysfunction/failure, overzealous fluid replacement)

Fluid shifts, fluid deficit (excessive losses)

Electrolyte imbalance (potassium, calcium); severe acidosis

Uremic effects on cardiac muscle/oxygenation

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as


the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Maintain cardiac output as evidenced by BP and HR/rhythm within patients


normal limits; peripheral pulses strong and equal with adequate capillary refill
time.

Nursing Interventions

Rationale
Fluid volume excess, combined with
hypertension (common in renal failure)

Monitor BP and HR.

and effects of uremia, increases cardiac


workload and can lead to cardiac failure.
In ARF, cardiac failure is usually reversible.
Changes in electromechanical function
may become evident in response to
progressing renal failure and accumulation
of toxins and electrolyte imbalance.

Observe ECG or telemetry for changes in

Peaked T wave, wide QRS, prolonged PR

rhythm.

interval is usually associated


withhyperkalemia. Flat T wave, peaked P
wave, and appearance of the U waves
usually indicate hypokalemia. Prolonged
QT interval may reflect calcium deficit.

Auscultate heart sounds.

Development of S3/S4 is indicative of


failure. Pericardial friction rub may be only
manifestation of uremic pericarditis,
requiring prompt intervention and possibly

Nursing Interventions

Rationale
acute dialysis.
Pallor may reflect vasoconstriction or

Assess color of skin, mucous membranes,

anemia. Cyanosis is a late sign and is

and nail beds. Note capillary refill time.

related to pulmonary congestion and/or


cardiac failure.
Use of drugs (like antacids) containing

Note occurrence of slow pulse,

magnesium can result in

hypotension, flushing, nausea and

hypermagnesemia, potentiating the

vomiting, and depressed level of

neuromuscular dysfunction and risk of a

consciousness.

respiratory or cardiac arrest. Use


aluminum-hydroxide-based antacid.
Gastrointestinal bleeding is a known
complication of renal failure; however, its
pathogenesis remains uncertain. Some
have attributed gastrointestinal bleeding
to the effects of uremia on the
gastrointestinal mucosa; others have

Monitor for GI bleeding by guaiac testing

suggested that uremia may affect platelet

all stools for blood.

adhesiveness, which may explain the


prolonged gastrointestinal bleeding seen in
patients with renal failure. In addition, the
role of heparinization and the widespread
use of antiplatelet agents in patients on
dialysis have been implicated in the
etiology of gastrointestinal bleeding.

Investigate reports of muscle cramps,

Neuromuscular indicators of hypocalcemia,

numbness of fingers, with muscle

which can also affect cardiac contractility

twitching, hyperreflexia.

and function.

Maintain bed rest or encourage adequate

Reduces oxygen consumption and cardiac

rest and provide assistance with care and

Nursing Interventions

Rationale

desired activities.

workload.

Monitor laboratory studies:


During oliguric phase, hyperkalemia is
present but often shifts to hypokalemia in
diuretic or recovery phase. Any potassium
Potassium.

value associated with ECG changes


requires intervention. Note: A serum level
of 6.5 mEq or higher constitutes a medical
emergency.
In addition to its own cardiac effects,

Calcium.

calcium deficit enhances the toxic effects


of potassium.
Dialysis or calcium administration may be

Magnesium.

necessary to combat the CNS-depressive


effects of an elevated serum magnesium
level.

Administer and/or restrict fluids as


indicated.

Cardiac output depends on circulating


volume (affected by both fluid excess and
deficit) and myocardial muscle function.
Maximizes available oxygen for myocardial

Provide supplemental oxygen if indicated.

uptake to reduce cardiac workload and


cellular hypoxia.

Administer medications as indicated:


Inotropic agents: digoxin (Lanoxin)

May be used to improve cardiac output by


increasing myocardial contractility and
stroke volume. Dosage depends on renal
function and potassium balance to obtain

Nursing Interventions

Rationale
therapeutic effect without toxicity.
Serum calcium is often low but usually
does not require specific treatment in ARF.

Calcium gluconate

Calcium gluconate may be given to treat


hypocalcemia and to offset the effects of
hyperkalemia by modifying cardiac
irritability.
Increased phosphate levels may occur as a

Aluminum hydroxide gels (Amphojel,


Basaljel)

result of failure of glomerular filtration and


require use of phosphate-binding antacids
to limit phosphate absorption from the GI
tract.
Temporary measure to lower serum

Glucose and/or insulin solution

potassium by driving potassium into cells


when cardiac rhythm is endangered.
May be used to correct acidosis or

Sodium bicarbonate or sodium citrate

hyperkalemia (by increasing serum pH) if


patient is severely acidotic and not
suffering from fluid overload.
Exchange resin trades sodium for

Sodium polystyrene sulfonate (Kayexalate)


with or without sorbitol.

potassium in the GI tract to lower serum


potassium level. Sorbitol may be included
to cause osmotic diarrhea to help excrete
potassium.

Prepare for/assist with dialysis as


necessary.

May be indicated for persistent


dysrhythmias, progressive HF
unresponsive to other therapies.

3. Risk for Imbalanced Nutrition


Nursing Diagnosis

Nutrition: imbalanced, risk for less than body requirements

Risk factors may include

Protein catabolism; dietary restrictions to reduce nitrogenous waste products

Increased metabolic needs

Anorexia, nausea/vomiting; ulcerations of oral mucosa

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as


the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Maintain/regain weight as indicated by individual situation, free of edema.

Nursing Interventions

Rationale
Aids in identifying deficiencies and dietary
needs. General physical condition, uremic

Assess and document dietary intake.

symptoms (nausea, anorexia), and


multiple dietary restrictions affect food
intake.
Minimizes anorexia and nausea associated

Provide frequent, small feedings.

with uremic state and/or diminished


peristalsis.

Give patient/SO a list of permitted foods

Provides patient with a measure of control

or fluids and encourage involvement in

within dietary restrictions. Food from

menu choices.

home may enhance appetite.

Offer frequent mouth care or rinse with

Mucous membranes may become dry and

Nursing Interventions

Rationale
cracked. Mouth care soothes, lubricates,
and helps freshen mouth taste, which is

diluted acetic acid solution. Give gums,

often unpleasant because of uremia and

hard candy, breath mints between meals.

restricted oral intake. Rinsing with acetic


acid helps neutralize ammonia formed by
conversion of urea.
The fasting or catabolic patient normally

Weigh daily.

loses 0.20.5 kg/day. Changes in excess


of 0.5 kg may reflect shifts in fluid
balance.

Monitor laboratory studies: BUN,

Indicators of nutritional needs,

albumin, transferrin, sodium, and

restrictions, and necessity for and

potassium.

effectiveness of therapy.
Determines individual calorie and nutrient
needs within the restrictions, and identifies

Consult with dietitian support team.

most effective route and product (oral


supplements, enteral or parenteral
nutrition).
The amount of needed exogenous protein
is less than normal unless patient is on
dialysis. Carbohydrates meet energy

Provide high-calorie, low to moderate

needs and limit tissue catabolism,

protein diet. Include complex

preventing keto acid formation from

carbohydrates and fat sources to meet

protein and fat oxidation. Carbohydrate

caloric needs and essential amino acids.

intolerance mimicking DM may occur in

Avoid concentrated sugar sources. Give

severe renal failure. Essential amino acids

anorectic patients small, frequent meals.

improve nitrogen balance and nutritional


status, stimulate repair of tubular
epithelial cells, and enhance patients
ability to fight systemic complications.

Nursing Interventions

Maintain proper electrolyte balance by


strictly monitoring levels.

Rationale
Medications and decrease in GFR can
cause electrolyte imbalances and may
further cause renal injury.
Restriction of these electrolytes may be

Restrict potassium, sodium, and


phosphorus intake as indicated.

needed to prevent further renal damage,


especially if dialysis is not part of
treatment, and/or during recovery phase
of ARF.

Administer medications as indicated:


Iron deficiency may occur if protein is
Iron preparations

restricted, patient is anemic, or GI


function is impaired.
Restores normal serum levels to improve
cardiac and neuromuscular function, blood
clotting, and bone metabolism. Note: Low

Calcium carbonate

serum calcium is often corrected as


phosphate absorption is decreased in the
GI system. Calcium may be substituted as
a phosphate binder.

Vitamin D

Necessary to facilitate absorption of


calcium from the GI tract.
Vital as coenzyme in cell growth and

B complex and C vitamins, folic acid

actions. Intake is decreased because of


protein restrictions.

Antiemetics: prochlorperazine

Given to relieve N/V and may enhance oral

(Compazine), trimethobenzamide (Tigan).

intake.

4. Risk for Infection


Risk factors may include

Depression of immunologic defenses (secondary to uremia)

Invasive procedures/devices (e.g., urinary catheterization)

Changes in dietary intake/malnutrition

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as


the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Experience no signs/symptoms of infection.

Nursing Interventions
Promote good hand washing by patient
and staff.

Rationale

Reduces risk of cross contamination.

Avoid invasive procedures,


instrumentation, and manipulation of
indwelling catheters whenever possible.

Limits introduction of bacteria into body.

Use aseptic technique when caring and

Early detection of developing infection

manipulating IV and invasive lines.

may prevent sepsis.

Change site dressings per protocol. Note


edema, purulent drainage.
Provide routine catheter care and promote
meticulous perineal care. Keep urinary

Reduces bacterial colonization and risk of

drainage system closed and remove

ascending UTI.

indwelling catheter as soon as possible.


Encourage deep breathing, coughing,

Prevents atelectasis and mobilizes

frequent position changes.

secretions to reduce risk of pulmonary

Nursing Interventions

Rationale
infections.

Assess skin integrity.

Excoriations from scratching may become


secondarily infected.
Fever (higher than 100.4F) with
increased pulse and respirations is typical

Monitor vital signs.

of increased metabolic rate resulting from


inflammatory process, although sepsis can
occur without a febrile response.
Although elevated WBCs may indicate
generalized infection, leukocytosis is

Monitor laboratory studies: WBC count

commonly seen in ARF and may reflect

with differential.

injury within the kidney. A shifting of the


differential to the left is indicative of
infection.
Verification of infection and identification

Obtain specimen(s) for culture and


sensitivity and administer appropriate
antibiotics as indicated.

of specific organism aids in choice of the


most effective treatment. Note: A number
of anti-infective agents require
adjustments of dose and/or time while
renal clearance is impaired.

5. Risk for Deficient Fluid Volume


Risk factors may include

Excessive loss of fluid (diuretic phase of ARF, with rising urinary volume and
delayed return of tubular reabsorption capabilities)

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as


the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Display I&O near balance; good skin turgor, moist mucous membranes,
palpable peripheral pulses, stable weight and vital signs, electrolytes within
normal range.

Nursing Interventions

Rationale
Assessment can help estimate fluid
replacement needs. Fluid intake should

Measure I&O accurately. Weigh daily.

approximate losses through urine,

Calculate insensible fluid losses.

nasogastric or wound drainage, and


insensible water losses (diaphoresis,
metabolism).
Diuretic phase of ARF may revert to

Provide allowed fluids throughout 24-hr

oliguric phase if fluid intake is not

period.

maintained or nocturnal dehydration


occurs.

Monitor BP (noting postural changes) and

Orthostatic hypotension and tachycardia

HR.

suggest hypovolemia.
In diuretic or postobstructive phase of
renal failure, urine output can exceed 3
L/day. Extracellular fluid volume depletion

Note signs and symptoms of dehydration:

activates the thirst center, and sodium

dry mucous membranes, thirst, dulled

depletion causes persistent thirst,

sensorium, peripheral vasoconstriction.

unrelieved by drinking water. Continued


fluid losses including inadequate
replacement may lead to hypovolemic
state.

Control environmental temperature; limit

May reduce diaphoresis, which contributes

Nursing Interventions

Rationale

bed linens as indicated.

to overall fluid losses.


In nonoliguric ARF or in diuretic phase of
ARF, large urine losses may result in

Monitor laboratory studies

sodium wasting while elevated urinary


sodium acts osmotically to increase fluid
losses. Restriction of sodium may be
indicated to break the cycle.

6. Deficient Knowledge
May be related to

Lack of exposure/recall

Information misinterpretation

Unfamiliarity with information resources

Possibly evidenced by

Questions/request for information, statement of misconception

Inaccurate follow-through of instructions/development of preventable

Complications

Desired Outcomes

Verbalize understanding of condition/disease process, prognosis, and potential


complications.

Identify relationship of signs/symptoms to the disease process and correlate


symptoms with causative factors.

Verbalize understanding of therapeutic needs.

Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Interventions

Rationale

Review disease process, prognosis, and

Provides knowledge base from which

Nursing Interventions

Rationale

precipitating factors if known.

patient can make informed choices.

Explain level of renal function after acute


episode is over.

Patient may experience residual defects in


kidney function, which may or may not be
permanent.
Although these options would have been

Discuss renal dialysis or transplantation if


these are likely options for the future.

previously presented by the physician,


patient may now be at a point when
options need to be considered and may
desire additional input.

Review dietary plan and restrictions.


Include fact sheet listing food restrictions.

Encourage patient to observe


characteristics of urine and amount,
frequency of output.

Establish regular schedule for weighing.

Adequate nutrition is necessary to


promote tissue healing; adherence to
restrictions may prevent complications.

Changes may reflect alterations in renal


function and need for dialysis.

Useful tool for monitoring fluid and dietary


needs.

Provide emotional support to the patient

To reassure them of the all the procedures

and family.

that patient may undergo.

Review fluid restriction. Remind patient to

Depending on the cause and stage of ARF,

spread fluids over entire day and to

patient may need to either restrict or

include all fluids (ice) in daily fluid counts.

increase intake of fluids.

Discuss activity restriction and gradual


resumption of desired activity. Encourage
use of energy-saving, relaxation, and
diversional techniques.

Patient with severe ARF may need to


restrict activity and/or may feel weak for
an extended period during lengthy
recovery phase, requiring measures to
conserve energy and reduce boredom.

Nursing Interventions

Discuss reality of continued presence of


fatigue.

Rationale
Decreased metabolic energy production,
presence of anemia, and states of
discomfort commonly result in fatigue.

Determine ADLs and personal


responsibilities. Identify available
resources and support systems.

Helps patient manage lifestyle changes


and meet personal needs.

Recommend scheduling activities with

Prevents excessive fatigue and conserves

adequate rest periods.

energy for healing, tissue regeneration.


Medications that are concentrated in

Review use of medication. Encourage


patient to discuss all medications and
herbal supplements with physician.

and/or excreted by the kidneys can cause


toxic cumulative reactions and/or
permanent damage to kidneys. Some
supplements may interact with prescribed
medications and may electrolytes.
Renal function may be slow to return

Stress necessity of follow-up care,

following acute failure (up to 12 mo), and

laboratory studies.

deficits may persist, requiring changes in


therapy to avoid recurrence.

Identify symptoms requiring medical


intervention: decreased urinary output,

Prompt evaluation and intervention may

sudden weight gain, presence of edema,

prevent serious complications or

lethargy, bleeding, signs of infection,

progression to chronic renal failure.

altered mentation.

Other Possible Nursing Care Plans

Fluid Volume, deficient (specify)dependent on cause, duration, and stage of


recovery.

Fatiguedecreased metabolic energy production/dietary restriction, anemia,


increased energy requirements, e.g., fever/inflammation, tissue regeneration.

Infection, risk fordepression of immunologic defenses (secondary to


uremia), changes in dietary intake/malnutrition, increased environmental
exposure.

Therapeutic Regimen: ineffective managementcomplexity of therapeutic


regimen, economic difficulties, perceived benefit.

2. Activity Intolerance
Nursing Diagnosis

Activity intolerance

May be related to

Imbalance between myocardial oxygen supply and demand

Presence of ischemic/necrotic myocardial tissues

Cardiac depressant effects of certain drugs (beta-blockers, antiarrhythmics)

Possibly evidenced by

Alterations in heart rate and BP with activity

Development of dysrhythmias

Changes in skin color/moisture

Exertional angina

Generalized weakness

Desired Outcomes

Demonstrate measurable/progressive increase in tolerance for activity with


heart rate/rhythm and BP within patients normal limits and skin warm, pink,
dry.

Report absence of angina with activity.

Nursing Interventions

Rationale
Trends determine patients response to

Document heart rate and rhythm and

activity and may indicate myocardial

changes in BP before, during, and after

oxygen deprivation that may require

activity. Correlate with reports of chest

decrease in activity level and/or return to

pain or shortness of breath.

bedrest, changes in medication regimen,


or use of supplemental oxygen.

Encourage rest initially. Thereafter, limit


activity on basis of pain and/or adverse
cardiac response. Provide nonstress
diversional activities.

Reduces myocardial workload and oxygen


consumption, reducing risk of
complications.

Activities that require holding the breath


Instruct patient to avoid increasing

and bearing down (Valsalva maneuver)

abdominal pressure (straining during

can result in bradycardia (temporarily

defecation).

reduced cardiac output) and rebound


tachycardia with elevated BP.

Explain pattern of graded increase of


activity level: getting up to commode or
sitting in chair, progressive ambulation,
and resting after meals.

Review signs and symptoms reflecting


intolerance of present activity level or
requiring notification of nurse or physician.

Progressive activity provides a controlled


demand on the heart, increasing strength
and preventing overexertion.

Palpitations, pulse irregularities,


development of chest pain, or dyspnea
may indicate need for changes in exercise
regimen or medication.
Provides continued support and/or

Refer to cardiac rehabilitation program.

additional supervision and participation in


recovery and wellness process.

5. Ineffective Tissue Perfusion


Nursing Diagnosis

Risk for Ineffective Tissue Perfusion

Risk factors may include

Reduction/interruption of blood flow, e.g., vasoconstriction,


hypovolemia/shunting, and thromboembolic formation

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as


the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Demonstrate adequate perfusion as individually appropriate, e.g., skin warm


and dry, peripheral pulses present/strong, vital signs within patients normal
range, patient alert/oriented, balanced I&O, absence of edema, free of
pain/discomfort.

Nursing Interventions

Investigate sudden changes or continued


alterations in mentation (changes in LOC,
mentation, stupor).

Inspect for pallor, cyanosis, mottling, cool


and clammy skin. Note strength of
peripheral pulses.

Rationale
Cerebral perfusion is directly related to
cardiac output and is also influenced by
electrolyte and/or acid-base variations,
hypoxia, and systemic emboli.
Systemic vasoconstriction resulting from
diminished cardiac output may be
evidenced by decreased skin perfusion and
diminished pulses.

Monitor respirations, note work of

Cardiac pump failure and/or ischemic pain

breathing.

may precipitate respiratory distress;

Nursing Interventions

Rationale
however, sudden or continued dyspnea
may indicate thromboembolic pulmonary
complications.
Decreased intake or persistent nausea

Monitor intake, note changes in urine


output. Record urine specific gravity as
indicated.

may result in reduced circulating volume,


which negatively affects perfusion and
organ function. Specific gravity
measurements reflect hydration status and
renal function.

Assess GI function, noting anorexia,


decreased or absent bowel sounds, nausea
and vomiting, abdominal distension,
constipation.

Reduced blood flow to mesentery can


produce GI dysfunction, e.g., loss of
peristalsis. Problems may be aggravated
by use of analgesics, decreased activity,
and dietary changes.
Enhances venous return, reduces venous
stasis, and decreases risk of

Encourage active or passive leg exercises,

thrombophlebitis; however, isometric

avoidance of isometric exercises.

exercises can adversely affect cardiac


output by increasing myocardial work and
oxygen consumption.

Assess for Homans sign (pain in calf on


dorsiflexion), erythema, edema.

Indicators of deep vein thrombosis (DVT),


although DVT can be present without a
positive Homans sign.
Limits venous stasis, improves venous

Instruct patient in application or periodic

return, and reduces risk of

removal of antiembolitic hose, when used.

thrombophlebitis in patient who is limited


in activity.

Monitor laboratory data: ABGs, BUN,

Indicators of organ perfusion and function.

creatinine, electrolytes, coagulation

Abnormalities in coagulation may occur as

Nursing Interventions

Rationale

studies (PT, aPTT, clotting times).

a result of therapeutic measures.

Administer medications as indicated:


Reduces mortality in MI patients, and is
taken daily. Aspirin also reduces coronary
Antiplatelet agents: aspirin, abciximab
(ReoPro), clopidogrel (Plavix);

reocclusion after percutaneous


transluminal coronary angioplasty (PTCA).
ReoPro is an IV drug used as an adjunct to
PTCA for prevention of acute ischemic
complications.
Low-dose heparin is given during PTCA
and may be given prophylactically in high-

Anticoagulants: heparin or enoxaparin


(Lovenox);

risk patients (e.g., atrial fibrillation,


obesity, ventricular aneurysm, or history
of thrombophlebitis) to reduce risk of
thrombophlebitis or mural thrombus
formation.

Oral anticoagulants: anisindione


(Miradon), warfarin (Coumadin);

Used for prophylaxis and treatment of


thromboembolic complications associated
with MI.
Reduces or neutralizes gastric acid,

Cimetidine (Tagamet), ranitidine (Zantac),

preventing discomfort and gastric

antacids;

irritation, especially in presence of reduced


mucosal circulation.

Assist with reperfusion

Thrombolytic therapy is the treatment of

therapy: Administer thrombolytic agents,

choice (when initiated within 6 hr) to

e.g., alteplase (Activase, rt-PA), reteplase

dissolve the clot (if that is the cause of the

(Retavase), streptokinase (Streptase),

MI) and restore perfusion of the

anistreplase (Eminase), urokinase,

myocardium.This procedure is used to

(Abbokinase);

open partially blocked coronary arteries

Nursing Interventions

Rationale
before they become totally blocked. The
mechanism includes a combination of
vessel stretching and plaque compression.
Intracoronary stents may be placed at the

Prepare for PTCA (balloon angioplasty),

time of PTCA to provide structural support

with or without intracoronary stents;

within the coronary artery and improve


the odds of long-term patency.
More intensive monitoring and aggressive

Transfer to critical care.

interventions are necessary to promote


optimum outcome.

1. Decreased Cardiac Output


Nursing Diagnosis

Decreased Cardiac Output

May be related to

Altered myocardial contractility/inotropic changes

Alterations in rate, rhythm, electrical conduction

Structural changes (e.g., valvular defects, ventricular aneurysm)

Possibly evidenced by

Increased heart rate (tachycardia), dysrhythmias, ECG changes

Changes in BP (hypotension/hypertension)

Extra heart sounds (S3, S4)

Decreased urine output

Diminished peripheral pulses

Cool, ashen skin; diaphoresis

Orthopnea, crackles, JVD, liver engorgement, edema

Chest pain

Desired Outcomes

Display vital signs within acceptable limits, dysrhythmias absent/controlled,


and no symptoms of failure (e.g., hemodynamic parameters within acceptable
limits, urinary output adequate).

Report decreased episodes of dyspnea, angina.

Participate in activities that reduce cardiac workload.

Nursing Interventions

Rationale
Tachycardia is usually present (even at
rest) to compensate for decreased
ventricular contractility. Premature atrial
contractions (PACs), paroxysmal atrial

Auscultate apical pulse, assess heart rate,

tachycardia (PAT), PVCs, multifocal atrial

rhythm. Document dysrhythmia if

tachycardia (MAT), and atrial fibrillation

telemetry is available.

(AF) are common dysrhythmias associated


with HF, although others may also
occur. Note: Intractable ventricular
dysrhythmias unresponsive to medication
suggest ventricular aneurysm.
S1 and S2 may be weak because of
diminished pumping action. Gallop

Note heart sounds.

rhythms are common (S3and S4), produced


as blood flows into noncompliant
chambers. Murmurs may reflect valvular
incompetence.
Decreased cardiac output may be reflected
in diminished radial, popliteal, dorsalis

Palpate peripheral pulses.

pedis, and post tibial pulses. Pulses may


be fleeting or irregular to palpation, and
pulsus alternans (strong beat alternating
with weak beat) may be present.

Monitor BP.

In early, moderate, or chronic HF, BP may


be elevated because of increased SVR. In
advanced HF, the body may no longer be

Nursing Interventions

Rationale
able to compensate, and profound
hypotension may occur.
Pallor is indicative of diminished peripheral
perfusion secondary to inadequate cardiac

Inspect skin for pallor, cyanosis.

output, vasoconstriction, and anemia.


Cyanosis may develop in refractory HF.
Dependent areas are often blue or mottled
as venous congestion increases.
Kidneys respond to reduced cardiac output
by retaining water and sodium. Urine

Monitor urine output, noting decreasing

output is usually decreased during the day

output and concentrated urine.

because of fluid shifts into tissues but may


be increased at night because fluid returns
to circulation when patient is recumbent.

Note changes in sensorium: lethargy,


confusion, disorientation, anxiety, and
depression.

May indicate inadequate cerebral perfusion


secondary to decreased cardiac output.
Physical rest should be maintained during

Encourage rest, semirecumbent in bed or

acute or refractory HF to improve

chair. Assist with physical care as

efficiency of cardiac contraction and to

indicated.

decrease myocardial oxygen demand/


consumption and workload.

Provide quiet environment: explain

Psychological rest helps reduce emotional

therapeutic management, help patient

stress, which can produce

avoid stressful situations, listen and

vasoconstriction, elevating BP and

respond to expressions of feelings.

increasing heart rate.


Commode use decreases work of getting

Provide bedside commode. Have patient

to bathroom or struggling to use bedpan.

avoid activities eliciting a vasovagal

Vasovagal maneuver causes vagal

response (straining during defecation,

stimulation followed by rebound

holding breath during position changes).

tachycardia, which further compromises


cardiac function.

Elevate legs, avoiding pressure under

Decreases venous stasis, and may reduce

Nursing Interventions

Rationale

knee. Encourage active and passive

incidence of thrombus or embolus

exercises. Increase activity as tolerated.

formation.

Check for calf tenderness, diminished

Reduced cardiac output, venous pooling,

pedal pulses, swelling, local redness, or

and enforced bed rest increases risk of

pallor of extremity.

thrombophlebitis.
Incidence of toxicity is high (20%)

Withhold digitalis preparation as indicated,

because of narrow margin between

and notify physician if marked changes

therapeutic and toxic ranges. Digoxin may

occur in cardiac rate or rhythm or signs of

have to be discontinued in the presence of

digitalis toxicity occur.

toxic drug levels, a slow heart rate, or low


potassium level.

Administer supplemental oxygen as

Increases available oxygen for myocardial

indicated.

uptake to combat effects of hypoxia.


A variety of medications may be used to

Administer medications as indicated:

increase stroke volume, improve


contractility, and reduce congestion.
Diuretics, in conjunction with restriction of
dietary sodium and fluids, often lead to
clinical improvement in patients with
stages I and II HF. In general, type and

Diuretics: furosemide (Lasix), ethacrynic


acid (Edecrin), bumetanide (Bumex),
spironolactone (Aldactone).

dosage of diuretic depend on cause and


degree of HF and state of renal function.
Preload reduction is most useful in treating
patients with a relatively normal cardiac
output accompanied by congestive
symptoms. Loop diuretics block chloride
reabsorption, thus interfering with the
reabsorption of sodium and water.

Vasodilators: nitrates (Nitro-Dur,

Vasodilators are the mainstay of treatment

Isordil); arterial dilators: hydralazine

in HF and are used to increase cardiac

(Apresoline); combination

output, reducing circulating volume

drugs: prazosin (Minipress);

(venodilators) and decreasing SVR,


thereby reducing ventricular

Nursing Interventions

Rationale
workload. Note: Parenteral vasodilators
(Nitropress) are reserved for patients with
severe HF or those unable to take oral
medications.

ACE inhibitors: benazepril (Lotensin),


captopril (Capoten), lisinopril (Prinivil),
enalapril (Vasotec), quinapril (Accupril),
ramipril (Altace), moexipril (Univasc).

Angiotensin II receptor
antagonists: eprosartan (Teveten),
irbesartan (Avapro), valsartan (Diovan);

ACE inhibitors represent first-line therapy


to control heart failure by decreasing
ventricular filling pressures and SVR while
increasing cardiac output with little or no
change in BP and heart rate.
Antihypertensive and cardioprotective
effects are attributable to selective
blockade of AT1(angiotensin II) receptors
and angiotensin II synthesis.
Increases force of myocardial contraction
when diminished contractility is the cause
of HF, and slows heart rate by decreasing

Digoxin (Lanoxin)

conduction velocity and prolonging


refractory period of the atrioventricular
(AV) junction to increase cardiac efficiency
/output.
These medications are useful for shortterm treatment of HF unresponsive to

Inotropic agents: amrinone (Inocor),


milrinone (Primacor), vesnarinone (ArkinZ);

cardiac glycosides, vasodilators, and


diuretics in order to increase myocardial
contractility and produce vasodilation.
Positive inotropic properties have reduced
mortality rates 50% and improved quality
of life.
Useful in the treatment of HF by blocking

Beta-adrenergic receptor

the cardiac effects of chronic adrenergic

antagonists:carvedilol (Coreg), bisoprolol

stimulation. Many patients

(Zebeta), metoprolol (Lopressor);

experience improved activity tolerance and


ejection fraction.

Nursing Interventions

Rationale
Decreases vascular resistance and venous
return, reducing myocardial workload,

Morphine sulfate.

especially when pulmonary congestion is


present. Allays anxiety and breaks the
feedback cycle of anxiety to catecholamine
release to anxiety.

Antianxiety agents and sedatives.

Promote rest, reducing oxygen demand


and myocardial workload.
May be used prophylactically to prevent
thrombus and embolus formation in

Anticoagulants: low-dose heparin, warfarin

presence of risk factors such as venous

(Coumadin).

stasis, enforced bed rest, cardiac


dysrhythmias, and history of previous
thrombotic episodes.
Because of existing elevated left

Administer IV solutions, restricting total


amount as indicated. Avoid saline
solutions.

ventricular pressure, patient may not


tolerate increased fluid volume (preload).
Patients with HF also excrete less sodium,
which causes fluid retention and increases
myocardial workload.
Fluid shifts and use of diuretics can alter

Monitor and replace electrolytes.

electrolytes (especially potassium and


chloride), which affect cardiac rhythm and
contractility.
ST segment depression and T wave
flattening can develop because of

Monitor serial ECG and chest x-ray


changes.

increased myocardial oxygen demand,


even if no coronary artery disease is
present. Chest x-ray may show enlarged
heart and changes of pulmonary
congestion.

Measure cardiac output and other

Cardiac index, preload, afterload,

functional parameters as indicated.

contractility, and cardiac work can be

Nursing Interventions

Rationale
measured noninvasively by using thoracic
electrical bioimpedance (TEB) technique.
Useful in determining effectiveness of
therapeutic interventions and response to
activity.

Monitor laboratory studies:


BUN, creatinine.

Elevation of BUN or creatinine reflects


kidney hypoperfusion.
May be elevated because of liver

Liver function studies (AST, LDH).

congestion and indicate need for smaller


dosages of medications that are detoxified
by the liver.

Prothrombin time (PT), activated partial

Measures changes in coagulation

thromboplastin time (aPTT) coagulation

processes or effectiveness of anticoagulant

studies.

therapy.
May be necessary to correct

Prepare for insertion and maintenance of


pacemaker, if indicated.

bradydysrhythmias unresponsive to drug


intervention, which can aggravate
congestive failure and/or produce
pulmonary edema.

Prepare for surgery as indicated:


Heart failure due to ventricular aneurysm
or valvular dysfunction may require
valve replacement, angioplasty, coronary
artery bypass grafting (CABG).

aneurysmectomy or valve replacement to


improve myocardial contractility/ function.
Revascularization of cardiac muscle by
CABG may be done to improve cardiac
function.

Cardiomyoplasty.

Cardiomyoplasty, an experimental
procedure in which the latissimus dorsi
muscle is wrapped around the heart and
electrically stimulated to contract with

Nursing Interventions

Rationale
each heartbeat, may be done to augment
ventricular function while the patient is
awaiting cardiac transplantation or when
transplantation is not an option.
Other new surgical techniques include
transmyocardial revascularization
(percutaneous [PTMR]) using CO2 laser

Transmyocardial revascularization.

technology, in which a laser is used to


create multiple 1-mm diameter channels
in viable but underperfused cardiac
muscle.
An intra-aortic balloon pump (IABP) may
be inserted as a temporary support to the
failing heart in the critically ill patient with
potentially reversible HF. A batterypowered ventricular assist device (VAD)

Assist with mechanical circulatory support


system, such as IABP or VAD, when
indicated.

may also be used, positioned between the


cardiac apex and the descending thoracic
or abdominal aorta. This device receives
blood from the left ventricle (LV) and
ejects it into the systemic circulation,
often allowing patient to resume a nearly
normal lifestyle while awaiting heart
transplantation. With end-stage HF,
cardiac transplantation may be indicated.

4. Impaired Gas Exchange


Nursing Diagnosis

Risk for Impaired Gas Exchange

Risk factors may include

Alveolar-capillary membrane changes, e.g., fluid collection/shifts into


interstitial space/alveoli

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as


the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Demonstrate adequate ventilation and oxygenation of tissues by


ABGs/oximetry within patients normal ranges and free of symptoms of
respiratory distress.

Participate in treatment regimen within level of ability/situation.

Nursing Interventions
Auscultate breath sounds, noting crackles,
wheezes.

Rationale
Reveals presence of pulmonary congestion
and collection of secretions, indicating
need for further intervention.

Instruct patient in effective coughing,

Clears airways and facilitates oxygen

deep breathing.

delivery.

Encourage frequent position changes.

Helps prevent atelectasis and pneumonia.

Maintain chair or bed rest, with head of


bed elevated 2030 degrees, semi-

Reduces oxygen demands and promotes

Fowlers position. Support arms with

maximal lung inflation.

pillows.
Place patient in Fowlers position and give

To help patient breath more easily and

supplemental oxygen.

promote maximum chest expansion.


Hypoxemia can be severe during
pulmonary edema. Compensatory changes
are usually present in chronic HF. Note: In

Graph graph serial ABGs, pulse oximetry.

patients with abnormal cardiac index,


research suggests pulse oximeter
measurements may exceed actual oxygen
saturation by up to 7%.

Administer supplemental oxygen as

Increases alveolar oxygen concentration,

Nursing Interventions

Rationale

indicated.

which may reduce tissue hypoxemia.

Administer medications as indicated:


Diuretics: furosemide (Lasix)

Reduces alveolar congestion, enhancing


gas exchange.
Increases oxygen delivery by dilating

Bronchodilators: aminophylline

small airways, and exerts mild diuretic


effect to aid in reducing pulmonary
congestion.

5. Impaired Skin Integrity


Nursing Diagnosis

Risk for impaired Skin Integrity

Risk factors may include

Prolonged bedrest

Edema, decreased tissue perfusion

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as


the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes

Maintain skin integrity.

Demonstrate behaviors/techniques to prevent skin breakdown.

Nursing Interventions

Rationale

Inspect skin, noting skeletal prominences,

Skin is at risk because of impaired

presence of edema, areas of altered

peripheral circulation, physical immobility,

circulation, or obesity and/or emanciation.

and alterations in nutritional status.

Provide gentle massage around reddened

Improves blood flow, minimizing tissue

or blanched areas.

hypoxia. Note: Direct massage of

Nursing Interventions

Rationale
compromised area may cause tissue
injury.

Encourage frequent position changes,

Reduces pressure on tissues, improving

assist with active and passive range of

circulation and reducing time any one area

motion (ROM) exercises.

is deprived of full blood flow.

Provide frequent skin care: minimize

Excessive dryness or moisture damages

contact with moisture and excretions.

skin and hastens breakdown.

Check fit of shoes and slippers and change


as needed.

Dependent edema may cause shoes to fit


poorly, increasing risk of pressure and skin
breakdown on feet.
Interstitial edema and impaired circulation

Avoid intramuscular route for medication.

impede drug absorption and predispose to


tissue breakdown and development of
infection.

Provide alternating pressure, egg-crate


mattress, sheepskin elbow and heel
protectors.

Reduces pressure to skin, may improve


circulation.

Diabetes mellitus (DM) is a chronic diseases characterized by insufficient production


of insulin in the pancreas or when the body cannot effectively use the insulin it
produces. This leads to an increased concentration of glucose in the bloodstream
(hyperglycemia). It is characterized by disturbances in carbohydrate, protein, and fat
metabolism.
Types
Diabetes mellitus occurs in four forms classified by etiology: type 1, type 2, gestational
diabetes mellitus, and other specific types. Heres a breakdown of the types:

Type 1 diabetes is characterized by the lack of insulin production. It is


formerly known as insulin-dependent or childhood-onset diabetes. Type 1 is
further subdivided into immune-mediated diabetes and idiopathic diabetes.
Children and adolescents with type 1 immune-mediated diabetes rapidly

develop ketoacidosis, but most adults with this type experience only modest
fasting hyperglycemia unless they develop and infection as another stressor.
Patients with type 1 idiopathic diabetes are prone to ketoacidosis.

Type 2 diabetes is caused by the bodys ineffective use of insulin. It is


previously called non-insulin dependent or adult-onset diabetes. Most patients
with type 2 diabetes are obese.

Other specific types category includes people who have diabetes as a result
of a genetic defect, endocrinopathies or exposure to certain drugs or
chemicals.

Gestational diabetes mellitus (GDM) occurs during pregnancy. Glucose


tolerance levels usually return to normal after delivery.

Statistics
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 (1) previously
undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in excess of available
insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5)
stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes
can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a lifethreatening emergency caused by a relative or absolute deficiency of insulin.
Contents [show]

Nursing Care Plans


This post contains 6 diabetes mellitus Nursing Care Plans (NCP)
Nursing Priorities
1. Restore fluid/electrolyte and acid-base balance.
2. Correct/reverse metabolic abnormalities.
3. Identify/assist with management of underlying cause/disease process.
4. Prevent complications.

5. Provide information about disease process/prognosis, self-care, and treatment


needs.
Discharge Goals
1. Homeostasis achieved.
2. Causative/precipitating factors corrected/controlled.
3. Complications prevented/minimized.
4. Disease process/prognosis, self-care needs, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.
Diagnostic Studies

Serum glucose: Increased 2001000 mg/dL or more.

Serum acetone (ketones): Strongly positive.

Fatty acids: Lipids, triglycerides, and cholesterol level elevated.

Serum osmolality: Elevated but usually less than 330 mOsm/L.

Glucagon: Elevated level is associated with conditions that produce (1) actual
hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack
of insulin. Therefore, glucagon may be elevated with severe DKA despite
hyperglycemia.

Glycosylated hemoglobin (HbA1C): Evaluates glucose control during past 8


12 wk with the previous 2 wk most heavily weighted. Useful in differentiating
inadequate control versus incident-related DKA (e.g., current upper respiratory
infection [URI]). A result greater than 8% represents an average blood glucose
of 200 mg/dL and signals a need for changes in treatment.

Serum insulin: May be decreased/absent (type 1) or normal to high (type 2),


indicating insulin insufficiency/improper utilization (endogenous/exogenous).
Insulin resistance may develop secondary to formation of antibodies.

Electrolytes:

Sodium: May be normal, elevated, or decreased.

Potassium: Normal or falsely elevated (cellular shifts), then markedly


decreased.

Phosphorus: Frequently decreased.

Arterial blood gases (ABGs): Usually reflects low pH and decreased


HCO3 (metabolic acidosis) with compensatory respiratory alkalosis.

CBC: Hct may be elevated (dehydration); leukocytosis suggest


hemoconcentration, response to stress or infection.

BUN: May be normal or elevated (dehydration/decreased renal perfusion).

Serum amylase: May be elevated, indicating acute pancreatitis as cause of


DKA.

Thyroid function tests: Increased thyroid activity can increase blood


glucose and insulin needs.

Urine: Positive for glucose and ketones; specific gravity and osmolality may
be elevated.

Cultures and sensitivities: Possible UTI, respiratory or wound infections.

1. Risk for Infection


Nursing Diagnosis

Risk for Infection

Risk factors may include

High glucose levels, decreased leukocyte function, alterations in circulation

Preexisting respiratory infection, or UTI

Desired Outcomes

Identify interventions to prevent/reduce risk of infection.

Demonstrate techniques, lifestyle changes to prevent development of

infection.
Nursing Interventions

Rationale

Observe for the signs of infection and


inflammation: fever, flushed
appearance, wound drainage, purulent
sputum, cloudy urine.

Patients with DM may be admitted with


infection, which could have precipitated
the ketoacidotic state. They may also
develop nosocomial infection.

Teach and promote good hand hygiene.

Reduces risk of cross-contamination.

Maintain asepsis during IV insertion,

Increased glucose in the blood creates

Nursing Interventions

Rationale

administration of medications, and


providing wound or site care. Rotate IV
sites as indicated.

an excellent medium for bacteria to


thrive.

Provide catheter or perineal care. Teach


female patients to clean from front to
back after elimination.

Minimizes risk of UTI. Comatose patient


may be at particular risk if urinary
retention occurred before
hospitalization. Note: Elderly female
diabetic patients are especially prone to
urinary tract and/or vaginal yeast
infections.

Provide meticulous skin care: gently


massage bony areas, keep skin dry. Keep
linens dry and wrinkle-free.

Peripheral circulation may be ineffective


or impaired, placing the patient at
increased risk for skin breakdown and
infection.

Auscultate breath sounds.

Rhonchi may indicate accumulation of


secretions possibly related to pneumonia
or bronchitis. Crackles may results from
pulmonary congestion or edema from
rapid fluid replacement or heart failure.

Place in semi-Fowlers position.

Facilitates lung expansion; reduces risk


of aspiration.

Reposition and encourage coughing or


deep breathing if patient is alert and
cooperative. Otherwise, suction airway
using sterile technique as needed.

Aids in ventilating all lung areas and


mobilizing secretions. Prevents stasis of
secretions with increased risk of
infection.

Provide tissues and trash bag in a


convenient location for sputum and
other secretions. Instruct patient in
proper handling of secretions.

To minimizes spread of infection.

Encourage and assist with oral hygiene.

Reduces risk of oral/gum disease.

Encourage adequate dietary and fluid


intake (approximately 3000 mL/day if
not contraindicated by cardiac or renal
dysfunction), including 8 oz of cranberry
juice per day as appropriate.

Decreases susceptibility to infection.


Increased urinary flow prevents stasis
and aids in maintaining urine pH/acidity,
reducing bacteria growth and flushing
organisms out of system. Note: Use of

Nursing Interventions

Rationale
cranberry juice can help prevent
bacteria from adhering to the bladder
wall, reducing the risk of recurrent UTI.

Administer antibiotics as appropriate.

Early treatment may help prevent


sepsis.

2. Risk for Disturbed Sensory Perception


Nursing Diagnosis

Risk for Disturbed Sensory Perception

Risk factors may include

Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance

Desired Outcomes

Maintain usual level of mentation.

Recognize and compensate for existing sensory impairments.


Nursing Interventions
Rationale

Monitor vital signs and mental status.

To provide baseline from which to


compare abnormal findings.

Call the patient by name, reorient as


needed to place, person, and time. Give
short explanations, speak slowly and
enunciate clearly.

Decreases confusion and helps maintain


contact with reality.

Schedule and cluster nursing time and


interventions.

To provide uninterrupted rest periods


and promote restful sleep, minimize
fatigue and improve cognition.

Keep patients routine as consistent as


possible. Encourage participation in
activities of daily living (ADLs) as able.

Helps keep patient in touch with reality


and maintain orientation to the
environment.

Protect patient from injury by avoiding or

Disoriented patients are prone to injury,

Nursing Interventions

Rationale

limiting the use of restraints as


necessary when LOC is impaired. Place
bed in low position and pad bed rails if
patient is prone to seizures.

especially at night, and precautions need


to be taken as indicated. Seizure
precautions need to be taken as
appropriate to prevent physical injury,
aspiration, and falls.

Evaluate visual acuity as indicated.

Retinal edema or detachment,


hemorrhage, presence of cataracts or
temporary paralysis of extraocular
muscles may impair vision, requiring
corrective therapy and/or supportive
care.

Observe and investigate reports of


hyperesthesia, pain, or sensory loss in
the feet or legs. Investigate and look for
ulcers, reddened areas, pressure points,
loss of pedal pulses.

Peripheral neuropathies may result in


severe discomfort, lack of or distortion of
tactile sensation, potentiating risk of
dermal injury and impaired balance.

Provide bed cradle. Keep hands and feet


warm, avoiding exposure to cool drafts
and/or hot water or use of heating pad.

Reduces discomfort and potential for


dermal injury.

Assist patient with ambulation or


position changes.

Promotes patient safety, especially when


sense of balance is affected.

Monitor laboratory values: blood


glucose, serum osmolality, Hb/Hct,
BUN/Cr.

Imbalances can impair mentation. Note:


If fluid is replaced too quickly, excess
water may enter brain cells and cause
alteration in the level of consciousness
(water intoxication).

Carry out prescribed regimen for


correcting DKA as indicated.

Alteration in thought processes or


potential for seizure activity is usually
alleviated once hyperosmolar state is
corrected.

3. Powerlessness
Nursing Diagnosis

Powerlessness

May be related to

Long-term/progressive illness that is not curable

Dependence on others

Possibly evidenced by

Reluctance to express true feelings; expressions of having no control/influence


over situation

Apathy, withdrawal, anger

Does not monitor progress, nonparticipation in care/decision making

Depression over physical deterioration/complications despite patient


cooperation with regimen

Desired Outcomes

Acknowledge feelings of helplessness.

Identify healthy ways to deal with feelings.

Assist in planning own care and independently take responsibility for self-care

activities.
Nursing Interventions

Rationale

Encourage patient and/or SO to express


feelings about hospitalization and
disease in general.

Identifies concerns and facilitates


problem solving.

Acknowledge normality of feelings.

Recognition that reactions are normal


can help patient problem-solve and seek
help as needed. Diabetic control is a fulltime job that serves as a constant
reminder of both presence of disease
and threat to patients health.

Assess how patient has handled


problems in the past. Identify locus of
control.

Knowledge of individuals style helps


determine needs for treatment goals.
Patient whose locus of control is internal
usually looks at ways to gain control
over own treatment program. Patient
who operates with an external locus of

Nursing Interventions

Rationale
control wants to be cared for by others
and may project blame for
circumstances onto external factors.

Provide opportunity for SO to express


concerns and discuss ways in which he
or she can be helpful to patient.

Enhances sense of being involved and


gives SO a chance to problem-solve
solutions to help patient prevent
recurrence.

Ascertain expectations and/or goals of


patient and SO.

Unrealistic expectations or pressure from


others or self may result in feelings of
frustration and loss of control. These can
impair coping abilities.

Determine whether a change in


relationship with SO has occurred.

Constant energy and thought required


for diabetic control often shifts the focus
of a relationship. Development of
psychological concerns affecting selfconcept may add further stress.

Encourage patient to make decisions


related to care: ambulation, schedule for
activities, and so forth.

Communicates to patient that some


control can be exercised over care.

Support participation in self-care and


give positive feedback for efforts.

Promotes feeling of control over


situation.

4. Imbalanced Nutrition Less Than Body Requirements


Nursing Diagnosis

Imbalanced Nutrition Less Than Body Requirements

May be related to

Insulin deficiency (decreased uptake and utilization of glucose by the tissues,


resulting in increased protein/fat metabolism)

Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain;


altered consciousness

Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol,


and growth hormone), infectious process

Possibly evidenced by

Increased urinary output, dilute urine

Reported inadequate food intake, lack of interest in food

Recent weight loss; weakness, fatigue, poor muscle tone

Diarrhea

Increased ketones (end product of fat metabolism)

Desired Outcomes

Ingest appropriate amounts of calories/nutrients.

Display usual energy level.

Demonstrate stabilized weight or gain toward usual/desired range with normal

laboratory values.
Nursing Interventions

Rationale

Weigh daily or as ordered.

Weighing serves as an assessment tool


to determine the adequacy of nutritional
intake.

Ascertain patients dietary program and


usual pattern then compare with recent
intake.

Identifies deficits and deviations from


therapeutic needs.

Auscultate bowel sounds. Note reports of


abdominal pain, bloating, nausea,
vomiting of undigested food. Maintain
NPO status as indicated.

Hyperglycemia and fluid and electrolyte


disturbances can decrease gastric
motility and/or function (due to
distention or ileus) affecting choice of
interventions. Note: Chronic difficulties
with decreased gastric emptying time
and poor intestinal motility may suggest
autonomic neuropathies affecting the GI
tract and requiring symptomatic
treatment.

Provide liquids containing nutrients and


electrolytes as soon as patient can
tolerate oral fluids then progress to a

Oral route is preferred when patient is


alert and bowel function is restored.

Nursing Interventions

Rationale

more solid food as tolerated.

Identify food preferences,


including ethnic and cultural needs.

If patients food preferences can be


incorporated into the meal plan,
cooperation with dietary requirements
may be facilitated after discharge.

Include SO in meal planning as


indicated.

To promote sense of involvement and


provide information to the SO to
understand the nutritional needs of the
patient. Note: Various methods available
or dietary planning include exchange
list, point system, glycemic index, or pre
selected menus.

Observe for signs of hypoglycemia:


changes in LOC, cold and clammy skin,
rapid pulse, hunger, irritability, anxiety,
headache, lightheadedness, shakiness.

Hypoglycemia can occur once blood


glucose level is reduced and
carbohydrate metabolism resumes and
insulin is being given. If the patient is
comatose, hypoglycemia may occur
without notable change in LOC. This
potentially life-threatening emergency
should be assessed and treated quickly
per protocol. Note: Type 1 diabetics of
long standing may not display usual
signs of hypoglycemia because normal
response to low blood sugar may be
diminished.

Perform fingerstick glucose testing.

Beside analysis of serum glucose is more


accurate than monitoring urine sugar.
Urine glucose is not sensitive enough to
detect fluctuations in serum levels and
can be affected by patients individual
renal threshold or the presence of
urinary retention. Note: Normal levels for
fingerstick glucose testing may vary
depending on how much the patient ate
during his last meal. In general: 80120
mg/dL (4.46.6 mmol/L) before meals or
when waking up; 100140 mg/dL (5.5
7.7 mmol/L) at bedtime.

Nursing Interventions

Rationale

Administer regular insulin by


intermittent or continuous IV method: IV
bolus followed by a continuous drip via
pump of approximately 510 U/hr so that
glucose is reduced by 50 mg/dL/hr.

Regular insulin has a rapid onset and


thus quickly helps move glucose into
cells. The IV route is the initial route of
choice because absorption from
subcutaneous tissues may be erratic.
Many believe the continuous method is
the optimal way to facilitate transition to
carbohydrate metabolism and reduce
incidence of hypoglycemia.

Administer glucose solutions: dextrose


and half-normal saline.

Glucose solutions may be added after


insulin and fluids have brought the blood
glucose to approximately 400 mg/dL. As
carbohydrate metabolism approaches
normal, care must be taken to avoid
hypoglycemia.

Provide diet of approximately 60%


carbohydrates, 20% proteins, 20% fats
in designated number of meals and
snacks.

Complex carbohydrates (apples,


broccoli, peas, dried beads, carrots,
peas, oats) decrease glucose
levels/insulin needs, reduce serum
cholesterol levels, and promote
satiation. Food intake is scheduled
according to specific insulin
characteristics and individual patient
response. Note: A snack at bedtime of
complex carbohydrates is especially
important (if insulin is given in divided
doses) to prevent hypoglycemia during
sleep and potential Somogyi response.

Administer other medications as


indicated: metoclopramide (Reglan);
tetracycline.

May be useful in treating symptoms


related to autonomic neuropathies
affecting GI tract, thus enhancing oral
intake and absorption of nutrients.

5. Deficient Fluid Volume


Nursing Diagnosis

Deficient Fluid Volume

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

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 Interventions
Rationale

Assess patients history related to


duration or intensity of symptoms such
as vomiting, excessive urination.

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.

Respiratory pattern: Kussmauls


respirations, acetone breath.

Hypovolemia may be manifested by


hypotension and tachycardia. Estimates
of severity of hypovolemia may be made
when patients systolic BP drops more
than 10 mmHg from a recumbent to a
sitting then a standing position. Note:
Cardiac neuropathy may block reflexes
that normally increase heart rate.
Lungs remove carbonic acid through
respirations, producing a compensatory
respiratory alkalosis for ketoacidosis.

Nursing Interventions

Rationale
Acetone breath is due to breakdown of
acetoacetic acid and should diminish as
ketosis is corrected. Correction of
hyperglycemia and acidosis will cause
the respiratory rate and pattern to
approach normal.

Respiratory rate and quality, use of


accessory muscles, periods of apnea,
and appearance of cyanosis.

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, and


turgor.

Although fever, chills, and diaphoresis


are common with infectious process,
fever with flushed, dry skin and
decreased skin turgor may reflect
dehydration.

Assess peripheral pulses, capillary refill,


and mucous membranes.

Indicators of level of hydration,


adequacy of circulating volume.

Monitor I&O and note urine specific


gravity.

Provides ongoing estimate of volume


replacement needs, kidney function, and
effectiveness of therapy.

Weigh daily.

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.

Maintains hydration and circulating


volume.

Promote comfortable environment.


Cover patient with light sheets.

Avoids overheating, which could promote


further fluid loss.

Investigate changes in mentation and


LOC.

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

Nursing Interventions

Rationale
predispose patient to aspiration.

Insert and maintain indwelling urinary


catheter.

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.

6. Fatigue
Nursing Diagnosis

Fatigue

May be related to

Decreased metabolic energy production

Altered body chemistry: insufficient insulin

Increased energy demands: hypermetabolic state/infection

Possibly evidenced by

Overwhelming lack of energy, inability to maintain usual routines, decreased


performance, accident-prone

Impaired ability to concentrate, listlessness, disinterest in surroundings

Desired Outcomes

Verbalize increase in energy level.

Display improved ability to participate in desired activities.


Nursing Interventions
Rationale

Discuss with patient the need for


activity. Plan schedule with patient and
identify activities that lead to fatigue.

Education may provide motivation to


increase activity level even though
patient may feel too weak initially.

Nursing Interventions

Rationale

Alternate activity with periods of rest


and uninterrupted sleep.

To prevent excessive fatigue.

Monitor pulse, respiratory rate, and BP


before and after activity.

Indicates physiological levels of


tolerance.

Discuss ways of conserving energy while


bathing, transferring, and so on.

Patient will be able to accomplish more


with a decreased expenditure of energy.

Increase patient participation in ADLs as


tolerated.

Increases confidence level, self-esteem


and tolerance level.