Assessment

Subjective: Palagi ako naiihi as verbalized by the patient. Objective: Dry skin Generalized body weakness Restless Anxious Irritable

Diagnosis
Fluid Volume Deficit r/t active fluid loss (increased urine output)

Planning
Short Term: Patient will maintain urine output >30 ml/hr Patient will demonstrate elastic skin turgor and moist, pink mucous membranes. Long Term: Patient will have adequate fluid balance

Intervention
Monitor Vital signs Weigh patient daily.

Rationale

Evaluation
Patient will maintain urine output >30 ml/hr Patient will demonstrate elastic skin turgor and moist, pink mucous membranes.

Changes in weight can provide information on fluid balance and the adequacy of volume replacement. 1lb = 2.2kg

Measure and record urine output hourly; report urine output less than 30ml for 2 consecutive hours.

Fluid volume deficit reduces glomerular filtration and renal blood flow causing oliguria. The patient in DKA may also be undergoing osmotic diuresis and have excessive outputs.

 Assess skin turgor, mucous membranes and complaints of thirst.

Poor turgor, dry membranes and excessive thirst are all signs of dehydration.

Encouraged food and fluids high in sodium. Dependent: Administer medication as ordered. PNSS

To replace sodium loss in the body.

Replace fluid loss.