CACAPIT, LOVELY ROSE S.

NDA NCENH06 10/22/2020

NURSING CARE PLAN- DKA
ASSESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION
THE PROBLEM

SUBJECTIVE: “Sa Emesis could lead to LTO: Measure and record Fluid volume deficit After 3 days of
isang araw 8 na dehydration because Within 3 days of urine output hourly; reduces glomerular nursing intervention
beses na ako electrolytes were nursing intervention report urine output filtration and renal the patient was able
nagsuka” loss. Emesis occurs the patient will be less than 30 ml for 2 blood flow causing to maintain normal
for the reason that it able to: consecutive hours oliguria. The patient fluid volume/
OBJECTIVE: is one of the signs -maintain normal fluid in DKA may also be normovolemic.
-lethargic and symptoms of volume and undergoing osmotic
-decreased skin metabolic acidosis normovolemic diuresis and have After 8 hours of
turgor due to the reason -maintain no emesis excessive outputs. nursing intervention,
-dry lips that there are the patient has
-decreased fluid increased ketone STO: Weigh patient daily Changes in weight reduced the times of
intake bodies in circulation. Within 8 hours of can provide vomiting. No signs of
Ketone bodies were nursing intervention information on fluid dehydration noted.
NURSING formed the patient will be balance and the Patient was able to
DIAGNOSIS: because there is able to: adequacy of volume understand and
Fluid Volume deficit insulin deficiency -stop or reduce times replacement. explain measures
related to electrolyte there will be of vomiting that were taken or
imbalances breakdown of fats -normovolemic Assess neurological Alterations in mental treat to prevent fluid
(lipolysis) takes -no signs of status status can occur from volume loss.
place. Lipolysis dehydration severe volume
will lead to increased -explain measure that depletion and altered
fatty acids can be taken or treat sodium levels,
and glycerol. The to prevent fluid patients are also at
free fatty acids volume loss risk for seizures.
are converted into
ketone bodies Maintain fluid intake Maintains hydration/
in the liver. So thus, of at least 2500 circulating volume
increased mL/day within cardiac
ketone bodies will tolerance when oral
lead to intake is resumed
CACAPIT, LOVELY ROSE S.
NDA NCENH06 10/22/2020
NURSING CARE PLAN- DKA
metabolic acidosis.
Accumulation Promote comfortable Avoids overheating,
of ketones is environment. Cover which could promote
reflected in urine patient with light further fluid loss.
and blood sheets.

Monitor for effects of Volume replacement

IV therapy is necessary to
provide adequate
circulation, perfusion
and oxygenation of
the tissues.
Replacement is
adequate when vitals
signs are back to
baseline

DEPENDENT:
Initiate and Insulin is necessary
administer Insulin to correct the
therapy. ketoacidosis.

Initiate and Initial goal is to

administer IV correct circulatory
therapy. Half-strength volume deficit. IV
normal saline therapy may be
(0.45%) solution. needed to replace
fluid losses caused
by vomiting.