Nursing Diagnosis Intervention
Risk for Fluid Volume Assess precipitating factors
Deficit such as other illnesses, new-
onset diabetes, or poor
compliance with treatment
regimen.
Monitor hourly intake and
output.
Monitor BP especially for
orthostatic hypotension.
Monitor temperature.
Risk for Infection Assess for signs of infection
and inflammation.
Observe client’s feet for
ulcers, infected toenails, or
other medical problems.
Observe aseptic technique
during IV insertion and
medication administration.
Provide skin care.
Encourage proper
handwashing technique.
Deficient Knowledge Client will verbalize
understanding of the
disease condition and
potential complication.
Rationale
These will provide baseline
data for education once
with resolved
hyperglycemia. Urinary tract
infection and pneumonia
are the most common
infections causing DKA and
HHNS among older clients.
Oliguria or anuria results
from reduced glomerular
filtration and renal blood
flow.
Monitor BP especially for
orthostatic hypotension.
Monitor temperature.
Infection is a common cause
of DKA. Signs of infection
includes fever, chills,
dysuria, and increased WBC
count.
Due to impaired circulation
in diabetes, foot injuries are
predisposed to poor wound
healing.
Elevated blood sugar
weakens the immune
system thus clients are
more prone to infection.
An intact skin protects
against infection.
To avoid the risk of cross-
contamination.
Client will verbalize
understanding of the
disease condition and
potential complication.
Desired Outcomes
Client will remain
normovolemic as evidenced
by urinary output greater
than 30 ml/hr, normal skin
turgor, good capillary refill,
normal blood pressure,
palpable peripheral pulses,
and blood glucose levels
between 70-200 mg/dL.
Client will identify
interventions to prevent
reduce risk of infection.
Client will demonstrate
techniques, lifestyle
changes to prevent the
development of infection.
Client will verbalize
understanding of the
disease condition and
potential complication.
Client will correctly perform
necessary procedures and
explain rationale on each
action.
Client will demonstrate
lifestyle changes and
participate in treatment
regimen.
 Client will correctly perform
necessary procedures and
explain rationale on each
action.
Client will demonstrate
lifestyle changes and
participate in treatment
regimen.
Client will verbalize
understanding of the
disease condition and
potential complication.
Client will correctly perform
necessary procedures and
explain rationale on each
action.
Imbalanced Nutrition: Less Determine client’s dietary
Than Body Requirements program and usual pattern.
Monitor weight daily or as
indicated.
Auscultation bowel sounds,
note the presence of
abdominal pain/abdominal
bloating, nausea or
vomiting. Maintain on NPO
status, as indicated.
Involve patients in planning
family as indicated.
Recognize signs of
hypoglycemia.
Client will correctly perform
necessary procedures and
explain rationale on each
action.
Client will demonstrate
lifestyle changes and
participate in treatment
regimen.
Client will verbalize
understanding of the
disease condition and
potential complication.
Client will correctly perform
necessary procedures and
explain rationale on each
action.
Recognizes deficits and Client will display normal
deviations from therapeutic energy level.
needs. Client will take appropriate
amounts of
calories/nutrients.
Client will demonstrate
stabilized weight or gain
toward desired range with
normal laboratory values.
Assessing sufficiency of food
intake, including absorption
and utilization.
Imbalances in the fluid and
electrolytes and
hyperglycemia reduces
gastric motility resulting in
delayed gastric emptying
that will influence the
selected intervention.
Provide information on the
family to understand the
nutritional needs of the
patient.
Hypoglycemia can occur
because of a reduced
carbohydrate metabolism
while still given insulin, it
can potentially be life
threatening and should be
recognized.