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Assessment
Nursing
Diagnosis
Planning
Intervention
Rationale
Evaluation
Subjective:
The patient doesn’t verbalize anything
but based on the case she is
experiencing fatigue and has
decreased oral intake which is
subjective data.
(NANDA edition 11, p. 320) and (Weber
and Kelley, Health assessment in
nursing, p.8)
Objective:
- Decrease skin turgor.
- Intractable Vomiting (emesis)
(nausea), non-bloody &
nonbilious.
- Increase pulse rate (124 beats
per minute): decrease pulse
volume and pressure. blood
pressure of 123/81 mm Hg,
respiratory rate of 25 breaths
per minute, pulse oximetry of
97% on ambient air, and
temperature of 97.6ºF/36.4 C.
- Increase serum sodium/
Hypernatremia (159 meq/l
after 6 hours up until 3
rd
day)
Norma range: 135-145 meq/L
Short Term
After 30 minutes
of nursing
intervention, the
patient will
maintain fluid
volume at a
functional level
as evidenced by
good skin turgor
(less than 3
seconds).
Long term
After 8 hours of
nursing
intervention, the
patient will
verbalize
understanding of
causative factors
and the purpose
of individual
therapeutic
intervention and
medications.
Independent
1. Assist the patient in
vomiting, measure the
vomitus and describe it like if
it is watery or solid.
2. Position the patient in
semi fowlers position.
3. Monitor Blood sugar
4. Observe and monitor U/O,
color, and measure the
amount of specific gravity.
5. Offer Ice chips
6. Provide frequent oral and
eye care.
1.
2. Help to maintain body
circulation. By decreasing
oxygen consumption and
risk of decompensation.
This will enhance venous
return.
3. To know if the patient is
compensating for the
treatment. Inc in BS will
promote hyperosmosis
condition of the blood.
4. To more accurately
determine replacement
needs.
5. Rehydrate the patient
orally.
6. to prevent injury
especially if the patient
skin is dry.
Short Term
After 30 minutes of nursing
intervention, the patient was
able to maintain fluid volume
at a functional level as
evidenced by good skin
turgor (less than 3 seconds).
Long term
After 8 hours of nursing
intervention, the patient was
able to verbalize
understanding of causative
factors (skipping metformin
schedule) and the purpose of
individual therapeutic
intervention and
medications.
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- Increase serum osmolality (363
mOsm/kg), Normal: 275 to
295 mOsm/kg.
Dependent
1. administer 0.9% normal
saline as prescribed by the
physician.
2. administer IV insulin
(regular) infusion/drip
(titrate: 180 mg/dl) as
prescribed by the physician.
3. Administer antiemetic
drug-like metoclopramide or
plasil as prescribed by the
physician.
Collaborative:
1. Refer to internist
immediately.
1. Will correct the
dehydrated status,
hypernatremia of the
patient and will prevent
shock. This is the priority
intervention in a patient
who has DKA and HHNS.
2. Slowly correct the
hyperglycemic status of
the patient and prevent
sudden hypoglycemia.
3. To stop the vomiting of
the patient.
1. they are specialized in
treating this kind of
disease.
Bibliography
1. Janet weber and Jane Kelley., Health Assessment in Nursing, (Wolters Kluwer, 2018), p.8.
2. Marilynn Doenges et al., Nurse’s pocket guide edition 11, (iGroup Press, 2008), p.320.
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2
nd
NCP
Disturbed sensory perception related to
biochemical imbalance as evidenced by
the altered level of consciousness
(obtunded) secondary to Hypernatremia
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Assessment
Nursing Diagnosis
Planning
Intervention
Rationale
Evaluation
Subjective:
No subjective cues were stated.
Objective:
- altered sensorium
(Obtunded, responsive to
pain, and poor receptive
in verbal stimuli.
- Increase serum sodium/
Hypernatremia (159
meq/l after 6 hours up
until 3
rd
day)
- Increase pulse rate (124
beats per minute), blood
pressure of 123/81 mm
Hg, respiratory rate of 25
breaths per minute, pulse
oximetry of 97% on
ambient air, and
temperature of
97.6ºF/36.4 C.
- GCS of 11
Disturbed sensory
perception related
to biochemical
imbalance as
evidenced by the
altered level of
consciousness
(obtunded)
secondary to
Hypernatremia
Short Term
After 30
minutes- 1 hour
of nursing
intervention,
the patient will
regain a normal
level of
consciousness.
Long term
After 72 hours
of nursing
intervention,
the patient will
identify external
factors that
contribute to
alterations in
sensory ability.
Independent
1. Monitor LOC.
2. Position the patient in semi
fowlers position and
reposition every 2 hours.
3. Provide safety measures as
needed by raising the side
rails, bed in a low position,
grab bars, and adequate
lighting.
3. Monitor laboratory results
like serum electrolytes
specifically Na.
4. Avoid isolation of patient
physically.
5. Speak to the patient during
care. Including Reorientation
to person, place, and time.
6. Promote a stable
environment with continuity
of care by the same
1. Any alteration to this is
vital to the prognosis of
the patient.
2. To provide comfort and
prevent pressure ulcers.
3. Patients with decreased
sensorium needed a
prompt safety
intervention because they
are at risk for falls and
injury.
3. The most sensitive cell
in sodium changes is
neurons, and any
alteration with it causes
ALOC.
4. prevent further
confusion
5. presenting reality and
promoting comfort.
6. To prevent further
confusion to the patient.
Short Term
After 30 minutes- 1 hour
of nursing intervention,
the patient was able to
regain a normal level of
consciousness.
Long term
After 72 hours of nursing
intervention, the patient
was able to identify the
external factor that
contributes to
alterations in her
sensory ability like
skipping her metformin
medication.
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personnel as much as
possible.
7. Minimize discussion of
negatives within patients’
hearing.
8. Eliminate extraneous
noise/stimuli, including
nonessential equipment,
alarms/audible monitor
signals when possible.
9. Provide sensory
stimulation including familiar
smells or sounds tactile
stimulation with a variety of
objects changing of light
intensity and other cues as
care is given.
10. Review of basic and
specific safety information
like saying I am on your side,
this is hot water, and swallow
now.
Dependent
1. administer 0.9% normal
saline as prescribed by the
physician.
7. patient may
misinterpret and believe
references are to herself.
8. To prevent further
confusion and to promote
an environment that is
conducive to rest.
9. Touching is an
important part of caring in
a deep psychological need
communication presents
or connection with
another human being.
10. To prevent injury
1. will correct
hypernatremia of the
patient that will correct
also the ALOC of her.
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Unformatted Attachment Preview

Assessment Nursing Diagnosis Planning Fluid volume deficit related to hypertonic dehydration as evidenced by decreased skin turgor and hypernatremia, secondary to diabetes mellitus. Short Term After 30 minutes of nursing intervention, the patient will maintain fluid volume at a functional level as evidenced by good skin turgor (less than 3 seconds). Subjective: The patient doesn’t verbalize anything but based on the case she is experiencing fatigue and has decreased oral intake which is subjective data. (NANDA edition 11, p. 320) and (Weber and Kelley, Health assessment in nursing, p.8) Objective: - Decrease skin turgor. - Intractable Vomiting (emesis) (nausea), non-bloody & nonbilious. - Increase pulse rate (124 beats per minute): decrease pulse volume and pressure. blood pressure of 123/81 mm Hg, respiratory rate of 25 breaths per minute, pulse oximetry of 97% on ambient air, and temperature of 97.6ºF/36.4 C. - Increase serum sodium/ Hypernatremia (159 meq/l after 6 hours up until 3rd day) Norma range: 135-145 meq/L Intervention Independent 1. Assist the patient in 1. vomiting, measure the vomitus and describe it like if it is watery or solid. Rationale Evaluation Short Term After 30 minutes of nursing intervention, the patient was able to maintain fluid volume at a functional level as evidenced by good skin 2. Position the patient in 2. Help to maintain body turgor (less than 3 seconds). semi fowlers position. circulation. By decreasing oxygen consumption and Long term risk of decompensation. After 8 hours of nursing This will enhance venous intervention, the patient was return. able to verbalize understanding of causative Long term 3. Monitor Blood sugar 3. To know if the patient is factors (skipping metformin After 8 hours of compensating for the schedule) and the purpose of nursing treatment. Inc in BS will individual therapeutic intervention, the promote hyperosmosis intervention and patient will condition of the blood. medications. verbalize understanding of 4. Observe and monitor U/O, 4. To more accurately causative factors color, and measure the determine replacement and the purpose amount of specific gravity. needs. of individual therapeutic 5. Offer Ice chips 5. Rehydrate the patient intervention and orally. medications. 6. Provide frequent oral and 6. to prevent injury eye care. especially if the patient skin is dry. - Increase serum osmolality (363 mOsm/kg), Normal: 275 to 295 mOsm/kg. Dependent 1. administer 0.9% normal saline as prescribed by the physician. 1. Will correct the dehydrated status, hypernatremia of the patient and will prevent shock. This is the priority intervention in a patient who has DKA and HHNS. 2. Slowly correct the 2. administer IV insulin hyperglycemic status of (regular) infusion/drip the patient and prevent (titrate: 180 mg/dl) as sudden hypoglycemia. prescribed by the physician. 3. Administer antiemetic 3. To stop the vomiting of drug-like metoclopramide or the patient. plasil as prescribed by the physician. Collaborative: 1. Refer to immediately. internist 1. they are specialized in treating this kind of disease. Bibliography 1. Janet weber and Jane Kelley., Health Assessment in Nursing, (Wolters Kluwer, 2018), p.8. 2. Marilynn Doenges et al., Nurse’s pocket guide edition 11, (iGroup Press, 2008), p.320. 2nd NCP Disturbed sensory perception related to biochemical imbalance as evidenced by the altered level of consciousness (obtunded) secondary to Hypernatremia Assessment Subjective: No subjective cues were stated. Objective: - altered sensorium (Obtunded, responsive to pain, and poor receptive in verbal stimuli. - - - Increase serum sodium/ Hypernatremia (159 meq/l after 6 hours up until 3rd day) Increase pulse rate (124 beats per minute), blood pressure of 123/81 mm Hg, respiratory rate of 25 breaths per minute, pulse oximetry of 97% on ambient air, and temperature of 97.6ºF/36.4 C. Nursing Diagnosis Disturbed sensory perception related to biochemical imbalance as evidenced by the altered level of consciousness (obtunded) secondary to Hypernatremia Planning Intervention Independent 1. Monitor LOC. Short Term After 30 minutes- 1 hour of nursing intervention, 2. Position the patient in semi the patient will fowlers position and regain a normal reposition every 2 hours. level of consciousness. 3. Provide safety measures as Long term needed by raising the side rails, bed in a low position, After 72 hours grab bars, and adequate of nursing lighting. intervention, the patient will identify external 3. Monitor laboratory results factors that like serum electrolytes contribute to specifically Na. alterations in sensory ability. Rationale Evaluation 1. Any alteration to this is vital to the prognosis of Short Term the patient. After 30 minutes- 1 hour of nursing intervention, 2. To provide comfort and the patient was able to prevent pressure ulcers. regain a normal level of consciousness. Long term 3. Patients with decreased sensorium needed a prompt safety intervention because they are at risk for falls and injury. After 72 hours of nursing intervention, the patient was able to identify the external factor that contributes to alterations in her 3. The most sensitive cell sensory ability like in sodium changes is skipping her metformin neurons, and any medication. alteration with it causes ALOC. 4. Avoid isolation of patient 4. prevent physically. confusion further GCS of 11 5. Speak to the patient during 5. presenting reality and care. Including Reorientation promoting comfort. to person, place, and time. 6. Promote a stable 6. To prevent further environment with continuity confusion to the patient. of care by the same personnel possible. as much as 7. Minimize discussion of 7. patient may negatives within patients’ misinterpret and believe hearing. references are to herself. 8. Eliminate extraneous noise/stimuli, including nonessential equipment, alarms/audible monitor signals when possible. 8. To prevent further confusion and to promote an environment that is conducive to rest. 9. Provide sensory stimulation including familiar smells or sounds tactile stimulation with a variety of objects changing of light intensity and other cues as care is given. 9. Touching is an important part of caring in a deep psychological need communication presents or connection with another human being. 10. Review of basic and specific safety information like saying I am on your side, this is hot water, and swallow now. Dependent 1. administer 0.9% normal saline as prescribed by the physician. 10. To prevent injury 1. will correct hypernatremia of the patient that will correct also the ALOC of her. Name: Description: ...
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