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Nsg Dx Ineffective breathing pattern related to acidosis as evidenced by DKA

Rationale Lack of glucose in cells results in catabolism of fats and proteins, leading to excessive amounts of fatty acids and their metabolites known as ketones or ketoacids, in the blood. Excessive ketones in the blood cause ketoacidosis. Ketone bodies are acids; their accumulation in the circulation due to lack of insulin leads to metabolic acidosis. However, as dehydration develops, the glomerular filtration rate in the kidney is decreased, and excretion of acids becomes more limited. Ketoacidosis leads to Kussmauls respirations. Kussmaul respirations represent the bodys attempt to decrease the acidosis, counteraffecting the effect of the ketone build-up.

Nsg Interventions 1. Administer oxygen as ordered.

Rationale Airway and breathing remain the first priority. Oxygen administration may help alleviate the patient tachypnea. Detects respiratory compensation during a time of the respiratory crisis of Kussmaul breathing (caused by the DKA). Gravity pulls the diaphragm downward, allowing greater chest expansion and lung ventilation. To limit fatigue.

2. Monitor oxygen saturation levels and assess depth or rhythm of respirations every hour.

3. Elevate head of the bed.

4. Encourage adequate rest periods between activities. 5. Review environmental factors.

May require avoidance/modification of lifestyle or environment to limit impact on clients breathing.


Provides constant monitoring of neurological status .

6. Assess LOC by evaluating neurological responses and patients ability to effectively answer questions every hour. Fluid volume deficit r/t electrolyte imbalances Though the patient doesnt manifest polydispsia and polyuria, emesis occurs. Emesis could lead to dehydration because 1. 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

electrolytes were loss. Emesis occurs for the reason that it is one of the signs and symptoms of metabolic acidosis due to the reason that there are increased ketone bodies in circulation. Ketone bodies were formed because there is insulin deficiency there will be breakdown of fats (lipolysis) takes place. Lipolysis will lead to increased fatty acids and glycerol. The free fatty acids are converted into ketone bodies in the liver. So thus, increased ketone bodies will leads to metabolic acidosis. Accumulation of ketones is reflected in urine and blood.

undergoing osmotic diuresis and have excessive outputs. 2. Weigh patient daily. Changes in weight can provide information on fluid balance and the adequacy of volume replacement. 1lb = 2.2kg. Alterations in mental status can occur from severe volume depletion and altered sodium levels, patients are also at risk for seizures. Insulin is necessary to correct the ketoacidosis. Insulin has an affinity to the tubing. With the administration of insulin, the potassium re-enters the cells along with the glucose. 50ml must be primed through the tubing, to allow the mixture to coat the tubing and make sure the patient is receiving the true dose. Initial goal is to correct circulatory volume deficit. Hypotonic saline solution may be used for patients with high blood pressure. IV therapy may be needed to replace fluid losses caused by vomiting. Fluid therapy causes expansion of plasma volumes, and a return of normal renal function, which is

3. Assess neurological status.

4. Initiate and administer Insulin therapy: IV bolus dose of regular insulin is followed by continuous infusion. Prime the line by wasting 50ml of the mixture. 5. Initiate and administer IV therapy Half-strength normal saline (0.45%) solution.

essential. 6. Monitor for effects of IV therapy. Volume replacement is necessary to provide adequate circulation, perfusion and oxygenation of the tissues. Replacement is adequate when vital signs are back to baseline. Potassium is added to Iv infusions once renal function has been established and serum potassium levels are below 5.5 mEq/L. As hydration progresses, laboratory values will change as the electrolytes move from compartment to fluid compartment. Potassium replacement becomes more crucial with the administration of insulin. Insulin causes potassium to move into the intracellular compartment at the time acidosis is corrected. Avoids overheating, which could promote further fluid loss.

7. Administer potassium IV as ordered: typically 20 to 30 mEq/L.

8. Promote comfortable environment. Cover patient with light sheets. 9. Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed.

Maintains hydration/circulating volume.

Imbalanced Nutrition: less than body requirement related to catabolism of fats and proteins for fuels.

Insulin deficiency leads to breakdown of fats and proteins. Catabolism of fats and proteins occurs because the transport of glucose and amino acids into cells is impaired, as well as the synthesis of protein and glycogen. In turn, these metabolic abnormalities affect lipid metabolism.

1. Weigh daily or as indicated.

Assesses adequacy of nutritional intake (absorption and utilization). Identifies deficits and deviations from therapeutic needs.

2. Ascertain patients dietary program and usual pattern; compare with recent intake. 3. Auscultate bowel sounds. Note reports of abdominal pain/bloating, nausea, vomiting of undigested food.

Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility/function (distension or ileus), affecting choice of interventions. Note: Long-term difficulties with decreased gastric emptying and poor intestinal motility suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment.

4. Provide small and frequent feeding.

5. Perform fingerstick glucose testing.

Bedside analysis of serum glucose is more accurate (displays current levels) than monitoring urine sugar, which 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/renal failure.

Note: Some studies have found that a urine glucose of 20% may be correlated to a blood glucose of 140360 mg/dL. 6. Administer regular insulin by intermittent or continuous IV method, e.g., IV bolus followed by a continuous drip via pump of approximately 5 10 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. Complex carbohydrates decrease glucose levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics (e.g., peak effect) and individual patient response. Note:A snack at bedtime (hs) of complex carbohydrates is especially important (if insulin is given in divided doses) to prevent hypoglycemia during sleep and potential Somogyi response. Education may provide motivation to increase activity level even though patient may

7. Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals/snacks.

Fatigue related to metabolic acidosis and Decreased metabolic energy production

Insulin functions are to transports and metabolize glucose for energy. Since there is insulin

1. Discuss with patient the need for activity. Plan schedule with patient and identify

deficiency, there will be weakness. In addition to, metabolic acidosis develops as ketoacids bind with bicarbonate ions in the buffer, leading to decreased serum bicarbonate levels and decreased serum pH. As dehydration progresses, renal compensation are reduced, acidosis becomes decompensated, and serum pH falls, resulting in loss of consciousness. So thus, Lethargy and weakness causes fatigue to the patient.

activities that lead to fatigue. 2. Alternate activity with periods of rest/uninterrupted sleep. 3. Monitor pulse, respiratory rate, and BP before/after activity.

feel too weak initially. Prevents excessive fatigue.

Indicates physiological levels of tolerance.

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