5.

Deficient Fluid Volume

Nursing Diagnosis

Deficient Fluid Volume

May be related to

Osmotic diuresis (from hyperglycemia)

Excessive gastric losses: diarrhea, vomiting

Restricted intake: nausea, confusion

Possibly evidenced by

[Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and
symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]

Possibly evidenced by

Increased urinary output, dilute urine

Weakness; thirst; sudden weight loss

Dry skin/mucous membranes, poor skin turgor

Hypotension, tachycardia, delayed capillary refill

Desired Outcomes

Demonstrate adequate hydration as evidenced by stable vital signs, palpable

peripheral pulses, good skin turgor and capillary refill, individually appropriate
urinary output, and electrolyte levels within normal range.
Nursing Interventions

Rationale

Assess patients history related to duration

Assists in estimation of total volume

or intensity of symptoms such as vomiting,

depletion. Symptoms may have been

excessive urination.

present for varying amounts of time (hours

to days). Presence of infectious process

Nursing Interventions

Rationale
results in fever and hypermetabolic state,
increasing insensible fluid losses.

Monitor vital signs:

Hypovolemia may be manifested by
hypotension and tachycardia. Estimates of
severity of hypovolemia may be made when
Note orthostatic BP changes.

patients systolic BP drops more than 10

mmHg from a recumbent to a sitting then a
standing position. Note: Cardiac neuropathy
may block reflexes that normally increase
heart rate.
Lungs remove carbonic acid through
respirations, producing a compensatory
respiratory alkalosis for ketoacidosis.

Respiratory pattern: Kussmauls respirations,

acetone breath.

Acetone breath is due to breakdown of

acetoacetic acid and should diminish as
ketosis is corrected. Correction of
hyperglycemia and acidosis will cause the
respiratory rate and pattern to approach
normal.
In contrast, increased work of breathing,

Respiratory rate and quality, use of

shallow, rapid respirations, and presence of

accessory muscles, periods of apnea, and

cyanosis may indicate respiratory fatigue

appearance of cyanosis.

and/or that patient is losing ability to

compensate for acidosis.
Although fever, chills, and diaphoresis are

Temperature, skin color, moisture, and

common with infectious process, fever with

turgor.

flushed, dry skin and decreased skin turgor

may reflect dehydration.

Nursing Interventions

Rationale

Assess peripheral pulses, capillary refill, and

Indicators of level of hydration, adequacy of

mucous membranes.

circulating volume.
Provides ongoing estimate of volume

Monitor I&O and note urine specific gravity.

replacement needs, kidney function, and

effectiveness of therapy.
Provides the best assessment of current

Weigh daily.

fluid status and adequacy of fluid

replacement.

Maintain fluid intake of at least 2500 mL/day

within cardiac tolerance when oral intake is

Maintains hydration and circulating volume.

resumed.
Promote comfortable environment. Cover

Avoids overheating, which could promote

patient with light sheets.

further fluid loss.

Changes in mentation can be due to
abnormally high or low glucose, electrolyte
abnormalities, acidosis, decreased cerebral

Investigate changes in mentation and LOC.

perfusion, or developing hypoxia.

Regardless of the cause, impaired
consciousness can predispose patient to
aspiration.
Provides for accurate ongoing measurement
of urinary output, especially if autonomic

Insert and maintain indwelling urinary

neuropathies result in neurogenic bladder

catheter.

(urinary retention/overflow incontinence).

May be removed when patient is stable to
reduce risk of infection.

6. Fatigue

Nursing Diagnosis

Fatigue

May be related to

Decreased metabolic energy production

Altered body chemistry: insufficient insulin

Increased energy demands: hypermetabolic state/infection

Possibly evidenced by

Overwhelming lack of energy, inability to maintain usual routines, decreased

performance, accident-prone

Impaired ability to concentrate, listlessness, disinterest in surroundings

Desired Outcomes

Verbalize increase in energy level.

Display improved ability to participate in desired activities.

Nursing Interventions

Rationale

Discuss with patient the need for activity.

Education may provide motivation to

Plan schedule with patient and identify

increase activity level even though patient

activities that lead to fatigue.

may feel too weak initially.

Alternate activity with periods of rest and

uninterrupted sleep.
Monitor pulse, respiratory rate, and BP
before and after activity.

To prevent excessive fatigue.

Indicates physiological levels of tolerance.

Discuss ways of conserving energy while

Patient will be able to accomplish more with

bathing, transferring, and so on.

a decreased expenditure of energy.

Increase patient participation in ADLs as

Increases confidence level, self-esteem and

Nursing Interventions
tolerated.

Rationale
tolerance level.

7. Deficient Fluid Volume

Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose
to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic
diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit
or polyuria.
Nursing diagnosis

Deficient Fluid Volume related to intracellular dehydration secondary to diabetes

mellitus

Possibly evidenced by

Elevated temperature

Increased urine output

Sweating

Thirst

Exhaustion

Weight loss

Dry skin and/or mucous membrane

Desired outcomes

Patient will verbalize understanding of causative factors and purpose of individual

therapeutic interventions and medications.

Patient will improve or maintain fluid volume at a functional level as evidenced by

individual good skin turgor, moist mucous membrane, and stable vital signs.
Nursing Interventions

Rationale

Establish rapport

Friendly and trusting relationship with patient and

to be able to understand each others concern.

Take and record vital signs.

To obtain baseline data.

Monitor the temperature.

To monitor changes in temperature.

Assess skin turgor and mucous

membranes for signs of dehydration.
Monitor intake and output
Encourage patient to increase fluid
intake as tolerated.
Administer IVF as ordered.

Dry mucous membranes are signs of dehydration.

To assess for signs of dehydration.
To replace fluid loss and prevent dehydration.
To replace lost electrolytes and fluids.

8. Imbalanced Nutrition: Less Than Body Requirements

Due to decrease of lack of insulin in the body, the glucose level continuously rises because
glucose cannot be utilized without the presence of insulin. Glucose is the source of energy,
while insulin is the vehicle to transport glucose to the body tissues. Because of decreased
insulin level in the bloodstream, the cells starved, leading to alteration of metabolism. The
body needs glucose for metabolism; there will be a breakdown of energy reserved from
adipose tissue, muscles and liver (glucagons). This will result to weight loss. But the energy
breaks down, the glucose level continuously increase because there is less amount of
insulin. The body tissues need to be fed, this will lead to polyphagia and polydipsia because
the tissue are not being fed and need glucose for metabolism.
Nursing Diagnosis

Imbalanced Nutrition: less than body requirement r/t insulin deficiency

Possibly evidenced by

Poor muscle tone

Generalized weakness

Increased thirst

Increased urination

Polyphagia

Loss of weight

Desired outcomes

Patient will verbalize understanding of causative factors when known and

necessary interventions are identified for diabetic client.

Patient will demonstrate improvement of weight and nutrition towards goal.

Nursing Interventions

Rationale

Ascertain understanding of individual

To determine what information to be

nutritional needs.

provided to client or SO.

Discuss eating habits and encourage

diabetic diet (balanced diet) as prescribed by
the doctor.

To achieve health needs of the patient with

the proper food diet for his condition.

Document actual weight, do not estimate.

Patients may be unaware of their actual

Note total daily intake including patterns and

weight or weight loss due to estimation of

time of eating.

weight.

Consult dietician and/or physician for further

assessment and recommendation regarding
food preferences and nutritional support.

To reveal changes that should be made in

the clients dietary intake. For greater
understanding and further assessment of
specific foods.

9. Fatigue
Diabetes Mellitus is a group of metabolic diseases characterized by increased levels of
glucose in the blood resulting from defects in insulin secretion, insulin action, or both. In
type 2 diabetes, people have decreased sensitivity to insulin and impaired beta cell
functioning resulting in decreased insulin production. Glucose derived from food cannot be
stored in the liver thereby remaining into the bloodstream. The beta cells of the islets of

Langerhans release glucagon which stimulates the liver to release the stored glucose. After
8 12 hours, the liver forms glucose from the breakdown of noncarbohydrate substances,
including amino acids resulting to muscle wasting which results to weakness.
Nursing Diagnosis

Fatigue RT decreased muscular strength

Possibly evidenced by

Generalized weakness

Increased respiratory rate

Weight loss

Fatigue

Limited ROM

Inability to perform ADLs

Desired outcomes

Patient will be able to identify measures to conserve and increase body energy.

Patient will be free from signs and symptoms of fatigue.

Nursing Interventions

Assess response to activity.

Assess muscle strength of patient and
functional level of activity.

Rationale
Response to an activity can be evaluated to
achieve desired level of tolerance.
To determine the level of activity.
Education may provide motivation to

Discuss with patient the need for activity.

increase activity level even though patient

may feel too weak initially.

Alternate activity with periods of rest or

Prevents excessive fatigue. Indicates

uninterrupted sleep.

physiological levels of tolerance.

Monitor pulse, respiration rate and blood

pressure before and after activity.

Tolerance develops by adjusting frequency,

duration and intensity until desired level is
achieved.

Perform activities slowly with frequent rest

Interventions should be directed at delaying

periods.

the onset of fatigue and optimizing muscle

efficiency.
Promote energy conservation techniques by

Symptoms of fatigue are alleviated with rest.

discussing ways of conserving energy while

Also, patient will be able to accomplish more

bathing, transferring and performing ADLs.

with a decreased expenditure of energy.

Provide adequate ventilation.

For proper oxygenation.

Instruct patient to perform deep breathing

exercises.

Helps promote relaxation.

Provide comfort and safety measures.

To be free from injury during activity.

Administer oxygen as ordered.

To provide proper ventilation.

10. Risk for Infection

Risks for infection is an increased probability of invasion of pathogenic organisms for a
patient with DM. Clients with diabetes are susceptible to infections because of
polymorphonuclear leukocyte function, diabetic neuropathies, and vascular insufficiency as
a result is a poor glycemic control; thus making a wound to heal slowly because the
damaged of the vascular system cannot carry sufficient oxygen, WBC, nutrients, and
antibodies to the injured site. Thereby infections increase and enhance possibility of further
complications.
Nursing Diagnosis

Risk for Infection

Risk factors

Chronic hyperglycemia

Neurogenic bladder

Peripheral vascular disease

Possibly evidenced by

[Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and
symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]

Desired outcomes

Patient will be free of infections as evidenced by normothermia, negative cultures,

and WBC within normal levels.
Nursing Interventions

Assess temperature every four (4) hours.

Notify physician if fever occurs.

Rationale
Fever is a sign of an infection Infection is the
most common cause of diabetic ketoacidosis
(DKA).

Monitor for signs of infection (e.g., fever,

These are indicators of pneumonia which is

rhonchi, dyspnea, and/or cough).

common among patients with DM.

Assess for dysuria, tachycardia,

diaphoresis, nausea, vomiting, and
abdominal pain.
Assess for erythema, swelling, and
purulent drainage at IV sites.

These are indicators of UTI. Neurogenic

bladder predisposes to UTI.
These are signs of IV catheter infections.

11. Risk for Impaired Skin Integrity

Risk factors

Decreased circulation and sensation caused by peripheral neuropathy and arterial

obstruction.

Possibly evidenced by

[Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and
symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]

Desired outcomes

Patients skin on legs and feet remains intact while the patient is hospitalized.

Patient will demonstrate proper foot care.

Nursing Interventions

Rationale

Assess integrity of the skin. Assess knee and

These are assessments for neuropathy.

deep tendon reflexes and proprioception.

Skin on lower extremity pressure points is

at great risk for ulceration.

Use foot cradle on the bed. Use space boots
on ulcerated heels, elbow protectors, and
pressure-relief mattresses.
Wash feet daily with mild soap and warm
water. Check water temperature before
immersing feet in the water.
Inspect feet daily for erythema or trauma.
Change socks or stockings daily. Encourage
the patient to wear white cotton socks.
Use gentle moisturizers on the feet.

To prevent pressure on pressure-sensitive

points.
Decreased sensation increases the risk for
burns.
These are signs that the skin needs
preventive care.
To prevent infection from moisture.
White fabric enables easy visualization of
blood or exudates.
Moisturizers soften and lubricate dry skin,
preventing skin cracking.

Cut toenails straight across after softening

This action prevents ingrown toenails,

toenails with a bath.

which could cause infection.

The patient should not walk barefoot.

This is a high risk for trauma and may

result in ulceration and infection.

12. Risk for Unstable Blood Glucose

Risk factors

Inadequate blood glucose monitoring

Lack of adherence to diabetes management

Medication management

Physical activity

Stress

Rapid growth periods

Insulin deficiency or excess

Possibly evidenced by

[Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and
symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]

Desired outcomes

Patient has a blood glucose reading of less than 180 mg/dL; fasting blood glucose
levels of less than <140 mg/dL; and hemoglobin A1C level <7%.

Nursing Interventions
Assess blood glucose level before
meals and at bedtime.
Assess for anxiety, tremors, and
slurring of speech. Treat
hypoglycemia with 50% dextrose.
Assess feet for temperature,
pulses, color, and sensation.
Administer basal and prandial
insulin.
Teach patient how to perform home
glucose monitoring.

Rationale
Blood glucose should be between 140 to 180 mg/dL.
Non-intensive care patients should be maintained at
pre-meal levels <140 mg/dL.
These are signs of hypoglycemia and D50 is
treatment for it.
To monitor peripheral perfusion and neuropathy.
Adherence to the therapeutic regimen promotes
tissue perfusion. Keeping glucose in the normal range
slows progression of microvascular disease.
Blood glucose is monitored before meals and at
bedtime. Glucose values are used to adjust insulin
doses.

Report BP of more than 160 mm

Hypertension is commonly associated with diabetes.

Hg (systolic). Administer

Control of BP prevents coronary artery disease,

hypertensive as prescribed.

stroke, retinopathy, and nephropathy.

Instruct patient to avoid heating

pads and always to wear shoes
when walking.
Monitor urine albumin to serum
creatinine for renal failure.

13. Deficient Knowledge

Patients have decreased sensation in the extremities

due to peripheral neuropathy.
Renal failure causes creatinine >1.5 mg/dL.
Microalbuminuria is the first sign of diabetic
nephropathy.

May be related to

Unfamiliarity with insulin injection

Dietary modifications

Exercise for normoglycemia

Unfamiliarity with information

Interpretation

Possibly evidenced by

Requests of information

Statements of concern

Inadequate follow-through of instructions

Development of preventable complications

Desired outcomes

Before discharge, patient will demonstrate knowledge of insulin injection,

symptoms, and treatment of hypoglycemia and diet.

Nursing Interventions
Explain that long-acting insulin
(Lantus) only need to be
injected once or twice daily.

Rationale
Long-acting insulin does not have a peak of action.
Insulin glargine is effective over 24 hours.

Explain that regular prandial

insulins (Humulin) should be
injected 30 mins before meals.

Dosage may be adjusted based on the actual amount of

Rapid acting insulins (Novolog,

food ingested because rapid acting insulins can be given

Humalog) may be injected

after a meal.

before or after eating.

Explain that insulin dosages

may need to be adjusted.

Insulin dosage should be reduced when fasting for

surgery, when not eating, or when hypoglycemia occurs.
Illness or infection may increase insulin requirements.

Teach patient to rotate insulin

Multiple injections in the same site may cause fat

injection sites.

deposits.

Explain the importance of

inserting the needle

This ensures deep subcutaneous administration of insulin.

perpendicular to the skin.

Verify that the patient
understands and demonstrates

Monitoring provides data on the degree of glucose control

the technique and timing of

and identifies the need for changes in the insulin dosage.

home monitoring of glucose.

Teach patient to follow a diet
that is low in simple sugars,
low in fat, and high in fiber and
whole grains.
Teach patient that anxiety,
tremors, and slurred speech
are signs of hypoglycemia.

A diet low in fat and high in fiber helps to control

cholesterol and triglycerides. Three daily meals and an
evening snack is recommended. Refined and simple
sugars should be reduced, and complex carbohydrates,
such as cereals, rice, should be increased.
These are indicators of hypoglycemia, which causes
seizures, coma, and death.

Teach patient to treat

Hypoglycemia should be treated with a carbohydrate

hypoglycemia with crackers, a

snack. If the patient is unconscious, glucagon should be

snack, or glucagon injection.

given IM by a caregiver.

Other Possible Nursing Care Plans

Risk for risk-prone behaviorrisk factors may include all-encompassing

changes in lifestyle, self-concept requiring lifelong adherence to therapeutic
regimen, and internal/altered locus of control.

Compromised family copingmay be related to inadequate or incorrect

information or understanding by primary persons, other situation crises or
situations the SOs may be facing, lifelong condition requiring behavioral changes
impacting family.