Nursing Process: Diabetic Ketoacidosis Flashcards

Questions and Answers

What is the primary focus of assessment for a patient with Diabetic Ketoacidosis (DKA)?

Monitoring ECG for dysrhythmias and assessing vital signs, blood gases, breath sounds, and mental status.

Which of the following are major nursing diagnoses for patients with DKA or HHS? (Select all that apply)

Deficient knowledge about diabetes self-care (correct)

Risk for electrolyte imbalance (correct)

Risk for deficient fluid volume (correct)

Increased muscle mass

What are potential complications of DKA or HHS?

Fluid overload, hypokalemia, hyperglycemia and ketoacidosis, hypoglycemia, and cerebral edema.

What are the major goals for a patient treatment plan in DKA or HHS?

Maintenance of fluid and electrolyte balance, increased knowledge about diabetes, decreased anxiety, and absence of complications. Signup and view all the answers

What should a nurse monitor to maintain fluid and electrolyte balance in patients?

Intake and output, vital signs, laboratory values of serum electrolytes, and signs of dehydration. Signup and view all the answers

Cerebral edema is more common in adults than in children during treatment for DKA.

False Signup and view all the answers

What should be included in patient education for preventing DKA or HHS? (Select all that apply)

Following a diabetes management plan Signup and view all the answers

What is an expected patient outcome for managing DKA or HHS?

Achieving fluid and electrolyte balance and demonstrating knowledge about DKA and HHS. Signup and view all the answers

Match the expected patient outcomes with their descriptions:

Fluid and electrolyte balance = Demonstrates intake and output balance Knowledge about DKA and HHS = Identifies factors leading to DKA and HHS Decreased anxiety = Identifies strategies to decrease anxiety Absence of complications = Exhibits normal cardiac rate and rhythm Signup and view all the answers

Study Notes

Assessment

Monitor ECG for dysrhythmias indicating abnormal potassium levels in DKA.
Assess vital signs (blood pressure, pulse), arterial blood gases, breath sounds, and mental status hourly.
Include neurologic checks to prevent cerebral edema, a serious complication.
For HHS, assess vital signs, fluid status, and lab values due to dehydration risk.
Consider age-related physiological changes during assessment, especially in older patients.

Diagnosis

Risk for deficient fluid volume due to polyuria and dehydration.
Risk for electrolyte imbalance from fluid loss or shifts.
Deficient knowledge regarding diabetes self-care.
Anxiety linked to fear of diabetes management failures and misinformation.

Collaborative Problems/Potential Complications

Fluid overload, potentially leading to pulmonary edema and heart failure.
Risk of hypokalemia during treatment.
Hyperglycemia and ketoacidosis as common complications.
Hypoglycemia as a possible outcome of treatment.
Risk of cerebral edema, particularly in pediatric patients.

Planning and Goals

Aim for maintenance of fluid and electrolyte balance.
Increase patient knowledge regarding diabetes management and self-care.
Decrease anxiety levels in patients.
Prevent complications during treatment and recovery.

Nursing Interventions

Measure intake and output; administer IV fluids and electrolytes as prescribed.
Monitor serum electrolytes, especially sodium and potassium, and vital signs hourly.
Assess breath sounds, level of consciousness, and cardiac status regularly.
Evaluate patient's understanding of diabetes management and adherence to treatment.
Educate on DKA/HHS triggers and strategies for management and prevention.
Provide reassurance through cognitive strategies to reduce anxiety, such as imagery and music.
Closely monitor patients for fluid overload, especially those with preexisting conditions.
Prevent hypokalemia through cautious potassium replacement; ensure renal function first.
Gradually reduce blood glucose levels to prevent cerebral edema; use hourly flow sheets for monitoring.
Arrange follow-up care with home care nurses or outpatient education centers for ongoing diabetes management.

Evaluation

Achieve fluid and electrolyte balance with stable intake/output and normal vital signs.
Patient demonstrates knowledge about DKA/HHS, including prevention strategies.
Reduced anxiety levels with identified coping strategies.
Absence of complications reflected in normal cardiac function and stable blood glucose/ketone levels.

Description

This quiz focuses on the nursing process for managing patients with Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Syndrome. It includes key definitions and assessments necessary for nursing care, such as monitoring vital signs and ECG. Perfect for nursing students preparing for clinical practice.