NUR251 Assessment | Nursing Care Plan

NUR251 Assessment 1 S1 2020
Assessment One Template
Task 1
Diabetes ketoacidosis in children requires regular assessment of their vital
signs, neurologic behaviour, blood glucose level, glucose and ketones in the
urine and fluid concentration. Lily is a 15 year old child who was diagnosed with
diabetes mellitus at a young age and is now admitted to the hospital due to
diabetes ketoacidosis. The assessment should include documentation of the
initial care plan for the patient followed by changes in the assessment in
progress notes. Further assessment for preparing care plan for the patient must
be according to the clinical judgement by the nurse.
The nurse should check her vital signs where respiratory rate is high that
is RR – 24 breaths per minute (normal rate is 12 -20). Respiratory failure is
directly correlated diabetes ketoacidosis. High respiratory rate is associated with
deficiency in potassium ions leading to hypokalemia, fall in magnesium ions
levels and lower serum levels of phosphorus due to hypophosphatemia. Lily’s
potassium level below normal (3-8 mmol/L) that is 2.4 mmol/L. If the potassium
level is not monitored and kept under normal range then increasing muscle
weakness can occur thereby affecting respiratory muscles and causing
respiratory failure. High respiratory rate is an indication of decreased potassium
level (Gallo de Moraes & Surani, 2019). This respiratory assessment is
concentrated on measuring respiratory rate, depth and rhytm of the child that is
number of breaths taken by the child in one minute which must be recorded.
This record must be compared with the initial record of respiratory rate in the
initial assessment (Rch.org.au, 2020).
Low sodium level in the serum is associated with diabetes ketoacidosis in
children. This is mainly caused by hyperglycemia that induces hyponatremia. It
has been seen incase of Lily whose serum level of sodium is below normal range
( 135-145 mEq/L) that is 128 mEq/L. The nurse should measure the serum
sodium level using osmometer that indicates plasma osmolality or Posm (Liamis
et al., 2015). Severe hyponatremia can cause fatigue, exhaustion and tiredness if
the sodium level is not balanced in the blood. Low sodium levels can also cause
loss of appetite as seen in case of Lily who is unwilling to eat. Gastrointestinal
assessment criteria must be followed by the nurse to inspect, the shape, size and
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abnormalities of the abdomen to understand the why Lily does not feel like
eating (Rch.org.au, 2020).
Another assessment for monitoring blood glucose level is done by
monitoring HbAc1 (O Ekpebegh et al., 2014). Hyperglycemia is a common
condition in diabetes ketoacidosis. Normal level of blood glucose is the between
4 and 8 mmol/L but in case of Lily the blood glucose level is 12 mmol/L, which is
very high signifying increased glucose in the blood due to lack of insulin to
control glucose level and this is an indicator of type 1 diabetes. Glucose level is
increased in patients like Lily if it is not monitored and can lead to many
complications such as obesity, kidney failure and impairment of vision. Urinalysis
can be performed for assessing the presence of ketones and glucose in the urine
with the help of urine dipstick. Presence of ketone in the body is an important
indicator of ketoacidosis where the ketones as byproduct of lipid metabolism are
released in increased amount with the urine (Siafarikas & O’Connell, 2010). Any
abnormal finding during urinalysis such as presence of ketones must be
documented with the initial pathology results to identify the abnormalities and
preparing appropriate nursing action (Rch.org.au, 2020).
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Task 2
Nursing Care Plan: Mrs Lily Orange
Nursing problem: Risk of fluid volume deficit
Related to: decreased fluid intake, gastric losses, fatigue and low blood pressure.
Goal of care Nursing
interventions
Rationale Evaluation
Reducing risk of
type 1 diabetes
Measuring her
weight daily
Improve circulatory
fluid volume deficit
Reducing feeling of
sadness
Decrease tendency
of fever
To assess the start of
new disease that may
show comorbidity with
diabetes.
To assess any increase
or decrease in her
weight.
Administration of fluid
such as 0.9% NaCl or
any isotonic solution.
Checking her
temperature with
thermometer to see if
she has fever.
There are studies that confirm the presence of
psychiatric disorders such as depression and
anxiety along with chronic diseases such as
type 1 diabetes (Maia et al., 2014)
Patients with more than 10% weight loss
indicates severe deficit of fluid volume. A
normal weight is indicated when total fluid
intake is more than total fluid elimination
(Metheny, 2011).
Improving gastric issues by maintaining fluid
balance inside the body and this can be
achieved with 0.9% Nacl. This seems to be the
best solution to prevent dysnatremia and
recover fluid depletion (Moritz & Ayus, 2010).
Fever with dry skin is also an indication of
dehydration (Moritz & Ayus, 2010).
Lily will no more feel sad and will not
develop any psychiatric disorder. No
other disease will develop therefore
chances of reducing diabetes is high.
Weight loss will be recovered in case
of Lily when she takes right amount of
fluid thereby reducing fatigue.
This will decrease her feeling of
tiredness and will rehydrate her body.
Regulate her body temperature to
reduce fever.
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