Concept Map

J.H., a 34-year-old Native American man, was admitted to the emergency department after he was found unconscious by his wife in their home.

History of GI flu for 1 week

Stopped taking insulin
2 days ago
Blood glucose
730 mg/dL

Diabetic
50 Units insulin daily
Ketoacidosis
Blood pH
7.26

Found unconscious Deep and rapid

Blood glucose breathing
Blood glucose 730 mg/dL 730 mg/dL
Blood pH 7.26 Flushed and dry skin
Found unconscious Acetone breath smell
Acetone breath
smell

Ineffective self-health Risk for unstable blood Risk for deficient fluid volume
management glucose levels Risk for electrolyte imbalance

Fluid Balance (NOC)

Knowledge: Diabetes Blood Glucose Level
Electrolyte and Acid/Base
Management (NOC) (NOC)
Balance (NOC)

Teaching: Disease Process (NIC) Hypovolemia Management (NIC)

Assess level of knowledge of disease and treatment.
Discuss rationale behind treatment.
Discuss lifestyle changes to prevent future
complications.
Instruct on which signs and symptoms to report to
health care provider.
Hyperglycemia Management
Observe for indications of dehydration.
(NIC)
Monitor fluid status, including intake and output.
Monitor for signs and symptoms of hyperglycemia: polyuria,
Monitor vital signs and weight.
polydipsia, polyphagia, or headache.
Maintain a steady IV infusion flow rate to replace fluids and
Anticipate situations in which insulin requirements will increase
electrolytes.
(e.g., flu).
Facilitate adherence to diet and exercise regimen.
Fluid/Electrolyte Management (NIC)
Monitor laboratory results re: fluid balance (e.g., hematocrit,
serum osmolality).

Key
Medical Nursing Clinical
Risk Diagnostics/ Nursing Expected
Diagnosis Diagnosis Medications Manifestations
Factors Labs Interventions Outcome

Copyright 2014 by Mosby, an imprint of Elsevier Inc.