Ity.

Impairment of the thirst center in the brain occurs,making it impossible for

the patient to drink enough fluid to prevent dehydration. This problem is worse
in the older adult with diabetes because age related changes in the thirst
center reduce the patients sensation of thirst.
NOC planning : expected outcomes. The diabetic patients is expected to
have few episodes of hyperglycemia and avoid HHS. Indicators include that
the patient consistently demonstrates these behaviors :

Maintains blood glucose levels within the target range

Use antidiabetic drugs appropriately
Remains well hydrated
Describes when to seek help form health care professional.

Intervention
Monitoring. Assess for manifestations of HHS ( see tables 67-16 and t67-17
for symptoms of hyperglycemia .) continually assess fluid status.
Fluid therapy. The goal of therapy iso to rehydrate the patient and resore
normal blood glucose levelswithin 36 to 72 hours. The choice of fluid
replacement and the rate of infusion are critical in managing HHS. The
severity of the CNS problems is related to the level of blood hyperosmolarity
cellular dehydration. Re-establishing fluid balance in blood cells is a difficult
and slow process, and many patients s recove baseline CNS function until
hours after blood glucose ;evels have returned to normal.
The first objective for fluid repleacement in HHS is to increase blood
nolume. In shock or severe hypotension, give normal saline. Otherwise, use
half normal saline because it more rapidly corrects the water defeicit. Infuse at
1 L/hr until central venous pressure or pulmonary capillary wedge pressure
begins to rise or untl blood pressure and urine output are adequate. The rate
is then reduced to 100 to 200 mL/hr. half of the estimated water deficit is
replaced in the first 12 hours, and the rest is given over ttthe next 36 hours .
body weight, urine output, kidney function, and the presence ortion determine
the rate of fluid infusion. In patients with congestive heart failure, real
insufficiency, or acute kidney failure, monitor central venous pressure. Assses
the patients hourly for sign of cerebral edema abrupt changes in mental
status, abnormal neurologic sign, and coma. Immediately report changes in
the level of consicousneess; changes in pupil size, shape, or reaction; or
seizures. Lack of improvement in level of consciousness may indicate
inadequate rates of fluid replacemenet or reducation in plasma osmolarity.
Regression after initial improvement may indicate a too rapid reducation in

plasma osmolarity. A slow but steady improvement in CNS function is the best
evidence that fluid management is statisfactory.
Continuing therapy. IV insulin is administered after adequate fluids have
been replaced. Stoner ( 2005 ) suggest aninitial bolus dose of 0.15 unti per kg
IV followed by a drip unit per kg per hours untll blood glucose levels fall to 250
mg/dL (13.9 mmol/L ). A reducation of blood glucose of 50 to 70 mgldL per
hours is a reasonable goal. Monitor the patient closely for indications of
hypokalemia. Total body potassium depletion is often unrecognized because
the levelof potassium in the blood may be normal or high. The serum
potassium level may drop quickly when insulin therapy is stared. Potassium
replacement is intifiated once urin output is adequate. Sserum electrolytes
should be followed every 1 to 2 hours until stable, and the patients cardiac
rhtym should be monitored continuously for sign of hypokalemia or
hyperkalemia. Patient education and intervenyions to minimize dehydrayion
are similar ti those for ketoacidosis.
Community based care
Health teaching
Education about blood glucose begins at the time of diagnosis. It takes place
in a hospital or outpatient setting, clinic, nurses, nutritionists, pharmacists,
social workers, and psychologist. Diabetes is a condition that is managed by
the patient. Therefore edication be a continuous process. Education is
provided to patient to achieve blood glucose control to the maximum of their
abilities.
Assessing learning needs and readiness to leran. Gather information about
the patients current knowledge, skills, attitudes, and behaviors. The patient
must have a basic level of understanding about diabetes management in
oreder to reach target blod glucose levels. Assess his or her awareness of
diabetes and the needs of both patient and family before teaching. This
assessment includes :

Age, occupation
Mobility, visual acuity, hearing loss, dexterity
Likes, dislikes, fears
Current lifestyle
Evaluation of general health, attitudes about health current level oof

self care
Learning ability and style, willingness to learn
Acceptance of diabetes, current knowledge of diabetes and its
treatment

Psychological status ( denial, depression, anxiety)

Level of alertness and ability to concentrate
Skills needs, attitudes, goals
Educational and literacy level
Ethnic background, cultural and/or religious influeneces
Home situations

Adult learness want information that applies directly to them find out what
concerns the patient most about having diabetes, and ask what he or she
want to learn.Adult learness want information that applies directly to them find
out what concerns the patient most about having diabetes, and ask what he or
she want to learn. Learning is enhanced when it is related to what the learner
already knows. Start with that the patient already knows, and build on that
base. Because they will be managing their own care after discharge, patients
tend to focus pn issues most important to them. Treatment measures that
need to start soon after diagnosis may be of more interest to the patient than
long term control. Leraning is reinforced and retained when it can be applied
immediately and repeatedly.
The patient psycal condition dictates the timing of teaching. He or she
does not have the energy complex information when blood glucose levels are
fluctuating. Explaining that wellm controlled blood glucose level improve the
sense of well being can help the patients accept the therapy plan. Pace your
teching to match the patients energy level. Use an infornal teaching prosses
until he or she feel able to attend a formal class.
Each patient learns in his or her own way. A successful diabetic education
program combines several teaching methods. Some patient learn better when
thy read pamphlets. Other learn better they watch videos. Learning improves
when the equitment is handled techniques are practiced, success is rewarded
and errors are concerrted immediately.
Assessing phsycal, cognitive, and emotional limitations. Assess the
patients education and reading level to determine what level of information to
present. He or she must be able to understand the printed material. It is
important to match the literacy level of printed material provided to the
literacy level of the dianetic patients. Even highly educated patients do not
want to read complicated information when they are sick.developed creative
teaching strategis for the patients who can not read.
Assess the patients ability to read printed information, insulin labels, and
markings on syringes and equipment. May with type 2 diabetes have

presbyopia ( age-related far-sightedness) and other visual difficulties made

worse by blurred vision caused by fluctuating blood glucose levels.
Assess the patients ability to conceptualize. Adjusting insulin dosage
based on blood glucose monitoring is a difficult concept and may not be
appropriate for patients who cannot understand it. Managing drugs, exercise
and diet requires complex interpretation and behavior.
Assess manual dexterity for any physical limitations that may alter the
teaching plan. A hand injury, tremors, or servere arthritis may require a
change in insulin preparation.
Information is best learned when the patients is ready. Those with newly
diagnosed diabetes are facing a life crisis. Some are motivated to learn
information and are willing to change lifelong behaviors. Other may grieve the
loss of their previous lifestyle and use denial as a means of coping. In this
instance, the patients may not be able to learn needed information right away.
Survivsl skills information. The initial phase of diabetic education involes
teaching information necessary for the survival of anyone diagnosed diabetes.
Survival information includes :

Simple information on pathophysiologi of diabetes

Learning how to prepare and administer insulin or how to take oral

medications for diabetes

Basic diet information
Monitoring of blood glucose and ketones
Recognition, treatment and prevention of hypologlycemia and

hyperglycemia
Sick-day management
Where to buy diabetic supplies and hw to store them
When and how to notify the primary care provider

A nutritionist provides the initial diet instruction. The patients needs to

understand what to eat, and when to eat, how muc to eat, and when to eat.
Stress the importance of eating on time and the dangers of skipping meals. He
or she must know how to maintain food intake during illness. Reinforce dietary
instructon, answer question, and refer questions to the nutritionist or primary
care provider as indicated.
After being taught, the patients should be able to identify the drugs
needed to control blood glucose levels. If insulin is needed, he or she must
able to prepare and give the dose accurately using sterile technique. The
patients must also be state when insulin is to be injected, where insulin is
indicated, and how insulin is stored. Stress the dangers of skip doce. Carefully

review drug interactions, especially with older patients taking oral antidiabetic
drugs.
Patients should be able to state their plan for regulary physical activity.
They must be able to describe the relationship between exercise and blood
glucose control and identify situations in which activity should not be
performed. Provide