ALGORITMA DKA (DIABETIC KETOACIDOSIS)

DKA

Dx : Gg. Pertukaran gas

Kesadaran Sadar NOC : Gas exchange (0402)

 GCS 11 – 12 Napas bau buah, Hiperventilasi NIC :

(Letargi) Resspirasi > 1. O2 Therapy (3220)
 GCS 8 – 10 Inspirasi, Frek > 30 2. Respiration Monitoring (3350)
(Kusmaul).
(Stupor)
 GCS < 5
(Koma) Hiperosmolalitas Dx : Gg. Keseimbangan
asam basa & elektrolit

Dx : Penurunan Kesadaran Anion Gap me Celah osmosis NOC : Electrolyte &

- Cl-, SO4-, PO4- Acid/Base Balance (0600)
- Asam laktat
- Keton
NOC : NIC :
1. Status neurologi :
1. Acid base management (1910)
kesadaran (0912) 2. Acid base management : Acidosis
2. Vital sign (0802) - HCO3- < 22-26 acid base management (1911)
mMol/L 3. Acid base monitoring (1920)
- pH < 7,35 4. Electrolyte management (2000)
NIC : 5. Eelectrolyte monitoring (2020)
1. Bed rest care (0740) 6. Hypercalemia electrolyte
2. Positioning (0840) management (2002)
3. Consiousness monitoring
(2620)
4. Haemodynamic Dx : Ketidakseimbangan
regulation (4150) cairan
5. Hypovolemic
management (4180)
6. Termo regulation (3900) - Reduksi Urin (+) Glikosuria NOC : Fluid Balance (0601)
Gula
- Berat Jenis Urine
< 1,0020 – 1,0035 NIC :
- Peningkatan rasa haus 1. Fluid management (4120)
- Kelelahan 2. Hypercalemia management
- Sesak napas (2120)
- Output > Intake Volume Cairan 3. Fluid monnitoring (4130)
- Mual muntah - Turgor Kulit Jelek
- Dehidrasi 4. Hypovolemic management (4180)
- Kelembaban Kulit 5. Intra vein therapy (4200)
- Takikardia Menurun 6. Shock prevention (4260)
7. Venous acces device maintenance
(2440)
Hipoglikemia

Glukagon (-), Epinefrin (-) - Luka (+) Dx : Gg. Integritas Jaringan

- Nadi (-)
- Akral Dingin
Kerusakan sel pankreas (+) NOC :
- Warna Hitam 1. Infection severity (0703)
- Jaringan 2. Neurogical status (0909)
Kronik Hiperglikemia Kadar Gula Darah Nekrotik 3. Wound healing : primary
300-800 mg/dL intention (1102)
4. Wound healing : secondary
intention (1103)
Neuropati Gangren 5. Sensory function (2405)
Amputasi

Ulkus Makroangiopati NIC :

1. Neurogical monitoring (2620)
2. Peripheral sensation management
Nekrotomi Antibiotik (2660)
3. Lower extremity monitoring
(3480)
4. Wound care (3660)
5. Wound irrigation (3680)
6. Incision site care (3440)
7. Teaching : foot care (5603)