About
An acid-base disturbance characterized by low arterial pH and arterial HCO3.
Assess
ABG's; warm, flushed, dry skin; Kussmaul's respirations; weak, thready pulses, decreased blood pressure; lethargy, confusion, coma, muscle weakness ranging to paralysis.
Complications
Seizures, injury, electrolyte disturbances
Coma, death
Diagnosis
- Acute confusion related to acid base disturbance and electrolyte imbalances
- Impaired physical mobility related to muscle weakness
- Impaired breathing pattern related to deep and rapid respirations
Goals
- The client will remain free from injury.
- The client will have a return of ABG's to normal or compensated levels.
Interventions
- Monitor Intake and output, VS, ABG's, electrolytes, and pulse oximetry.
- Assess neurological status frequently.
- Institute seizure precautions.
- Administer fluids and IV fluids as ordered.
- If hypoglycemic, administer prescribed insulin and monitor blood glucose frequently.
- Maintain a patent IV.
- Monitor for signs/ symptoms of complications.
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