(SOLVED) A number of nursing diagnoses are possible in this scenario. Given the provided information, formulate at least two nursing diagnoses

1) Fluid volume deficit related to elevated blood glucose, as evidenced by fruity odor to breath, dried skin and mucous membranes, and patient statements of "it's drying me out."

Altered thought processes related to metabolic abnormalities (fluid volume deficit), as evidenced by statements that "they put the evil eye on me, they want me to die, they are drying out my body it's draining me dry they are yelling, they are yelling no, no, I'm not bad oh God, don't let them get me!"

2) For each of your nursing diagnoses, write out one long-term outcome (the problem, what should change, etc.). Include a time frame, desired change, and three criteria that will help you evaluate whether the outcome has been met, not met, or partially met.

Problem: Fluid volume deficit
Desired change: Patient's fluid volumes will be within normal limits within 36 hours.
Criteria: (1) Patient's serum electrolytes (sodium, potassium, magnesium, phosphate, etc.) will be within normal limits.

(2) Patient's intake and output from all sources will be approximately 2 L/day.'

(3) Specific gravity will be within normal limits.

(4) Fingerstick blood sugar (FSBS) will be within normal range.

Problem: Altered thought processes (delusions, etc.)
Desired change: Patient's mental state will return to precondition status after correction of fluid volume deficit caused by hyperglycemic hyperosmolar non ketosis within 48 hours of admission.
Criteria:

(1) Patient will deny any feelings of anyone trying to harm him.

(2) Patient will deny hearing voices.

(3) Patient will acknowledge understanding that nonadherence to medication was the cause of the deterioration in his mental status.

3) What specific needs might you consider when planning nursing care for Mr. Gonzales?

Language barrier
Hispanic cultural beliefs/religious beliefs
Level of education
Anxiety level
History of violence
Compliance history
Any substance abuse
Patient's/family's psychiatric history and treatment
Support systems

4) Subjective: Patient's mother reports that patient becomes confused and anxious, and also his symptoms related to diagnosis of paranoid schizophrenia become exacerbated. She also reports that he was shopping with her at the supermarket and suddenly fell. The squad was called, and he was brought to the ED.

Objective: On admission, patient's breath demonstrates a fruity odor. He appears confused and anxious, saying, "They put the evil eye on me, they want me to die, they are drying out my body it's draining me dry they are yelling, they are yelling no, no, I'm not bad oh God, don't let them get me!"

Assessment: Patient demonstrating s/s of fluid volume deficit as manifested by dry skin and mucous membranes, complaints of "being dried out," and altered (delusional) thought processes resulting from alterations in fluid volumes and possible electrolytes imbalances.

Plan:
1. Correct fluid volume deficit.
2. Monitor and correct blood sugar.
3. Monitor thought process.
4. Manage anxiety.

Intervention: Check FSBS AC and HS, administer prescribed insulin coverage AC and HS. Obtain list of medications, including oral hypoglycemic, from family members, and obtain a physician assistant order for the same. Obtain appropriate neuroleptic medication coverage for altered thought processes. Assess the effectiveness of antipsychotic medications q shift. Provide reassurance and reality testing for patient PRN. Obtain an order for fluid rehydration and intake and output q shift.

Evaluation:
The patient's FSBS will return to normal limits within 48 hours of admission.
The patient's electrolyte values (Na, K, etc.) will be returned to normal limits within 48 hours of admission.
The patient will report being less anxious within 6 hours of admission.
A patient will deny feelings of persecution and other delusional thought processes within 8 hours of admission.