Nursing Care Plan (NCP) for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

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Outline

Pathophysiology

HHNS occurs in Type 2 diabetics when the body is unable to excrete excess sugar in the blood. The blood becomes very concentrated (hyperosmolar) but does not produce ketones. Initially, it causes polyuria, frequent urination, but as it progresses, the urine becomes more concentrated and takes on a dark appearance and frequency is decreased. Dehydration often occurs and can lead to seizures, coma and death.  HHNS is a serious condition that generally affects the elderly population.

Etiology

Most commonly, HHNS is triggered by periods of illness such as a common cold or bacterial infection. The inflammation process raises blood glucose levels. When the glucose level stays elevated, often over 600 mg/dL, for extended periods of time, polyuria occurs as the body pulls water from inside the cells to try to rid itself of the extra glucose through the urine. As the urine is expelled and the cells dehydrate, electrolytes become imbalanced as sodium, potassium and chloride are lost. Since some insulin is present in Type 2 diabetes, ketones are not produced. Severe dehydration leads to extreme thirst, confusion, seizures, coma and death.

Desired Outcome

Maintain blood glucose levels within target range for patient, attain optimal hydration and fluid balance.

Subjective Data:

  • Extreme thirst 
  • Drowsiness
  • Confusion 
  • Loss of vision 
  • Weakness on one side of the body 
  • Hallucinations

Objective Data:

  • Blood glucose level >600 mg/dL
  • Dry mucous membranes 
  • Warm, dry skin that does not sweat 
  • High fever

Nursing Interventions and Rationales

Nursing Intervention (ADPIE) Rationale
Monitor blood glucose levels The hallmark of HHNS is extremely elevated blood glucose levels >600 mg/dL
Encourage optimal hydration and administer IV fluids (Normal Saline) to maintain fluid balance. Excessive urination can cause dehydration. Encourage oral fluids as tolerated and administer IV fluids to re-establish tissue perfusion and maintain electrolyte balance.
Insulin (Regular) infusion to reduce blood glucose level. Monitor for hypokalemia. Monitor blood glucose levels and serum potassium. As insulin is administered, potassium is lost. Initiate potassium supplementation as necessary.
Frequently assess level of consciousness and mentation The brain is an insulin-dependent tissue. With elevated glucose levels, there is not enough insulin to normalize and the patient becomes confused, dizzy and may have changes in level of consciousness. Patients often experience drowsiness.
Monitor for hyperthermia and treat with antipyretics (fever reducers), cool compresses and cooled IV fluids Thermoregulation is impaired as urine production decreases; sweating decreases and electrolytes become imbalanced.
Monitor vitals for hypotension and tachycardia Most likely related to dehydration and hypovolemia. Patient is at risk for hypovolemic shock.
Educate patient on disorder  Always important to educate patient throughout and give them resources they can use when at home 

Writing a Nursing Care Plan (NCP) for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

A Nursing Care Plan (NCP) for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

https://my.clevelandclinic.org/health/diseases/21147-hyperosmolar-hyperglycemic-syndrome

https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199

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Transcript

Hi everyone. Today, we’re going to be putting together a nursing care plan for hyperosmolar hyperglycemic, nonketotic syndrome, or HHNS. So let’s get started. First, we’re going to go over pathophysiology. So HHNS occurs in type two diabetes. When the body is unable to excrete excess sugar in the blood, the blood becomes very concentrated or hyperosmolar, but does not produce ketones. Nursing considerations: you want to monitor vital signs, glucose levels, level of consciousness, signs of hypoglycemia after treatment with IV fluids and medication. Desired outcome: you’re going to maintain blood glucose levels within target range for the patient, obtain optimal hydration and fluid balance. 

So we’re going to go ahead and get into the care plan. We’re going to be going in, and we’re going to be writing in some of the subjective data and some of the objective data. So what are you going to see with the patient, or what will they tell you? One of the main things you’re going to notice is extreme thirst. And one of the hallmarks is going to be a blood glucose level that’s going to be greater than 600 milligrams per deciliter (mg/dL). They will also have a high fever. Other things you may notice are that they complain of drowsiness, confusion, any loss of vision, weakness on one side of the body, possible hallucinations, dry mucous membranes, warm dry skin that does not sweat and, and that high fever. 

So one of the nursing interventions, we’re going to start, we’re going to make sure we’re monitoring their blood glucose levels. Hallmark of HHNS is the blood glucose levels. That’s greater than 600. So we want to make sure we’re monitoring for that. Another intervention we’re going to do is encourage optimal hydration and administer IV fluids, such as normal saline to maintain fluid balance. So we want to give IV fluids as excess urination can cause dehydration. So encouraging those oral fluids as tolerated and administering IV fluids can help reestablish the tissue perfusion and maintain electrolyte balance. Another invention we’re going to be doing is giving insulin to reduce that blood glucose level; you want to monitor for hypoglycemia. So we’re going to monitor the glucose levels and the serum potassium levels – as insulin is administered, potassium is lost. So you want to initiate potassium supplement as necessary. Another intervention that we’re going to be doing is to make sure that we are monitoring level of consciousness. The brain is an insulin dependent tissue; with elevated glucose levels, there’s not enough insulin to normalize and the patient becomes confused or dizzy, or has changes in their level of consciousness. So patients often experience drowsiness. Another intervention that we want to do is to monitor for hyperthermia. 

Thermoregulation is impaired as urine production decreases and sweating decreases. So you want to be sure you’re treating with antipyretics and/or giving cool compresses to help bring that down. We’re going to monitor vital signs because they can be hypotensive. And you’ll notice they’ll have tachycardia. So high heart rate it’s most likely related to dehydration, and they are at risk for hypovolemic shock. And, as always, we want to educate; we want to make sure we’re educating them as far as managing their glucose levels at home and giving them any sort of resources that they can use once they are at home. 

All right, we’re going to get into the key points here. So pathophysiology and etiology. This occurs in type two diabetes. When the body is unable to excrete excess sugar in the blood, the blood becomes very concentrated, but does not produce ketones. Most are caused by the common cold or a bacterial infection. Some subjective and objective data: what you’re going to see with the patient is they are going to say they have extreme thirst and dehydration from excess urination, drowsiness, and confusion. The blood glucose will be greater than 600 – that is the hallmark for this condition. Warm, dry skin that does not sweat and high fever. We’re going to monitor this patient. We’re going to monitor vital signs, looking for hypotension, tachycardia, fever, glucose levels, LOCs, and hyperthermia Administer medications; we’re going to administer IV fluids such as isotonic solutions to keep them hydrated, regular insulin, and antipyretics. And there you have that care plan. 

You guys did awesome. We love you guys. Go out, be your best self and, as always, happy nursing.

 

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