14. Nonketotic hyperglycemic hyperosmolar coma (NKHHC): profound hyperglycemia and dehydration without ketosis or ketoacidosis; seen in noninsulin-dependent diabetes; brought on by infection or illness. This condition may lead to impaired consciousness and seizures. The patient is critically ill. Mortality rate is over 50%.
    1. Pathophysiology: hyperglycemia greater than 1000 mg/dL causes osmotic diuresis, depletion of extracellular fluid, and hyperosmolarity related to infection or another stressor as the precipitating factor. Patient unable to replace fluid deficits with oral intake.
    2. Risk factors:
       1. Old age.
       2. History of non-insulin-dependent diabetes.
       3. Infections: pneumonia, pyelonephritis, pancreatitis, gram-negative infections.
       4. Kidney failure: uremia and peritoneal dialysis or hemodialysis.
       5. Shock:
          1. Lactic acidosis related to bicarbonate deficit.
          2. Myocardial infarction.
       6. Hemorrhage:
          1. GI.
          2. Subdural.
          3. Arterial thrombosis.
       7. Medications:
          1. Diuretics.
          2. Glucocorticoids.
       8. Tube feedings.
    3. Assessment:
       1. Subjective data:
          1. Confusion.
          2. Lethargy.
       2. Objective data:
          1. Nystagmus.
          2. Dehydration.
          3. Aphasia.
          4. Nuchal rigidity.
          5. Hyperreflexia.
          6. Lab data:
             1. Blood-glucose level 1000 mg/dL.
             2. Serum sodium and chloride-normal to elevated.
             3. BUN >60 mg/dL (higher than in ketoacidosis because of more severe gluconeogenesis and dehydration).
             4. Arterial pH-slightly depressed.
    4. Analysis/nursing diagnosis:
       1. Risk for injury related to hyperglycemia.
       2. Altered renal peripheral tissue perfusion related to vascular collapse.
       3. Ineffective airway clearance related to coma.
    5. Nursing care plan/implementation:
       1. Goal: promote fluid and electrolyte balance.
          1. IVs: fluids and electrolytes, sodium chloride solution used initially to combat dehydration. Rate of infusion will be determined by BP assessment, cardiovascular status, balance between fluid input and output, and lab values.
          2. Monitor I&O because of the high volume of fluid replaced in the critical stage of this condition.
          3. Administer nursing care for the problem that precipitated this serious condition.
          4. Food by mouth when client is able.
       2. Goal: prevent complications.
          1. Administer regular insulin (initial dose usually 5-15 U) and food, as ordered.
          2. Uncontrolled condition leads to cardiovascular disease, renal failure, blindness, and diabetic gangrene.