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The first priority is to maintain adequate fluid balance. The action of glucose as an osmotic diuretic places the patient at risk for severe fluid volume deficits. If he or she is awake, encourage the patient to drink water and sugar-free drinks without caffeine. Because patients are usually tachycardic, caffeinated beverages are contraindicated. Because severe hyperglycemia is accompanied by increased serum osmolarity and accompanying decreases in mental status, fluid replacement is accomplished by the IV route in most cases. If rapid fluid resuscitation is needed, use a large-gauge peripheral IV site with a short length to provide for rapid fluid replacement. Keep the tubing as short as possible from the IV bag or bottle, and avoid long loops of tubing at a level below the patient's heart. Monitor for signs of underhydration (mental status that remains depressed, dry mucous membranes, soft eyeballs) and overhydration (pulmonary congestion, neck vein distension, shortness of breath, frothy sputum, cough).

Patients with the most severe cases of hyperglycemia have a risk of ineffective airway clearance because of decreased mental status and airway obstruction by the tongue. Have airway equipment near the patient's bedside at all times, including an oral and nasal airway, an endotracheal tube, and a laryngoscope. If the patient develops snoring, slow respirations, or apnea, maintain the patient's airway and breathing with a manual resuscitator bag and notify the physician immediately.

If the patient has hyperglycemia because of diabetes mellitus or HNKS, provide appropriate patient teaching. Discuss the administration of insulin; a consistent and appropriate technique of insulin administration is critical for optimal blood glucose control. Whenever possible, have the patient administer her or his own insulin. Encourage exercise. Instruct the patient about self-monitoring to recognize the signs and symptoms of hyperglycemia and hypoglycemia. Teach the patient and significant others how to prevent skin and lower-extremity infection, ulcers, and poor wound healing.

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