Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid metabolism. The primary feature of this disorder is elevation in blood glucose levels (hyperglycemia), resulting from either a defect in insulin secretion from the pancreas, a change in insulin action, or both. Sustained hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.

Deficient Fluid VolumeGlucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.

Assessment Nursing Diagnosis

Planning NursingInterventions

Rationale Evaluation

Subjective: (none) Objective:

elevated     temperature of 38.4°C/axilla

increased urine output. sweating of the skin thirst exhaustion weight loss dry skin or  mucous

membrane

Deficient Fluid Volume r/t intracellular DHN 2° the DM II

Short Term:After 3° of NI, patient shall have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications. Long Term:

After 2 days of NI, the patient shall have maintained fluid volume at a functional level as evidenced by

Establish rapport Take and record vital signs

Monitor the temperature

Assess skin turgor and mucous membranes for signs of dehydration

Encourage the patient to increase fluid intake

Administer IVF as ordered by the Doctor

Administer anti-pyretic as prescribed by the

Friendly relationship with patient and to be able to each other’s concern To obtain baseline data

To monitor changes in temperature

Dry skin and mucous membranes are signs of dehydration

To replace fluid loss and prevent

Short Term:After 3° of NI, patient will have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications. Long Term:

After 2 days of NI, the patient will have maintained fluid volume at a functional level as evidenced by

individual good skin turgor, moist mucous membrane and stable vital signs.

Doctor. dehydration

To replace electrolytes and fluid loss

To decrease body temperature and will have less occurrence of dehydration.

individual good skin turgor, moist mucous membrane and stable vital signs

Imbalanced Nutrition: Less Than Body RequirementsDue to decrease of lack of insulin in the body, the glucose level continuously rises because glucose can’t be utilized without the presence of insulin. Glucose is the source of energy, while insulin is the vehicle to transport glucose to the body tissues. Because of decrease insulin level in the blood stream, the cells starved, leading to alteration of metabolism. The body needs glucose for metabolism; there will be a breakdown of energy reserved from adipose tissue, muscles and liver (glucagons). This will result to weight loss. But the energy breaks down, the glucose level continuously increase because there is less amount of insulin. The body tissues need to be fed, this will lead to polyphagia and polydipsia because the tissue are not being fed and need glucose for metabolism.

Assessment Nursing Diagnosis

Planning NursingInterventions

Rationale Evaluation

Subjective:Æ Objective:

Pt. manifested:

- poor muscle tone

- generalized

Imbalanced Nutrition: less than body requirement r/t insulin deficiency

Short Term: After 3° of NI, patient shall have verbalized understanding of causative factors when

Establish rapport Ascertain understanding of individual nutritional needs

Discuss eating habits and encourage diabetic diet as prescribed by the Doctor

Friendly relationship with patient and to be able to each other’s concern To determine what

Short Term: After 3° of NI, patient will have verbalized understanding of causative factors when

weakness

- increased thirst

- increased urination

-polyphagia

Pt. may    manifest:

- loss of weight

known and necessary interventions and identified diabetic client.

Long Term:

After 1-4 months of NI, the patient shall have demonstrated weight gain toward goal.

Document actual weight, do not estimate.

Note total daily intake including patterns and time of eating.

Consult  dietician/physician for further assessment and recommend-dation regarding food preferences and nutri-tional support

information to be provided to client/SO

- To achieve health needs of the patient with the proper food diet for is/her disease

- Patient may be un aware of their actual weight or weight loss due to estimating weight.

- To reveal changes that should be made in client’s dietary intake

- For greater understanding and further assessment of specific foods.

known and necessary interventions and identified diabetic client.

Long Term:

After 1-4 months of NI, the patient will have demonstrated weight gain toward goal.

Fatigue Diabetes Mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood resulting from defects in insulin secretion, insulin action, or both. In type 2 diabetes, people have decreased sensitivity to insulin and impaired beta cell functioning resulting in decreased insulin production. Glucose derived from food cannot be stored in the liver thereby remaining into the bloodstream. The beta cells of the islets of Langerhans release glucagon which stimulates the liver to release the stored glucose. After 8 – 12 hours, the liver forms

glucose from the breakdown of noncarboghydrate substances, including amino acids resulting to muscle wasting which results to weakness.

Assessment Nursing Diagnosis

Planning NursingInterventions

Rationale Evaluation

Subjective: (none) Objective:

generalized weakness

increased respiratory rate of 25cpm

presence of non-healing wound on both feet

body weakness

wt. loss fatigue limited ROM inability to

perform ADL altered VS altered

sensorium

Fatigue related to decreased muscular strength

Short Term:After 2-3º of nursing interventions, the patient will be able to identify measures to conserve and increase body energy. Long Term:

After 3-5 days of nursing interventions, the patient will be free from signs of fatigue

-Assess response to activity -Asses muscle strength of patient and functional level of activity.

-Discuss with patient the need for activity

-Alternate activity with periods of rest/ uninterrupted sleep.

-Monitor pulse, respiration rate and blood pressure before/after activity

-Perform activity slowly with frequent rest periods

-Promote energy conservation techniques by discussing ways of conserving energy while bathing, transferring and

-Response to an activity can be evaluated to achieve desired level of tolerance. -To determine the level of activity

-Education may provide motivation to increase activity level even though patient may feel too weak initially

-Prevents excessive fatigue

-Indicates physiological levels of tolerance

-Tolerance develops by adjusting frequency, duration and intensity until desired activity level is achieved.

-Interventions

The patient shall have been able to identify measures to conserve and increase body energy The patient shall have been free from signs of fatigue

so on.

-Provide adequate ventilation

-Provide comfort and safety

-Instruct patient to perform deep breathing exercises

-Instruct client to increase Vitamins A, C and D and protein in her diet.

-Instruct also patient to increase iron in diet

-Administer oxygen as ordered.

should be directed at delaying the onset of fatigue and optimizing muscle efficiency. Symptoms of fatigue are alleviated with rest.  Also, patient will be able to accomplish more with a decreased expenditure of energy.

-For proper oxygenation

-To be free from injury

-Promotes relaxation

-For muscle strength and tissue repair

-To prevent weakness and paleness

-To provide proper ventilation

Risk for Infection

Risks for infection is a increased probability of invasion of pathogenic organisms for a pt. with DM wound is possible in the furure.Clients with diabetes are susceptible to infections because of polymorphonuclear leukocyte function, diabetic neuropathies, and vascular insufficiency as a result is a poor glycemic control; thus making a wound to heal slowly because the damaged of the vascular system cannot carry sufficient oxygen, WBC, nutrients, and antibodies to the injured site. Thereby infections increase and enhance possibility of further complications.

Assessment Nursing Diagnosis

Planning NursingInterventions

Rationale Evaluation

Subjective:Æ Objective:

Pt. manifested:

-purulent discharge

-hyperthermia

Pt. may manifest:

-altered circulation

-immunological deficit

Risk for infection related to disease condition.

Short Term: After 4 hours of NPI the risks factors of occurrence of infection will be reduce or control to a manageable level by a clean bed and maintain skin intact.

Long Term:

After 1-2 weeks of NPI, pt will be free of purulent drainage or erythema and be afebrile

-Establish rapport -Take and record vital signs

-Encourage expression of feelings and anxieties

- Observe non – verbal cues

-Encourage client to look at/touch affected body part

-Encourage verbalization of and role play anticipated conflicts

-encourage to increase fluid intake

-increase Vit. C in the diet

-increase CHON intake

-change dressing

-provide a safe and quiet environment

- to obtain patient’s trust and cooperation - To obtain baseline data

- facilitates grieving the loss

- non – verbal cues is more accurate than verbal cues

- to begin to incorporate changes into body image

- to enhance handling of potential problems

-to prevent dehydration

-to boost immune system and promote collagen formation

-for tissue repair

Short Term: -The pt. shall have identified risks factors of occurrence of infection shall have reduced or controlled to a manageable level by a clean bed and skin intact.

Long Term:

-The patient shall be free of purulent damage or erythema and be febrile

-Take Due meds on time

-to promote healing and prevent contamination of the wound

-to promote pt’s comfort

- To met the body’s requirements

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