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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 insulinaction, 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.
Assessment
Nursing Diagnosis
Planning
Nursing Rationale Intervention s Establish rapport Take and record vital signs Friendly relationship with patient and to be able to each others concern To obtain baseline data
Evaluation
Subjective: (none Deficient ) Fluid Objective: Volume r/t intracellula r DHN 2 y elevated the DM II temperature of 38.4C/axill a y increased urine output. y sweating of the skin y thirst y exhaustion y weight loss y dry skin or mucous membrane
Short Term:After 3 of NI, patient shall have verbalized understanding of causative factors and purpose of individual therapeutic interventions andmedications . Long Term:
Short Term:After 3 of NI, patient will have verbalized understanding of causative Monitor the factors and temperature purpose of individual Assess skin therapeutic turgor and To monitor interventions mucous changes in andmedications membranes temperature . for signs of Long Term: dehydration Dry skin After 2 days of Encourage and mucous After 2 days of NI, the patient the patient to membranes NI, the patient shall have increase fluid are signs of will have maintained dehydration maintained intake fluid volume at fluid volume at a functional To replace a functional Administer level as level as fluid loss IVF as evidenced by and prevent evidenced by ordered by individual good the Doctor dehydration individual good skin turgor, skin turgor, moist mucous Administer To replace moist mucous membrane and anti-pyretic electrolytes membrane and stable vital stable vital as prescribed and fluid signs. signs loss by the
Doctor.
Assessmen Nursing t Diagnosis Subjective: Imbalanced Nutrition: less Objective: than body requirement r/t insulindeficie Pt. manifested ncy : - poor muscle tone generalized weakness - increased thirst - increased
Planning Short Term: After 3 of NI, patient shall have verbalized understandi ng of causative factors when known and necessary intervention s and identified diabetic client.
Rationale
Evaluation Short Term: After 3 of NI, patient will have verbalized understandi ng of causative factors when known and necessary intervention s and identified diabetic client.
Friendly relationship with patient and to be able to each others concern To determine what information Discuss eating to be provided to habits and encourage diabetic client/SO diet as prescribed by the Doctor - To achieve health needs of Document actual the patient with the proper food weight, do not diet for is/her estimate. disease Note total daily - Patient may be intake including patterns and time un aware of their actual weight or
Long Term: of eating. After 1-4 months of NI, the patient shall have demonstrat ed weight gain toward goal. Consult dietician/physician for furtherassessment and recommenddation regarding food preferences and nutri-tional support
Long Term:
After 1-4 months of - To reveal NI, the changes that patient will should be made have in clients dietary demonstrat intake ed weight gain toward goal. - For greater understanding and furtherassessmen t of specific foods.
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
Planning
Nursing Rationale Interventio ns -Assess response to activity -Asses muscle strength of patient and functional level of activity. -Discuss with patient the need for activity -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
Evaluatio n The patient shall have been able to identify measures to conserve and increase body energy The patient shall have been free
y y y y y
generalized weakness increasedrespiratory rate of 25cpm presence of nonhealing wound on both feet body weakness wt. loss fatigue limited ROM inability to perform ADL
Short Term:After 2-3 of nursing intervention s, the patient will be able to identify measures to conserve and increase body energy. Long
y y
-Alternate activity with periods of After 3-5 rest/ days of uninterrupte nursing intervention d sleep. s, the patient will -Monitor be free pulse, from signs respiration offatigue rate and blood pressure before/after activity Term:
patient may feel too weak initially -Prevents excessivefatig ue -Indicates physiological levels of tolerance
-Tolerance develops by adjusting -Perform frequency, activity duration and slowly with intensity until frequent rest desired periods activity level is achieved. -Promote energy -Interventions conservation should be techniques directed at by delaying the discussing onset ways of of fatigueand conserving optimizing energy muscle while efficiency. bathing, Symptoms transferring offatigue are and so on. alleviated with rest. Also, -Provide patient will be adequate able to ventilation accomplish more with a decreased -Provide comfort and expenditure of energy. safety -Instruct -For proper
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.
oxygenation -To be free from injury -Promotes relaxation -For muscle strength and tissue repair -To prevent weakness and paleness -To provide proper ventilation
Nursing Diagnosis
Planning Short Term: After 4 hours of NPI the risks factors of occurrence of infection will be reduce or control to a manageable
Nursing Interventions -Establish rapport -Take and record vital signs -Encourage expression of feelings and
Rationale - to obtain patients trust and cooperation - To obtain baseline data - facilitates grieving the
Evaluation Short Term: -The pt. shall have identified risks factors of occurrence of infection shall have
level by a clean anxieties bed and maintain skin - Observe non intact. verbal cues Long Term: After 1-2 weeks of NPI, pt will be free of purulent drainage or erythema and be afebrile -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
loss
reduced or controlled to - non verbal a cues is more manageable accurate than level by a clean bed verbal cues and skin - to begin to intact. incorporate changes into Long Term: body image -The patient - to enhance shall be free of purulent handling of damage or potential erythema problems and be febrile -to prevent dehydration -to boost immune system and promote collagen formation -for tissue repair
-to promote -provide a safe healing and prevent and quiet contamination environment of the wound -Take Due meds on time -to promote pts comfort - To met the bodys requirements
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