INTRODUCTION: Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin. The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and b ecause it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin -dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary necessary if treatment with diet and oral medication is not working. The causes of diabetes mellitus are unclear, however, there seem to be both hereditary (genetic factors passed on in families) and environmental factors involved. Research has shown that some people who de velop diabetes have common genetic markers. In Type I diabetes, the immune system, the body’ s defense system against infection, is believed to be triggered by a virus or another microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a role. In Type II diabetes, the pancreas may produce enough insulin, however, cells have become resistant to the insulin produced and it may n ot work as effectively. Symptoms of Type II diabetes can begin so g radually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight loss, slow wound healing, healing, urinary tract infections, gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while a patient is seeing a doctor about another health concern that is actually being caused by the yet undiagnosed diabetes. Individuals who are at high risk of developing Type II diabetes mellitus include people who:
are obese (more than 20% above their ideal body weight)
have a relative with diabetes mellitus
belong to a high-risk ethnic population (African-American, Native American, Hispanic, Hispanic, or Native Hawaiian)
have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg)
have high blood pressure (140/90 mmHg or above)
have a high density lipoprotein cholesterol level less than o r equal to 35 mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL
have had impaired glucose tolerance or impaired fasting glucose on previous testing
Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle changes. It is best managed with a team approach to empower the client to successfu successfully lly manage the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the various health disciplines involved; provides care and education and promotes the client’s health and well being. Diabetes is a major public health worldwide. Its complications cause many devastating health problems. ANATOMY AND PHYSIOLOGY PHYSIOLOGY:: Every cell in the human body needs energy in order to function. The body’s primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for later use. W hen there is not enough insulin produced or when the doorway no long er recognizes the insulin key, glucose stays stays in the blood rather entering the cells.
PATHOPHYSIOLOGY:
Image Source: www.caninsulin.com/Pathophysiology-algorithm.htm DIAGNOSTIC TEST: Several blood tests are used to measure blood glucose levels, the primary test for diagnosing diabetes. Additional tests can determine the type of diabetes and its severity.
Random blood glucose test — for a random blood glucose test, blood can be drawn a t any time throughout the day, regardless of when the person last ate. A random blood glucose level of 200 mg/dL (11.1 mmol/L) or higher in persons who have symptoms of high blood glucose (see “Symptoms” above) suggests a diagnosis of diabetes.
Fasting blood glucose test — fasting blood glucose testing involves measuring blood glucose after not eating or drinking for 8 to 12 hours (usually overnight). A normal fasting blood glucose level is less than 100 mg/dL. A fasting blood glucose of 126 mg/dL (7.0 mmol/L) or higher indicates diabetes. The test is done by taking a small sample of blood from a vein or fingertip. It must be repeated on another day to confirm that it remains abnormally high (see “Criteria for diagnosis” below).
Hemoglobin A1C test (A1C) — The A1C blood test measures the average blood glucose level during the past two to three months. It is used to monitor blood glucose control in people with known diabetes, but is not normally used to diagnose diabetes. Normal values for A1C are 4 to 6 percent (show figure 3). The test is done by taking a small sample of blood from a vein or fingertip.
Oral glucose tolerance test — Oral glucose tolerance testing (OGTT) is the most sensitive test for diagnosing diabetes and pre-diabetes. However, the OGTT is not routinely recommended because it is inconvenient compared to a fasting blood glucose test.
The standard OGTT includes a fasting blood glucose test. The person then d rinks a 75 gram liquid glucose solution (which tastes very sweet, and is usually cola or orange-flavored). Two hours later, a second blood glucose level is measured. Oral glucose tolerance testing is routinely performed at 24 to 28 weeks of pregnancy to screen for gestational diabetes; this requires drinking a 50 gram glucose solution with a blood glucose level drawn one hour later. For women who have an abnormally elevated blood glucose level, a second OGTT is performed on another day after drinking a 100 gram glucose solution. The blood glucose level is measured before, and at one, two, and three hours after drinking the solution. MEDICATIONS: When diet, exercise and maintaining a he althy weight aren’t enough, you may need the help of medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes and some people with type 2 diabetes must take insulin every day to replace what their pancreas is unable to produce. Unfortunately, insulin can’t be taken in pill form because enzymes in your stomach break it down so that it becomes ineffective. For that reason, many people inject themselves with insulin using a syringe or an insulin pen injector,a device that looks like a pen, except the cartridge is filled with insulin. Others may use an insulin pump, which provides a continuous supply of insulin, eliminating the need for daily shots. The most widely used form of insulin is synthetic human insulin, which is chemically identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isn’t perfect. One of its chief failings is that it doesn’t mimic the way natural insulin is secreted. But newer types of insulin, known as insulin analogs, more closely resemble the way natural insulin acts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine (Lantus). A number of drug options exist for treating type 2 diabetes, including: · Sulfonylurea drugs. These medications stimulate your pancreas to produce and release more insulin. For them to be effective, your pancreas must produce some insulin on its own. Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are prescribed most often. The most common side effect of sulfonylureas is low blood sugar, especially during the first four months of therapy. You’re at much greater risk of low blood sugar if you have impaired liver or kidney function. · Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to sulfonylureas, but you’re not as likely to develop low blood sugar. Meglitinides work quickly, and the results fade rapidly. · Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class available in the United States. It works by inhibiting the production and release of glucose from your liver, which means you need less insulin to transport blood sugar into your cells. One advantage of metformin is that is tends to cause less weight gain than do other diabetes medications. Possible side effects include a metallic taste in your mouth, loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and d iarrhea. These effects usually decrease over time and are less likely to occur if you take the medication with food. A rare but serious side effect is lactic acidosis, which results when lactic acid builds up in your b ody. Symptoms include tiredness, weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is especially likely to occur if you mix this medication with alcohol or have impaired kidney function. · Alpha-glucosidase inhibitors. These drugs block the action of enzymes in your digestive tract that break down carbohydrates. That means sugar is absorbed into your bloodstream more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal. Drugs in this class include acarbose (Precose) and miglitol (Glyset). Although safe and effective, alpha-glucosidase inhibitors can cause abdominal bloating, gas and diarrhea. If taken in high doses, they may also cause reversible liver damage. · Thiazolidinediones. These drugs make your body tissues more sensitive to insulin and keep your liver from overproducing glucose. Side effects of thiazolidinediones, such as rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight gain and fatigue. A far more serious potential side effect is liver
damage. The thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because it caused liver failure. If your doctor prescribes these drugs, it’s important to have your liver checked every two months during the first year of therapy. Contact your doctor immediately if you experience any of the signs and symptoms of liver damage, such as nausea and vomiting, abdominal pain, l oss of appetite, dark urine, or yellowing of your skin and the whites of your eyes (jaundice). These may not always be related to diabetes medications, but your doctor will n eed to investigate all possible causes. · Drug combinations. By combining drugs from different classes, you may be able to control your blood sugar in several different ways. Each class of oral medication can be combined with drugs from any other class. Most doctors prescribe two drugs in combination, although sometimes three drugs may be prescribed. Newer medications, such as Glucovance, which contains both glyburide and metformin, combine different oral drugs in a single tablet. NURSING INTERVENTIONS:
Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance.
Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin.
Demonstrate and explain thoroughly the procedure for insulin self -injection. Help patient to achieve mastery of technique by taking step by step approach.
Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen.
Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycemia.
Explain the importance of exercise in maintaining or reducing weight.
Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia.
Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes.
Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow
Pathophysiology of Diabetes Mellitus
Risk for Infection — Diabetes Mellitus Nursing Diagnosis: Risk for Infection Risk factors may include: High glucose levels, decreased leukocyte function, alterations in circulation Preexisting respiratory infection, or UTI Desired Outcomes:
Identify interventions to prevent/reduce risk of infection. Demonstrate techniques, lifestyle changes to prevent development of infection.
Nursing Interventions
Rationale
Observe for signs of infection and
Patient may be admitted with infection,
inflammation, e.g., fever, flushed appearance,
which could have precipitated the
wound drainage, purulent sputum, cloudy
ketoacidotic state, or may develop a
urine.
nosocomial infection.
Promote good handwashing by staff and
Reduces risk of cross-contamination.
patient. Maintain aseptic technique for IV insertion
High glucose in the blood creates an excellent
procedure, administration of medications, and
medium for bacterial growth.
providing maintenance/site care. Rotate IV sites as indicated. Provide catheter/perineal care. Teach the
Minimizes risk of UTI. Comatose patient may
female patient to clean from front to back
be at particular risk if urinary rete ntion
after elimination
occurred before hospitalization. Note: Elderly female diabetic patients are especially prone to urinary tract/vaginal yeast infections.
Provide conscientious skin care; gently
Peripheral circulation may be impaired,
massage bony areas. Keep the skin dry, linens
placing patient at increased risk for skin
dry and wrinkle-free.
irritation/breakdown and infection.
Auscultate breath sounds.
Rhonchi indicate accumulation of secretions possibly related to pneumonia/bronchitis (may have precipitated the DKA). Pulmonary congestion/edema (crackles) may result from rapid fluid replacement/HF.
Place in semi-Fowler’s position.
Facilitates lung expansion; reduces risk of aspiration.
Reposition and encourage coughing/deep
Aids in ventilating all lung areas and
breathing if patient is alert and cooperative.
mobilizing secretions. Prevents stasis of
Otherwise, suction airway, using sterile
secretions with increased risk of infection.
technique, as needed. Provide tissues and trash bag in a convenient
Minimizes spread of infection.
location for sputum and other secretions. Instruct patient in proper handling of secretions. Encourage/assist with oral hygiene.
Reduces risk of oral/gum disease.
Encourage adequate dietary and fluid intake
Decreases susceptibility to infection.
(approximately3000 mL/day if not
Increased urinary flow prevents stasis and aids
contraindicated by cardiac or renal
in maintaining urine pH/acidity, reducing
dysfunction), including 8 oz of cranberry juice
bacteria growth and flushing organisms out of
per day as appropriate.
system. Note: Use of cranberry juice can help prevent bacteria from adhering to t he bladder wall, reducing the risk of recurrent UTI.
Administer antibiotics as appropriate.
Early treatment may help prevent sepsis.
Risk for Disturbed Sensory Perception — Diabetes Mellitus Nursing Diagnosis: Sensory Perception, risk for disturbed (specify) Risk factors may include Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance Desired Outcomes
Maintain usual level of mentation. Recognize and compensate for existing sensory impairments. Nursing Interventions
Monitor vital signs and mental status.
Rationale Provides a baseline from which to compare abnormal findings, e.g., fever may affect mentation.
Address patient by name; reorient as needed to place, person, and time.
Decreases confusion and helps maintain contact with reality.
Give short explanations, speaking slowly and enunciating clearly. Schedule nursing time to provide for uninterrupted rest periods.
Promotes restful sleep, reduces fatigue, and may improve cognition.
Keep patient’s routine as consistent
Helps keep patient in touch with
as possible. Encourage participation
reality and maintain orientation to
in activities of daily living (ADLs) as
the environment.
able.
Protect patient from injury
Disoriented patient is prone to
(avoid/limit use of restraints as able)
injury, especially at night, and
when level of consciousness is
precautions need to be taken as
impaired. Place bed in low position.
indicated. Seizure precautions need
Pad bed rails and provide soft airway
to be taken as appropriate to prevent
if patient is prone to seizures.
physical injury, aspiration.
Evaluate visual acuity as indicated.
Retinal edema/detachment, hemorrhage, presence of cataracts or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy and/or supportive care.
Investigate reports of hyperesthesia,
Peripheral neuropathies may result
pain, or sensory loss in the feet/legs.
in severe discomfort, lack
Look for ulcers, reddened areas,
of/distortion of tactile sensation,
pressure points, loss of pedal pulses.
potentiating risk of dermal injury and impaired balance.
Provide bed cradle. Keep hands/feet warm, avoiding exposure to cool
Reduces discomfort and potential for dermal injury.
drafts/hot water or use of heating pad. Assist with ambulation/position changes.
Promotes patient safety, especially when sense of balance is affected.
Monitor laboratory values, e.g.,
Imbalances can impair mentation.
blood glucose, serum osmolality,
Note: If fluid is replaced too quickly,
Hb/Hct, BUN/Cr.
excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication).
Carry out prescribed regimen for correcting DKA as indicated.
Alteration in thought processes/potential for seizure activity is usually alleviated once hyperosmolar state is corrected.
Powerlessness — Diabetes Mellitus Nursing Diagnosis: Powerlessness May be related to Long-term/progressive illness that is not curable Dependence on others Possibly evidenced by
Reluctance to express true feelings; expressions of having no control/influence over situation Apathy, withdrawal, anger Does not monitor progress, nonparticipation in care/decision making Depression over physical deterioration/complications despite patient cooperation with regimen Desired Outcomes:
Acknowledge feelings of helplessness. Identify healthy ways to deal with feelings. Assist in planning own care and independently take responsibility for selfcare activities.
Nursing Interventions Encourage patient/SO to express feelings about hospitalization and
Rationale Identifies concerns and facilitates problem solving.
disease in general. Acknowledge normality of feelings.
Recognition that reactions are normal can help patient problemsolve and seek help as needed. Diabetic control is a full-time job that serves as a constant reminder of both presence of disease and threat to patient’s health/life.
Assess how patient has handled
Knowledge of individual’s style helps
problems in the past. Identify locus
determine needs for treatment goals.
of control.
Patient whose locus of control is internal usually looks at ways to gain
control over own treatment program. Patient who operates with an external locus of control wants to be cared for by others and may project blame for circumstances onto external factors. Provide opportunity for SO to
Enhances sense of being involved
express concerns and discuss ways in
and gives SO a chance to problem-
which he or she can be helpful to
solve solutions to help patient
patient.
prevent recurrence.
Ascertain expectations/goals of patient and SO.
Unrealistic expectations/pressure from others or self may result in feelings of frustration/loss of control and may impair coping abilities.
Determine whether a change in relationship with SO has occurred.
Constant energy and thought required for diabetic control often shifts the focus of a relationship. Development of psychological concerns/visceral neuropathies affecting self-concept (especially sexual role function) may add further stress.
Encourage patient to make decisions related to care, e.g., ambulation,
Communicates to patient that some control can be exercised over care.
time for activities, and so forth. Support participation in self-care and give positive feedback for
Promotes feeling of control over situation.
efforts.
Imbalanced Nutrition Less Than Body Requirements — Diabetes Mellitus
Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements May be related to: Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism) Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process Possibly evidenced by:
Increased urinary output, dilute urine Reported inadequate food intake, lack of interest in food Recent weight loss; weakness, fatigue, poor muscle tone Diarrhea Increased ketones (end product of fat metabolism) Desired Outcomes:
Ingest appropriate amounts of calories/nutrients. Display usual energy level. Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.
Nursing Interventions Weigh daily or as indicated.
Rationale Assesses adequacy of nutritional intake (absorption and utilization).
Ascertain patient’s dietary program
Identifies deficits and deviations from
and usual pattern; compare with
therapeutic needs.
recent intake. Auscultate bowel sounds. Note
Hyperglycemia and fluid and
reports of abdominal pain/bloating,
electrolyte disturbances can decrease
nausea, vomiting of undigested food.
gastric motility/function (distension
Maintain nothing by mouth (NPO)
or ileus), affecting choice of
status as indicated.
interventions. Note: Long-term difficulties with decreased gastric emptying and poor intestinal motility suggest autonomic neuropathies affecting the GI tract and requiring
symptomatic treatment. Provide liquids containing nutrients
Oral route is preferred when patient
and electrolytes as soon as patient
is alert and bowel function is
can tolerate oral fluids; progress to
restored.
more solid food as tolerated. Identify food preferences, including
If patient’s food preferences can be
ethnic/cultural needs.
incorporated into the meal plan, cooperation with dietary requirements may be facilitated after discharge.
Include SO in meal planning as
Promotes sense of involvement;
indicated.
provides information for SO to understand nutritional needs of patient. Note:Various methods available or dietary planning include exchange list, point system, glycemic index, or preselected menus.
Observe for signs of hypoglycemia,
Once carbohydrate metabolism
e.g., changes in level of
resumes (blood glucose level
consciousness, cool/clammy skin,
reduced) and as insulin is being
rapid pulse, hunger, irritability,
given, hypoglycemia can occur. If
anxiety, headache, lightheadedness,
patient is comatose, hypoglycemia
shakiness.
may occur without notable change in level of consciousness (LOC). This potentially life-threatening emergency should be assessed and treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished.
Perform fingerstick glucose testing.
Bedside analysis of serum glucose is more accurate (displays current levels) than monitoring urine sugar,
which is not sensitive enough to detect fluctuations in serum levels and can be affected by patient’s individual renal threshold or the presence of urinary retention/renal failure. Note: Some studies have found that a urine glucose of 20% may be correlated to a blood glucose of 140–360 mg/dL. Administer regular insulin by
Regular insulin has a rapid onset and
intermittent or continuous IV
thus quickly helps move glucose into
method, e.g., IV bolus followed by a
cells. The IV route is the initial route
continuous drip via pump of
of choice because absorption from
approximately 5–10 U/hr so that
subcutaneous tissues may be erratic.
glucose is reduced by 50 mg/dL/hr.
Many believe the continuous method is the optimal way to facilitate transition to carbohydrate metabolism and reduce incidence of hypoglycemia.
Administer glucose solutions, e.g.,
Glucose solutions may be added after
dextrose and half-normal saline.
insulin and fluids have brought the blood glucose to approximately 400 mg/dL. As carbohydrate metabolism approaches normal, care must be taken to avoid hypoglycemia.
Provide diet of approximately 60%
Complex carbohydrates (e.g., corn,
carbohydrates, 20% proteins, 20%
peas, carrots, broccoli, dried beans,
fats in designated number of
oats, apples) decrease glucose
meals/snacks.
levels/insulin needs, reduce serum cholesterol levels, and promote satiation. Food intake is scheduled according to specific insulin characteristics (e.g., peak effect) and individual patient response.
Note:A
snack at bedtime (hs) of complex carbohydrates is especially important (if insulin is given in divided doses)
to prevent hypoglycemia during sleep and potential Somogyi response. < Administer other medications as
May be useful in treating symptoms
indicated, e.g., metoclopramide
related to autonomic neuropathies
(Reglan); tetracycline.
affecting GI tract, thus enhancing oral intake and absorption of nutrients.
Fatigue — Diabetes Mellitus Nursing Diagnosis: Fatigue May be related to Decreased metabolic energy production Altered body chemistry: insufficient insulin Increased energy demands: hypermetabolic state/infection Possibly evidenced by
Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone Impaired ability to concentrate, listlessness, disinterest in surroundings Desired Outcomes
Verbalize increase in energy level. Display improved ability to participate in desired activities. Nursing Interventions
Discuss with patient the need for
Rationale Education may provide motivation to
activity. Plan schedule with patient
increase activity level even though
and identify activities that lead to
patient may feel too weak initially.
fatigue. Alternate activity with periods of
Prevents excessive fatigue.
rest/uninterrupted sleep. Monitor pulse, respiratory rate, and
Indicates physiological levels of
BP before/after activity. Discuss ways of conserving energy
tolerance. Patient will be able to accomplish
while bathing, transferring, and so
more with a decreased expenditure
on.
of energy.
Increase patient participation in ADLs as tolerated.
Increases confidence level/selfesteem and tolerance level.
Nursing Diagnosis and Nursing Intervention
Fluid volume deficient related to osmotic diuresis from hyperglycemia Planning After 8 hours of nursing interventions, the patient will demonstrate adequate hydration. Intervention
Monitor orthostatic blood pressure changes. Rational : Hypovolemia may be manifested by hypotension and tachycardia. Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane. Rational : Indicators of level of d ehydration, adequacy of circulating volume. Monitor respiratory pattern like Kussmaul’s respirations and acetone breath. Rational : Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Monitor input and output. Note urine specific gravity. Rational : Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. Promote comfortable environment. Cover patient with light sheets. Rational : Avoids overheating, which could promote further fluid loss. Monitor temperature, skin color and moisture. Rational : Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration.
3 Nursing Care Plan Diabetes Mellitus - Diagnosis, Interventions and Rational Nursing Diagnosis for Diabetes Mellitus 1. Nursing Diagnosis : Fluid Volume Deficit related to osmotic diuresis. Goal: Demonstrate adequate hydration evidenced by stable vital signs, palpable peripheral pulse, skin turgor and capillary refill well, individually appropriate urinary output, and electrolyte levels within normal limits. Nursing Intervention:
1.) Monitor vital signs. Rational: hypovolemia can be manifested by hypotension and tachycardia. 2.) Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes. Rational: This is an indicator of the level of dehydration, or an adequate circulating volume. 3.) Monitor input and output, record the specific gravity of urine. Rational: To provide estimates of the need for fluid replacement, renal function, and effectiveness of the therapy given. 4.) Measure weight every day. Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid. 5.) Provide fluid therapy as indicated. Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual patients. 2. Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirmentsrelated to insufficiency of insulin, decreased oral input. Goal: Digest the amount of calories / nutrients right Shows the energy level is usually Stable or increasing weight. Nursing Intervention: 1.) Determine the patient's diet and eating patterns and compared with food that can be spent by the patient. Rationale: Identify deficiencies and deviations from the therapeutic needs. 2.) Weigh weight per day or as indicated. Rational: Assessing an adequate food intake (including absorption and utilization). 3.) Identification of preferred food / desired include the needs of ethnic / cultural. Rational: If the patient's food preferences can be included in meal planning, this cooperation can be pursued after discharge. 4.) Involve patients in planning the family meal as indicated. Rationale: Increase the sense of involvement; provide information on the family to understand the patient's nutrition. 5.) Give regular insulin treatment as indicated. Rational: regular insulin has a rapid onset and quickly and therefore can help move glucose into cells. c. Nursing Diagnosis : Risk for Infection related to hyperglikemia. Goal: Identify interventions to prevent / reduce the risk of infection. Demonstrate techniques, lifestyle changes to prevent infection. Nursing Intervention: 1). Observed signs of infection and inflammation. Rationale: Patients may be entered with an infection that usually has sparked a state of ketoacidosis or may have nosocomial infections. 2). Improve efforts to prevention by good hand washing for all people in contact with patients including the patients themselves.
Rationale: Prevents cross infection. 3). Maintain aseptic technique in invasive procedures. Rational: high glucose levels in blood would be the best medium for the growth of germs. 4). Give your skin with regular care and earnest. Rational: the peripheral circulation may be disturbed that puts patients at increased risk of damage to the skin / skin irritation and infection. 5). Make changes to the position, effective coughing and encourage deep breathing. Rational: memventilasi Assist in all areas and mobilize pulmonary secretions.
