NURSING CARE OF PATIENT WITH DIABETES MELLITUS

Arranged to fill English Task of D IV Nursing Semester 8

Arranged by:
Alfika Dewi Wijayanti P07120213001

Arsinda Prastiwi P07120213007

Ichtiarfi Waryanuarita P07120213020
Wanti Nurin Salasa P07120213037

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

PROGRAM STUDI D-IV KEPERAWATAN ANESTESI
POLTEKKES KEMENKES YOGYAKARTA
TAHUN 2017
 BAB I
PREFACE

A. Description
The major sources of the glucose that circulates in the blood are through
the absorption of ingested food in the gastrointestinal tract and formation of
glucose by the liver from food substances.
Diabetes mellitus is a group of metabolic diseases that occurs with
increased levels of glucose in the blood. Diabetes mellitus most often results in
defects in insulin secretion, insulin action, or even both.
B. Classification
The classification system of diabetes mellitus is unique because
research findings suggest many differences among individuals within each
category, and patients can even move from one category to another, except for
patients with type 1 diabetes.

Diabetes has major classifications that include type 1 diabetes, type 2

diabetes, gestational diabetes, and diabetes mellitus associated with other
conditions. The two types of diabetes mellitus are differentiated based on their
causative factors, clinical course, and management.
C. Pathophysiology

Diabetes Mellitus has different courses of pathophysiology because of it

has several types.
 Insulin is secreted by beta cells in the pancreas and it is an anabolic
hormone. When we consume food, insulin moves glucose from blood to
muscle, liver, and fat cells as insulin level increases. The functions of insulin
include the transport and metabolism of glucose for energy, stimulation of
storage of glucose in the liver and muscle, serves as the signal of the liver to
stop releasing glucose, enhancement of the storage of dietary fat in adipose
tissue, and acceleration of the transport of amino acid into cells. Insulin and
glucagon maintain a constant level of glucose in the blood by stimulating the
release of glucose from the liver.

1. Type 1 Diabetes Mellitus

Type 1 diabetes mellitus is characterized by destruction of the

pancreatic beta cells. A common underlying factor in the development of
type 1 diabetes is a genetic susceptibility. Destruction of beta cells leads to
a decrease in insulin production, unchecked glucose production by the
liver and fasting hyperglycemia. Glucose taken from food cannot be stored
in the liver anymore but remains in the blood stream. The kidneys will not
reabsorb the glucose once it has exceeded the renal threshold, so it will
appear in the urine and be called glycosuria. Excessive loss of fluids is
accompanied by excessive excretion of glucose in the urine leading to
osmotic diuresis. There is fat breakdown which results in ketone
production, the by-product of fat breakdown.

2. Type 2 Diabetes Mellitus

Type 2 diabetes mellitus has major problems of insulin resistance

and impaired insulin secretion. Insulin could not bind with the special
receptors so insulin becomes less effective at stimulating glucose uptake
and at regulating the glucose release. There must be increased amounts of
insulin to maintain glucose level at a normal or slightly elevated level.
However, there is enough insulin to prevent the breakdown of fats and
production of ketones.
Uncontrolled type 2 diabetes could lead to hyperglycemic,
hyperosmolar nonketotic syndrome. The usual symptoms that the patient
may feel are polyuria, polydipsia, polyphagia, fatigue, irritability, poorly
healing skin wounds, vaginal infections, or blurred vision.

3. Gestational Diabetes Mellitus

With gestational diabetes mellitus (GDM), the pregnant woman
experiences any degree of glucose intolerance with the onset of pregnancy.
The secretion of placental hormones causes insulin resistance, leading to
hyperglycemia. After delivery, blood glucose levels in women with GDM
usually return to normal or later on develop type 2 diabetes.
D. Epidemiology

Diabetes mellitus is now one of the most common disease all over the
world. Here are some quick facts and numbers on diabetes mellitus. More than
23 million people in the United States have diabetes, yet almost one-third are
undiagnosed. By 2030, the number of cases is expected to increase more than
30 million.
Diabetes is especially prevalent in the elderly; 50% of people older than
65 years old have some degree of glucose intolerance. People who are 65 years
and older account for 40% of people with diabetes. African-Americans and
members of other racial and ethnic groups are more likely to develop diabetes.
In the United States, diabetes is the leading cause of non-traumatic
amputations, blindness in working-age adults, and end-stage renal disease.
Diabetes is the third leading cause of death from disease. Costs related to
diabetes are estimated to be almost $174 billion annually.

E. Causes
The exact cause of diabetes mellitus is actually unknown, yet there are
factors that contribute to the development of the disease.
1. Type 1 Diabetes Mellitus

Genetics. Genetics may have played a role in the destruction of the beta
cells in type 1 DM. Environmental factors. Exposure to some environmental
factors like viruses can cause the destruction of the beta cells.
 2. Type 2 Diabetes Mellitus

Excessive weight or obesity is one of the factors that contribute to type 2

DM because it causes insulin resistance. Lack of exercise and a sedentary
lifestyle can also cause insulin resistance and impaired insulin secretion.

3. Gestational Diabetes Mellitus

If woman have overweight before pregnancy and added extra weight, it

makes it hard for the body to use insulin. If a woman in pregnancy a parent
or a sibling who has type 2 DM, you are most likely predisposed to GDM.

F. Clinical Manifestations

Clinical manifestations depend on the level of the patients hyperglycemia.

1. Polyuria or increased urination. Polyuria occurs because the
kidneys remove excess sugar from the blood, resulting in a higher urine
production.

2. Polydipsia or increased thirst. Polydipsia is present because the

body loses more water as polyuria happens, triggering an increase in the
patients thirst.

3. Polyphagia or increased appetite. Although the patient may

consume a lot of food but glucose could not enter the cells because of
insulin resistance or lack of insulin production.

4. Fatigue and weakness. The body does not receive enough energy
from the food that the patient is ingesting.

5. Sudden vision changes.The body pulls away fluid from the eye in
an attempt to compensate the loss of fluid in the blood, resulting in trouble
in focusing the vision.

G. Symptoms of Diabetes Mellitus.

 1. Tingling or numbness in hands or feet. Tingling and numbness
occur due to a decrease in glucose in the cells.

2. Dry skin. Because of polyuria, the skin becomes dehydrated.

3. Skin lesions or wounds that are slow to heal. Instead of entering

the cells, glucose crowds inside blood vessels, hindering the passage of
white blood cells which are needed for wound healing.

4. Recurrent infections. Due to the high concentration of glucose,

bacteria thrives easily.

H. Prevention
Appropriate management of lifestyle can effectively prevent the
development of diabetes mellitus.
1. Standard lifestyle recommendations, metformin, and placebo are
given to people who are at high risk for type 2 diabetes.
2. The 16-lesson curriculum of the intensive program of lifestyle
modifications focused on weight reduction of greater than 7% of initial body
weight and physical activity of moderate intensity.
3. It also included behavior modification strategies that can help
patients achieve their weight reduction goals and participate in exercise.

I. Complication
If diabetes mellitus is left untreated, several complications may arise
from the disease.
1. Hypoglycemia. Hypoglycemia occurs when the blood glucose falls
to less than 50 to 60 mg/dL because of too much insulin or oral
hypoglycemic agents, too little food, or excessive physical activity.
2. Diabetic Ketoacidosis. DKA is caused by an absence or markedly
inadequate amounts of insulin and has three major features of
hyperglycemia, dehydration and electrolyte loss, and acidosis.
 3. Hyperglycemic Hyperosmolar Nonketotic Syndrome. HHNS is a
serious condition in which hyperosmolarity and hyperglycemia predominate
with alteration in the sense of awareness.
H. Assessment and Diagnostic Findings
Hypoglycemia may occur suddenly in a patient considered
hyperglycemic because their blood glucose levels may fall rapidly to 120
mg/dL or even less.
1. Serum glucose: Increased 2001000 mg/dL or more.

2. Serum acetone (ketones): Strongly positive.

3. Fatty acids: Lipids, triglycerides, and cholesterol level elevated.

4. Serum osmolality: Elevated but usually less than 330 mOsm/L.

5. Glucagon: Elevated level is associated with conditions that

produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma,
infection), or (3) lack of insulin. Therefore, glucagon may be elevated with
severe DKA despite hyperglycemia.

6. Glycosylated hemoglobin (HbA1C): Evaluates glucose control

during past 812 week with the previous 2 wk most heavily weighted.
Useful in differentiating inadequate control versus incident-related DKA
(e.g., current upper respiratory infection [URI]). A result greater than 8%
represents an average blood glucose of 200 mg/dL and signals a need for
changes in treatment.

7. Serum insulin: May be decreased/absent (type 1) or normal to high

(type 2), indicating insulin insufficiency/improper utilization
(endogenous/exogenous). Insulin resistance may develop secondary to
formation of antibodies.

8. Electrolytes
 9. Sodium: May be normal, elevated, or decreased.

10. Potassium: Normal or falsely elevated (cellular shifts), then

markedly decreased.

11. Phosphorus: Frequently decreased.

12. Arterial blood gases (ABGs): Usually reflects low pH and

decreased HCO3 (metabolic acidosis) with compensatory respiratory
alkalosis.

13. CBC: Hct may be elevated (dehydration); leukocytosis suggest

hemoconcentration, response to stress or infection.

14. BUN: May be normal or elevated (dehydration/decreased renal

perfusion).

15. Serum amylase: May be elevated, indicating acute pancreatitis as

cause of DKA.

16. Thyroid function tests: Increased thyroid activity can increase

blood glucose and insulin needs.

17. Urine: Positive for glucose and ketones; specific gravity and
osmolality may be elevated.

18. Cultures and sensitivities: Possible UTI, respiratory or wound

infections.

I. Medical Management
Here are some medical interventions that are performed to manage diabetes
mellitus.
 1. Normalize insulin activity. This is the main goal of diabetes
treatment normalization of blood glucose levels to reduce the
development of vascular and neuropathic complications.

2. Intensive treatment. Intensive treatment is three to four insulin

injections per day or continuous subcutaneous insulin infusion, insulin
pump therapy plus frequent blood glucose monitoring and weekly contacts
with diabetes educators.

3. Exercise caution with intensive treatment. Intensive therapy must

be done with caution and must be accompanied by thorough education of
the patient and family and by responsible behavior of patient.

4. Diabetes management has five components and involves constant

assessment and modification of the treatment plan by healthcare
professionals and daily adjustments in therapy by the patient.
J. Nutritional Management
1. The foundations. Nutrition, meal planning, and weight control are
the foundations of diabetes management.

2. Consult a professional. A registered dietitian who understands

diabetes management has the major responsibility for designing and
teaching this aspect of the therapeutic plan.

3. Healthcare team should have the knowledge. Nurses and other

health care members of the team must be knowledgeable about nutritional
therapy and supportive of patients who need to implement nutritional and
lifestyle changes.

4. Weight loss. This is the key treatment for obese patients with type
2 diabetes.
 5. How much weight to lose? A weight loss of as small as 5% to 10%
of the total body weight may significantly improve blood glucose levels.
6. Other options for diabetes management. Diet education, behavioral
therapy, group support, and ongoing nutritional counselling should be
encouraged.
K. Meal Planning
1. Criteria in meal planning. The meal plan must consider the
patients food preferences, lifestyle, usual eating times, and ethnic and
cultural background.

2. Managing hypoglycemia through meals. To help prevent

hypoglycemic reactions and maintain overall blood glucose control, there
should be consistency in the approximate time intervals between meals
with the addition of snacks as needed.

3. Assessment is still necessary. The patients diet history should be

thoroughly reviewed to identify his or her eating habits and lifestyle.

4. Educate the patient. Health education should include the

importance of consistent eating habits, the relationship of food and insulin,
and the provision of an individualized meal plan.
5. The nurses role. The nurse plays an important role in
communicating pertinent information to the dietitian and reinforcing the
patients for better understanding.

L. Other Dietary Concerns

1. Alcohol consumption. Patients with diabetes do not need to give up
alcoholic beverages entirely, but they must be aware of the potential
adverse of alcohol specific to diabetes.

2. If a patient with diabetes consumes alcohol on an empty stomach,

there is an increased likelihood of hypoglycemia.
 3. Reducing hypoglycemia. The patient must be cautioned to
consume food along with alcohol, however, carbohydrate consumed with
alcohol may raise blood glucose.

4. How much alcohol intake? Moderate intake is considered to be one

alcoholic beverage per day for women and two alcoholic beverages per
day for men.

5. Artificial sweeteners. Use of artificial sweeteners is acceptable, and

there are two types of sweeteners: nutritive and nonnutritive.

6. Types of sweeteners. Nutritive sweeteners include all of which

provides calories in amounts similar to sucrose while nonnutritive have
minimal or no calories.

7. Exercise. Exercise lowers blood glucose levels by increasing the

uptake of glucose by body muscles and by improving insulin utilization.

8. A person with diabetes should exercise at the same time and for the
same amount each day or regularly.
9. A slow, gradual increase in the exercise period is encouraged.
M. Using a Continuous Glucose Monitoring System
1. A continuous glucose monitoring system is inserted
subcutaneously in the abdomen and connected to the device worn on a
belt.

2. This can be used to determine whether treatment is adequate over a

24-hour period.
3. Blood glucose readings are analyzed after 72 hours when the data
has been downloaded from the device.
N. Testing for Glycated Hemoglobin
 1. Glycated hemoglobin or glycosylated hemoglobin, HgbA1C, or
A1C reflects the average blood glucose levels over a period of
approximately 2 to 3 months.

2. The longer the amount of glucose in the blood remains above

normal, the more glucose binds to hemoglobin and the higher the glycated
hemoglobin becomes.

3. Normal values typically range from 4% to 6% and indicate

consistently near-normal blood glucose concentrations.
O. Pharmacologic Therapy
1. Exogenous insulin. In type 1 diabetes, exogenous insulin must be
administered for life because the body loses the ability to produce insulin.

2. Insulin in type 2 diabetes. In type 2 diabetes, insulin may be

necessary on a long-term basis to control glucose levels if meal planning
and oral agents are ineffective.

3. Self-Monitoring Blood Glucose (SMBG). This is the cornerstone

of insulin therapy because accurate monitoring is essential.

4. Human insulin. Human insulin preparations have a shorter duration

of action because the presence of animal proteins triggers an immune
response that results in the binding of animal insulin.

5. Rapid-acting insulin. Rapid-acting insulins produce a more rapid

effect that is of shorter duration than regular insulin.

6. Short-acting insulin. Short-acting insulins or regular insulin should

be administered 20-30 minutes before a meal, either alone or in
combination with a longer-acting insulin.
7. Intermediate-acting insulin. Intermediate-acting insulins or NPH or
Lente insulin appear white and cloudy and should be administered with
food around the time of the onset and peak of these insulins.

8. The rapid-acting and short-acting insulins are expected to cover the

increase in blood glucose levels after meals; immediately after the
injection.

9. Intermediate-acting insulins are expected to cover subsequent

meals, and long-acting insulins provide a relatively constant level of
insulin and act as a basal insulin.

10. Approaches to insulin therapy. There are two general approaches to

insulin therapy: conventional and intensive.

11. Conventional regimen. Conventional regimen is a simplified

regimen wherein the patient should not vary meal patterns and activity
levels.

12. Intensive regimen. Intensive regimen uses a more complex

insulin regimen to achieve as much control over blood glucose levels as is
safe and practical.

13. A more complex insulin regimen allows the patient more flexibility
to change the insulin doses from day to day in accordance with changes in
eating and activity patterns.

14. Methods of insulin delivery. Methods of insulin delivery include

traditional subcutaneous injections, insulin pens, jet injectors, and insulin
pumps.

15. Insulin pens use small prefilled insulin cartridges that are loaded
into a pen-like holder.
 16. Insulin is delivered by dialing in a dose or pushing a button for
every 1- or 2-unit increment administered.

17. Jet injectors deliver insulin through the skin under pressure in an
extremely fine stream.

18. Insulin pumps involve continuous subcutaneous insulin infusion

with the use of small, externally worn devices that closely mimic the
function of the pancreas.

19. Oral antidiabetic agents may be effective for patients who have
type 2 diabetes that cannot be treated by MNT and exercise alone.

20. Oral antidiabetic agents. Oral antidiabetic agents include

sulfonylureas, biguanides, alpha-glucosidase inhibitors, thiazolidinediones,
and dipeptidyl-peptidase-4.

21. Half of all the patients who used oral antidiabetic agents eventually
require insulin, and this is called secondary failure.
22. Primary failure occurs when the blood glucose level remains high 1
month after initial medication use.

P. Nursing Management
Nurses should provide accurate and up-to-date information about the patients
condition so that the healthcare team can come up with appropriate
interventions and management.
 BAB II
NURSING CARE

A. Nursing Assessment

The nurse should assess the following for patients with Diabetes Mellitus:
1. Assess the patients history. To determine if there is presence of
diabetes, assessment of history of symptoms related to the diagnosis of
diabetes, results of blood glucose monitoring, adherence to prescribed
dietary, pharmacologic, and exercise regimen, the patients lifestyle,
 cultural, psychosocial, and economic factors, and effects of diabetes on
functional status should be performed.

2. Assess physical condition. Assess the patients blood

pressure while sitting and standing to detect orthostatic changes.

3. Assess the body mass index and visual acuity of the patient.

4. Perform examination of foot, skin, nervous system and mouth.

5. Laboratory examinations. HgbA1C, fasting blood glucose, lipid
profile, microalbuminuria test, serum creatinine level, urinalysis, and ECG
must be requested and performed.
B. Diagnoses
The following are diagnoses observed from a patient with diabetes mellitus.
1. Risk for unstable blood glucose level related to insulin resistance,
impaired insulin secretion, and destruction of beta cells.

2. Risk for infection related to delayed healing of open wounds.

3. Deficient knowledge related to unfamiliarity with information, lack

of recall, or misinterpretation.

4. Risk for disturbed sensory perception related to endogenous

chemical alterations.

5. Impaired skin integrity related to delayed wound healing.

6. Ineffective peripheral tissue perfusion related to too much glucose
in the bloodstream

C. Planning and Goals

Main article: 13+ Diabetes Mellitus Nursing Care Plans
Achievement of goals is necessary to evaluate the effectiveness of the
therapy.
1. Acknowledge factors that lead to unstable blood glucose.
 2. Maintain glucose in satisfactory range.

3. Verbalize plan for modifying factors to prevent or minimize shifts

in glucose levels.

4. Achieve timely wound healing.

5. Identify interventions to prevent or reduce Risk for Infection.

6. Regain or maintain the usual level of cognition.

7. Homeostasis achieved.

8. Causative/precipitating factors corrected/controlled.

9. Complications prevented/minimized.

10. Disease process/prognosis, self-care needs, and therapeutic

regimen understood.
11. Plan in place to meet needs after discharge.

D. Nursing Priorities
1. Restore fluid/electrolyte and acid-base balance.

2. Correct/reverse metabolic abnormalities.

3. Identify/assist with management of underlying cause/disease

process.

4. Prevent complications.
5. Provide information about disease process/prognosis, self-care, and
treatment needs.
E. Nursing Interventions
The healthcare team must establish cooperation in implementing the
following interventions.
 1. Educate about home glucose monitoring. Discuss glucose
monitoring at home with the patient according to individual parameters
to identify and manage glucose variations.

2. Review factors in glucose instability. Review clients common

situations that contribute to glucose instability because there are multiple
factors that can play a role at any time like missing meals, infection, or
other illnesses.

3. Encourage client to read labels. The client must choose foods

described as having a low glycemic index, higher fiber, and low-fat
content.

4. Discuss how clients antidiabetic medications work. Educate client

on the functions of his or her medications because there are combinations
of drugs that work in different ways with different blood glucose control
and side effects.

5. Check viability of insulin. Emphasize the importance of

checking expiration dates of medications, inspecting insulin for
cloudiness if it is normally clear, and monitoring proper storage and
preparation because these affect insulin absorbability.

6. Review type of insulin used. Note the type of insulin to be

administered together with the method of delivery and time of
administration. This affects timing of effects and provides clues to
potential timing of glucose instability.
7. Check injection sites periodically. Insulin absorption can vary day
to day in healthy sites and is less absorbable in lipohypertrophic tissues.
F. Evaluation
To check if the regimen or the interventions are effective, evaluation must be
done afterward.
 1. Evaluate clients knowledge on factors that lead to an unstable
blood glucose level.
2. Evaluate the clients level of blood glucose.
3. Verbalized achievement of modifying factors that can prevent or
minimize shifts in glucose level.
4. Achieved timely wound healing.
5. Identified interventions that can prevent or reduce risk for
infection.
6. Evaluate maintenance of the usual level of cognition.
G. Discharge and Home Care Guidelines
The responsibility of the healthcare team members does not end when the
patient is discharged. The following are guidelines that should be discussed
before the patient is discharged from the hospital.
1. Patient empowerment is the focus of diabetes education.
2. Patient education should address behavior change, self-efficacy,
and health beliefs.

3. Address any underlying factors that may affect diabetic control.

4. Simplify the treatment regimen if it is difficult for the patient to

follow.

5. Adjust the treatment regimen to meet patient requests.

6. Establish as specific plan or contract with the patient with simple,

measurable goals.

7. Provide positive reinforcement of self-care behaviors performed

instead of focusing on behaviors that were neglected.

8. Encourage the patient to pursue life goals and interests, and

discourage an undue focus on diabetes.
 9. Educate client on wound care, insulin preparation, and glucose
monitoring.

10. Instruct client to comply with the appointment with the healthcare
provider at least twice a year for ongoing evaluation and routine nutrition
updates.

11. Remind the patient to participate in recommended health

promotion activities and age-appropriate health screenings.
12. Encourage participation in support groups with patients who have
had diabetes for many years as well for those who are newly diagnosed.
H. Documentation Guidelines
The following should be documented for patients with diabetes mellitus.
1. Document findings related to individual situation, risk factors,
current caloric intake and dietary pattern, and prescription medication
use.

2. Document results of laboratory tests.

3. Document the teaching plan and those involved in the planning.

4. Document individual responses to interventions, teaching, and

actions performed.

5. Document specific actions and changes made.

6. Document progress towards desired outcomes.

7. Document modifications in the plan of care, if any.

 BAB III
NURSING CASE REPORT

I.Assessment
1. Identity
Name : Mr. S
Age : 51 years old
Gender : Male
Diagnose : DM type II
RM Number: 01.07.xx.xx
2. Medis Record
Patient said has a family member with diabetes mellitus.
3. Activity / Rest
 Patient has no weakness or fatigue.
4. Circulation
Symptoms: ulcers on the legs, a long healing process, tingling /
numbness in the extremities.
Signs: skin hot, dry and reddish.
5. Ego integrity
Patient still can take care of himself
6. Elimination
Symptoms: changes in the pattern of urination (polyuria), nocturia
Signs: dilute urine, pale dry, polyuri.
Patient said often feel thirsty and often has a urination at the night.
7. Food / fluid
Symptoms: loss of appetite, nausea / vomiting, do not follow the diet,
weight loss.
Symptoms: dry skin / scaly, ugly turgor.
Patient has no complain about nausea but sometimes feel like has a full
stomach and abdominal pain. GDS : 350 mg/dl
8. Pain / comfort
Symptoms: pain in the ulcer wound
Signs: face grimacing with palpitations, looks very carefully.
9. Security
Patient has a little ulceration on his foot.

J. Diagnoses
1. Fluid Volume Deficit related to limited input.
2. Imbalanced Nutrition, Less Than Body Requirements related to
insulin insufficiency, decreased oral input: a full stomach, abdominal
pain, change in consciousness: hypermetabolism status, the release of
stress hormones.
3. Risk for Infection related to inadequate peripheral defense, changes
in circulation, high blood sugar levels, invasive procedures and skin
damage.
 4. Knowledge Deficit: about condition, prognosis and treatment needs
related to misinterpretation of information / do not know the source of
information.

K. Planning (Nursing Intervention)

 C. Planning (Nursing Intervention)

Diagnose NOC NIC Rational

Fluid Volume Deficit
Expected outcomes: 1. Monitor vital signs, 1. Hypovolemia can
Patients showed an note the presence of be manifested by
improvement in fluid orthostatic blood hypotension and
balance, pressure. tachycardia.
the criteria; spending 2. Assess breathing and 2. The lungs secrete
adequate urine (normal breath patterns. carbonic acid is
range), vital signs 3. Assess temperature, produced through
stable, clear peripheral color and moisture. respiration compensated
4. Assess peripheral respiratory alkalosis, the
pulse pressure, good
pulses, capillary refill, state of ketoacidosis.
skin turgor, capillary
skin turgor and mucous 3. Fever, chills, and
refill well and mucous
membranes. diaphoresis is common
membranes moist or
5. Monitor intake and in the infection process.
wet.
output. Record the urine Fever with skin redness,
specific gravity. dry, maybe a picture of
6. Measure body
dehydration.
weight every day. 4. Is an indicator of
7. Collaboration fluid
the level of dehydration
therapy as indicated
or adequate circulating
volume.
5. Provide the
estimated need for fluid
replacement, renal
function and the
 effectiveness of a given
therapy.
6. Provide the best
results of the
assessment of the status
of ongoing fluid and
further in giving
replacement fluids.
7. Type and amount
of fluid depends on the
degree of dehydration
and individual patient
response.
Imbalanced Nutrition, Less Goal: weight can be 1. Measure body 1. Knowing eating
Than Body Requirements increased with normal weight per day as adequate income.
laboratory values and indicated. 2. Identify deviations
no signs of 2. Determine the diet from the requirements.
malnutrition. program and diet of 3. Influence of
patients compared with intervention options.
Expected outcomes: food that can be spent on 4. Potentially life-
Patients are able to the patient. threatening, which
express an 3. Auscultation of must be multiplied and
understanding of bowel sounds, record the handled appropriately.
presence of abdominal 5. It is useful to
substance abuse,
pain / abdominal control blood sugar
decrease the amount of
bloating, nausea, levels.
intake (diet on
 nutritional status). vomiting, keep fasting as
Demonstrate behaviors, indicated.
lifestyle changes to 4. Observation of the
improve and maintain a signs of hypoglycemia,
proper weight. such as changes in level
of consciousness, cold /
humid, rapid pulse,
hunger and dizziness.
5. Collaboration in the
delivery of insulin, blood
sugar tests and diet.
Risk for Infection Goal: Infection does not 1. Observation for 1. Incoming patients
occur. signs of infection and with infections that
inflammation such as normally might have
Expeected outcomes: fever, redness, pus in the been able to trigger a
Identify individual risk wound, purulent sputum, state ketosidosis or
factors and potential urine color cloudy and nosocomial infections.
interventions to reduce foggy. 2. Prevention of
infection. 2. Increase prevention nosocomial infections.
Maintain a safe aseptic efforts by performing 3. Glucose levels in
environment. good hand washing, each the blood will be the
contact on all items best medium for the
related to the patient, growth of germs.
including his or her own 4. Reduce the risk of
patients. urinary tract infection.
3. Maintain aseptic 5. Peripheral
circulation can be
 technique in invasive impaired which puts
procedures (such as patients at increased
infusion, catheter folley, risk of damage to the
etc.). skin / eye irritation and
4. Attach catheter / infection.
perineal care do well. 6. Makes it easy for
5. Give skin care with the lung to expand,
regular and earnest. lowering the risk of
Massage depressed bone hypoventilation.
area, keep skin dry, dry 7. Early handling can
linen and tight (not help prevent the onset
wrinkled). of sepsis.
6. Position the patient
in semi-Fowler position.
7. Collaboration
antibiotics as indicated.
Knowledge Deficit Goal: patient expressed 1. Assess the level of 1. Find out how much
understanding of the knowledge of the client experience and
conditions, procedures and family about the knowledge of the client
and effects of the disease. and family about the
treatment process. 2. Give an explanation disease.
to the client about 2. By knowing the
Expected outcomes: diseases and conditions diseases and conditions
Perform the necessary now. now, clients and their
procedures and explain 3. Encourage clients families will feel calm
the rationale of an and families to pay and reduce anxiety.
attention to her diet. 3. Diet and proper
 action.
Initiate the necessary
lifestyle changes and
participate in treatment
regimen.
4. Ask the client and
reiterated family of
materials that have been
given.
diet helps the healing
process.
4. Knowing how
much understanding of
clients and their
families and assess the
success of the action
taken.

L. Implementation and Evaluation

Time/ Dx Implementation Evaluation
Fluid Volume Deficit - Monitor vital signs, note the S : patients has no complain
07.00 a.m presence of orthostatic blood O:
07.15 a.m pressure. - Patient has good skin turgor and
- Monitor intake and output. mucous membranes moist or wet
Record the urine specific gravity. - BP : 150/80 mmHg
- Measure body weight every HR : 78 bpm
day. RR : 20
- GDS : 350 mg/dl
- UO : 500 cc

Imbalanced Nutrition, - Measure body weight
Less Than Body - Determine the diet program
and diet of patients
Requirements - Auscultation of bowel sounds,
08.00 a.m record the presence of abdominal
pain / abdominal bloating, nausea,
vomiting
- Observation of the signs of
hypoglycemia, such as changes in
level of consciousness, cold /
humid, rapid pulse, hunger and
dizziness.
Risk for Infection - Observation for signs of
9.0 a.m infection and inflammation such
as fever, redness, pus in the
wound, purulent sputum, urine
color cloudy and foggy.
- Teach patient and family how
to get good hand washing, each
contact on all items related to the
patient
- Maintain aseptic technique in
invasive procedures (such as
- Body weight : 65 kg
A : Fluid volume deficit handled
P : Monitor vital sign
S : Patients said thirsty
O:
- Skin isnt pale
- Body weight : 65 kg
- Patients diet program used up
A : Imbalanced Nutrition, Less Than Body
Requirements partly handled
P : Monitor sign of hypoglicemia
S : Patients said that able to be good hand
washing on him and his family
O:
- There is no sign of infection and
inflammation
- Patient can do handwashing
correctly
A : Risk for infection handled
P : Monitor sign of infection and inflamation
 infusion, catheter folley, etc.).
Knowledge Deficit - Give an explanation to the
9.30 a.m client about diseases and
conditions now.
- Ask the clients and families to
pay attention to her diet.
S : Patients said that understand about his
condition
O:
- Patient and his family can re
explain about disease
A : Knowledge deficit handled
P : Monitor patients diet program