Nursing Care Plan Diabetes Mellitus

Assessment

1. Family Health History
Are there families who suffer from illnesses such as client?
2. Patient Health History and Previous Treatment
How long suffered from DM client, how to handle, get what kind of insulin therapy, how to take the medicine whether regular or not, what is done to cope with illness clients.
3. Activity / Rest:
Tired, weak, hard Moves / walking, muscle cramps, decreased muscle tone.
4. Circulation
Is there a history of hypertension, AMI, claudication, numbness, tingling in the extremities, ulcers on the feet long healing time, tachycardia, changes in blood pressure
5. Ego Integrity
Stress, anxiety
6. Elimination
Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea
7. Food / Fluids
Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, the use of diuretics.
8. Neurosensori
Dizziness, headache, numbness, muscle weakness numbness, paraesthesia, visual disturbances.
9. Pain / Leisure
Abdominal strain, pain (is / weight)
10. Respiratory
Cough with or without purulent sputum
11. Security
Dry skin, itching, skin ulcer.


Nursing Problems

1. High risk of nutritional deficiencies: lack of demand
2. Lack of fluid volume
3. Disruption of skin integrity
4. A risk of injury


Intervention

1. High risk of nutritional deficiencies: lack of demand reduction associated with oral input, anorexia, nausea, increased metabolism of proteins, fats.
Destination: the patient's nutritional needs are met
Results Criteria:
Patients can digest the amount of calories or the right nutrients
Stable weight or additions to the range typically
Intervention:

* Measure your weight every day, or according to the indication.
* Determine the diet and eating patterns of patients and compare it with food that can be spent on patients.
* Auscultation bowel sounds, noted the existence of abdominal pain / abdominal bloating, nausea, vomit food that has not had time to digest, maintain a state of fasting according to the indication.
* Provide a liquid diet containing foods (nutrients) and the electrolyte immediately if the patient is able to tolerate the oral.
* Involve the patient's family at this meal digestion according to the indication.
* Observe the signs of hypoglycemia such as changes in level of consciousness, skin moist / cold, rapid pulse, hunger, sensitive stimuli, anxiety, headaches.
* Collaboration blood sugar checks.
* Collaboration delivery of insulin treatment.
* Collaboration with dieticians.

2. Lack of fluid volume associated with osmotic diuresis.
Destination: liquid or hydration needs of patients are met
Results Criteria:
Patients showed an adequate hydration evidenced by stable vital signs, palpable peripheral pulse, skin turgor and capillary filling good, right individual urine elimination and electrolyte levels within normal limits.
Intervention:

* Monitor vital signs, note the change ortostatik TD
* Monitor the breathing pattern as the respiratory kusmaul
* Review the frequency and quality of breathing, use of aids breathing muscles
* Review the peripheral pulse, capillary filling, skin turgor and mucous membranes
* Monitor intake and expenditure
* Maintain fluid to provide at least 2500 ml / day within tolerable limits heart
* Note things such as nausea, vomiting and distension of the stomach.
* Observations of increased fatigue, edema, irregular pulse
* Collaboration: give normal fluid therapy with or without copy dextrosa, monitor laboratory examination (Ht, BUN, Na, K).

3. Integrity of skin disorders associated with changes in metabolic status (peripheral neuropathy).
Destination: the integrity of skin disorders can be reduced or showed healing.
Results Criteria:
Wound condition showed improvement and non-infected tissue
Intervention:

* Review the wound, the epitelisasi, color changes, edema, and discharge, the frequency of dressing change.
* Review of vital signs
* Review of pain
* Perform wound care
* Collaboration delivery of insulin and medication.
* Collaboration antibiotics as indicated.

4. A risk of injury associated with decreased visual function
Destination: patients do not experience injury
Criteria Results: patients can meet their needs without experiencing injury
Intervention:

* Avoid slippery floors.
* Use a low bed.
* Orient clients to the room.
* Help clients in daily activities
* Help patients in ambulasi or change positions.