Subjective and objective

data that is pertinent to the

nursing diagnosis.

Subjective:

Nursing Diagnosis
R/T & AEB

Impaired
metabolic
function R/T
- Fatigue
- Nausea and vomiting insufficient
insulin
- Polyuria
secondary to
- Polyphagia
ineffective beta
- Nocturia
cells in
- Weakness
pancreatic
- Lethargy
- Glucose level at 400 islets; increased
insulin
from home test
requirements
secondary to
Objective:
infections,
stress, and/or
- Increased urine
illness;
output
unstable serum
- Diluted urine
- Lab glucose values of glucose levels
AEB: As
>600, 296, 232, and
evidenced by
220.
diluted urine,
fatigue, and
increased
glucose levels
throughout the
day.

Short and long term

measurable and realistic
patient goals & outcomes

Nursing interventions (Including

all assessments, treatments,
medications). Be specific.

Long-term - Will
Assess and record
maintain adequate
Vital signs and
metabolic function for
neurological status every
3 months without any
1 to 4 hours and PRN
hyper or hypoglycemic Blood glucose level and
S/S.
ordered and PRN. Fasting,
preprandial, and 3 a.m.
Short-Term By the
blood glucose levels may
end of my shift patient
be needed.
will better understand
how to give oneself a
shot. I will have him
repeat back to me what Assist child/family with
was taught to ensure
self-monitoring of blood
teaching was effective.
glucose PRN.
Signs/symptoms of hyper
or hypoglycemia every 2
to 4 hours and PRN
IV fluids and condition of
IV site every hour.

Documented rationale for

your interventions and
references (must include
reference for rationale-author
and page number)

Evaluation of goals:
achieved or measurable
changes? How would
you evaluate to
determine if goals were
met?

If a child experiences
altered metabolic
function the vital signs
will be out of the normal
range (can be increased
of decreased) and the
child can experience
decreased level of
consciousness as a result
of glucose being unable
to enter the cells. (Axton
& Fugate 2009).
Assessing and recording
blood glucose levels
provides information
about hyperglycemia
and hypoglycemia and
directs needed treatment
measures. It is necessary
to record the amount of
IV fluids every hour to
make sure the child is
not being over or under
hydrated . the IC site
needs the to be assessed
every hour for signs of
redness or swelling.

Long-term goal
unable to assess at
this time.
Short-term goal
Patient was hesitant
about giving himself
a shot but with some
instruction and
encouragement do
the staff and family
he was able to
finally give himself
his insulin shot.
Prior to doing so he
repeated everything
back to me and the
nurse as to how to
keep things sterile,
give himself a shot,
and discard of the
needle properly.

Teaching Goals
Child and family will
be able to verbalize at
least 4 characteristics
of impaired metabolic
function such as:
Increased number of
times child voids.
Increased thirst
Weight loss
Lethargy or stupor
Nausea/vomiting
Child and /or family
will be able to
verbalize knowledge
of care such as:
Glucose monitoring
Insulin dosage
adjustment
Insulin
administration and
site rotation
Food plan
(carbohydrate
counting) and
exercise
Regular eye
examination
Foot care
Nephrotic screening
Identification of any

Maintain diabetic flow sheet.

Include blood glucose levels,
insulin dose, injection site,
clinical observations, urine
test results, and intake and
output.
Keep accurate record of
intake and output.

Provides information
that helps detects hyper
and hypoglycemia.
(Axton & Fugate 2009).

Increased urinary output

may indicate
hyperglycemia, which
causes osmotic diuresis
and can lead to
dehydration. (Axton &
Fugate 2009).
Weigh child daily on same
Decrease in weight may
scale at same time each day. initially be due to
Record weight and compare
dehydrations or may
the previous weight.
indicate catabolism,
which is caused by
inability of glucose to
enter the cells. (Axton &
Fugate 2009).
Administer IV maintenance
IV fluids are necessary
and replacement fluids and
to combat dehydration.
supplements (such as
Potassium is needed to
potassium bicarbonate) and
combat decreased total
indicated. Assess and records body potassium. (Axton
childs response.
& Fugate 2009).
When indicated, administer
Insulin is administered
insulin on schedule. Assess
to facilitate glucose
and record effectiveness
entry into the cells.
(Axton & Fugate 2009).

Teaching Goals
evaluated:
Both him and his
mother were able
to verbalize at least
4 characteristics of
impaired metabolic
function by the end
of my shift and the
both of them were
also able to
verbalize
knowledge of care
for those listed in
the goals section.

signs and symptoms

of hyper and
hypoglycemia and
the correct action for
each.
When to contact
health care provider

If child is hypoglycemic,
administer fruit juice (4 oz.),
regular soda (4 oz.), or
glucose tablets to provide
approximately 10 to 15
grams of carbohydrate or 40
calories. Repeat if child does
not feel better in 10 to 15
minutes. If severe
hypoglycemia occurs and the
child is unable to swallow,
administer glucagon as
indicated. Assess and record
childs response.
Teach child/family about
characteristics of altered
metabolic function. Assess
and record results.

Teaching child and family

about care. Assess and
record childs familys
knowledge of and
participation in care
regarding glucose
monitoring, etc.

Carbohydrates are
needed to combat
hypoglycemia and
return child to a
balanced metabolic
state. (Axton & Fugate
2009).

Increased knowledge
will assist the
child/family in
recognizing and
reporting changes in the
childs condition.
(Axton & Fugate 2009).
Education of
child/family will allow
for accurate care.
(Axton & Fugate 2009).

Subjective and objective

data that is pertinent to the
nursing diagnosis.

Nursing Diagnosis
R/T & AEB

Short and long term

measurable and realistic
patient goals & outcomes

Nursing interventions (Including

all assessments, treatments,
medications). Be specific.

Documented rationale for

your interventions and
references (must include
reference for rationale-author
and page number)

Evaluation of goals:
achieved or measurable
changes? How would
you evaluate to
determine if goals were
met?

Subjective:

Deficient fluid
volume R/T
osmotic
diuresis
secondary to
hyperglycemia,
vomiting, and
decreased oral
intake.

Long-term Patient
will drink 6 8 8oz
glasses of water a day
for a month.

Assess and record

HR, RR, BP, and urine
specific gravity every 4
hours and PRN
IV fluids and condition of
IV site ever hour
Laboratory values as
indicated. Report any
abnormalities to the
physician.
S/S of deficient fluid
volume every 4 hours and
PRN

Provides information
about fluid status of
patient. If patient has
fluid volume deficit, the
HR will increase at first,
and eventually decrease.
It is necessary to record
the amount of IV fluids
every hour to make sure
the child is not being
over or under hydrated.
The IV site needs to be
assessed every hour for
signs of redness or
swelling. (Axton &
Fugate 2009).

Long-term goal
Unable to assess at
this time.
Short-term goal on
top of IV fluids the
patient drank 4
glasses of water and
a can of soda

Provide mouth care every 4

hours and PRN. Record
results.

Mouth care is needed

because the child is
prone to dehydration
and dry mucous
membranes. (Axton &
Fugate 2009).

Weigh child daily on same

scale at same time of day.
Document results and
compare to previous weight.

Weight loss is due to

dehydration as well as
the inability of glucose
to enter the cell, which

- Polyuria
- Weight loss
Objective:
- Flushed dry skin
- Dry mucous
membranes
- Decreased skin
turgor
- Tachycardia (average
heart rater = 90 beats
per/min)

AEB:
Excessive thirst
and tachycardia
(average heart
rater = 90 beats
per/min).

Short-Term Child
will have adequate
fluid volume by the
end of my shift, as
evidence by:
- Adequate fluid
intake IV and oral
vs. urine output
(1ml/kg/day)
- Moist mucous
membranes
- Rapid skin recoil
(less than 2 to 3
seconds)
- Urine specific
gravity from 1.008
1.020
- Heart rate with in
acceptable ranges
(70-90bpm)

triggers catabolism and

results in weight loss.
(Axton & Fugate 2009).

Teaching Goals
Child and/or family
will be able to
verbalize at least 4
characteristics of fluid
volume deficient such
as:
- Increased number
of times child voids
- Vomiting
- Flushed dry skin
- Weight loss
- Rapid heart rate
Child and/or family
will be able to
verbalize knowledge
of care such as:
- Monitoring intake
and output
- Identification of any
S/S of fluid volume
deficient and the
correct action.
- When to contact
health care provider

Teach child/family about

characteristics of deficient
fluid volume. Assess and
record results.

Increased knowledge
will assist the
child/family in
recognizing and
reporting changes in the
childs condition.
(Axton & Fugate 2009).

Teach child/family about

care. Assess and record
childs/familys knowledge
of and participation in care
regarding monitoring intake
and output, etc.

Education of
child/family will allow
for accurate care.
(Axton & Fugate 2009).

Administer IV maintenance
and replacement fluids and
supplements (such as
potassium bicarbonate) and
indicated. Assess and records
childs response.

IV fluids are necessary

to combat dehydration.
Potassium is needed to
combat decreased total
body potassium. (Axton
& Fugate 2009).

Teaching Goals
evaluated:
The patient and
family were able to
verbalize at least 4
characteristics of
fluid volume
deficient and were
able to verbalize
knowledge of care
necessary to
prevent any
deficient of fluid
volume.

Subjective and objective

data that is pertinent to the
nursing diagnosis.

Nursing Diagnosis
R/T & AEB

Short and long term

measurable and realistic
patient goals & outcomes

Subjective:

Electrolyte
imbalance:
sodium losses
and potassium
losses R/T
sodium losses
secondary to
vomiting and
osmotic
diuresis and
potassium
losses
secondary to
polyuria.

- Weakness
- Lethargy
- Dry skin
Objective:
- Rapid heart rate
- Hyponatremia
- Hypokalemia

AEB: Lab
values of 129
mEq/L (L) of
sodium and 3.4
mEq/L (L) of
potassium.

Nursing interventions (Including

all assessments, treatments,
medications). Be specific.

Documented rationale for

your interventions and
references (must include
reference for rationale-author
and page number)

Evaluation of goals:
achieved or measurable
changes? How would
you evaluate to
determine if goals were
met?

Long-term Patient is Assess and record

able to successfully
HR and BP every 4 hours
keep both potassium
IV fluids and condition of
levels and sodium
IV sited every hour
levels within the
Laboratory values as
recommended ranges
indicated. Report any
for the next 3 months.
abnormalities to the
physician.
Short-Term Child
S/S of electrolyte
will maintain adequate
imbalance q4hr PRN.
electrolyte balance by
the end of my shift as
evidence by:
- Serum sodium from
135-145 mEq/L
- Serum potassium
from 3.5-5.0 mEq/L
- Heart rate within
When indicated, initiate use
acceptable range
of a cardiac monitor.
(70-90.)
Evaluate and record results
of EKG strips at least
once/shift.

Provides information
about electrolyte status
of patient. If patient has
fluid volume deficit, the
HR will increase at first,
and eventually decrease.
The BP will eventually
decrease. It is necessary
to record the amount of
IV fluids every hour to
make sure the child is
not being over or under
hydrated. The IV site
needs to be assessed
every hour for signs of
redness or swelling.
(Axton & Fugate 2009).

Long-term goal
Unable to assess at
this time.

Ensure that proper

supplements are added to IV
fluids.

Supplements are needed

to combat the effects of
insulin deficiency.
(Axton & Fugate 2009).

Provides information
about serum potassium
influence on cardiac
rhythm. (Axton &
Fugate 2009).

Short-term goal
we where able to get
the patients
potassium (3.5-5.0
mEq/L)and sodium
(135-145 mEq/L)
levels within the
recommended
healthy ranges

Teaching Goals
Child and/or family
will be able to
verbalize at least 4
characteristics of
electrolyte imbalance:
sodium losses and
potassium losses such
as:
- Weakness
- Delirium
- Flushed skin
- Rapid heart rate
- Coma
Child and/or family
will be able to
verbalize knowledge
of care such as:
- Identification of any
S/S of electrolyte
imbalance and the
correct action for
each.
- When to contact
health care
provider.

Teaching Goals
evaluated:
Teach child/family about
characteristics of electrolyte
imbalance: sodium losses
and potassium losses. Assess
and record results.

Increased knowledge
will assist the
child/family in
recognizing and
reporting changes in the
childs condition.
(Axton & Fugate 2009).

Teach child/family about

care. Assess and record
childs/familys knowledge
of and participation in care
regarding identification of
any S/S of electrolyte
imbalance, etc.

Education of
child/family will allow
for accurate care.
(Axton & Fugate 2009).

The patient and

family were able
to success fully
remember and
verbalize 4
characteristics of
electrolyte
imbalance. They
had some trouble
doing so
considering all the
other things they
had to remember
but they were
successful in the
end.

Subjective and objective

data that is pertinent to the
nursing diagnosis.

Nursing Diagnosis
R/T & AEB

Short and long term

measurable and realistic
patient goals & outcomes

Nursing interventions (Including

all assessments, treatments,
medications). Be specific.

Risk for
Infection R/T
High glucose
levels,
decreased
leukocyte
function,
alterations in
circulation

Long-term patient
will go without any
new infections at
insulin injection sits
for the next 3 months.

Observe for signs of

infection and inflammation,
e.g., fever, flushed
appearance, wound drainage,
purulent sputum, cloudy
urine.

Documented rationale for

your interventions and
references (must include
reference for rationale-author
and page number)

Patient may be admitted

with infection, which
could have precipitated
the ketoacidotic state, or
may develop a
nosocomial infection.
Short-Term Identify
(Bauldoff & Burke
interventions to
2010)
prevent/reduce risk of Promote good hand washing Reduces risk of crossinfection by the end of by staff and patient.
contamination.
my shift and
(Bauldoff & Burke
demonstrate
2010)
techniques and
Provide conscientious skin
Peripheral circulation
lifestyle changes to
care; gently massage bony
may be impaired,
prevent development
areas. Keep the skin dry,
placing patient at
of infection to
linens dry and wrinkle-free.
increased risk for skin
patient/family.
irritation/breakdown and
infection. (Bauldoff &
Burke 2010)
Encourage adequate dietary
Decreases susceptibility
and fluid intake
to infection. Increased
(approximately3000 mL/day urinary flow prevents
if not contraindicated by
stasis and aids in
cardiac or renal dysfunction), maintaining urine
including 8 oz of cranberry
pH/acidity, reducing
juice per day as appropriate. bacteria growth and
flushing organisms out
of system. Note: Use of

Evaluation of goals:
achieved or measurable
changes? How would
you evaluate to
determine if goals were
met?

Long-term goal
Unable to asses at
this time.
Short-term goal
Patient and family
were able to
successfully identify
infection risks in
their lives and how
to prevent them.
Also we were able
to teach them better
hand washing
technique of which
they practiced
themselves.

__________________

Teaching Goals
Child and/or family
will be able to
verbalize at least 4
characteristics of
infection prevention:
Administer antibiotics as
- Washing hands
appropriate.
frequently
- Sterile technique
with injection of
insulin.
- Proper disposal of
used materials to
insure there is no
cross contamination
or accidental
reusing of materials.
- Oral hygiene
- Foot care
- Hydration
- Good diet
- Exercise and
precautions while
doing so.

cranberry juice can help

prevent bacteria from
adhering to the bladder
wall, reducing the risk
of recurrent UTI.
(Bauldoff & Burke
2010)
Early treatment may
help prevent sepsis.
(Bauldoff & Burke
2010)

Teaching Goals
evaluated:
Patient and family
are now able to
verbalize not only
4 but many more
ways to prevent
infection.

Subjective and
objective data that is
pertinent to the
nursing diagnosis.

Nursing Diagnosis R/T &

AEB

Short and long term

measurable and realistic
patient goals & outcomes

Nursing interventions (Including

all assessments, treatments,
medications). Be specific.

Documented rationale for

your interventions and
references (must include
reference for rationale-author
and page number)

Evaluation of goals:
achieved or measurable
changes? How would
you evaluate to
determine if goals were
met?

Subjective:
- I dont know
much about the
resources in our
area that deal
with diabetes in
kids.
- We are pretty
much living on
one income.
Objective:
- Facial worry in
the mothers face
not only for her
son but also for
the finances.
- Mother appears
very tired and
ready to go
home.

Caregiver role strain

R/T deficient of
knowledge about
community resources
AEB: difficulty
accessing community
resources, and
emotional anxiety
when it comes to
finances and
distributing motherly
care evenly between
all her children. Lack
of sleep.

Long-term Family
will report low or no
feelings of burden or
distress by 3 months
due to there
accustoming to
managing diabetes.

Encourage the caregiver to

talk about feelings, concerns,
uncertainties, and fears.
Acknowledge the frustration
associated with caregiver
responsibilities.
Help the caregiver problem
solve to meet the care
recipient's needs.

Caregivers need a safe

outlet for their feelings
regarding the care
situation (Narayan et al,
2001).

Long-term goal
unable to assess at
this time.

Short-Term Family
will identify resources
available to help in
giving care.

Using problem solving

helping the caregiver
identify the problem, its
sources, and generating
potential solutions has
been shown to lower
distress in caregivers
(Given et al, 2006).
Identify potential caregiver
Caregivers can have
resources such as mastery,
simultaneous positive
social support, optimism, and and negative responses
positive aspects of care.
to providing care.
(Pinquart & Sorenson,
2003).

Short-term goal
utilizing both the
patients and
mothers cellular
phones we were
able to find 4 groups
in the are close to
there home that help
in not only people
get used to living
with diabetes but
also groups for
those taking care of
the person with
diabetes.

Help the caregiver to identify Caregivers sometimes

and utilize support systems.
feel abandoned and need
assistance to activate
their support systems
(Borg & Hallberg,
2006).