LA MADRID, Hanna Mae B.

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for Unstable After a day of - Administer basal and - Adherence to the After a day of
Blood Glucose as executing the prandial insulin. therapeutic regimen executing the
-- evidenced by necessary promotes tissue perfusion. necessary
Insulin deficiency interventions, the Keeping glucose in the interventions, the
or excess. patient will normal range slows the patient was able
Objective: achieve the progression of to achieve the ff.
following microvascular disease. outcomes:
CBG (before taking outcomes:
insulin): 273 mg/dl - Watch out for signs of - An elevated blood glucose - Patient has a
- Patient has a morning hyperglycemia. level arising in the morning blood glucose
CBG (after taking blood glucose due to insufficient level of reading of less
insulin): 51 mg/dl reading of less insulin (causes the dawn than 180 ml/dl;
than 180 ml/dl; phenomenon or BG levels fasting blood
- dizziness fasting blood begin to rise at 3 AM) glucose levels of
- slow to react glucose levels of less than <140
- confused less than <140 - Teach patient how to - Blood glucose is mg/dl;
- lethargic mg/dl; hemoglobin perform home glucose monitored before meals and hemoglobin A1C
- shakiness A1C level <7% monitoring. at bedtime. Glucose values level <7%
are used to adjust insulin
- Patient will doses. - Patient will
achieve and achieve and
maintain glucose - Report BP of more than - Hypertension is commonly maintain glucose
in satisfactory 160 mmHg. Administer associated with diabetes. in satisfactory
range of <140 hypertensive as Control of BP prevents range of <140
mg/dl prescribed. coronary artery disease, mg/dl
stroke, retinopathy, and
- Patient will nephropathy. - Patient will
acknowledge key acknowledge key
factors that may factors that may
contribute to - Instruct patient to take contribute to
unstable blood oral hypoglycemic unstable blood
glucose levels. medications as directed. glucose levels.

- Instruct patient to take

insulin as directed.
LA MADRID, Hanna Mae B.
- Instruct patient on the
proper injection of insulin.
- Stress the importance of
achieving blood glucose
control.
- Explain the importance
of having consistent meal
content or timing.
- Educate patient on
maintaining consistency
in the amount of food and
the approximate time
intervals between meals.
- The absorption of insulin
is more consistent when
insulin is always injected in
the same anatomical site.
- Control of blood glucose
levels within non-diabetic
range can significantly
reduce the development
and progression of
complications.
- Recommendation is three
meals of equal size, evenly
spaced mealtimes (5-6
hours apart), with one or
two snacks. Pacing food
intake throughout the day
places more manageable
demands on the pancreas.
- A consistent amount of
food and time interval
between meals helps
prevent hypoglycemic
reactions and maintain
overall blood glucose
control.
LA MADRID, Hanna Mae B.
ASSESSMENT DIAGNOSIS OUTCOME INTERVENTIONS RATIONALE EVALUATION

Subjective: Deficient After executing the - Explain that long-acting - Long-acting insulin does Before discharge,
knowledge necessary nursing insulin only needed to be not have a peak of action. patient was able to
“Ma’am, pwede po related to interventions, the injected once or twice daily. Insulin glargine is effective demonstrate
for over 24 hours.
bang unfamiliarity patient is expected knowledge of insulin
pakipaliwanag with information to achieve the - Explain that regular - Dosage may be adjusted
injection,
nang mabuti kung as evidenced by following outcome: prandial insulins (Humulin) based on the actual amount symptoms, and
ano po yung dapat requests of should be injected 30 of food ingested because treatment of
at hindi dapat na information. - Before discharge, minutes before meals. rapid-acting insulins can be hypoglycemia and
gawin sa patient will Rapid-acting insulins may given after a meal. diet.
kondisyon ko?” as demonstrate be injected before or after
verbalized by the knowledge of eating.
patient. insulin injection,
symptoms, and - Explain that insulin - Insulin dosage should be
dosage might need to be reduced when fasting for
Objective: treatment of
adjusted. surgery, when not eating, or
hypoglycemia and when hypoglycemia occurs.
- confused diet. Illness or infection may
- seek of increase insulin
information requirements.

- Teach patient to rotate - Systematic rotation of

insulin injection sites. injection sites is
recommended to prevent
lipodystrophy.

- Explain the importance of - A 90-degree angle is the

inserting the needle
perpendicular to the skin.
best insertion angle because
this ensures deep
subcutaneous administration
of insulin. Injection that is
too deep or too shallow may
affect the rate of absorption
of the insulin.

- Use various tools to - In using variety of teaching

complement teaching and materials, make sure that
maintain flexibility with they match the patient’s
regard to teaching method. learning needs, language,
and reading level.
LA MADRID, Hanna Mae B.
- Teach patient to follow a
diet that is low in simple
sugars, low fat, and high in
fiber and whole grains.
- Teach patient to recognize
signs of hypoglycemia.
- Teach patient to treat
hypoglycemia with
crackers, a snack, or
glucagon injection.
- Provide written
information about diabetes
management for the patient
to refer to.
- A diet low fat and high in
fiber helps to control
cholesterol and triglycerides.
Three daily meals and an
evening snack is
recommended. Refined and
simple sugars should be
reduced and complex
carbohydrates, such as
cereals, rice should be
increased.
- Signs includes shakiness,
sweating, nervousness,
weakness, hunger, changes
in LOC. Hypoglycemia occurs
when the blood glucose levels
drop to less than 60 mg/dl.
Explain that hypoglycemia
occurs when there is too
much insulin, too little food,
too much oral hypoglycemic
agents or excessive physical
activity.
- Hypoglycemia should be
treated with a carbohydrate
snack (15 mg from a fast
acting source – soda, fruit
juices, candies)
- Reinforces learning and
convey the maximum
amount of information.
LA MADRID, Hanna Mae B.
ASSESSMENT DIAGNOSIS OUTCOME INTERVENTIONS RATIONALE EVALUATION

Subjective: After executing the - Teach and promote good - Hand hygiene is the single Before discharge,
Risk for infection necessary nursing hand hygiene. most effective way in patient was able to:
-- related to high interventions, the preventing the transmission
of diseases. Include the
glucose levels. patient is expected - Identify
patient’s SO in teaching.
to achieve the interventions to
Objective: following outcome - Maintain asepsis during - Increased glucose in the prevent/reduce risk
before his IV insertion, administration blood creates excellent of infection.
- flushed skin discharge: of medications, and medium for immune
- sweating providing wound care or dysfunction and for - Demonstrate
- chills - Identify site care. Rotate IV sites as pathogens to thrive. techniques, lifestyle
- warm to touch interventions to indicated. changes to prevent
prevent/reduce risk development of
Body Temp: of infection. - Provide catheter or - Urinary tract infections are infection.
perineal care. Teach female more prevalent in individuals
38°C/axilla
patients to clean from front with diabetes.
- Demonstrate to back after elimination.
WBC: 15.47 techniques, lifestyle
changes to prevent - Provide meticulous skin - An impairment or
development of care by gently massaging ineffective peripheral
infection. bony areas, keep skin dry. circulation can place the
Keep linens dry and patient at risk for increased
wrinkle-free. skin breakdown and
development of infection.

- Place in semi-Fowler’s - Facilitates lung expansion;

position. reduces risk of aspiration.

- Encourage coughing or - Helps in the ventilation of

deep breathing as the
patient is alert and
cooperative. Frequent
repositioning is also
recommended.
all lung areas and in
mobilizing secretions – stasis
of secretions can increase the
risk of infection.

- Provide tissues and trash - To help minimize the

bag in a convenient location spread of infection.
for sputum and other
secretions. Instruct patient
in proper handling of
secretions.
LA MADRID, Hanna Mae B.
- Encourage and assist with
oral hygiene.
- Encourage increase in
fluid intake unless
contraindicated.
- Administer antibiotics as
indicated.
- Reduces risk of oral/ gum
disease
- Increase fluid intake to
approximately 3,000 mL per
day to increase urinary flow
and prevent stasis of urine
which may increase
susceptibility of infection.
- Early treatment may help
prevent sepsis as patients
with diabetes are more prone
to serious infectious
diseases.