Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid metabolism.

metabolism. The primary feature of this disorder is

elevation in blood glucose levels (hyperglycemia), resulting from either a defect in insulin secretion from the pancreas, a change in insulinaction, or both. Sustained
hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the
eyes, nerves, kidneys, and blood vessels.
Deficient FIuid VoIume
Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine
acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.
Assessment Nursing
Diagnosis
Planning Nursing
Interventions
Rationale Evaluation
Subjective: (none)
Objective:
O elevated
temperature
oI
38.4C/axill
a
O increased
urine output.
O sweating oI
the skin
O thirst
O exhaustion
O weight loss
O dry skin or
mucous
membrane
DeIicient
Fluid
Volume r/t
intracellular
DHN 2 the
DM II
Short
Term:AIter 3
oI NI, patient
shall have
verbalized
understanding oI
causative Iactors
and purpose oI
individual
therapeutic
interventions
andmedications.
Long Term:
AIter 2 days oI
NI, the patient
shall have
maintained Iluid
volume at a
Iunctional level
Establish
rapport
Take and
record vital
signs
Monitor the
temperature
Assess skin
turgor and
mucous
membranes Ior
signs oI
dehydration
Encourage the
patient to
increase Iluid
Friendly
relationship
with patient
and to be able
to each
other`s
concern
To obtain
baseline data
To monitor
changes in
temperature
Dry skin and
mucous
membranes
are signs oI
dehydration
Short
Term:AIter 3
oI NI, patient
will have
verbalized
understanding
oI causative
Iactors and
purpose oI
individual
therapeutic
interventions
andmedications.
Long Term:
AIter 2 days oI
NI, the patient
will have
maintained
Iluid volume at
as evidenced by
individual good
skin turgor,
moist mucous
membrane and
stable vital signs.
intake
Administer IVF
as ordered by
the Doctor
Administer
anti-pyretic as
prescribed by
the Doctor.
To replace
Iluid loss and
prevent
dehydration
To replace
electrolytes
and Iluid loss
To decrease
body
temperature
and will have
less
occurrence oI
dehydration.
a Iunctional
level as
evidenced by
individual good
skin turgor,
moist mucous
membrane and
stable vital
signs
mbaIanced Nutrition: Less Than Body Requirements
Due to decrease of lack of insulin in the body, the glucose level continuously rises because glucose can't be utilized without the presence of insulin. Glucose is the
source of energy, while insulin is the vehicle to transport glucose to the body tissues. Because of decrease insulin level in the blood stream, the cells starved,
leading to alteration of metabolism. The body needs glucose for metabolism; there will be a breakdown of energy reserved from adipose tissue, muscles and liver
(glucagons). This will result to weight loss. But the energy breaks down, the glucose level continuously increase because there is less amount of insulin. The body
tissues need to be fed, this will lead to polyphagia and polydipsia because the tissue are not being fed and need glucose for metabolism.
Assessment Nursing Diagnosis Planning Nursing
Interventions
Rationale Evaluation
Subjective:
Objective:
Imbalanced
Nutrition: less than
body requirement
Short Term:
AIter 3 oI NI,
patient shall have
Establish rapport
Ascertain
understanding oI
Friendly
relationship with
patient and to be
Short Term:
AIter 3 oI
NI, patient
!t.
maniIested:
- poor
muscle tone
- generalized
weakness
- increased
thirst
- increased
urination
-polyphagia
!t. may
maniIest:
- loss oI
weight
r/t insulindeIiciency verbalized
understanding oI
causative Iactors
when known and
necessary
interventions and
identiIied
diabetic client.
Long Term:
AIter 1-4 months
oI NI, the patient
shall have
demonstrated
weight gain
toward goal.
individual nutritional
needs
Discuss eating habits
and encourage
diabetic diet as
prescribed by the
Doctor
Document actual
weight, do not
estimate.
Note total daily
intake including
patterns and time oI
eating.
Consult
dietician/physician
Ior
Iurtherassessment and
recommend-dation
regarding Iood
preIerences and nutri-
tional support
able to each other`s
concern
To determine what
inIormation to be
provided to
client/SO
- To achieve health
needs oI the patient
with the proper Iood
diet Ior is/her
disease
- !atient may be un
aware oI their actual
weight or weight
loss due to
estimating weight.
- To reveal changes
that should be made
in client`s dietary
intake
- For greater
understanding and
Iurtherassessment oI
speciIic Ioods.
will have
verbalized
understanding
oI causative
Iactors when
known and
necessary
interventions
and identiIied
diabetic
client.
Long Term:
AIter 1-4
months oI NI,
the patient
will have
demonstrated
weight gain
toward goal.
atigue
Diabetes Mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood resulting from defects
in insulin secretion, insulin action, or both. n type 2 diabetes, people have decreased sensitivity to insulin and impaired beta cell functioning resulting in
decreased insulin production. Glucose derived from food cannot be stored in the liver thereby remaining into the bloodstream. The beta cells of the islets of
Langerhans release glucagon which stimulates the liver to release the stored glucose. After 8 12 hours, the liver forms glucose from the breakdown of
noncarboghydrate substances, including amino acids resulting to muscle wasting which results to weakness.
Assessment Nursing
Diagnosis
Planning Nursing
Interventions
Rationale Evaluation
Subjective: (none)
Objective:
O generalized weakness
O increasedrespiratoryrat
e oI 25cpm
O presence oI non-
healing wound on both
Ieet
O body weakness
O wt. loss
O Iatigue
O limited ROM
O inability to perIorm
ADL
O altered VS
O altered sensorium
Fatiguerelated
to decreased
muscular
strength
Short
Term:AIter 2-3
oI nursing
interventions, the
patient will be
able to identiIy
measures to
conserve and
increase body
energy.
Long Term:
AIter 3-5 days oI
nursing
interventions, the
patient will be
Iree Irom signs
oIIatigue
-Assess
response to
activity
-Asses muscle
strength oI
patient and
Iunctional level
oI activity.
-Discuss with
patient the need
Ior activity
-Alternate
activity with
periods oI rest/
uninterrupted
sleep.
-Monitor pulse,
respiration rate
and blood
pressure
beIore/aIter
activity
-Response to an
activity can be
evaluated to
achieve desired
level oI
tolerance.
-To determine
the level oI
activity
-Education may
provide
motivation to
increase activity
level even
though patient
may Ieel too
weak initially
-!revents
excessiveIatigue
-Indicates
physiological
levels oI
The patient
shall have
been able to
identiIy
measures to
conserve and
increase body
energy
The patient
shall have
been Iree
Irom signs
oI Iatigue
-!erIorm
activity slowly
with Irequent
rest periods
-!romote
energy
conservation
techniques by
discussing
ways oI
conserving
energy while
bathing,
transIerring and
so on.
-!rovide
adequate
ventilation
-!rovide
comIort and
saIety
-Instruct patient
to perIorm
deep breathing
exercises
-Instruct client
to increase
tolerance
-Tolerance
develops by
adjusting
Irequency,
duration and
intensity until
desired activity
level is
achieved.
-Interventions
should be
directed at
delaying the
onset
oI Iatigueand
optimizing
muscle
eIIiciency.
Symptoms
oIIatigue are
alleviated with
rest. Also,
patient will be
able to
accomplish
more with a
decreased
expenditure oI
energy.
Vitamins A, C
and D and
protein in her
diet.
-Instruct also
patient to
increase iron in
diet
-Administer
oxygen as
ordered.
-For proper
oxygenation
-To be Iree
Irom injury
-!romotes
relaxation
-For muscle
strength and
tissue repair
-To prevent
weakness and
paleness
-To provide
proper
ventilation
Risk for nfection
#isks for infection is a increased probability of invasion of pathogenic organisms for a pt. with DM wound is possible in the furure. Clients with
diabetes are susceptible to infections because of polymorphonuclear leukocyte function, diabetic neuropathies, and vascular insufficiency as a
result is a poor glycemic control; thus making a wound to heal slowly because the damaged of the vascular system cannot carry sufficient oxygen,
WBC, nutrients, and antibodies to the injured site. Thereby infections increase and enhance possibility of further complications.
Assessment Nursing
Diagnosis
Planning Nursing
Interventions
Rationale Evaluation
Subjective:
Objective:
!t. maniIested:
-purulent
discharge
-hyperthermia
!t. may
maniIest:
-altered
circulation
-
immunological
deIicit
Risk Ior
inIectionrelated
to disease
condition.
Short Term:
AIter 4 hours oI
N!I the risks
Iactors oI
occurrence oI
inIection will be
reduce or control
to a manageable
level by a clean
bed and maintain
skin intact.
Long Term:
AIter 1-2 weeks
oI N!I, pt will be
Iree oI purulent
drainage or
erythema and be
aIebrile
-Establish
rapport
-Take and
record vital
signs
-Encourage
expression oI
Ieelings and
anxieties
- Observe non
verbal cues
-Encourage
client to look
at/touch
aIIected body
part
-Encourage
verbalization oI
and role play
anticipated
conIlicts
-encourage to
increase Iluid
intake
-increase Vit. C
- to obtain
patient`s trust
and
cooperation
- To obtain
baseline data
- Iacilitates
grieving the
loss
- non verbal
cues is more
accurate than
verbal cues
- to begin to
incorporate
changes into
body image
- to enhance
handling oI
potential
problems
-to prevent
dehydration
-to boost
immune
system and
Short Term:
-The pt. shall
have
identiIied
risks Iactors
oI occurrence
oI inIection
shall have
reduced or
controlled to
a manageable
level by a
clean bed and
skin intact.
Long Term:
-The patient
shall be Iree
oI purulent
damage or
erythema and
be Iebrile
in the diet
-increase
CHON intake
-change
dressing
-provide a saIe
and quiet
environment
-Take Due
meds on time
promote
collagen
Iormation
-Ior tissue
repair
-to promote
healing and
prevent
contamination
oI the wound
-to promote
pt`s comIort
- To met the
body`s
requirements