Nursing Care Plans

1.
Deficient Fluid Volume

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 Subjective: (none)Objective:
Nursing Diagnosis Planning
Deficient Fluid Short Term:After 3 of Volume r/t NI, patient shall have intracellular DHN 2verbalized understanding the DM II of causative factors and elevated purpose of individual temperature of therapeutic interventions 38.4C/axilla and medications.Long increased urine Term:After 2 days of NI, output. the patient shall have sweating of the maintained fluid volume skin at a functional level as thirst evidenced by individual exhaustion good skin turgor, moist weight loss mucous membrane and stable vital signs. dry skin or mucous membrane
Nursing Interventions Establish rapport Take and record vital signsMonitor the temperatureAssess skin turgor and mucous membranes for signs of dehydration Encourage the patient to increase fluid intake
Rationale Friendly relationship with patient and to be able to each others concernTo obtain baseline dataTo monitor changes in temperature Dry skin and mucous membranes are signs of dehydration To replace fluid loss and prevent dehydration
Evaluation Short Term:After 3 of NI, patient will have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.Long Term:After 2 days of NI, the patient will have maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs
Administer IVF as ordered by To replace electrolytes and fluid the Doctor loss Administer anti-pyretic as prescribed by the Doctor. To decrease body temperature and will have less occurrence of dehydration.
2. Imbalanced Nutrition: Less Than Body Requirements

Due to decrease of lack of insulin in the body, the glucose level continuously rises because glucose cant 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 Rationale Evaluation Interventions Subjective:Obje Imbalanced Nutrition: less than Short Term:After 3 of Establish rapport Friendly relationship with Short Term:After 3 of NI, patient will ctive:Pt. body requirement r/t insulin NI, patient shall have Ascertain understanding of patient and to be able to each have verbalized understanding of manifested:- poor deficiency verbalized understanding individual nutritional needs others concern causative factors when known and muscle toneof causative factors when Discuss eating habits and To determine what information necessary interventions and identified generalized known and necessary encourage diabetic diet as to be provided to client/SOdiabetic client.Long Term:After 1-4 weakness interventions and prescribed by the Doctor To achieve health needs of the months of NI, the patient will have identified diabetic Document actual weight, do not patient with the proper food diet demonstrated weight gain toward client.Long Term:After 1- estimate. for is/her disease- Patient may goal. - increased thirst 4 months of NI, the Note total daily intake including be un aware of their actual patient shall have patterns and time of eating. weight or weight loss due to - increased demonstrated weight gain estimating weight.urination toward goal. Consult dietician/physician for To reveal changes that should be made in clients dietary further assessment and -polyphagia recommend-dation regarding food intake preferences and nutri-tional Pt. may support - For greater understanding and manifest: further assessment of specific foods. - loss of weight Nursing Diagnosis Planning
3. Fatigue
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. In 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 Subjective: (none)Objective:

generalized weakness increased respiratory rate of 25cpm presence of nonhealing wound on both feet body weakness wt. loss fatigue limited ROM inability to perform ADL altered VS altered sensorium
Nursing Diagnosis Fatigue related to decreased muscular strength
Planning
Nursing Rationale Interventions Short Term:After -Assess response to activity- -Response to an activity can be evaluated to achieve 2-3 of nursing Asses muscle strength of desired level of tolerance. interventions, the patient and functional level of -To determine the level of activity-Education may provide patient will be able activity.-Discuss with patient motivation to increase activity level even though patient to identify the need for activity-Alternate may feel too weak initially-Prevents excessive fatiguemeasures to activity with periods of rest/ Indicates physiological levels of tolerance conserve and uninterrupted sleep.-Monitor increase body pulse, respiration rate and -Tolerance develops by adjusting frequency, duration and energy.Long blood pressure before/after intensity until desired activity level is achieved. Term:After 3-5 activity days of nursing -Interventions should be directed at delaying the onset of interventions, the -Perform activity slowly with fatigue and optimizing muscle efficiency. Symptoms of patient will be free frequent rest periods fatigue are alleviated with rest. Also, patient will be able from signs of to accomplish more with a decreased expenditure of fatigue -Promote energy conservation energy. techniques by discussing ways of conserving energy while -For proper oxygenation bathing, transferring and so on. -To be free from injury
Evaluation The patient shall have been able to identify measures to conserve and increase body energyThe patient shall have been free from signs of fatigue
-Provide adequate ventilation -Promotes relaxation -Provide comfort and safety -Instruct patient to perform deep breathing exercises -Instruct client to increase Vitamins A, C and D and protein in her diet. -Instruct also patient to increase iron in diet -Administer oxygen as ordered. -For muscle strength and tissue repair -To prevent weakness and paleness -To provide proper ventilation
4. Risk for Infection

Risks 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 Subjective:Objective:Pt. Risk for infection manifested:-purulent related to disease discharge-hyperthermia condition. Pt. may manifest: -altered circulation -immunological deficit Planning Nursing Rationale Evaluation Interventions Short Term:After 4 hours of -Establish rapport-Take and - to obtain patients trust Short Term:-The pt. shall have identified risks NPI the risks factors of record vital signs-Encourage and cooperation- To obtain factors of occurrence of infection shall have occurrence of infection will expression of feelings and baseline data- facilitates reduced or controlled to a manageable level be reduce or control to a anxieties- Observe non verbal grieving the loss- non by a clean bed and skin intact.Long Term:manageable level by a clean cues-Encourage client to look verbal cues is more accurate The patient shall be free of purulent damage bed and maintain skin at/touch affected body part than verbal cues- to begin to or erythema and be febrile intact.Long Term:After 1-2 incorporate changes into weeks of NPI, pt will be free -Encourage verbalization of and body image of purulent drainage or role play anticipated conflicts erythema and be afebrile - to enhance handling of potential problems -encourage to increase fluid intake -to prevent dehydration
-increase Vit. C in the diet -increase CHON intake -change dressing -provide a safe and quiet environment -Take Due meds on time
-to boost immune system and promote collagen formation -for tissue repair -to promote healing and prevent contamination of the wound -to promote pts comfort - To met the bodys requirements

Nursing Care Plans

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1.

Deficient Fluid Volume

Nursing Diagnosis Planning

2. Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis Fatigue related to decreased muscular strength

4. Risk for Infection

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