Nursing Diagnosis and Nursing Interventions

Nursing Intervention for Diabetes Mellitus

Diabetes mellitus (DM) is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period. Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced. Symptoms of high blood sugar include frequent urination, increased thirst, and increased hunger. Acute complications include diabetic ketoacidosis and nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, stroke, chronic kidney failure, foot ulcers, and damage to the eyes.

Nursing Intervention for Diabetes Mellitus

  1. Fluid Volume Deficit related to osmotic diuresis

    Goal :
    Liquid or hydration needs of patients are met

    Expected Results :
    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.

    Nursing Intervention :
    • Monitor vital signs, note the change orthostatic vital signs
    • Monitor the breathing pattern as the respiratory kussmaul
    • 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 output
    • Maintain fluid to provide at least 2500 ml / day within tolerable heart limits
    • Note things such as nausea, vomiting and distension of the stomach.
    • Observations of increased fatigue, edema, irregular pulse
    • Collaboration: give normal fluid therapy, monitor laboratory examination (Ht, BUN, Na, K).

  2. Disorders Impaired Skin Integrity  reated to changes in metabolic status (peripheral neuropathy).

    Goal :
    The integrity of skin disorders can be reduced or showed healing.

    Expected Results :
    Wound condition showed improvement and non-infected tissue

    Nursing 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 medication.
    • Collaboration antibiotics as indicated.

  3. Risk for injury related to decreased visual function

    Goal :
    Patients do not experience injury

    Expected 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.

  4. Imbalanced Nutrition: less than body requirements related to reduction oral input, anorexia, nausea, increased metabolism of proteins, fats.

    Goal :
    The patient's nutritional needs are met

    Expected Results :
    Patients can digest the amount of calories or the right nutrients
    Stable weight or additions to the range typically

    Nursing 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.

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