ASSESSMENT S> ihi ako ng ihi as verbalized by patient D> CBG= 353 g/dL >(+) polyuria >(+)polydypsia >(+)polyphagia

>wt= 84kg

EXPALNATION OF THE PROBLEM Diabetes Mellitus is a metabolic disease characterized by irregular carbohydrate, protein, and lipid metabolism. The primary feature of this disorder is elevation in blood glucose levels (hyperglycemia) which is seen in the patient, resulting from either a defect in insulin secretion from the pancreas, a change in insulin action, 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 which we do not want to happen to our patient.

GOALS AND OBJECTIVES LTO: after 72 hours of nursing interventions patient will be able to: a. Verbalize 4 long-term side effects of unmanaged diabetes by discharge. Demonstrate to the RN how to take his blood sugar and how to get himself insulin injections by discharge.

NURSING INTERVENTIONS DIAGNOSTICS a. Document actual weight, do not estimate. Note total daily intake including patterns and time of eating. b. Investigate changes in mentation.

RATIONALE

EVALUATION

a.

Patient may be unaware of their actual weight or weight loss due to estimating weight. Changes in mentation reflect abnormally high or low glucose level, acidosis, electrolyte imbalances and decreased cerebral perfusion.

b.

b.

STO: patient Blood Glucose will be 110-200 within 8 hours

THERAPEUTICS: Independent a. Maintain aseptic technique for IV insertion procedure, administration of medications b. Provide maintenance and site care to IV site Rotate IV sites as indicated.

a.

High glucose in the blood creates an excellent medium for bacterial growth. High glucose in the blood creates an excellent medium for bacterial growth. High glucose in the blood creates an excellent medium for bacterial growth. Peripheral circulation

b.

c.

c.

d.

Provide conscientious

d.

References: retrieved from: http://wps.prenhall.com/wps/media/objects/3918/4012970/NursingTools/ch50_NCP_IneffAirClear_1395-1396.pdf http://nsc-ultimatex.blogspot.com/2010/11/ineffective-airway-clearance.html

skin care, gently massage bony areas. Keep the skin dry, linens dry and wrinkle free

maybe impaired, placing patient at increased risk for skin irritation or breakdown and infection.

Dependent e. Monitor blood glucose level

e.

Basis for patient medication and meal plan To facilitate use of insulin to the body

f.

Administer humulin as ordered

f.

EDUCATIVE: a. Educate patient for proper diet and exercise a. To prevent complications

References: retrieved from: http://wps.prenhall.com/wps/media/objects/3918/4012970/NursingTools/ch50_NCP_IneffAirClear_1395-1396.pdf http://nsc-ultimatex.blogspot.com/2010/11/ineffective-airway-clearance.html