Assessment

Subjective:
Mataasparinyungblood
sugarkosakatawanas
verbalizedbythepatient
Objective:
*IncreasedUrinaryOutput
*Weakness
*Fatigue
*DiluteUrine
*PoorMuscletone

Diagnosis

Objectives

UnstableBlood
GlucoseLevelrelated
tolackofdiabetes
managementor
adherencetodiabetes
actionplan;inadequate
bloodglucose
monitoringor
medication
management

ShortTerm:
After4hoursof
nursinginterventionthe
patientwillbeableto
verbalizeplanfor
modifyingfactorsto
preventorminimize
complications
Longterm:
After12daysof
nursinginterventionthe
patientwillbeableto
maintainglucosein
satisfactoryrange.

Intervention
Independent:
*Establishrapport
*Monitorandrecord
vitalsigns
*PerformFingerStick
GlucoseTesting.As
certainwhetherclient
andsoareadeptat
bloodglucose
monitoringandare
testingaccordingto
plan

ForclientonInsulin:
*reviewtype(s)of
insulinused,suchas
rapid,shortacting,
intermediate,long
acting,remixedallthe
deliverymethodSQ,
inhaledorpump.
*Reviewpatients
dietaryprogramand
usualpatterncompose
withrecentintake
*IncludeSOinmeal
planningasindicated

COLABORATIVE:
Monitorlaboratory
studiessuchassevere
glucose,acetone,Ph,
HCO3

Rationale
*Togaintrustand
cooperation
*Toobtaininitialdata
*Allavailableglucose
monitorswillprovide
satisfactoryreadingif
properlyusedand
maintainedand
routinelycalibrated
Note:UnstableBlood
Glucoseisoften
associatedwithfailure
toperformtestingona
regularschedule
*Thesefactorsaffect
timingofeffectsand
providecluesto
potentialtimingof
glucoseinstability
*Identifiesdeficitsand
deviationsfrom
therapeuticplan,which
mayprecipitate
unstableglucoseand
uncontrolled
hyperglycemia
*Promotesenseof
involvement;provides
informationforsoto
understandnutritional
needsofthepatient.
*Bloodglucosewill
deceaseslowlywith
controlledfluid
replacementandinsulin
therapy

Evaluation
ShortTerm:
After4hoursofnursing
intervention,thepatient
wasabletoverbalizeplan
formodifyingfactorsto
preventorminimize
complications.
LongTerm:
After12daysofnursing
interventionthepatient
wasabletomaintain
glucoseinsatisfactory
range.

Assessment
Subjective:
Sobrangnamamanasparin
angkatawankoas
verbalizedbythepatient
Objective:
*alteredrespiratorypattern
*Changesinbloodpressure
*Crackles
*Edema
*Intakegreaterthanoutput
*rapidweightgain

Diagnosis

Objectives

Excessfluidvolume
relatedtoexcessfluid
intakeorretention

ShortTerm:
After4hoursof
nursingintervention,
thepatientwillbeable
tostateabilitytobreath
comfortably

Independent:
*Establishrapport

Intervention

Longterm:
After12daysof
nursinginterventionthe
patientwillbeableto
returntobaseline
weightandmaintain
vitalsignswithin
normallimits.

*Helppatientintoa
positionthataids
breathingsuchas
fowlersorsemi
fowlers
*Administeroxygenas
ordered.
*Measureandrecord
intakeandoutput

*Monitorandrecord
vitalsigns

*Accesspatientdaily
foredema,including
ascitesanddependent
orseveraledema
*Encouragepatientto
coughanddeepbreath
everytwohours.
*Maintainpatienton
sodiumrestricteddiet
asordered.
Dependent:
Administerdiagnostics
asorderedbythe
physician

Rationale

Evaluation

ShortTerm:
*Togaintrustand
After4hoursofnursing
cooperation
intervention,thepatient
*Toobtaininitialdata/ wasabletostateability
Changesmayindicate tobreathcomfortably
fluidorelectrolyte
imbalance
LongTerm:
*toincreasechest
After12daysof
expansionand
nursinginterventionthe
improveventilation
patientwasableto
returntobaselineweight
andmaintainvitalsigns
*Toenhancearterial
withinnormallimits.
bloodoxygenation
*Intakegreaterthat
outputmayindicate
fluidretentionand
possibleoverload.
*Fluidoverloador
decreasedosmotic
pressuremayresultin
edema,especiallyin
dependentareas
*toprevent
pulmonary
complications
*Toreduceexcess
fluidandpreventre
accumulation
*Topromotefluid
excretion.Record
effects.

Assessment

Diagnosis

Objectives

(NotApplicable;Presenceof
signsandsymptoms
establishesandactual
diagnosis)

Riskforinfection
relatedtohighglucose
levels,decreased
leukocytefunction,
alterationsin
circulation

ShortTerm:
After4hoursof
nursingintervention,
thepatientwillbeable
toidentifyinterventions
topreventorreduce
riskofinfection
Longterm:
After12daysof
nursinginterventionthe
patientwillbeableto
demonstratetechniques
andlifestylechangesto
preventdevelopmentof
infection

Intervention
Independent:
*Establishrapport
*Monitorandrecord
vitalsigns
*Promotegoodhand
washingbystaffand
patient.
*Observeforsignsof
infectionand
inflammationfever,
flushedappearance,
wounddrainage,
cloudywind
*Inspectpatientsfeet,
notingpresenceof
ulcersorinfected
ingrowntoenails,or
otherproblemrequiring
medicalornursing
intervention.

Rationale

Evaluation

ShortTerm:
*Togaintrustand
After4hoursofnursing
cooperation
intervention,thepatient
*Toobtaininitialdata wasabletoidentify
interventionstoprevent
orreduceriskof
*Reducesriskof
infection
crosscontamination.
*Patientmaybe
admittedwith
infectionwhichcould
haveprecipitatedthe
acidicstateormay
developnosocomial
infection
*Footinjuriesand
impairedcirculation
areassociatedwith
manycomplicationsin
diabeticsinduring
cellulitisand
amputations.

*Providetissueand
trashbagina
convenientlocationfor
sputumandother
secretionsinstruct
patientinproper
handlingofsecretions

*Minimizespreadof
infection

Collaborative:
Administerantibiotics
asappropriate

*Earlytreatmentmay
helpsepsis

LongTerm:
After12daysof
nursinginterventionthe
patientwasableto
demonstratetechniques
andlifestylechangesto
preventdevelopmentof
infection