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Assessment is the first step in the nursing process and basic overall.
Assessment of patients with diabetes mellitus (Doenges, 1999) include:
a. Activity / Rest
Symptoms: weakness, fatigue, difficulty moving / walking, muscle cramps,
decreased muscle tone.
Signs: decreased muscle strength.
b. Circulation
Symptoms: ulcers on the legs, a long healing process, tingling / numbness in the
extremities.
Signs: skin hot, dry and reddish.
c. Ego integrity
Symptoms: depend on others.
Signs: anxiety, sensitive stimuli.
d. Elimination
Symptoms: changes in the pattern of urination (polyuria), nocturia
Signs: dilute urine, pale dry, poliurine.
e. Food / fluid
Symptoms: loss of appetite, nausea / vomiting, do not follow the diet, weight loss.
Symptoms: dry skin / scaly, ugly turgor.
f. Pain / comfort
Symptoms: pain in the ulcer wound
Signs: face grimacing with palpitations, looks very carefully.
g. Security
Symptoms: dry skin, itching, skin ulcers.
Symptoms: fever, diaphoresis, damaged skin, lesion / ulceration
h. Counseling / learning
Symptoms: family risk factors diabetes, heart disease, stroke, hypertension, long
healing. The use of drugs such as steroids, diuretics (thiazides): diantin and
phenobarbital (may increase blood glucose levels).
Nursing Diagnosis for Diabetes Mellitus
Nursing diagnoses in patients with diabetes mellitus (Doenges, 1999) are:
1.
Fluid Volume Deficit related to osmotic diuresis, gastric loss, excessive
diarrhea, nausea, vomiting, limited input, mental mess.
2.
Imbalanced Nutrition, Less Than Body Requirements related to insulin
insufficiency, decreased oral input: anorexia, nausea, a full stomach, abdominal
pain, change in consciousness: hypermetabolism status, the release of stress
hormones.
3.
Risk for Infection related to inadequate peripheral defense, changes in
circulation, high blood sugar levels, invasive procedures and skin damage.
4.
Fatigue related to decreased metabolic energy production, changes in blood
chemistry, insulin insufficiency, increased energy demand, hypermetabolism status
status / infection.
5.
Knowledge Deficit: about condition, prognosis and treatment needs related to
misinterpretation of information / do not know the source of information.