NURSING CARE PLAN HRP NSG.

DIAGNOSIS Deficient Fluid Volume r/t intracellular DHN 2 the DM II AMB Subjective:(none) Objective:

elevated temperature of 38.4C increased urine output. sweating of the skin thirst exhaustion weight loss dry skin or mucous membrane

PATHOPHYSIO LOGY 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.

CLIENT OUTCOME Within 8 hours of nursing intervention the patient shall have maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs.

NSG. INTERVENTION 1. Establish rapport with client. 2. Take and record vital sign esp. temp. 3. Assess skin turgor and mucous membranes for signs of dehydration. 4. Encourage the patient to increase fluid intake. 5. Administer IVF as ordered by the Doctor.

RATIONALE to obtain patients trust and cooperation. to obtain baseline data and monitor changes in temperature. -Dry skin and mucous membranes are signs of dehydration.

EVALUATION

- To replace fluid loss and prevent dehydration.

- To replace electrolytes and fluid loss.

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NSG. DIAGNOSIS Imbalanced Nutrition: less than body requirement r/t insulin deficiency

AMB

Subjective: none Objective: -poor muscle tone - body weakness noted - increased thirst - increased urination -polyphagia

PATHOPHYSIO CLIENT OUTCOME LOGY Due to decrease of Within 8 hours of lack of insulin in nursing intervention the body, the the patient 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

NSG. INTERVENTION 1. Establish rapport with client. 2. Take and record vital sign esp. temp.

RATIONALE to obtain patients trust and cooperation. - to obtain baseline data and monitor changes in temperature. - To determine what information to be provided to client.

EVALUATION

3. Ascertain understanding of individual nutritional needs.

4. Discuss eating habits and encourage diabetic - To achieve health needs diet as prescribed by of the patient with the the Doctor. proper food diet 5. Document actual weight, do not estimate. 6. Note total daily intake including patterns and time of eating.

- Patient may be un aware of their actual weight or weight loss. - To reveal changes that should be made in clients dietary intake.

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NSG. DIAGNOSIS Fatigue related to decreased muscular strength

AMB Subjective:(none) Objective:

increased respiratory rate of 25cpm body weakness fatigue limited ROM noted inability to perform ADL without assistance

PATHOPHYSIO CLIENT OUTCOME LOGY Diabetes Mellitus Within 8 hours of is a group of nursing intervention metabolic diseases the patient 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

NSG. INTERVENTION 1. Establish rapport with client. 2. Take and record vital signs.

RATIONALE - to obtain patients trust and cooperation. - to obtain baseline data and monitor changes in temperature. -To determine the level of activity

EVALUATION

3. Asses muscle strength of patient and functional level of activity. 4. Provide comfort and safety 5. Instruct patient to perform deep breathing exercises 6. Instruct client to increase Vitamins A, C and D and protein in her diet.

- To be free from injury

- Promotes relaxation

- For muscle strength and tissue repair

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NSG. DIAGNOSIS

AMB Subjective:(none) Objective:

PATHOPHYSIO LOGY

CLIENT OUTCOME

NSG. INTERVENTION 6. Establish rapport with client. Take and record vital signs

RATIONALE to obtain patients trust and cooperation. - to obtain baseline data and monitor changes in temperature.

EVALUATION