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Compiled By:

Delia Moreira Amaral do Rosario


Jimris Herminton Baun
Necta Irmadani
Rendi TriWahyu A.
Yeni Ika Wahyuni

(10212019)
(10212020)
(10212014)
(10212011)
(10212006)

COMPREHENSIVE
NURSING
ASSESSMENT

Medical history before:


History of Diabetes Mellitus: 3 years history
of type 2 diabetes Mellitus
History of children born large: His past
obstetrical history included 5 vaginal
deliveries and six miscarriages.
Family history of disease: Family history
was positive for diabetes mellitus in her
mother
History of present illness: Diabetes Mellitus
type 2 for pregnant moment
Urinary tract: She had a history of poliura

Safety: She no had retinopaty , no evidence of


neuropathy and her was physical examination
was normal.
Diagnostic examination:
Blood glucose once daily in the morning
between 180 and 220 mg/dl
Glycosylated hemoglobin (HbA1c) level was
10,5% (normal <6,0 %)
Capillary blood glucose 4 hours lunch was
201 mg/dl

Nursing Diagnosis
High risk to changes in nutrition less than the
needs associated with the inability to digest and
use the nutrients are less precise
High risk of fetal injury associated with
increased maternal glucose levels
Lack of knowledge about the condition of
diabetes is associated with the error information

Intervention
Nursing Diagnosis 1. High risk to changes in
nutrition less than the needs associated with the
inability to digest and use the nutrients are less
precise
Objective: After taking action .x24 ooclock for
said patients nutrition needs are met
Criteria Results: Maintain fasting blood glucose
levels between 60-100 mg/dl and 2 hours after
eating no more than 140 mg/dl

Intervention:
Assess caloric intake and diet in 24 hours
Rational: Assist in evaluating the patients understanding of
the diet
Review of the importance of regular meals when taking insulin
Rational: Eat little and to avoid hyperglycemia, after eating and
hunger
Assess understanding of stress in diabetic
Rational: Stress can lead to increased levels of glucose,
creating fluctuations in insulin requeirements
Teach patients about the finger stick method to monitor
glucose alone
Rational: insulin requirements maybe assessed based on the
findings of serum blood glucose periodically

Nursing Diagnosis 2. High risk of fetal injury


associated with increased maternal glucose
levels
Objective: After taking action .x24 ooclock
for said patients
Criteria result: reaction showed a non stress
test and oxytocin challenge test or a
negative normal stress test construction

Intervention:
Assess diabetic control before conception
Rasional: helps reduce the risk of fetal mortality
and abnormal
Examine fetal movements and fetal pulse each
visit
Rational: placental insufficiency and maternal
ketosis may negatively affect fetal movements and
fetal heart rate.
Observation of the urine ketone
Rational: ketone bodies can cause damage to the
central nervous system that cannt be fixed

Nursing Dianosis 3: Lack of knowledge about the


condition of diabetes is associated with the error
information
Objective: After taking action .x24 ooclock for
said patients
Criteria Result:
Participate in the management of diabetes during
pregnancy
Reveals an understanding of the procedures,
laboratory tests and controlling activities that
involve monitoring the pregnancy itself and
insulin administration
Demonstrate proficiency monitor themselves and
insulin administration

Intervention
Provide information on the impact of pregnancy
on diabetic conditions and future expectations
Rational: increased knowledge can reduce fear,
icrease cooperation and help reduce fetal
complications.

Discuss the signs of infection


Rational: impotant to seek medical attention
early to avoid cooperation and help reduce fetal
complications

Thank You