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.
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.
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.
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:
- Fluid Volume Deficit related to osmotic diuresis, gastric loss, excessive diarrhea, nausea, vomiting, limited input, mental mess.
- 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.
- Risk for Infection related to inadequate peripheral defense, changes in circulation, high blood sugar levels, invasive procedures and skin damage.
- Fatigue related to decreased metabolic energy production, changes in blood chemistry, insulin insufficiency, increased energy demand, hypermetabolism status status / infection.
- Knowledge Deficit: about condition, prognosis and treatment needs related to misinterpretation of information / do not know the source of information.
Nursing Intervention and Implementation
for Diabetes Mellitus
Intervention is planning nursing actions that will be implemented to address the problem in accordance with the nursing diagnoses.
Implementation is the realization of management and nursing plans that had been developed at the planning stage.
Nursing Intervention and implementation in patients with diabetes mellitus (Doenges, 1999) include:
1). Fluid Volume Deficit
Patients showed an improvement in fluid balance,
the criteria; spending adequate urine (normal range), vital signs stable, clear peripheral pulse pressure, good skin turgor, capillary refill well and mucous membranes moist or wet.
Intervention / Implementation:
1. Monitor vital signs, note the presence of orthostatic blood pressure.
R: Hypovolemia can be manifested by hypotension and tachycardia.
2. Assess breathing and breath patterns.
R: The lungs secrete carbonic acid is produced through respiration compensated respiratory alkalosis, the state of ketoacidosis.
3. Assess temperature, color and moisture.
R: Fever, chills, and diaphoresis is common in the infection process. Fever with skin redness, dry, maybe a picture of dehydration.
4. Assess peripheral pulses, capillary refill, skin turgor and mucous membranes.
R: Is an indicator of the level of dehydration or adequate circulating volume.
5. Monitor intake and output. Record the urine specific gravity.
R: Provide the estimated need for fluid replacement, renal function and the effectiveness of a given therapy.
6. Measure body weight every day.
R: Provide the best results of the assessment of the status of ongoing fluid and further in giving replacement fluids.
7. Collaboration fluid therapy as indicated
R: Type and amount of fluid depends on the degree of dehydration and individual patient response.
2). Imbalanced Nutrition, Less Than Body Requirements
Goal: weight can be increased with normal laboratory values and no signs of malnutrition.
Patients are able to express an understanding of substance abuse, decrease the amount of intake (diet on nutritional status).
Demonstrate behaviors, lifestyle changes to improve and maintain a proper weight.
Intervention / Implementation:
1. Measure body weight per day as indicated.
R: Knowing eating adequate income.
2. Determine the diet program and diet of patients compared with food that can be spent on the patient.
R: Identify deviations from the requirements.
3. Auscultation of bowel sounds, record the presence of abdominal pain / abdominal bloating, nausea, vomiting, keep fasting as indicated.
R: Influence of intervention options.
4. Observation of the signs of hypoglycemia, such as changes in level of consciousness, cold / humid, rapid pulse, hunger and dizziness.
R: Potentially life-threatening, which must be multiplied and handled appropriately.
5. Collaboration in the delivery of insulin, blood sugar tests and diet.
R: It is useful to control blood sugar levels.
3). Risk for Infection
Goal: Infection does not occur.
Identify individual risk factors and potential interventions to reduce infection.
Maintain a safe aseptic environment.
Intervention / Implementation
1. Observation for signs of infection and inflammation such as fever, redness, pus in the wound, purulent sputum, urine color cloudy and foggy.
R: incoming patients with infections that normally might have been able to trigger a state ketosidosis or nosocomial infections.
2. Increase prevention efforts by performing good hand washing, each contact on all items related to the patient, including his or her own patients.
R: prevention of nosocomial infections.
3. Maintain aseptic technique in invasive procedures (such as infusion, catheter folley, etc.).
R: Glucose levels in the blood will be the best medium for the growth of germs.
4. Attach catheter / perineal care do well.
R: Reduce the risk of urinary tract infection.
5. Give skin care with regular and earnest. Massage depressed bone area, keep skin dry, dry linen and tight (not wrinkled).
R: peripheral circulation can be impaired which puts patients at increased risk of damage to the skin / eye irritation and infection.
6. Position the patient in semi-Fowler position.
R: Makes it easy for the lung to expand, lowering the risk of hypoventilation.
7. Collaboration antibiotics as indicated.
R: penenganan early can help prevent the onset of sepsis.
4. Fatigue - NCP Diabetes Mellitus
5. Knowledge Deficit
Goal: patient expressed understanding of the conditions, procedures and effects of the treatment process.
Perform the necessary procedures and explain the rationale of an action.
Initiate the necessary lifestyle changes and participate in treatment regimen.
Intervention / Implementation:
1. Assess the level of knowledge of the client and family about the disease.
R: Find out how much experience and knowledge of the client and family about the disease.
2. Give an explanation to the client about diseases and conditions now.
R: By knowing the diseases and conditions now, clients and their families will feel calm and reduce anxiety.
3. Encourage clients and families to pay attention to her diet.
R: Diet and proper diet helps the healing process.
4. Ask the client and reiterated family of materials that have been given.
R: Knowing how much understanding of clients and their families and assess the success of the action taken.