Diabetes Mellitus NCP

Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid
metabolism. The primary feature of this disorder is elevation in blood glucose levels (hyperglycemia), resulting from
either a defect in insulin secretion from the pancreas, a change in insulinaction, or both. Sustained hyperglycemia has
been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ
systems, including the eyes, nerves, kidneys, and blood vessels.
Deficient Fluid Volume

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.
Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention
s
Subjective: (none Deficient Short Establish Friendly
Short
) Fluid Term:After 3° rapport relationship
Term:After 3°
Objective: Volume r/t of NI, patient Take and with patient
of NI, patient
intracellula shall have record vital and to be
will have
 elevate r DHN 2° verbalized signs able to each
verbalized
d the DM II understanding other’s
understanding
temperature of causative Monitor the concern
of causative
of factors and temperature To obtain
factors and
38.4°C/axill purpose of baseline
purpose of
a individual Assess skin data
individual
therapeutic turgor and therapeutic
 increase interventions mucous To monitor interventions
d urine andmedications membranes changes in andmedications
output. . for signs of temperature .
Long Term: dehydration Long Term:
 sweatin Dry skin
g of the skin After 2 days of Encourage and mucous After 2 days of
NI, the patient the patient to membranes NI, the patient
 thirst shall have increase fluid are signs of will have
maintained intake dehydration maintained
 exhaust fluid volume at fluid volume at
a functional Administer To replace a functional
ion
level as IVF as fluid loss level as
evidenced by ordered by and prevent evidenced by
 weight
individual good the Doctor dehydration individual good
loss skin turgor, skin turgor,
moist mucous Administer To replace moist mucous
 dry skin membrane and anti-pyretic
or mucous electrolytes membrane and
stable vital as prescribed and fluid stable vital
membrane signs. signs
by the loss
Doctor.
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To decrease
body
temperature
and will
have less
occurrence
of
dehydration
.
Imbalanced Nutrition: Less Than Body

Requirements
Due to decrease of lack of insulin in the body, the glucose level continuously rises because glucose can’t 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 need to be fed, this will lead to
polyphagia and polydipsia because the tissue are not being fed and need glucose for metabolism.
Assessmen Nursing Planning Nursing Rationale Evaluation

t Diagnosis Interventions
Subjective: Imbalanced Short Term: Establish rapport
Friendly Short Term:
Æ Nutrition: less After 3° of Ascertain relationship with After 3° of
Objective: than body NI, patient understanding of
patient and to be NI, patient
requirement shall have individual able to each will have
Pt. r/t insulindeficie verbalized nutritional needs
other’s concern verbalized
manifested ncy understandi To determine understandi
: ng of Discuss eating what information ng of
causative habits and to be provided to causative
- poor factors encourage diabetic client/SO factors
muscle when diet as prescribed when
tone known and by the Doctor - To achieve known and
necessary health needs of necessary
- intervention
Document actual the patient with intervention
generalized s and weight, do not the proper food s and
weakness identified estimate. diet for is/her identified
diabetic disease diabetic
- increased client. Note total daily client.
thirst intake including - Patient may be
Long Term: patterns and time un aware of their Long Term:
- increased actual weight or
urination After 1-4 of eating. weight loss dueAfter 1-4
months of to estimating months of
- NI, the Consult weight. NI, the
polyphagia patient dietician/physician patient will
shall have for - To reveal have
Pt. may demonstrat furtherassessment changes that demonstrat
manifest: ed weight and recommend- should be made ed weight
gain toward dation regarding in client’s dietary gain toward
- loss of goal. food preferences intake goal.
weight and nutri-tional
support - For greater
understanding
and
furtherassessmen
t of specific
foods.
Fatigue
Diabetes Mellitus is a group of metabolic diseases 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 muscle wasting which
results to weakness.
Assessment Nursing Planning Nursing Rationale Evaluatio

Diagnosis Interventio n
ns
Subjective: (none) Fatiguerelat Short -Assess -Response to The
Objective: ed to Term:After response to an activity can patient
decreased 2-3º of activity be evaluated shall have
 generalized muscular nursing -Asses to achieve been able
weakness strength intervention muscle desired level to identify
s, the strength of of tolerance. measures
 increasedrespir patient will patient and -To determine to
atoryrate of 25cpm be able to functional the level of conserve
identify level of activity and
 presence of measures to activity. increase
non-healing wound conserve -Education body
on both feet and -Discuss may provide energy
increase with patient motivation to The
 body weakness body the need for increase patient
energy. activity activity level shall have
Long even though been free
Term: -Alternate patient may from
 wt. loss activity with feel too weak signs
After 3-5 periods of initially of fatigue
 fatigue days of rest/
nursing uninterrupte -Prevents
 limited ROM intervention d sleep. excessivefatig
s, the ue
 inability to patient will -Monitor
perform ADL be free pulse, -Indicates
from signs respiration physiological
 altered VS offatigue rate and levels of
blood tolerance
 altered pressure
before/after -Tolerance
sensorium
activity develops by
adjusting
-Perform frequency,
activity duration and
slowly with intensity until
frequent rest desired
periods activity level
is achieved.
-Promote
energy -Interventions
conservation should be
techniques directed at
by delaying the
discussing onset
ways of of fatigueand
conserving optimizing
energy muscle
while efficiency.
bathing, Symptoms
transferring offatigue are
and so on. alleviated
with rest.
-Provide Also, patient
adequate will be able to
ventilation accomplish
more with a
-Provide decreased
comfort and expenditure of
safety energy.
-Instruct -For proper
patient to oxygenation
perform
deep -To be free
breathing from injury
exercises
-Promotes
-Instruct relaxation
client to
increase -For muscle
Vitamins A, strength and
C and D and tissue repair
protein in
her diet. -To prevent
weakness and
-Instruct paleness
also patient
to increase -To provide
iron in diet proper
ventilation
-Administer
oxygen as
ordered.
Risk for Infection

Risks for infection is a increased probability of invasion of pathogenic organisms for a pt. with DM wound
is possible in the furure.Clients with diabetes are susceptible to infections because of polymorphonuclear
leukocyte function, diabetic neuropathies, and vascular insufficiency as a result is a poor glycemic control;
thus making a wound to heal slowly because the damaged of the vascular system cannot carry sufficient
oxygen, WBC, nutrients, and antibodies to the injured site. Thereby infections increase and enhance
possibility of further complications.
Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Interventions
Subjective:Æ Risk for Short Term: -Establish - to obtain Short Term:
Objective: infectionrelated After 4 hours rapport patient’s trust -The pt. shall
to disease of NPI the -Take and and have
Pt. manifested: condition. risks factors of record vital cooperation identified
occurrence of signs - To obtain risks factors
-purulent infection will baseline data of
discharge be reduce or -Encourage occurrence
control to a expression of - facilitates of infection
manageable feelings and grieving the shall have
-hyperthermia level by a clean anxieties loss reduced or
bed and controlled to
Pt. may maintain skin - Observe non - non – verbal a
manifest: intact. – verbal cues cues is more manageable
accurate than level by a
-altered Long Term: -Encourage verbal cues clean bed
circulation client to look and skin
After 1-2 at/touch - to begin to intact.
- weeks of NPI, affected body incorporate
immunological pt will be free part changes into Long Term:
deficit of purulent body image
drainage or -Encourage -The patient
erythema and verbalization - to enhance shall be free
be afebrile of and role handling of of purulent
play potential damage or
anticipated problems erythema and
conflicts be febrile
-to prevent
-encourage to dehydration
increase fluid
intake -to boost
immune
-increase Vit. system and
C in the diet promote
collagen
-increase formation
CHON intake
-for tissue
-change repair
dressing
-to promote
-provide a safe healing and
and quiet prevent
environment contaminatio
n of the
-Take Due wound
meds on time
-to promote
pt’s comfort
- To met the
body’s
requirements
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Diabetes Mellitus NCP

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Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid

Deficient Fluid Volume

Assessment Nursing Planning Nursing Rationale Evaluation

Imbalanced Nutrition: Less Than Body

Assessmen Nursing Planning Nursing Rationale Evaluation

Assessment Nursing Planning Nursing Rationale Evaluatio

-Instruct -For proper

Risk for Infection

Assessment Nursing Planning Nursing Rationale Evaluation

Photo courtesy of: link

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