Pflegediagnose für Diabetes Mellitus 1. Pflegediagnose: related to osmotic diuresis. Goal: Demonstrate adequate hydration evidenced by stable vital signs, palpable peripheral pulse, skin turgor and capillary refill well, individually appropriate urinary output, and electrolyte levels within normal limits.
Nursing Intervention: 1.) Monitor vital signs. Rational: hypovolemia can be manifested by hypotension and tachycardia. 2.) Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes. Rational: This is an indicator of the level of dehydration, or an adequate circulating volume. 3.) Monitor input and output, record the specific gravity of urine. Rational: To provide estimates of the need for fluid replacement, renal function, and effectiveness of the therapy given. 4.) Measure weight every day. Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid. 5.) Provide fluid therapy as indicated. Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual patients.
2. Pflegediagnose:related to insufficiency of insulin, decreased oral input. Goal: Digest the amount of calories / nutrients right Shows the energy level is usually Stable or increasing weight.
Nursing Intervention: 1.) Determine the patient's diet and eating patterns and compared with food that can be spent by the patient. Rationale: Identify deficiencies and deviations from the therapeutic needs. 2.) Weigh weight per day or as indicated. Rational: Assessing an adequate food intake (including absorption and utilization). 3.) Identification of preferred food / desired include the needs of ethnic / cultural. Rational: If the patient's food preferences can be included in meal planning, this cooperation can be pursued after discharge. 4.) Involve patients in planning the family meal as indicated. Rationale: Increase the sense of involvement; provide information on the family to understand the patient's nutrition. 5.) Give regular insulin treatment as indicated. Rational: regular insulin has a rapid onset and quickly and therefore can help move glucose into cells. c.
Krankenpflege-Diagnose: related to hyperglikemia. Goal: Identify interventions to prevent / reduce the risk of infection. Demonstrate techniques, lifestyle changes to prevent infection. Nursing Intervention: 1). Observed signs of infection and inflammation. Rationale: Patients may be entered with an infection that usually has sparked a state of ketoacidosis or may have nosocomial infections. 2). Improve efforts to prevention by good hand washing for all people in contact with patients including the patients themselves. Rationale: Prevents cross infection. 3). Maintain aseptic technique in invasive procedures. Rational: high glucose levels in blood would be the best medium for the growth of germs. 4). Give your skin with regular care and earnest. Rational: the peripheral circulation may be disturbed that puts patients at increased risk of damage to the skin / skin irritation and infection. 5). Make changes to the position, effective coughing and encourage deep breathing. Rational: memventilasi Assist in all areas and mobilize pulmonary secretions.
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