Assessment Subjective: Sige lang ko ug pangihi ug pirmi uhaw bisag sige ko inom ug tubig bugnaw as verbalized by the patient

Objective: Elevated temperature of 38 o C/ axilla Increased urine output Profuse sweating noted Excessive thirst noted Body malaise noted Dry skin, mucous membrane, and sunken eyeballs noted

Nursing Diagnosis Fluid volume deficit r/t intracellular dehydration 2o DM type II

Scientific Basis 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.

Planning Short term: After 3 of NI, patient shall have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications. Long term: After 2 days of NI, 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.

Nursing Intervention Establish rapport

Rationale
To have a friendly relationship with patient and to be able to verbalize each others concern. To obtain baseline data Dry skin and mucous membranes are signs of dehydration To replace the

Evaluation Short term: After 3o of NI, patient has verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.

Take and record vital signs Assess skin turgor and mucous membrane for signs of dehydration

Encourage the fluid loss and patient to increase prevent oral fluid intake dehydration Administer IVF as ordered Administer antipyretic as ordered

To replace electrolytes and fluid loss To decrease body temperature and will have less occurrence of dehydration

Long term: After 2 days of NI, the patient has maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs.

Nursing Diagnosis Subjective: Imbalanced Nutrition: less Kusog ko mukaon than body pero murag gutom requirement r/t lang gihapon ko insulin pirmi as deficiency verbalized by the patient Objective: Poor muscle tone noted Generalized body weakness noted Increased thirst noted Increased in appetite noted Increased in urination noted

Assessment

Scientific Basis
Due to decrease or lack of insulin in the body, the 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 need to be fed, this will lead to polyphagia and polydipsia because the tissue are not being fed and need glucose for metabolism.

Planning Short Term: After 3 of NI, patient shall have verbalized understanding of causative factors when known and necessary interventions and identified diabetic client. Long Term: After 1-4 months of NI, the patient shall have demonstrated weight gain toward goal.

Nursing Intervention Establish rapport

Rationale
To have a friendly relationship with patient and to be able to verbalize each others concern.

Evaluation Short Term:

Have patient understand personal nutritional needs

After 3 of NI, patient has verbalized understanding of causative factors when known and To increase necessary interventions and patients information about identified diabetic client. nutritional needs
for diabetics.

Long Term: After 1-4 months of NI, the patient has demonstrated weight gain toward goal.

Discuss eating habits and encourage diabetic diet as prescribed by the Doctor

To achieve health needs of the patient with the proper food diet for his disease.

Document actual weight of the patient

Patient may be un aware of their actual weight or weight loss due to estimating weight. To reveal changes that

Note total daily intake including patterns and time of eating.

should be made in clients dietary intake.

Consult dietician/physician for further assessment and recommendation regarding food preferences and nutri-tional support

For greater understanding and further assessment of specific foods.

Assessment Subjective: Kapoy pirmi akong paminaw sa akong lawas as verbalized by the patient Objective: Generalized weakness noted Increased respiratory rate of 25cpm noted presence of nonhealing wound on right leg noted noted to get tired easily inability to perform ADL noted

Nursing Diagnosis Fatigue related to decreased muscular strength

Scientific Basis
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

Planning Short Term:After 2-3 of nursing interventions, the patient will be able to identify measures to conserve and increase body energy. Long Term:

Nursing Intervention
Assess response to activity

Rationale
Response to an activity can be evaluated to achieve desired level of tolerance. To determine the level of activity tolerance

Evaluation

Asses muscle strength of patient and functional level of activity. Discuss with patient the need for activity

After 3-5 days of nursing interventions, the patient will be free from Alternate activity signs of fatigue

Education may provide motivation to increase activity level even though patient may feel too weak initially Prevents excessive fatigue

with periods of rest/ uninterrupted sleep. Monitor pulse, respiration rate and blood pressure before and after activity Perform activity slowly with

Indicates physiological levels of tolerance

Tolerance

which stimulates the liver to release the stored glucose. After 8 12 hours, the liver forms glucose from the breakdown of non-carbohydrate substances, including amino acids resulting to muscle wasting which results to weakness.

frequent rest periods

develops by adjusting frequency, duration and intensity until desired activity level is achieved. Interventions should be directed at delaying the onset of fatigue and optimizing muscle efficiency. Symptoms of fatigue are alleviated with rest. Also, patient will be able to accomplish more with a decreased expenditure of energy.

Promote energy conservation techniques by discussing ways of conserving energy while bathing, transferring and other ADLs.

Provide adequate ventilation For proper oxygenation Instruct client to increase Vitamins A, C and D and For muscle strength and tissue

protein in her diet. Instruct also patient to increase iron in diet

repair

To prevent weakness and paleness

Assessment Subjective: Dugay mayo ang akong samad sa akong operason as patient verbalized Objective: Flushed appearance noted Wound drainage noted

Nursing Diagnosis

Scientific Basis

Planning

Nursing Intervention

Rationale

Evaluation