Kelompok 2 : Program A10 1. Diagnosa 1 Deficit fluid Volume related to hiperglikemia Subyektif data : a.

Pasient was taking 48 unit insulin everyday Obyektif data: a. Breathing is deep and rapid b. Aceton smell on breath c. Blood glucose level of 730 mg/dl d. Blood ph 7,26 e. Vomiting Objective : a. Homeostasis can be depended b. stabiled blood glucosa level c. avoid the complication criteria results: a. Patient breath normally b. Smell on breath is not aceton c. Blood glucosa level of 90-120 d. Blood pH 7,35-7,45

No 1.

Intervention Monitor for vital sign

Rationale Hypovolemia can be showed by hipotensi and takikardia. Hipovolemia can be checked its heavy when patient sistolik blood pressure down until 10mmHg from fowler position to sit or stand up position When insulin is not available, blood glucose levels rise and the body metabolish fat for energy producing keton bodies Hiperglikemia and asidosis can make frequency and rate of breathing is abnormal because that is indication from difficulty of breathing and patient Maintenance fluid sirculation The menthal changing can be related to hyperglycemi or hipoglycemy, accidocis. Recognizing altering can be predispotition of aspiration in patien. Deficiency of fluid and electrolit can change gastrik motility which will often make vomiting and potentialy it can make deficiency fluid or electrolit

2.

Monitor for positive plasma keton, aseton breath

3.

Maintain frequency and facility of breathing, using accesories muscles, there is apnea periode and showing sianosis

4. 5.

Give fluid minimum 5-8L/day in the heart capacity tolerance Monitor the menthal changing, monitor GCS

6.

Write the result of assesment such as anorexia, abdomen pain and vomiting.

2. Diagnosa 2 Altered nutrition related to less food intake. Subjective data: Patient was vomiting and anorexia for 1 week Objective: The nutritional requirements can be met Criteria results: 1. patient is not vomiting and anorexia 2. Patients adhere to her diet. Action Plan: 1. Assess the nutritional status and eating habits. Rational: To know about the circumstances and the patient's nutritional needs so it can be given acts and setting adequate diet. 2. Instruct the patient to adhere to a diet that has been programmed. Rationale: Compliance with the diet can prevent the occurrence of complications hypoglycemia / hyperglycemia. 3. Weigh weight every week. Rational: Knowing the development of patient body weight (body weight is one indication to determine the diet). 4. Identify dietary changes. Rational: To determine whether the patient has been carrying out a diet program determined. 5. Cooperation with other health team for delivering insulin and diet diabetic. Rational: Delivery of insulin to increase glucose entry into in the network so that the blood sugar decreases, providing an appropriate diet can accelerate the decline in blood sugar and prevent complications.