Assessment Diagnosis Planning Intervention Rationale Evaluation

Risk for Unstable Short term Goal: Independent: Short-term Goal:

blood glucose level Goals are met
related to type II After 12 hours of Assess for signs of Manifestations of After 12 hours of
diabetes nursing hypoglycemia hypoglycemia may nursing intervention
Objective data: intervention the depend on every the patient will
patient will individual but are maintain glucose in
maintain glucose consistent. The satisfactory range
in satisfactory signs are both
range increased
adrenergic activity
and decreased
glucose delivery to
the brain. The
patient may
experience
tachycardia,
diaphoresis,
tremors, dizziness,
headache, fatigue,
hunger, and visual
charges

Monitor vital signs Hypertension is

specifically BP of commonly
more than 160 mm Hg associated with
(systolic) diabetes. Control of
BP prevents
coronary artery
disease, stroke,
retinopathy, and
nephropathy
Perform fingerstick All available
glucose testing. glucose monitors
Ascertain whether will provide
client is adept at blood satisfactory
glucose monitoring readings if properly
and are testing used and
according to plan. maintained and
routinely calibrated

Assess medications
taken regularly A lot of drugs can
cause fluctuations
in blood as a side
effect. Regular use
of salicylates,
disopyramide,
insulin, sulfonylurea
agents and
pentamidine can
cause
hypoglycemia

Review clients dietary

program and usual Identifies deficits
pattern; compare with and deviations from
recent intake therapeutic plan,
which may
precipitate unstable
glucose

Weigh daily or as
indicated Assesses adequacy
of nutritional intake-
both absorption and
 utilization

Monitor blood glucose

levels with a To identify and
glucometer at regular respond early to
intervals fluctuations in
glucose levels that
occur outside
normal parameters.

Observe for signs of

hypoglycemia- Once carbohydrate
changes in LOC, cool metabolism
and clammy skin, resumes, blood
rapid pulse, hunger, glucose level will
irritability, anxiety, fall, and as insulin is
headache, light- being adjusted,
headedness and hypoglycemia may
shakiness occur

Collaborative:

Monitor laboratory
studies, such as Blood glucose will
serum glucose decrease slowly
with controlled fluid
replacement and
insulin therapy.

Assessment Diagnosis Planning Interventions Rationale Evaluation

Objectives: Risk for Disturbed Short-term Goal: Independent: Short-term Goal:
Sensory Perfusion Monitor vital signs Provide a baseline
related to glucose and mental status from which to Goals are met
and electrolyte After 8 hours of compare abnormal After 8 hours of
imbalance nursing intervention findings; for nursing intervention
the patient will be instance, fever may the patient will be
able to demonstrate affect mentation able to demonstrate
improved or improved or
appropriate appropriate
response to stimuli Address client by Decrease confusion response to stimuli
name; reorient as and helps maintain
After 12 hours of needed to place, contact with reality After 12 hours of
nursing intervention person, time and nursing intervention
the patient will be situation. Give short the patient will be
able to regain and explanations, able to regain and
maintain usual level speaking slowly and maintain usual level
of consciousness enunciating clearly of consciousness
and perceptual and perceptual
functioning and functioning and
recognize limitations Schedule nursing Promotes restful recognize limitations
and seek assistance time to provide for sleep, reduces and seek assistance
as necessary. uninterrupted rest fatigue and may as necessary.
periods improve cognition

Keep client’s Helps keep client in

routine as touch with reality
consistent as and maintain
possible. orientation to the
Encourage environment
participation in
activities of daily
living (ADLs) as
able
Disoriented client is
prone to injury,
Protect client from especially at night
injury –avoid or limit and precautions
use of restraints as need to be taken as
able, place bed in indicated. Seizure
low position—when precautions reduce
cognition is risk of physical
impaired. Pad bed injury.
rails if client is
prone to seizures Reduces discomfort
and potential for
Provide bed cradle. dermal injury. Note:
Keep hands and Sudden
feet warm, avoiding development of cold
exposure to cool hands and feet may
drafts, hot water, or reflect
heating pad hypoglycemia,
suggesting need to
evaluate serum
glucose level

Promotes client
safety, especially
Assist with when sense of
ambulation or balance is affected.
position change

Collaborative: Alteration in thought

of process and
Carry out potential for seizure
prescribed regimen activity is usually
for correcting DKA, alleviated once
as indicated hyperosmolar state
is corrected

Imbalances can
impair mentation.
 Note: If fluid is
Monitor laboratory replaced too quickly,
values, such as water intoxication
blood glucose, can occur—sodium
serum osmolality concentration falls,
water enters brain
cells, and confusion,
disorientation, or
coma may develop

Assessment Diagnosis Planning Interventions Rationale Evaluation

Objectives: Risk for Infection Short-term Goal: Independent: Short-term Goal:
related to elevated Observe for signs Patients with DM Goals are met
serum creatinine After 12 hours of of infection and may be admitted After 12 hours of
level nursing inflammation: with infection, nursing
intervention the fever, flushed which could have intervention the
patient will appearance, precipitated the patient will
recognize any wound drainage, keto acidotic state. recognize any
changes in purulent sputum They may also changes in
sensory perception and cloudy urine develop sensory perception
and effectively nosocomial and effectively
cope up infection cope up

Practice and First-line defense

demonstrate to limit spread of
proper hand infection
hygiene

Provide for Reduces risk of

infection cross-
precautions or contamination to
isolations, as staff, visitors, and
indicated— other clients
standard
precautions of
gown, gloves, face
shield or googles,
respiratory mask or
filter and reverse
or negative
pressure room,
when available

Review individual Essential for well-

nutritional needs, being and recovery
appropriate
exercise program,
and need for rest

Instruct client/s in Self-care activities

techniques to that may provide
prevent spread of protection for client
infection, protect and others
the integrity of the
skin, and care for
wounds or lesions

Emphasize Premature
necessity of taking discontinuation of
antibiotics as treatment when
directed, especially client begins to feel
dosage and length well may result in
of therapy return of infection.
However,
unnecessary use
of antibiotics may
result in
development of
secondary
infections or
resistant organism

Collaborative: Provides
Obtain appropriate information to
specimens for diagnose infection
observation and and determine
culture and appropriate
sensitivities testing therapeutic
—nose, and throat interventions
swabs, sputum,
blood, urine, or
feces

Assist with medical Help determine the

procedures, such causative factors
as incision and for appropriate
drainage of therapeutic and
abscess, facilitates recovery
bronchoscopy, or
wound care, as
indicated.

Administer and Determines

monitor medication effectiveness of
regimen (e.g., therapy and
antimicrobials, presence of side
topical antibiotics) effects
and note client’s
response

Provide passive May prevent

protection such as development of
immune globulin, infection following
active protection exposure or
(e.g., vaccination, reduce the
or likelihood of
chemoprophylaxis, acquiring disease
as appropriate) in the future