University of Perpetual Help System DALTA Alabang Zapote Rd.

. Pamplona, Las Pinas City COLLEGE OF NURSING Batch 2010 2011

Assessment

Diagnosis

Scientific explanation

Planning

Implementation

Rationale

Evaluation

SUBJECTIVE y No subjective cues OBJECTIVE y Altered LOC y Inadequate food intake y Poor appetite y Right sided body weakness y Fatigue y Poor muscle tone y blood glucose level : 94 mg/dl

Risk for unstable blood glucose r/t lack of adherence to diabetes management.

Excessive refined sugar consumption causes repeated rapid rises in blood glucose levels to levels well above normal. This causes the pancreas to over-react, by pouring excessive amounts of insulin into the bloodstream. This reduces blood sugar levels to far below normal,

GOAL: The client will be able to maintain glucose in satisfactory range.

Independent Nsg. interventions: y y Established therapeutic communication with the client. EXPECTED y Determined y OUTCOMES: individual After rendering factors that necessary nursing may contribute interventions : to unstable a. The pt will glucose as be able to listed in risk demonstrate factors. compliance with the treatment regimen especially in DM II. b. The pt will be able to y Review clients y demonstrate dietary understandin program and g about the usual pattern; importance compare with

To gain patients trust and cooperation. Client or family history of diabetes; known diabetic with poor glucose control; eating disorders; poor exercise habits all can result in problems with glucose stability. Identifies deficits and deviations from therapeutic

Goal met. Client was able to maintain glucose at satisfactory range. 125mg/dl. She complied with the treatment regimen.

and drops the sugar level too fast.

of self management.

recent intake. Ascertained clients/ SOs knowledge and understanding of condition and treatment needs. y

Informed client/SOs about the importance and advantages of the management being done. compliance and y Discuss how clients atidiabetic medications work.

plan, which may precipitate unstable glucose and uncontrolled hyperglycemi a. To determine clients/SOs awareness about the condition and what is the importance of the treatment needs. For client/SOs to be knowledgeabl e about the management and for them to be encouraged to comply. Drugs and combinations of drugs work in varying ways with different

Auscultate bowel sounds. Note reports of abdominal pain and bloating, nausea, or vomiting.

Provide liquids containing nutrients and electrolytes as soon as client can tolerate oral fluids;

blood glucose control and side effects. Understandin g drug actions can help client avoid/reduce risk of potential for hypoglycemic reactions. Hyperglycemi a and fluid and electrolyte disturbances decrease gastric motility and function resulting in delayed gastric emptying, affecting choice of interventions. Oral route is preferred when client is alert and

progress to more solid food as tolerated. Identify food preferences, including ethnic and cultural needs.

Observe for signs of hypoglycemia changes in LOC, cool and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadednes s, and shakiness.

bowel function is restored. Incorporating as many of the clients food preferences into the meal plan as possible increases cooperation with dietary guidelines after discharge. Once carbohydrate metabolism resumes, blood glucose level will fall, and as insulin is being adjusted, hypoglycemia may occur. Enhances commitment to plan, optimizing outcome.