Assessment Diagnosis Objectives Intervention Rationale EvaluationSubjective:“Mataas parin yung blood sugar ko sa katawan” as verbalized by the patient

Objective:* Increased Urinary Output* Weakness * Fatigue* Dilute Urine* Poor Muscle tone

Unstable Blood Glucose Level related to lack of diabetes management or adherence to diabetes action plan; inadequate blood glucose monitoring or medication management

Short Term:After 4 hours of nursing intervention the patient will be able to verbalize plan for modifying factors to prevent or minimize complications

Long term:After 1-2 days of nursing intervention the patient will be able to maintain glucose in satisfactory range.

Independent:* Establish rapport

* Monitor and record vital signs* Perform Finger Stick Glucose Testing. As certain whether client and so are adept at blood glucose monitoring and are testing according to plan

For client on Insulin: * review type(s) of insulin used, such as rapid, short acting, intermediate, long acting, remixed all the delivery method – SQ, inhaled or pump.* Review patient’s dietary program and usual pattern compose with recent intake

*Include SO in meal planning as indicated

COLABORATIVE:Monitor laboratory studies such as severe glucose, acetone, Ph, HCO3

* To gain trust and cooperation* To obtain initial data

* All available glucose monitors will provide satisfactory reading if properly used and maintained and routinely calibrated Note: Unstable Blood Glucose is often associated with failure to perform testing on a regular schedule* These factors affect timing of effects and provide clues to potential timing of glucose instability

* Identifies deficits and deviations from therapeutic plan, which may precipitate unstable glucose and uncontrolled hyperglycemia* Promote sense of involvement; provides information for so to understand nutritional needs of the patient. * Blood glucose will decease slowly with controlled fluid replacement and insulin therapy

Short Term:After 4 hours of nursing intervention, the patient was able to verbalize plan for modifying factors to prevent or minimize complications.

Long Term:After 1-2 days of nursing intervention the patient was able to maintain glucose in satisfactory range.

Assessment Diagnosis Objectives Intervention Rationale EvaluationSubjective:“Sobrang namamanas parin ang katawan ko” as verbalized by the patient

Objective:* altered respiratory pattern* Changes in blood pressure * Crackles* Edema* In take greater than output* rapid weight gain

Excess fluid volume related to excess fluid intake or retention

Short Term:After 4 hours of nursing intervention, the patient will be able to state ability to breath comfortably

Long term:After 1-2 days of nursing intervention the patient will be able to return to baseline weight and maintain vital signs within normal limits.

Independent:* Establish rapport

* Monitor and record vital signs

* Help patient into a position that aids breathing such as fowler’s or semi-fowlers* Administer oxygen as ordered.* Measure and record intake and output

* Access patient daily for edema, including ascites and dependent or several edema

* Encourage patient to cough and deep breath every two hours.*Maintain patient on sodium restricted diet as ordered.

Dependent:Administer diagnostics as ordered by the physician

* To gain trust and cooperation* To obtain initial data / Changes may indicate fluid or electrolyte imbalance* to increase chest expansion and improve ventilation

* To enhance arterial blood oxygenation*Intake greater that output may indicate fluid retention and possible overload.* Fluid overload or decreased osmotic pressure may result in edema, especially in dependent areas* to prevent pulmonary complications* To reduce excess fluid and prevent re-accumulation

* To promote fluid excretion. Record effects.

Short Term:After 4 hours of nursing intervention, the patient was able to state ability to breath comfortably

Long Term:After 1-2 days of nursing intervention the patient was able to return to baseline weight and maintain vital signs within normal limits.

Assessment Diagnosis Objectives Intervention Rationale Evaluation(Not Applicable; Presence of signs and symptoms establishes and actual diagnosis)

Risk for infection related to high glucose levels, decreased leukocyte function, alterations in circulation

Short Term:After 4 hours of nursing intervention, the patient will be able to identify interventions to prevent or reduce risk of infection

Long term:After 1-2 days of nursing intervention the patient will be able to demonstrate techniques and lifestyle changes to prevent development of infection

Independent:* Establish rapport

* Monitor and record vital signs

* Promote good hand washing by staff and patient.* Observe for signs of infection and inflammation fever, flushed appearance, wound drainage, cloudy wind

*Inspect patient’s feet, noting presence of ulcers or infected ingrown toenails, or other problem requiring medical or nursing intervention.

* Provide tissue and trash bag in a convenient location for sputum and other secretions instruct patient in proper handling of secretions

Collaborative:Administer antibiotics as appropriate

* To gain trust and cooperation* To obtain initial data

* Reduces risk of cross-contamination.

* Patient may be admitted with infection which could have precipitated the acidic state or may develop nosocomial infection*Foot injuries and impaired circulation are associated with many complications in diabetics in during cellulitis and amputations.

*Minimize spread of infection

* Early treatment may help sepsis

Short Term:After 4 hours of nursing intervention, the patient was able to identify interventions to prevent or reduce risk of infection

Long Term:After 1-2 days of nursing intervention the patient was able to demonstrate techniques and lifestyle changes to prevent development of infection