PROBLEM #2 - IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENT

ASSESSMENT/ NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

CUES DIAGNOSIS EXPLANATION OUTCOME
S> Ø Imbalanced Due to lack of Short term: >Ascertain >To determine Short term:
O> Patient Nutrition: less insulin in the After 2 hours of understanding of what The pt shall
manifested: than body body, the nursing individual nutritional information to have verbalized
-fatigue requirement glucose level interventions, needs be provided to understanding
-poor muscle r/t insulin continuously the pt shall client/SO on the
tone deficiency rises because verbalize >Discuss eating >To achieve nutritional
-generalized glucose can’t be understanding habits and health needs of dietary intake
weakness utilized without on the encourage diabetic the patient with AEB taking high
-polydipsia the presence of nutritional diet as prescribed the proper food caloric and
-polyuria insulin. Glucose dietary intake by the Doctor diet for his protein rich
-polyphagia is the source of AEB taking high disease foods like liver
energy, while caloric and >Document actual >Patient may be and vegetables.
VS taken as insulin is the protein rich weight, do not unaware of their
follows: vehicle to foods like liver estimate actual weight or
T-36.3 C(axilla) transport glucose and vegetables. weight loss due
PR- 95 bpm to the body to estimating
RR- 17 bpm
BP- 110/70 mmHg tissues. Because weight
of decrease >Note total daily >To reveal
insulin level in Long term: intake including changes that Long term:
the blood stream, After 2 weeks of patterns and time of should be made The pt shall
the cells starved, nursing eating in client’s have gain at
leading to interventions, dietary intake least 2lbs
alteration of the pt. will gain- >Consult > For greater
metabolism. The at least 2lbs dietician/physician understanding
body needs for further and further
glucose for assessment and assessment of
metabolism; recommendation specific foods
there will be a regarding food
breakdown of preferences and
energy reserved nutritional support
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.

PROBLEM #3 - ACTIVITY INTOLERANCE

ASSESSMENT/ NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED
CUES DIAGNOSIS EXPLANATION OUTCOME
S> Ø Activity Because of lack Short term: >Take and >To obtain Short term:
O> Patient Intolerance r/t of insulin in the After 2 hours of record VS baseline data The pt shall have
manifested: insulin body, there will nursing >Note presence >To identify identified
-generalized deficiency / be cell starvation interventions, of factors causative techniques to
weakness fatigue / leading to the pt will contributing to /precipitating enhance activity
-slow, weak generalized decreased or identify fatigue factors tolerance AEB
movement weakness alteration of techniques to >Evaluate >To provide adequate bed
-body malaise energy or enhance activity current comparative rest.
-fatigue metabolism. tolerance AEB limitations/degre baseline
There will be adequate bed e of deficit in
VS taken as decreased rest. light or visual
follows: energy >Note client >To identify
T-36.1 C(axilla) production AEB reports of causative/
PR- 97 bpm body malaise or weakness, precipitating Long term:
RR- 16 bpm
BP- 110/70 mmHg weakness. Long term: fatigue, difficulty factors The pt shall have
Activities need After 3 days of accomplishing been able to
energy and nursing tasks report
glucose needs interventions, >Assess >To note for measurable
insulin to be the pt. will be cardiopulmonary progression/acce increase in
transferred to able to report response to lerating degree activity tolerance
the body tissues. measurable physical activity of fatigue AEB (-) body
Because of lack increase in including VS malaise.
of insulin in the activity tolerance before, during
body there will AEB (-) body and after activity
be decrease malaise. >Adjust or >To assist the pt
activity level reduce intensity while managing
exerted by the level or activities
patient. discontinue
activities that
cause undesired
physiologic
changes
>Increase >To conserve
exercise /activity energy
level gradually
>Plan care with >To reduce
rest periods fatigue
between
activities
>Promote >To enhance
comfort ability to
measures participate in
activities
>Plan for >To gradually
maximal increase muscle
activities within strength of the
the client’s ability body
 PROBLEM #4 - IMPAIRED SKIN INTEGRITY

ASSESSMENT/ NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED

CUES DIAGNOSIS EXPLANATION OUTCOME
S> Ø Impaired skin Type 2 Diabetes Short term: >Monitor and >To obtain Short term:
O> Patient integrity r/t Mellitus is a After 2 hours of record VS baseline data The pt shall
manifested: wound present condition of nursing >Asses >To determine have
-disruption of on the left foot. fasting interventions, condition of skin the presence of demonstrated
skin surface with hyperglycemia the pt will over bony necrotic tissue optimal
white lesion on that occurs demonstrate prominence for skin/wound care
the face despite the optimal breakdown routine AEB the
-destruction of availability of skin/wound care every 2 hours absence of
skin layers with endogenous routine AEB the >Establish local >To remove infection.
varying wounds insulin. Glucose absence of wound care necrotic debris
on the right and function as the infection. measure and to attain
lest lower energy gives dressing and
extremities. body, because treatment
of lack of insulin regimens and
VS taken as there would be Long term: achieve Long term:
follows: inadequate After 3 days of advantageous The pt's skin
T-36.2 C(axilla) glucose in the nursing wound healing shall have been
PR- 98 bpm body that interventions, >Frequent >To prevent freed from
RR- 15 bpm
BP- 100/80 mmHg doesn’t supply the pt’s skin will turning and development of further skin
other parts of be free of further repositioning other pressure breakdown AEB
the organs. With skin breakdown ulcer the performance
such having AEB the >Keep >To prevent of wound care.
impaired skin performance of surrounding invasion of
integrity. wound care. tissue free from microorganisms
excess moisture