NURSING CARE PLAN

On Patient with Diabetes Mellitus

 CASE
• Mr. A 69 years old Caucasian man suffered from diabetes, non
proliferative diabetic retinopathy peripheral sensory neuropathy, any
hypertension. His family has history of diabetic mellitus and hypertension.
Based on his lifestyle, he didn’t follow the meal plan, smoke, drank
alcohol, and do substance abuse.
• He complained of progressively worsening life sided facial pain. The pain
began from ear with purulent drainage from the ear. He also felt fever and
chilling. His left external auditory canal was 2 cm ring erythematous and
edematous and tender. Fundoscopic : arterio-venous crossing changes
HTN. Rectal : diffusely enlarge prostate without nodules. He has got
decrease sensation to light touch and pinprick in lower extremities. His
ankles reflexes were absent.
• Medication : Glyburide 5 mg twice a day, benazepril 10 mg daily.
NURSING ASSESSMENT & DIAGNOSES
Subjective Data : -
Risk for Unstable
Blood Glucose Disease
Objective Data : Level (Diabetes)
1. Glucose level : 426 mg/dl (N : 80-120 mg/dl) (00179)
2. HbA1c 11,8 % (N : 4-6 %)

#1 The problem is risk for unstable blood glucose level r/t disease
(diabetes mellitus) e/b glucose level lab test: 426 mg/dl and HbA1c
11,8 % as objective data.
NURSING ASSESSMENT & DIAGNOSES
Subjective Data : -

Risk for Ineffective

Disease
Objective Data : Cerebri Perfusion
(Hypertension
1. Platelet count 420.000/mL (N : 140.000-340.000/ mL) (00201)
2. Glucose level : 426 mg/dl (N : 80-120 mg/dl)
3. BP : 130/70 mmHg

# 2 The problem is risk for ineffective cerebri perfusion r/t

hipertension e/b by BP: 130/70 mmHg, Platelet count 420.000/mL as
objective data.
NURSING ASSESSMENT & DIAGNOSES
Subjective Data : -

Objective Data : Risk for Ineffective

Diseases and
1. Glyburide 5 mg twice a day Kidney Perfusion
Medicine
2. Benazepril 10 mg daily (00203)
3. BUN 38 mg/dl
4. Creatinin 2.3 mg/dl
5. Urinalysis +1

#3 The problem is risk for ineffective kidney perfusion r/t diabetes and history of
consuming medicine e/b medical diagnosis of diabetes disease, taking glyburide 5
mg twice a week and benaepril 10 mg daily, high BUN 38 mg/dl, high creatinin
serum 2.3 mg/dl, and protein in urin +1 and dysuria as objective data.
NURSING ASSESSMENT & DIAGNOSES
Subjective Data :
The patient felt decreased sensation to light touch Risk for Ineffective
and pinprick in lower extermitas Peripheral
Disease
Perfusion
Objective Data : (00204)
The patient’s ankles reflexes were absent

#4 The problem is risk for ineffective tissue perifer perfusion r/t

diseases e/b the decreased sensation to light touch and pinprick in
lower extermitas and the absence of ankles reflexes felt by the
patient as subjective data.
NURSING ASSESSMENT & DIAGNOSES
Subjective Data :
1. The patient complained of progressively worsening
pain. Location : left side of the face began from ear with
purulent drainage, and back pain
2. The patient said he felt nauseated and vomiting
Acute Pain Biological Injury
(00132) Agent

Objective Data :
1. There is purulent drainage from the left ear
2. Thympanic membrane was obscured by debris which
is warm and tender

#5 The problem is acute pain r/t biological injury agent e/b patient complained of
progressively worsening pain in left side of the face began from ear with purulent
drainage, and back pain as subjective data; purulent drainage from his left ear, and
obscured tympanic membrane by debris which is warm and tender as objective
data
NURSING ASSESSMENT & DIAGNOSES
Subjective Data :
Risk for Ineffective
The patient feel decreased sensation to light touch and
pinprick in lower extermitas Peripheral
Perfusion Disease
Objective Data :
The patient’s ankles reflexes were absent (00204)

• #6. The problem is impaired tissue integrity r/t interference

metabolism e/b 2 cm ring erythematous and edematous in the
left external auditory canal, granulation tissue, rashes and
cutaneous ulcers as objective data.
NURSING ASSESSMENT & DIAGNOSES
Subjective Data :
The patient felt fever and chilling
Hyperthermia
(00007) Disease
Objective Data :
The patient’s temperature 100 F/ 37,7 °C

• #7. The problem is hypertemia r/t diseases e/b the patient’

temperature is 100 F/ 37.7 C
 1. Unstable blood glucose level
• After doing the nursing intervention for 1x24 hour, patient will achieve
Blood glucose (2300)as evidenced by :

Indicator Before After

Blood glucose 2 4

Glycosylated hemoglobin 2 4

Explanation :
• 1: Severe
• 2: Substantial
• 3: Moderate
• 4: Mild
• 5: None
Hyperglikemia management ( 2120):
• Observe patient’s blood glucose levels
• Observe sign and symptoms of hyperglicemia like Glycosylated
hemoglobin
• Administer IV fluids
• Encourage oral fluid intake and sweets intake
• Give information to family that the diseases can descent and
must protect it
• Test blood glucose level of family
• Collaborate administered insulin dose with doctor
• Collaborate with nutrient specialist about exact dietary
 2 . Risk for ineffective tissue
perfusion.
• After doing the nursing intervention for 2x24 hour, patient will
achieve Tissue Perfusion : Cerebral (0406) as evidenced by :
Indicator Before After
The patient’s headache/ pain 3 5
The patient’s fever 4 5

Explanation :
• 1: Severe
• 2: Substantial
• 3: Moderate
• 4: Mild
• 5: None
Cerebral Perfusion Promotion (2550)
• Monitor neurological status
• Maintain serum glucose level within normal
• Administer pain medication
• Administer anticoagulant medication
3. Risk for ineffective kidney perfusion
• After doing the nursing intervention for 3x24 hour, patient will achieve
Kidney function (0504)as evidenced by

Indicator
Before After

Within 8-hours urine output 2 4

serum creatinin 2 4
urine protein 4 5
Explanation :
• 1: Severe
• 2: Substantial
• 3: Moderate
• 4: Mild
• 5: None
Acid Base Management (1910):
• Observe urine output
• Observe laboratory results
• Count liquid balance
• Count drop infuse
• Administer IV fluids agree with calculation before
• Give information to patient and family about cause
the problem come
• Collaboration with physician about agree medicine
• Collaboration with nutrient specialist about exact
dietary
4. Risk for ineffective tissue perfusion :
peripheral
• After doing the nursing intervention for 2x 24 hour, patient will achieve
Tissue Perfusion : peripheral (0407) as evidenced by :

Indicator Before After

The patient’s skin

3 5
breakdown Explanation :
The patient’s numbness 3 5
1: Severe
2: Substantial
3: Moderate
4: Mild
5: None
Peripheral Sensation Management (2660) :
• Monitor for paresthesia : numbness
• Instruct patient to visually monitor position of body
parT
• Instruct patient or family to examine skin daily for
alteration in skin integrity
• Discuss or identify causes of abnormal sensation
change
Collaboration to administer analgesic
 5. Acute Pain
• After doing the nursing intervention for 2x24 hour, patient will achieve Pain Level
(2102) as evidenced by

Indicator Before After Explanation :

1: Severe
The patient’s reported 2: Substantial
3 5
pain 3: Moderate
4: Mild
The patient’s nausea 3 5 5: None
Pain Management (1400)
• Monitor patient satisfaction with pain management at special
intervals
• Reduce factors that precipitate or increase the pain experience (fear,
fatigue, monotony, and lack of knowledge)
• Teach the use of non pharmacological techniques (relaxation, music
therapy, distraction)
• Collaborate with the patient, significant other, and other health
professionals to select and implement non pharmacological pain
relief measures (relaxation, music therapy, distraction)
Analgesic Administration (2210)
• Monitor vital signs before and after administering
analgesics
• Determine pain location, characteristics, quality, and
severity before medicating patient
• Check history for drug allergies
• Teach about the use of analgesics (e.g.: oral, consume
how many times a day)
• Collaborate administering analgesic: kaltrofen 3% 2x1
amp
 6. Impaired tissue integrity
After doing the nursing intervention for 2x24 hour, patient will achiev Tissue
Integrity: skin and mucous membranes (1101) as evidenced by
Indicator Before After

Abnormal Explanation :
3 5 1: Severe
pigmentation
2: Substantial
Skin lessions 3 5 3: Moderate
4: Mild
Sensation 2 4
5: None
Pressure ulcer care (3520):
• Monitor color, temperature, edema, moisture and
appearance of surrounding skin
• Monitor nutritional status
• Apply ointments
• Teach individual or family member wound care
procedures
• Administer oral medications
 7. Hypertemia
• After doing the nursing intervention for 2x24 hour, patient will achieve
Thermoregulation (0800) as evidenced by

Indicator Before After

Temperature 4 5 Explanation :
1: Severe
Chilling 4 5 2: Substantial
3: Moderate
4: Mild
5: None
Temperatur regulation (3900):
• Observe temperature at least every 2 hours
• Observe skin colours
• Administer IV fluids
• Instruct patient to drink water agree with necessary
• Give warm compress in folds area