NURSING DIAGNOSIS: Risk for fluid volume deficit related to frequent urination.

Transcription

1 NURSING CARE PLAN NURSING DIAGNOSIS: Risk for fluid volume deficit related to frequent urination. Goal: Provision of fluid balance. Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individuality appropriate urinary output. INTERVENTIONS RATIONALE 1. Obtain history from patient related to duration of intensity of symptoms 1. Assists in estimation of total volume depletion. like excessive urination. 2. Weight daily and record data gathered. 2. Rapid losses or gains of 5% more of total body weight indicate moderate to severe fluid volume deficit or 3. Monitor vital signs: excess. a. Body temperature 3a. A decreased body temperature

2 may result from hypovolemia. Although fever, chills, diaphoresis are common with infection process, fever with flushed, dry skin may reflect dehydration. 3b. An increased pulse rate and a b. Pulse rate weak, thread pulse may occur with fluid volume deficit. 3c. Correction of hyperglycemia will cause the rate and pattern to approach c. Respiratory rate normal. In contrast, increased work of breathing, shallow, rapid respirations; and presence of cyanosis may indicate respiratory fatigue. 3d. Hypovolemia may be manifested by hypotension and tachycardia. Estimates the severity of hypovolemia may be made when patient s systolic blood pressure d. Blood Pressure drops more than 10mmhg from a Recumbent to a sitting or standing position.

3 4. Maintain fluid intake of at least 2500 ml/day within cardiac tolerance when oral intake is 4. Adequate and increase in fluid intake can maintain hydration or circulating volume. resumed. NURSING DIAGNOSIS: Risk for infection related to insufficient knowledge on proper wound care. Goal: Have knowledge on proper wound care. Identify interventions to prevent or reduce risk of infection. Demonstrate techniques, lifestyle changes to prevent development of infection.

4 INTERVENTIONS RATIONALE 1. Observe for signs of infection and inflammation, like fever, flushed appearance, wound drainage. 1. Proper assessment for signs of infection can prevent any other complication and can provide essential care. 2. Educate the patient on how to care properly the wounds on step by step process. 2. Prevention of infection is best achieved through following the guidelines of wound care obtained during educating process. 3. Proper application and changing of 3. Change wound dressings if needed using proper techniques of changing and disposing contaminated materials. wound dressing can facilitate the prevention of progress or transfer of infection. 4. Fruits rich in vitamin c can boost the 4. Encourage patient to eat foods rich in immunity of an individual which helps vitamin c like citrus, oranges, him fight infection. pineapple etc. NURSING DIAGNOSIS: Imbalanced Nutrition: less than body requirements related to inability to utilize nutrients.

5 GOAL: Maintain normal nutritional status. Demonstrate stabilized weight or gain toward usual/desired range. INTERVENTIONS RATIONALE 1. Weight daily or as indicated. 1. Assesses adequate of nutritional intake By absorption and utilization of nutrients. 2. If patient s food preferences can be 2. Identify food preferences, including ethnic/cultural needs. incorporated into the meal plan, cooperation with dietary requirements may be facilitated. 3. Proper intake and distribution of meals can help an individual to maintain, reduce, or gain the ideal 3. Discuss proper distribution of meals weight that he should achieve. that the client prefers but may contribute in maintaining normal body weight.

6 XII. A. CONCLUSION In making this care study, I really appreciate how vital our organs are, that we should be very careful in doing things, in every action we take, because it may result to damage of such organ. Diabetes Mellitus is a very complex disease process if not treated appropriately. Patients with such condition should know how to control his lifestyle, diet, and avoid factors that could worsen the condition. Through this case study we learned many things that are necessary and have relevance to our future career. B. RECOMMENDATION This study aims to recommend a continued teaching to enhance skills and abilities of concerned people, and to develop a good quality loaded with knowledge. This is also to eradicate complications patients with Diabetes Mellitus XIII. IMPLICATION OF THE STUDY TO A. NURSING EDUCATION The care study provides the academe of nursing education the opportunity to focus on how to engage in care management of Diabetes Mellitus. And to renew the idea of dealing

7 patients easily, instead we must set much more effort in dealing with them because this is the times when they need more support. B. NURSING PRACTICE The care study provides a wider venue for nursing students to develop and enrich their skills and knowledge in rendering efficient and effective care. It sharpens our abilities in performing nursing measures to be rendered to our respective clients. Thus, provides us satisfactory exposure that can t be paid by any means. C. NURSING RESEARCH The care study helps in further investigation and research to optimize nursing care and expand the scope of nursing practice. Thus, continued investigation is further encouraged on the ultimate predisposing factor of having Diabetes Mellitus.