MATA KULIAH KEPERAWATAN

BAHASA INGGRIS

VIA ELIADORA TOGATOROP

1914901040

POLITEKNIK KESEHATAN TANJUNGKARANG

PRODI PROFESI NERS KEPERAWATAN TANJUNGKARANG

TAHUN AKADEMIK 2019/2020

 NURSING CARE

TO PATIENT WITH DIABETUS MELLITUS

IN ABDUL MOELOEK HOSPITAL LAMPUNG PROVINCE 2019

POLTEKKES TANJUNGKARANG KEMENKES RI

NURSING OF TANJUNGKARANG
NURSING PROFESSION STUDY PROGRAMS
2019
 NURSING ASSESMENTS
Biographical
cinformation

Name : Ms. Parti

Age: 46
Sex: Female
Marital Status: Marriage
Occupation: Farmer

Date: Aug 9th 2019 Time: 10:05 p.m Primary Language: English
Arrived via: (√)Wheelchair __Stretcher __Ambulatory
From: (√) Admitting __ER __Home __Other
Family G.P: Son
Admission Data

Weight: 55 kg Height: 165 cm BP: 140/80 mmHg

Temp : 36,2o C Pulse: 64x/ mnts Resp: 16x/ mnts
Reason for admission:
Patient has fainted. After ate meat 2 days ago, patient didn’t eat for 2 days.
Patient felt weak and afraid got hyperglicemia and stopped eating. Weakness felt
in upper and lower extremities, so that patient only move with minimum
movements. When patient mobilized, patient got weaker.

Usual Health Status:

Sometimes health, sometimes weak.
History of present complaint

Chronology of the illness:

Patient has diabetes. After eat a lot of meat 2 days ago, patient doesn’t eat
anything and getting weaker which become fainted.

Effect of the illness on the patient’s daily life:

Weakness
Previous hospitalization:
Patient has hospitalized at Hosp. Abdul Moeloek 3 months ago cause of
hyperglicemia.
Past health status

Previous surgery:
Patient never had any surgery.

Childhood disease:
Patient has no any disease that related to present disease.
 Narrative Notes:
Patient can lift her extremities with muscle strength 3. Patient feel weak. Blood
glucose level 35 mg/dL. Low pulse with high blood pressure. Peristaltic sound 6x
per minutes.

NURSING DIAGNOSES

1. Risk for unstable blood glucose level

2. Imbalanced nutrition: less than body requirement.
 NURSING CARE PLAN

Nursing
No Nursing Outcome Criterias Nursing Intervention Cares Rationales
Diagnoses
1 Imbalanced The following are the common Experts like a dietician can determine
Nutrition: Less goals and expected outcomes nitrogen balance as a measure of the
Than Body for Imbalanced Nutrition: Less Ascertain healthy body weight for age nutritional status of the patient. A
Requirements Than Body Requirements. and height. Refer to a dietitian for negative nitrogen balance may mean
complete nutrition assessment and protein malnutrition. The dietician can
methods for nutritional support. also determine the patient’s daily
 Patient presents
requirements of specific nutrients to
understanding of
promote sufficient nutritional intake.
significance of nutrition to
Patients may lose concern in addressing
healing process and general Set appropriate short-term and long-
this dilemma without realistic short-term
health. term goals.
goals.
 Patient or caregiver
A pleasing atmosphere helps in
verbalizes and
Provide a pleasant environment. decreasing stress and is more favorable
demonstrates selection of
to eating.
foods or meals that will
Elevating the head of bed 30 degrees
accomplish a termination
Promote proper positioning. aids in swallowing and reduces risk for
of weight loss.
aspiration with eating.
 Patient demonstrates
Oral hygiene has a positive effect on
behaviors, lifestyle changes
appetite and on the taste of food.
to recover and/or keep Provide good oral hygiene and
Dentures need to be clean,
appropriate weight. dentition.
fit comfortably, and be in the patient’s
 Patient displays nutritional
mouth to encourage eating.
ingestion sufficient to meet
If patient lacks strength, schedule rest Nursing assistance with activities of
metabolic needs as
periods before meals and open packages daily living (ADLs) will conserve the
manifested by stable
and cut up food for patient. patient’s energy for activities the patient
weight or muscle-mass
values. Patients who take longer than
measurements, positive
one hour to complete a meal may
nitrogen balance, tissue
require assistance.
 regeneration and exhibits Attention to the social perspectives of
Provide companionship during
improved energy level. eating is important in both hospital and
mealtime.
 Patient shows no signs of home settings.
malnutrition. Consider the use of seasoning for
 Patient takes adequate patients with changes in their sense of Seasoning may improve the flavor of the
amount of calories or taste; if not contraindicated. foods and attract eating.
nutrients.
 Patient maintains weight or Consider six small nutrient-dense meals
Eating small, frequent meals lessens the
displays weight gain on the instead of three larger meals daily to
feeling of fullness and decreases the
way to preferred goal, with lessen the feeling of fullness.
stimulus to vomit.
normalization of laboratory
values. For patients with physical impairments,
Special devices may be provided by an
 Patient weighs within 10% refer to an occupational therapist for
expert that can help patients feed
of ideal body weight adaptive devices.
themselves.
(IBW).
Adjustments of the thickness and
For patients with impaired swallowing,
consistency of foods to improve
coordinate with a speech therapist for
nutritional intake may be provided by a
evaluation and instruction.
speech therapist.
Determine time of day when the
patient’s appetite is at peak. Offer Patients with liver disease often have
highest calorie meal at that time. their largest appetite at breakfast time.

Patients with specific ethnic or religious

Encourage family members to bring
preferences or restrictions may not
food from home to the hospital.
consider foods from the hospital.
Such supplements can be used to
Offer high protein supplements based
increase calories and protein without
on individual needs and capabilities.
conflict with voluntary food intake.
Offer liquid energy supplements. Energy supplementation has been shown
to produce weight gain and reduce falls
in frail elderly living in the community.
 These beverages will decrease hunger
Discourage caffeinated or carbonated and lead to early satiety.
beverages.

Keep a high index of suspicion of

Impaired immunity is a critical adjunct
malnutrition as a causative factor in
factor in malnutrition-associated
infections.
infections in all age groups.
Metabolism and utilization of nutrients
Encourage exercise.
are improved by activity.
Nutritional support may be
recommended for patients who are
Consider the possible need for enteral or unable to maintain nutritional intake by
parenteral nutritional support with the the oral route. If gastrointestinal tract is
patient, family, and caregiver, as functioning well, enteral tube feedings
appropriate. are indicated. For those who cannot
tolerate enteral feedings, parenteral
nutrition is recommended.
Validate the patient’s feelings regarding
Validation lets the patient know that the
the impact of current lifestyle, finances,
nurse has heard and understands what
and transportation on ability to obtain
was said, and it promotes the nurse-
nutritious food.
patient relationship.
Once discharged, help the patient and
family identify area to change that will
Change is difficult. Multiple changes
make the greatest contribution to
may be overwhelming.
improved nutrition.

Accepting the patient’s or family’s

Adapt modification to their current preferences shows respect for their
practices. culture.
2 Risk for Unstable This information provides the basis for
The following are the common
Blood Glucose Assist the patient in identifying eating individualized dietary instruction related
Level goals and expected outcomes patterns that need to be modified. to the clinical condition that contributes
for Risk for Unstable Blood to fluctuation in blood glucose levels.

Glucose Level: Adherence to the therapeutic regimen

promotes tissue perfusion. Keeping
Administer basal and prandial insulin.
glucose in the normal range slows
 Patient has a blood glucose progression of microvascular disease.
reading of less than 180
mg/dL; fasting blood An individualized meal plan depends on
the patient’s body, weight, blood glucose
glucose levels of less than Refer to a registered dietitian for values, activity patterns, and specific
<140 mg/dL; and individualized diet instruction. clinical condition. Modifications in the
patient’s food intake will contribute
hemoglobin A1C level stabilization of blood glucose levels.
<7%.
Insulin is required to lower blood
glucose levels in type 1 diabetes, and for
many patients with type 2 diabetes.
Administer insulin medications as
Patients receiving TPN may require
directed.
insulin to maintain stable blood glucose
in response to high dextrose
concentration in the solution.

Report BP of more than 160 mm Hg Hypertension is commonly associated

(systolic). Administer hypertensive as with diabetes. Control of BP
prescribed. prevents coronary artery disease, stroke,
retinopathy, and nephropathy.
 A rapidly absorbed form of glucose is
indicated to manage hypoglycemia.
These forms of glucose may include oral
Provide food or other sources of glucose
intake of hard candy or fruit juice. For
as directed for hypoglycemia.
the patient who cannot take something
orally, intravenous injection of glucose
may be indicated.

Educate the patient about the A prescribed meal plan will help the
importance of following a prescribed patient maintain stable blood glucose
meal plan. levels.
The patient with diabetes needs to learn
Educate the patient about the proper about taking insulin or oral
ways of taking prescribed medications. hypoglycemic drugs to lower blood
glucose.

Patient involvement in the treatment

Review the progress toward goals
plan enhances adherence to treatment
during each patient visit.
plan.

Food intake is appropriate in most cases

Instruct the patient experiencing of hypoglycemia to raise blood glucose
hypoglycemia about appropriate actions levels. Eating a rapidly absorbed source
to raise blood glucose. of glucose is appropriate for patients
with diabetes.
Discuss the importance of balance Exercise balances glucose levels by
exercise with food intake. facilitating uptake of glucose into cells.
The patient needs to understand the
relationship of exercise, food intake, and
blood glucose levels.
 Capillary blood glucose monitoring
Teach the patient on measuring capillary
provides the patient with immediate
blood glucose.
information about blood glucose.

The medical team needs to be able to

Instruct patient to carry medical alert identify the patient as having a clinical
information. condition linked with unstable blood
glucose.

Refer the patient to an exercise

Specific exercises can be prescribed
physiologist, physical therapist, or
based on any physical limitations the
cardiac rehabilitation nurse for specific
patient may have.
exercise instructions.
 IMPLEMENTATIONS

No Interventions Signature N M E
Dx 1: Imbalanced nutrition : less than body requirements
Ascertain healthy body weight for age and
height. Refer to a dietitian for complete
1
nutrition assessment and methods for
nutritional support.
2 Set appropriate short-term and long-term goals.
3 Provide a pleasant environment.
4 Promote proper positioning.
5 Provide good oral hygiene and dentition.
If patient lacks strength, schedule rest periods
6 before meals and open packages and cut up
food for patient.
7 Provide companionship during mealtime.
Consider the use of seasoning for patients with
8 changes in their sense of taste; if not
contraindicated.
Consider six small nutrient-dense meals
9 instead of three larger meals daily to lessen the
feeling of fullness.
For patients with physical impairments, refer to
9
an occupational therapist for adaptive devices.
For patients with impaired swallowing,
10 coordinate with a speech therapist for
evaluation and instruction.
Determine time of day when the patient’s
11 appetite is at peak. Offer highest calorie meal
at that time.
Encourage family members to bring food from
12
home to the hospital.
Offer high protein supplements based on
13
individual needs and capabilities.
14 Offer liquid energy supplements.
Discourage caffeinated or carbonated
15
beverages.
Keep a high index of suspicion of malnutrition
16
as a causative factor in infections.
17 Encourage exercise.
Consider the possible need for enteral or
18 parenteral nutritional support with the patient,
family, and caregiver, as appropriate.
Validate the patient’s feelings regarding the
impact of current lifestyle, finances, and
19
transportation on ability to obtain nutritious
food.
20 Once discharged, help the patient and family
 identify area to change that will make the
greatest contribution to improved nutrition.
21 Adapt modification to their current practices.
Dx 2: Risk for unstable blood glucose level

Assist the patient in identifying eating patterns

1
that need to be modified.
2 Administer basal and prandial insulin.
Refer to a registered dietitian for
3
individualized diet instruction.
4 Administer insulin medications as directed.
Report BP of more than 160 mm Hg (systolic).
5
Administer hypertensive as prescribed.
Provide food or other sources of glucose as
6
directed for hypoglycemia.
Educate the patient about the importance of
7
following a prescribed meal plan.
Educate the patient about the proper ways of
8
taking prescribed medications.
Review the progress toward goals during each
9
patient visit.
Instruct the patient experiencing hypoglycemia
10 about appropriate actions to raise blood
glucose.
Discuss the importance of balance exercise
11
with food intake.
Teach the patient on measuring capillary blood
12
glucose.
Instruct patient to carry medical alert
13
information.
Refer the patient to an exercise physiologist,
14 physical therapist, or cardiac rehabilitation
nurse for specific exercise instructions.
 SOAP NOTES

No Date/ No. of Dx Evaluation

1 Aug 10th 2019 S:
06.00 a.m. “ I will bring food from home.”
O:
Dx 1 Injected with crystalloid liquid 500 ml/ 8 hours
A:
Imbalanced nutrition: less than body requirement.
P:
1. Refer to dietitian for right nutritition
2. Encourage exercise
3. Consider the possible need for enteral nutritional support
4. Make schedule to eat food/meals in one day
2 Aug 10th 2019 S:
02.00 p.m. “I was wrong not to eat enough, I must change my lifestyle,”
“I feel strong enough to have a little exercise.”
Dx 1 “I prefer eat food with salty taste.”
O:
1. Eat three times a day and twice meals
2. Weight 55,3 kg
3. High calories diet for patient
A:
Imbalanced nutrition: less than body requirement.
P:
1. Provide a pleasant environment, good oral hygiene and
companionship mealtime.
2. Educate not to eat carbonated beverages and caffeinated.

3 Aug 10th 2019 S:

09.00 p.m. “This food more delicious with clean oral.”
“I feel better when eating with this position.”
Dx 1 O:
1. Clean oral
2. IBW : 20,20
A:
Imbalanced nutrition: less than body requirement.
P:
1. Offer liquid energy suplements
2. Offer high protein suplements
4 Aug 10th 2019 S:
06.00 a.m. “I feel stronger.”
O:
Dx 2 1. Injected insuline 20 units + D40 2 ampules
2. Muscles strength 4
A:
Risk for unstable blood glucose level
P:
1. Identify food to be need to eat.
2. Provide food or other source of glucose as directed for
 hypoglycemia
3. Educate patient about the importance of prescribe meals
4. Give insuline 20 unit 8 hours to go with IM before breakfast
5. Check blood glucose level 2 hours post prandial
5 Aug 10th 2019 S:
02.00 p.m. “I will eat food to keep enough glucose in my body.”
“I remember to shot insuline first before breakfast or having a big
Dx 2 meal.”
O:
1. Injected insuline 20 units at 06.00 a.m
2. Blood glucose level 2 hours post prandial is 150 mg/dL.
A:
Risk for unstable blood glucose level
P:
1. Give insuline 16 unit 8 hours to go with IM
2. Instruct the patient experiencing hypoglycemia about
appropriate actions to raise blood glucose.
3. Discuss the importance of balance exercise with food intake
4. Teach the patient on measuring capillary blood glucose.
5. Instruct patient to carry medical alert information
6 Aug 10th 2019 S:
09.00 p.m. “I will eat food and have exercise to have stable glucose level.”
“Not eating is not recommended to decrease glocose level.”
Dx 2 “I will eat 2-3 tsp to increase my glucose level when I have
hypoglycemia.”
O:
1. Injected insuline 16 units at 02.00 p.m.
2. Patient can check their capilarry glucose level.
3. Glucose level is 200 mg/dL
A:
Risk for unstable blood glucose level
P:
1. Give insuline 24 unit 8 hours to go with IM
2. Review the progress toward goals during each patient visit
3. Report BP of more than 160 mm Hg (systolic). Administer
hypertensive as prescribed.
4. Refer the patient to an exercise physiologist, physical therapist,
or cardiac rehabilitation nurse for specific exercise instructions.