DIABETES MELLITUS

Devinision

According to WHO, Diabetes Mellitus (DM) is defined as a disease or chronic metabolic disorder with
multiple etiologies characterized by high blood sugar levels accompanied by disturbances in
carbohydrate, lipid and protein metabolism as a result of insulin function insufficiency.PENGKAJIAN

assessment

At this stage the author collects data from clients, client families, room nurses, doctors and Mr.'s
medical records. Bort with Diabetes Mellitus Type II Post Debridement Ukus Pedis at the Helios
Hildesheim hospital seta by conducting a direct physical examination on Mr. Bort and direct
observation on June 26 2019 at 09.30 PM.
client identity

Client name Mr. Bort, date of birth January 31, 1964, Gender Male, address Lutzowplatz 17, mitte ,
Berlin divorce status death. Christianity , Heiderbert university graduate education . Business
Consulting jobs. No. RM 263xxx, with a medical diagnosis of Diabetes Mellitus Type II Post
Debridement Ulkus Pedis date of entry 22 June 2019

Subjective data

1) The client says pain in the right leg

2) Pain like stabbing
3) Medium time
4) Quality of intermittent pain with a duration of 10-15 minutes
5) Pain is felt throughout the sole of the right foot
6) Pain decreases when the foot is silent
7) The patient says the sleep pattern is irregular
8) The client said his leg was swollen for 4 days
9) The client says it is difficult to defecate

data lens

1) The client looks grimacing and restless

2) The client is seen shaking his head
3) Blood pressure 110/70 mm Hg
4) The client looks sleepy
5) The client's leg looks bandaged on the right
6) Visible dirty wound bandages
7) The conjunctiva looks pale
8) No abdominal distension
9) Pulse 74 x/minute Temperature 36 degrees Celsius Respiration 17x/minute
NURSING DIAGNOSIS

Based on the scala pronas nursing diagnoses that arise in

Mr. Bort with Diabres Adaltrus post Debradamseur Cikus Padis is:

1) Instability of blood glucose levels is related to insulin resuscitation, which is indicated by

medical kidney stones, GDS 300
2) Acute pain related to physiological agents of injury which is characterized by the client
complaining of pain in the right leg
3) The risk of constipation related to decreased gastrointestinal motility with drug dependence
which is indicated by the client having to take laxatives for bowel movements 4) Damage to skin
integrity related to the presence of postoperative wounds characterized by the presence of
depridement wounds
5) The risk of infection is related to the presence of postoperative wounds marked by the
presence of a bandage on the right leg
6) Disturbed sleep patterns related to environmental barriers which are characterized by
clients complaining of irregular sleep patterns
7) Regulatory deficiency related to lack of information is marked by the client not knowing
about his illness
PURPOSE

A. Instability of blood glucose levels associated with insulin resistance after nursing interventions
for 3x24 hours it is expected that blood glucose levels can be resolved with the outcome
criteria
1. Glucose level stabilizes to 120
2. Understand dietary and exercise recommendations

B. Acute pain related to the physiological agent of injury. The goal is that after nursing
intervention for 3x24 hours, it is hoped that acute pain can improve with the outcome
criteria
1. The client's pain level is reduced to 3
2. Pay attention to relaxation techniques
3. Collaboration with related doctors

C. Risk for constipation related to decreased gastrointestinal motility and dependence on

laxatives. The goal is that after nursing intervention for 3x24 hours, it is hoped that there will
be no risk of constipation with the outcome criteria
1. Eliminate alvi 1 to 2x a day
2. Normal bowel noise
3. Scale CAS 0

D. Impaired writing integrity related to the presence of postoperative wounds

Objective - after nursing intervention has been carried out for 2x24 hours, it is hoped that
the damage to the skin integrity can be improved: with the following criteria:
1) Shows tissue integrity: skin and malcosa palpable

E. Risk for infection related to the presence of postoperative scars

Objective: after the intervention has been carried out for 28-34 hours, it is hoped that
the risk of infection will not occur with the following criteria:
1) There are no signs of infection such as (dolor, kaior rudor, sumor, das
fungstolesa) 2) Clients and families can clean hands and postoperative wounds 3)
Good skin integrity
4) Bad status (CRI 1 score, there is a weight reduction)

F. Disturbed sleep pattern related to environmental barriers

Objective: after 2 x 8 hours of nursing intervention, it is hoped that sleep patterns can be
resolved with the following criteria:
1) client says fresh

2) Sleep adequately 6-8 hours/day.

G. Knowledge deficiency related to lack of information

The goal after nursing intervention for 1x30 ment. it is expected that clients and families know
about the disease they are suffering from with the following criteria:
1) the client and family know about the disease

2) family das clients know the causes of injuries in people with DM

INTERVENTION

A. Instability of blood glucose levels related to insulin resistance

1. Assess blood glucose levels

2. encourage clients to low-calorie diet
3. Instruct the client to reduce foods that contain carbohydrates
4. Collaboration in giving insulin.

B. Acute pain related to the physiological agent of injury.

1. Assess pain level
2. Teach clients relaxation techniques, for example RND
3. Collaboration with pharmacology doctors

C. Risk for constipation related to decreased gastrointestinal motility and

dependence on laxatives
1. Assess faecal elimination rate, frequency and CAS scale
2. Instruct the client and family Pharmacological techniques such as abdominal
massage
3. Perform abdominal massage
4. Collaborative drug administration

D. Impaired written integrity related to the presence of postoperative

wounds

1. Assess the wound area after each wound care

2. drug delivery collaboration

E. The risk of infection associated with the presence of

postoperative scars

1. Assessment of wound criteria

2. Perform wound care
3. Teach the 6 steps of hand washing
4. Collaboration in administering antibiotics

F. F. sleep pattern disturbances related to environmental barriers

1. Assess the client's sleep patterns

2. Instruct client adequate sleep
3. Create a safe and comfortable atmosphere
4. Collaboration of drug administration if needed

G. Knowledge deficiency related to lack of information 1. Assess the

client's and family's level of knowledge
2. Education about the causes of DM
3. Instruct the client to exercise
Get involved

A. Instability of blood glucose levels related to insulin resistance 1. Monitor

blood glucose levels
2. monitor advise clients to low-calorie diet
3. monitor the client's suggestion to reduce foods that contain carbohydrates 4.
Collaboration giving insulin.

B. Acute pain related to the physiological agent of injury.

1. Monitor Assess the level of pain
2. Monitor. Teach clients relaxation techniques, for example RND
3. Collaboration with pharmacology doctors

C. Risk for constipation related to decreased gastrointestinal motility and

dependence on laxatives
1. Monitor Assess fecal elimination rate, frequency and CAS scale
2. Monitor. Instruct clients and families Pharmacological techniques such as
abdominal massage
3. Monitor Perform abdominal massage
4. Collaborative drug administration

D. damage to the integrity of writing related to the presence of

postoperative wounds 1. monitor the wound area every time you treat a
wound
2. Monitor collaborative drug administration

E. Risk for infection related to the presence of postoperative scars

1. Monitor the review of wound criteria
2. Monitor Perform wound care
3. Monitor Teach the 6 steps of hand washing
4. Collaboration in administering antibiotics

F. Disturbed sleep pattern related to environmental barriers

1. Monitor the client's sleep patterns

2. Monitor the client Suggest adequate sleep
3. monitor Create a safe and comfortable atmosphere
4. Collaboration of drug administration if needed

G. Knowledge deficiency related to lack of information

1. Monitor the level of knowledge of clients and families

2. Monitor education about the causes of DM 3. Monitor Instruct clients to exercise

EVALUATION

A diagnosis

- The client says he understands the disease

- it can be seen that the client and family understand what the
nurse is conveying - the problem is resolved

B diagnosis
- the client says the pain is reduced to a scale of 3
- the client looks relaxed
- the issue is resolved

C diagnosis
- the client says he can't defecate yet
- looks agitated
- problem not resolved

D diagnosis
- the client says there is a wound on the leg
- There are post-operative wounds
- Problem not resolved

diagnostic and
- The client says that after treating the wound the client feels
comfortable - The client looks relaxed
- The issue is resolved

F diagnosis
- The client says he can't sleep because it's too noisy
- Looks sleepy client
- Problem not resolved