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Standar Asuhan Keperawatan Diabetes Mellitus

Presentation · May 2019

DOI: 10.13140/RG.2.2.18928.00008

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Lukman Lukman
Politeknik Kesehatan Palembang
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ASUHAN KEPERAWATAN
DIABETES MELLITUS

Ns. Lukman, S.Kep., MM., M.Kep

Disampaikan pada Seminar “Kupas Tuntas Askep dan Penatalaksanaan DM Tipe II

pada Individu Dewasa pada Bulan Ramadhan” Palembang, 26 Mei 2019
 Statistics
• Morbidity: More than 20.8 million Americans diagnosed
with either type 1 or type 2 diabetes; affects 20% of people
over the age of 65 years; approximately 1.5 million new
cases of diabetes diagnosed in 2005 (National Diabetes
Information Clearinghouse [NDIC], 2007).
• Mortality: In 2002, diabetes was reported to be the sixth
leading cause of death (NDIC, 2007).
• Cost: In 2007, the total cost (direct and indirect) of diabetes
in the United States was estimated to be $174 billion (ADA,
2007).
PATOFISIOLOGI
• Diabetes mellitus (DM) is a chronic metabolic
disorder in which the body cannot metabolize
carbohydrates, fats, and proteins because of a lack of,
or ineffective use of, the hormone insulin.
• Diabetic ketoacidosis (DKA) is a life-threatening
emergency caused by a relative or absolute
deficiency of insulin.
Classification

a. Three primary types that are different disease

entities but share the symptoms and complications
of hyperglycemia
b. Type 1, type 2, and impaired glucose tolerance or
pre-diabetes—formerly known as “borderline
diabetes”
Etiology
• Conditions or situations known to exacerbate glucose
and insulin imbalance
– Previously undiagnosed or newly diagnosed type 1
diabetes
– Food intake in excess of available insulin
iii.Adolescence and puberty
– Exercise in uncontrolled diabetes
– Stress associated with illness, infection, trauma, or
emotional distress
Type 1 diabetes (ADA, 2004)
• An autoimmune disease possibly triggered by genetic and environmental factors,
such as with virus, toxin, stress
– 1. Destroys beta-cells in the pancreas
– 2. When 80% to 90% of the beta cells are destroyed, overt symptoms occur.
• Totally insulin-deficient; clients require exogenous insulin to survive (Peeples &
Seley, 2007).
• Characteristics
– 1. Usually occurs before 30 years of age, but can occur at any age
– 2. Peak incidence occurs during puberty
– 3.Abrupt onset of signs and symptoms of hyperglycemia
– 4. Prone to ketoacidosis
Type 2 diabetes (ADA, 2004)
• Involves a decreased ability to use the insulin produced in the
pancreas (Peeples & Seley, 2007)
– 1. Decreased insulin secretion in response to glucose levels
– 2. Insulin resistance blocking cells from absorbing glucose
– 3. Excess production of glucose because of defective
insulin secretory response
• Accounts for 90% to 95% of all diabetes in the United States
Type 2 diabetes (ADA, 2004)
• Characteristics
– 1. Usually occurs after 30 years of age, but is now occurring in
children and adolescents.
– 2. Increased prevalence in some ethnic groups—African
Americans, Hispanic/Latino, Native Americans, Asian Americans,
and Pacific Islanders
– 3. Strong genetic predisposition
– 4. Frequently obese
– 5. Not prone to ketoacidosis until late in course or with
prolonged hyperglycemia
Type 2 diabetes (ADA, 2004)

• Associated with many complications, including heart

disease and stroke, high blood pressure, blindness,
kidney and nervous system disease, amputations,
and complications of pregnancy
Client Assessment Database
ACTIVITY/REST
• Sleep and rest disturbances • Tachycardia & tachypnea at
• Weakness, fatigue, difficulty rest or with activity
walking and moving • Lethargy, disorientation,
• Muscle cramps, decreased coma
muscle strength • Decreased muscle strenght
and tone
CIRCULATION
• History of hypertension; • Decrased & absent
acute myocardial pulses
infarction (MI),
claudication, numbness, • Dysrhythmias
tingling of extremities • Crackles; jugular vein
(long-term effects) distention (JVD)  if
• Leg ulcers, slow healing heart failure present
• Tachycardia • Hot, dry, flushed skin;
• Postural BP chnages: sunken eyeballs  if
• ypertension dehydration is severe
EGO INTEGRITY
• Life stressors, including financial concerns
related to condition
• Anxiety, irritability
ELIMINATION
• Change in usual voiding pattern
• Excessive urination (polyuria)
• Nocturia
• Pain and burning, difficulty
voiding (infection neurogenic
bladder)
• Recent and recurrent urinary
tract infections (UTIs)
• Abdominal tenderness, bloating,
diarrhea
• Pale, yellow, dilute urine
• Polyuria may progress to
oliguria and anuria if severe
hypovolemia
• Cloudy, odorous urine
(infection)
• Abdomen firm, distended
FOOD/FLUID
• Loss of appetite, nausea and
vomiting
• Not following prescribed
diet, increased intake of
glucose and carbohydrates
• Weight loss over a period of
days or weeks
• Thirst
• Use of medications
exacerbating dehydration,
such as diuretics
• Dry and cracked skin, poor
skin tugor
• Abdominal rigidity and
distention
• Halitosis and sweet, fruity
breath odor
NEUROSENSORY
• Fainting spells, dizziness •
Headaches
• Tingling, numbness,
weakness in muscles
• Visual disturbances
• Confusion, disorientation
• Drowsiness, lethargy, stupor
& coma (later stages)
• Deep tendon reflexes (DTR)
may be decreased
• Seizure activity (late stages
of DKA or hypoglycemia)
PAIN/DISCOMFORT
• Abdominal bloating and pain
• Facial grimacing with abdominal
palpitation, gurading
RESPIRATION
• Air hunger (late stages • Tachycardia
of DKA) • Kussmaul’s respiration
• Cough, with and (metabolic acidosis
without purulent • Rhonchi, wheezes
sputum (infection) • Yellow or green sputum
(infection)
SAFETY
• Dry, itching skin, skin
ulcerations
• Paresthesia (diabetic
neuropathy)
• Fever, diaphoresis
• Skin breakdown, lession and
ulceration
• Decreased general strenght
and range of motion (ROM)
• Weakness and paralysis of
muscles, including
respiratory musculate if
potassium levels are
markedly decreased
SEXUALITY
• Vaginal discharge (prone to
infection)
• Problems with impotence (men),
orgasmic difficulty (women)
TEACHING/LEARNING
• Familial risk factors, such as diabetes
mellitus, heart disease, stroke, hypertension
• Slow and delayed healing
• Use of drugs, such as steroids, thiazide
diuretics, phenytoin (Dilantin), and
phenobarbital (can increase glucose levels)
• May or may not be taking diabetic
medications as ordered
Nursing Priorities
1. Restore fluid and electrolyte and acid-
acid-base
balance..
balance
2. Correct or reverse metabolic abnormalities.
3. Identify and assist with management of
underlying cause or disease process.
4. Prevent complications.
5. Provide information about disease process,
prognosis,, self-
prognosis self-care, and treatment needs.
DISCHARGE GOALS
1. Homeostasis achieved.
2. 2. Causative and precipitating factors
corrected or controlled.
3. Complications prevented or minimized.
4. Disease process, prognosis, self-care needs,
and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
 NURSING DIAGNOSIS
• Deficient Fluid Volume
• Unstable blood Glucose
Level
• Risk for Infection, [sepsis]
• risk for disturbed Sensory
Perception
• Fatigue
• Powerlessness
• Deficient Knowledge
[Learning Need] regarding
disease, prognosis,
treatment, self-care, and
discharge needs
 NURSING DIAGNOSIS
• Hipovolemia (D.0023) • Keletihan (D.0057)
• Ketidakstabilan kadar gula • Ketidakberdayaan (D.0092)
darah (D.0027) • Defisit Pengetahuan
• Risiko Infeksi (D.0142) (D.0111)
• Gangguan persepsi sensori
(D.0085)
Hipovolemia
Intervensi Utama
Manajemen Hipovolemia
Mengidentifikasi dan mengelola penurunan volume cairan
intravaskuler

Manajemen Syok Hipovolemik

Mengidentifikasi dan mengelola ketidakmampuan tubuh
menyediakan oksigen dan nutrien untuk mencukupi kebutuhan
jaringan akibat kehilangan cairan /darah berlebihan
Manajemen Hipovolemia
Observasi (Kaji) Terapeutik Edukasi Kolaborasi
(Mandiri)
Periksa tanda & gejala •Hitung Anjurkan Pemberian cairan
hipovolemia (nadi kebutuhan cairan memperbanyak IV isotonis (msi,
meningkat dan lemah, •Berikan posisi asupan cairan NaCl, RL
TD turun, turgor modified oral …hipotonis (mis
menurun, membran trendelenburg Anjurkan glukosa 2,5 %, NaCl
mukosa kering, vol urin •Berikan asupan menghindari 0,4%)
menurun, HT cairan oral perubahan …koloid
meningkat, haus, lemah posisi (mis.albumin,
- Monitor Intake mendadak Plasmanate)
Output Pemberian
produk darah
 Manajemen Syok Hipovolemik
Observasi (Kaji) Terapeutik (Mandiri) Kolaborasi
Monitor status •Pertahankan jalan napas paten Pemberian
kardiopulmonal (nadi, •Berikan O2 u/ mempertahankan Efineprin
napas, TD, MAP) saturasi O2 >94 Dipenhidramin, jika perlu
Monitor status •Persiapan intubasi , jika perlu Bronkodilator, jika perlu
oksigen (oksimetri •Berikan posisi syok (modified Krikotiroidektomi, jika
nadi, AGD) Trendelenburg) perlu
Monitor status cairan •Pasang jalur IV Intubasi endotrakeal, jika
(I, O, turgor kulit, CRT) •Pasang kateter urin untuk perlu
Monitor tk kesadaran menilai produksi urin Resusitasi cairan, jika
dan respon pupil) •Pasang NGT u/ dekomresi perlu
lambung, jika perlu
Ketidakstabilan kadar gula darah
Intervensi Utama
Manajemen Hiperglikemia
Mengidentifikasi dan mengelola kadar gula darah di atas
normal
Manajemen Hipoglikemia
Mengidentifikasi dan mengelola kadar gula darah endah
 Manajemen Hiperglikemia
Observasi (Kaji) Terapeutik Edukasi Kolaborasi
(Mandiri)
Identifikasi kemungkinan •Berikan asupan Hindari olahraga bila KGD Pemberian:
penyebab hiperglikemia cairan oral >250 mg/dL Insulin
Identifikasi situasi yg •Konsultasi dg Anjurkan monitor KGD Cairan IV
membutuhkan insulin meningkat medis jika mandiri Kalium
(penyakit kambuhan) memburuk Anjurkan kepatuhan
Minotor KGD •Fasilitasi terhadap diet dan olahraga
Monitor tanda dan gejala ambulasi jika ada Ajarkan pentingnya
hiperglikemia (3poli, kelemahan, hipetensi pemeriksaan keton urin
padangan kabur, sakit kepala) ortostatik Ajarkan pengelolaan DM
Monitor I & O (obat, insulin,
Monitor keton urin, kadar AGD,
elektrolit, TD, frekuensi nadi
 Manajemen Hipoglikemia
Observasi (Kaji) Terapeutik (Mandiri)
Identifikasi tanda & •Berikan karbohidrat
gejala hipoglikemia sederhana bila perlu
Identifikasi •Berikan karbohidrat
kemungkinan penyebab kompleks dan protein
sesuai diet
•Pertahankan kepatenan
jalan napas
•Pertahankan akses IV, jika
perlu
•Hub. Layanan medis bila
perlu
Edukasi Kolaborasi
Anjurkan membawa Pemberian:
karbohidrat sederhana Dektrose, jika
Anjurkan memakai perlu
identitas darurat yg tepat Glukagon jika
Anjurkan monitor KGD perlu
Anjurkan berdiskusi dg tim
perawatan ttg penyesuaian
program pengobatan
Jelaskan interaksi diet,
obat/insulin, olahraga
Ajarkan pengelolaan hipog
(tanda & gejala, risiko dan
pengobatan)
Ajarkan perawatan mandiri
untuk mencegah
hipoglikemia
Risiko Infeksi
Intervensi Utama
Manajemen Imunisasi/Vaksinasi
Mengidentifikasi dan mengelola pemberian
kekebalan tubuh secara aktif dan pasif
Pencegahan Infeksi
Mengidentifikasi dan menurunkan risiko
terserang organisme patogenik
 Manajemen Imunisasi
Imunisasi//Vaksinasi
Observasi (Kaji)
Identifikasi riw. Kes dan
alergi
Identifikasi KI pemberian
insulin (mis. Reaksi
anafilaksis)
Identifikasi status imunisasi
Terapeutik (Mandiri)
•Dokumentasikan informasi
vaksinasi (produsen, tgl
kedaluarsa)
•Jadwalkan imunisasi pd waktu
yg tepat
Edukasi
Jelaskan tujuan, manfaat, reaksi
terjadi, jadwal dan efek samping
Informasikan imunisasi yg
diwajibkan pemerintah (mis.
Hepatitis B, BCG, difteri, tetanus,
pertusis, H. Influenza, polio,
campak, meales, rubela)
Informasikan vaksinasi untuk
kejadian khusus (mis. Rabies,
tetanus)
Informasikan layanan Pekan
Imunisasi Nasional yg
menyediakan vaksin gratis
 PENCEGAHAN INFEKSI
Observasi (Kaji) Terapeutik (Mandiri) Edukasi Kolaborasi
Monitor tanda dan •Batasi jumlah Jelaskan tanda dan Kolaborasi pemberian
gejala infeksi lokal pengunjung gejala infeksi imunisasi bila perlu
dan sistemik •Berikan perawatan Ajarkan cara cuci
kulit pada area edema tangan yang benar
•Cuci tangan sblm dan Ajarkan etika batuk
sesudah kontak dg Ajarkan cara
pasien dan ling.pasien memeriksa kondisi
•Pertahankan teknik luka/luka operasi
aseptik pd pasien Anjurkan
beriko tinggi meningkatkan asupan
cairan
Keletihan
Intervensi Utama
Edukasi aktivitas/istirahat
Mengajarkan pengaturan aktivitas dan istirahat
Manajemen Energi
 Edukasi aktivitas
aktivitas//istirahat
Observasi (Kaji) Terapeutik (Mandiri) Edukasi
•Identifikasi kesiapan •Sediakan materi dan Jelaskan pentingnya
dan kemampuan media pengaturan aktivitas melakukan aktivitas
menerim informasi dan istirahat fisik/olahraga secara rutin
•Jadwalkan pemberian Anjurkan terlibat dlm
penkes sesuai kesepakatan aktivitas kelompok, bermain,
•Berikan kesemapatan dll
pasien dan klg untuk Anjurkan menyusun jadwal
bertanya aktivitas dan istirahat
Ajarkan cara
mengidentifikasi kebutuhan
istirahat (mis, kelelahan,
sesak napas saat aktivitas)
 OBSERVASI
- Identifikasi kesiapan &
kemampuan menerima
informasi
- Identifikasi faktor2 yg
meningkatkan dan m
menurunkan motivasi hidup
bersih dan sehat
TERAPEUTIK
DEFISIT EDUKASI - Sediakan materi dan media
penkes
PENGETAHUAN
(D 0111) KESEHATAN - Jadwalkan penkes sesuai
kesepakatan
- Berikan kesempatan bertanya
EDUKASI
- Jelaskan faktor risiko 
mempengaruhi kes
- Ajarkan prilaku hdup bersih
dan sehat
(PPNI, 2018) - Jelaskan strategi
meningkatkan PHBS
37
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