Impaired Skin Integrity related to Diabetes Mellitus

Nursing Diagnosis for Diabetes Mellitus: Impaired Skin Integrity

Goal: After nursing Interventions, improved wound healing:

Expected outcomes:

• Luka shrink in size and increase in granulation tissue.

Nursing Interventions:

Wound care

1. Note the characteristics of the wound: determine the size and depth of the wound, and the classification of the influence ulcers
2. Note the characteristics of the fluid that comes out secret
3. Clean with a liquid anti-bacterial
4. Rinse with 0.9% NaCl fluid
5. Perform nekrotomi, if necessary
6. Perform the appropriate tampon
7. With sterile gauze dressing as needed
8. Make dressing
9. Maintain a sterile dressing technique when performing wound care
10. Observe any changes in the packing
11. Compare and note any changes in the wound
12. Give position to avoid pressure

Rational:
Assessment of injuries, will be more realible done by the same caregiver in the same position and the same techniques.

Nursing Interventions for Diabetes Insipidus

Interventions

1. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss.
Ø Assess the fluid level of the patient
Ø Monitor vital signs frequently
Ø Restrict oral fluid intake.
Ø Administer hypotonic saline intravenously.
Ø Administer medications if ordered.
 
2. Disturbed sleeping pattern, insomnia related to nocturia as manifested by verbalization of patient about interrupted sleep.
Ø Assess the sleeping pattern of the patient
Ø Give psychological support.
Ø Advice the patient to restrict oral fluids
Ø Provide calm and quiet environment.
 
3. Activity intolerance related to fatigue and frequent urination as manifested by fatigue and weakness of the patient.
Ø Assess the activity status of the patient
Ø Give psychological support to the patient.
 
4. Anxiety related to course of disease and frequent urination as manifested by verbalization of anxious questions.
Ø Assess the anxiety level of the patient.
Ø Explain the patient about the disease and treatment.
Ø Provide calm and quiet environment.
Ø Divert the attention of the patient by talking about different matter.
 
5. Ineffective coping related to frequent urination as manifested by verbalization of negative feeling by the patient.
Ø Assess the coping ability of the patient
Ø Explain the patient about the disease and treatment
Ø Give psychological support.
 
6.Risk for complications related to excessive loss of fluid from the body as manifested by hypotension and weight loss.
Ø Assess the fluid volume of the patient
Ø Monitor vital signs frequently.
Ø Take immediate measures to restore fluid volume such as IV fluid therapy
Ø Administer medications as ordered.
 
7. Knowledge deficit regarding management of diabetes insipidus as manifested by verbalization of doubts by the patient
Ø Assess the knowledge level of the patient.
Ø Explain the management of diabetes insipidus to the patient.

Nursing Diagnosis for Diabetes Insipidus

Nursing Diagnosis for Diabetes Insipidus

Diabetes insipidus (DI) is a condition which causes frequent urination. The reduction in production or release of ADH results in fluid and electrolyte imbalance caused by increased urinary output. Depending on the cause, Diabetes insipidus may be transient or life long condition. In its clinically significant forms, diabetes insipidus is a rare disease.
Clinical Manifestations

• Diabetes insipidus is characterized by increased thirst and increased urination. The primary character of DI is polyuria, excretion of large quantities of urine ( 5-20L per day)with a very low specific gravity(less than 1.005) and urine osmolality of < 100mmol/kg. In partial DI urine output may be lower(2-4L per day).
• Polydipsia (excessive intke of fluids) is also a characteristic feature of DI. Patient compensate for fluid loss by drinking great amount of water. The patient with central DI favours cold or iced drinks. Nocturia occurs due to frequent tendency to urinate which interrups sleep of the patient.
• Central DI usually occurs suddenly with excessive fluid loss. DI usually has a triphastic pattern: the acute phase with abrupt onset of polyuria, an interphase where urine volume apparently normalizes, and a third phase where DI is permanent.
• If fluid loss is not compensated, severe fluid volume de ficit results. This deficit is manifested by weight loss, hypotension, tachycardia with decreased cardiac output, poor tissue turgor, irritability, mental dullness. Hypovolemic shock may develop if fluid volume is not restored.

Nursing Diagnosis for Diabetes Insipidus

1. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss.

2. Sleeping pattern disturbances, insomnia related to nocturia as manifested by verbalization of patient about interrupted sleep

3. Activity intolerance related to fatigue and frequent urination as manifested by weakness and fatigue of the patient.

4. Anxiety related to course of disease and frequent urination as manifested by verbalization of anxious questions.

5. Ineffective coping related to frequent urination as manifested by verbalization of negative feeling by the patient.

6. Risk for complications related to excessive loss of fluid from the body as manifested by hypotension and weight loss.

7. Knowledge deficit regarding management of diabetes insipidus as manifested by verbalization of doubts by the patient.

Source : http://studynursing.blogspot.in/search/label/Endocrine%20System