Nursing Plan for a child with:

DIABETES MIELLITUS TIP I

N.R., a 5 -year-old girl, is brought by her mother to see his nurse practitioner
because of a one-week history of excessive urination, excessive thirst,
unusual hunger, and fatigue. He has experienced no abdominal pain, nausea,
vomiting, or visual changes during this period of time. He has lost pound
in weight since his last clinic visit ! months ago. N.R. has been previously
healthy and has no family history of "#$.
Results of laboratory studies reveal a random blood glucose reading by
glucometer of %!& mg'd( and the presence of glucose but no ketones in
N.R.)s urine. *ased on these findings and an accompanying Hb+
,
level of
!.-., the nurse practitioner diagnoses N.R. with presumed "#$ without
#/+.
Question: 0hat is appropriate treatment for a newly diagnosed patient with
"#$ without #/+1
Answer: 2n the absence of #/+, the focus of therapy is on stabili3ation of
blood glucose levels, beginning insulin therapy and diet planning for the
patient, and teaching the patient and family to manage diet and insulin
therapy to prevent periods of hypoglycemia and hyperglycemia.
4or example, in N.R.)s case, the nurse practitioner would prescribe insulin
therapy and arrange for his family to be instructed in how to use a
glucometer at home to measure N.R.)s blood glucose levels four times a day.
"he family would then be provided with dietary planning information and
instructed to return to the office for followup evaluation 5e.g., in 6 days7 to
evaluate the effect of the insulin therapy and the family)s comfort with blood
sugar measurement and to reinforce teaching about insulin administration
and diet.
"he nurse practitioner could also refer N.R. and his family to a
multidisciplinary diabetes care team 5e.g., at a local hospital7 for further
information about meal planning, insulin therapy, blood glucose
measurement, managing illnesses and infections, managing hypoglycemia,
and controlling hyperglycemia to prevent long-term complications. "he
family should also receive psychosocial support regarding stress they may
be experiencing regarding N.R.)s illness. 8ngoing medical supervision of
patient care is typically performed by an endocrinologist in collaboration
with primary care providers.
,atherine, a 9-year-old girl, presents for care by her pediatrician after
week of bedwetting at night. Her mother explains that ,atherine has in
addition been hungrier and thirstier than usual for the past % weeks and
urinates fre:uently during the day. ;he has complained of abdominal pain
for the past % days but has had no diarrhea or vomiting.
<pon physical examination and comparison to her past growth records, the
pediatrician notes that ,atherine has lost % pounds over the past ! months.
<rinalysis reveals the presence of glucose and ketones in her urine, and
blood glucose evaluation by glucometer reveals a result of -& mg'd(,
leading the pediatrician to suspect "#$ with #/+. ,atherine is therefore
admitted to the hospital for treatment and observation.
Question: 0hat is appropriate treatment for a newly diagnosed patient with
"#$ and #/+1
Answer= #/+ is a medical emergency, as patients with #/+ are at risk for
cerebral edema, coma, and death. "he treatment of a patient with new onset
"#$ with #/+ re:uires admission to the hospital for intravenous fluid
rehydration, insulin drip therapy to control blood glucose levels, and close
monitoring of vital signs, neurological status, blood gases, blood glucose
levels, and electrolytes. "hese patients are hospitali3ed for several days to
allow medical stabili3ation and, once stabili3ed, initiation of diabetic
teaching by a multidisciplinary care team, often coordinated by an
endocrinologist.
#iabetic teaching of the patient and family includes providing information
about meal planning, blood glucose measurement, insulin therapy, managing
illnesses and infections, managing hypoglycemia, and controlling
hyperglycemia to prevent long-term complications. "he family should also
receive psychosocial support 5e.g., referral to a family therapist7, as needed,
regarding stress they may be experiencing regarding ,atherine)s illness.
8ngoing medical supervision of patient care is typically performed by an
endocrinologist in collaboration with primary care providers.
4ollowing is a sample diabetic meal plan of about ,!&& calories and %%&
grams of carbohydrates. >atients should also be encouraged to drink two --
ounce glasses of water with each meal.
Breafast
59!& calories, 5%.5 grams carbohydrate7
slice toasted whole wheat bread with teaspoon margarine
'6 cup egg substitute or cottage cheese
'% cup oatmeal
'% cup skim milk
'% small banana
Lunch
5595 calories, ?5 grams carbohydrate7
cup vegetable soup with 6@! crackers
turkey sandwich 5% slices whole wheat bread, ounce turkey,
ounce low-fat cheese, teaspoon mayonnaise7
small apple
Dinner
5!95 calories, !5 grams carbohydrate7
6 ounces broiled chicken breast
%'9 cup cooked brown rice
'% cup cooked carrots
small whole grain dinner roll with teaspoon margarine
"ossed salad with % tablespoons low-fat salad dressing
6 unsweetened canned apricot halves or small slice of angel food
cake
Snacs
5Aach has !& calories or 5 grams carbohydrate. >ick two per day.7
! fat-free tortilla chips with salsa
'% cup artificially sweetened chocolate pudding
ounce string cheese plus one small piece of fruit
9 cups light popcorn
!is of infections
related to Hyperglikemia.
Boal=
2dentify interventions to prevent ' reduce the risk of infection.
#emonstrate techni:ues, lifestyle changes to prevent infection.
Nursing 2ntervention=
7. 8bserved signs of infection and inflammation.
Rationale= >atients may be entered with an infection that usually has sparked
a state of ketoacidosis or may have nosocomial infections.
%7. 2mprove efforts to prevention by good hand washing for all people in
contact with patients including the patients themselves.
Rationale= >revents cross infection.
97. $aintain aseptic techni:ue in invasive procedures.
Rational= high glucose levels in blood would be the best medium for the
growth of germs.
67. Bive your skin with regular care and earnest.
Rational= the peripheral circulation may be disturbed that puts patients at
increased risk of damage to the skin ' skin irritation and infection.
57. $ake changes to the position, effective coughing and encourage deep
breathing.
Rational= memventilasi +ssist in all areas and mobili3e pulmonary
secretions.
%7 I"#alanced Nutrition Less than Bod$ !e%uir"ents
related to insufficiency of insulin, decreased oral input.
Boal=
#igest the amount of calories ' nutrients right
;hows the energy level is usually
;table or increasing weight.
Nursing Inter&ention:
.7 #etermine the patientCs diet and eating patterns and compared with food
that can be spent by the patient.
Rationale= 2dentify deficiencies and deviations from the therapeutic needs.
%.7 0eigh weight per day or as indicated.
Rational= +ssessing an ade:uate food intake 5including absorption and
utili3ation7.
9.7 2dentification of preferred food ' desired include the needs of ethnic '
cultural.
Rational= 2f the patientCs food preferences can be included in meal planning,
this cooperation can be pursued after discharge.
6.7 2nvolve patients in planning the family meal as indicated.
Rationale= 2ncrease the sense of involvementD provide information on the
family to understand the patientCs nutrition.
5.7 Bive regular insulin treatment as indicated.
Rational= regular insulin has a rapid onset and :uickly and therefore can help
move glucose into cells.
97 'luid (olu"e Deficit related to osmotic diuresis.
Boal=
#emonstrate ade:uate hydration evidenced by stable vital signs, palpable
peripheral pulse, skin turgor and capillary refill well, individually
appropriate urinary output, and electrolyte levels within normal limits.
Nursing Inter&ention:
.7 $onitor vital signs.
Rational= hypovolemia can be manifested by hypotension and tachycardia.
%.7 +ssess peripheral pulses, capillary refill, skin turgor, and mucous
membranes.
Rational= "his is an indicator of the level of dehydration, or an ade:uate
circulating volume.
9.7 $onitor input and output, record the specific gravity of urine.
Rational= "o provide estimates of the need for fluid replacement, renal
function, and effectiveness of the therapy given.
6.7 $easure weight every day.
Rational= "o provide the best assessment of fluid status of ongoing and
further to provide a replacement fluid.
5.7 >rovide fluid therapy as indicated.
Rational= "he type and amount of li:uid depends on the degree of lack of
fluids and the response of individual patients.
)*+ PLAN DE ,N-!I.I!E / 0A1 I

>acienta ".A. En vErstF de & ani, se pre3intF la camera de gardF EnsoGitF fiind de
mama ei, care este foarte speriatF pentru cF declarF cF fetiGa ei a slFbit foarte mult En
ultimul timp, deHi mFnIncF excesiv, urinea3F frecvent Hi mult, bea Hi foarte multe lichide,
nu manifestF dorinGa de JoacF sau lecGii Hi nici nu se poate odihni.
$ama declarF cF fetiGa nu a fost diagnosticatF pEnF acum cu diabet, dar ca En
familie existF o persoanF cu diabet tip 2, respectiv tatFl ei care nu locuieHte cu ele, fiind
divorGatF de 5 ani. Kn urmF cu aproximativ trei sFptFmIni fetiGa a suferit de amigdalitF, pe
care a tratat-o cu antibiotic timp de cinci 3ile Hi cu panadol pentru copii.
;e internea3F cu diagnosticul de dia#et 2aharat ti3 I insulino4de3endent Hi
pre3intF urmatoarele valori ale funcGiilor vitale Hi vegetative=
"ensiunea +rteriala L &&'!& mm Hg
>uls L !& b'min.
"emperatura L 9?, grade ,elsius
RespiraGie L %& resp.'min
;aturaGia oxigenului L MM.
Blicemie L %&& mg.
Blico3urie L &,5g gluco3F En urinF
PLAN DE ,N-!I.I!E PENT!U PA0IENTA T*E* 1iua 5 / 67*68*+659
I 4 0ULE-E!E DE DATE:
Nume= ".
>renume= A.
NIrsta= & ani
8cupa ia= elevF
-usturi 3ersonale=
alimenta ie= preferF dulciurile, nucile, bananele si piersicile
Ei plac Jocurile de logicF
adorF mu3ica si dansul
Stare fi2ic::
respira ii L %& resp.'min
puls L !& b.'min.
"ensiunea +rterialF L &&'!& mmHg
"emperatura L 9?, grade ,
glicemie L %&&mg .
glico3urie L &,5 g gluco3F En urinF
Enal ime L ,9& m
greutate L 9& kg
diure3a L 5 micGiuni'3i 5aproximativ 6('3i7
somn agitat, insuficient
Stare de igiena=
tegumente i mucoase uscate, dar curate
fanere curate i integre
0ondi ii 3siho4sociale =
se teme de boala in sine, de inJec ii i de complica iile posibile
II 4 ANALI1A I INTE!P!ETA!EA DATEL;!
Manifest:ri de de3enden ::
poliurie
polidipsie
polifagie
obosealF exageratF
scFdere En greutate
somn agitat
glicemie L %&&mg.
glico3urie L &,5 g gluco3F En urinF
Pro#le"e de de3enden : actuale:
eliminare inadecvatF prin exces de urinF
alimenta ie inadecvatF prin ingestie exageratF de alimente
intoleran F la efort fi3ic
incapacitate de a se odihni
anxietate
eliminare inadecvatF cantitativ Hi calitativ manifestatF prin poliurie Hi urini
deschise la culoare
risc de accidentare prin cFdere, datorat deshidratarii accentuate
tegumente si mucoase uscate
Pro#le"e de de3enden : 3oten iale:
risc de alterare a stFrii generale prin comF cetoacido3icF, sau chiar exitus
potenGial de deshidratare masivF prin eliminFri urinare excesive
risc de complica ii acute i cronice
risc de accidentare prin cFdere
Ne&oi afectate:
Nevoia de a se hidrata si a se alimenta
Nevoia de a elimina
Nevoia de a evita pericolele
Nevoia de a dormi si a se odihni
Nevoia de a EnvaGa
Nevoia de a se miHca Hi a avea o bunF posturF
Diagnostic de nursing= #eficit de volum lichidian cau3at de de3echilibrul
hidroelectrolitic manifestat prin polidipsie, polifagie Hi poliurie.
Ne&oi 3rioritare afectate=
- Nevoia de a se hidrata Hi alimenta
- Nevoia de a elimina
- Nevoia de a EnvFGa
III 4 PLANI'I0A!EA ,N-!I.I!IL;!
;#iecti&e:
- >acienta sF se poatF hidrata Hi alimenta corespun3Ftor nevoilor sale, adaptate
vIrstei Hi bolii sale
- >acienta sF pre3inte eliminFri corespun3Ftoare En raport cu vIrsta si boala sa
- >acienta sF fie echilibratF hidroelectrolitic
- >acienta sF obGinF echilibrul metabolismului glucidic
- >acienta sF pre3inte o stare de bine atIt fi3ic, cIt Hi psihic
- >acienta sF-Hi diminue3e riscul de accidentare
- >acienta sa-Hi reducF riscul de complicaGii acute Hi cronice
- >acienta sF pre3inte tegumente Hi mucoase integre
I( 4 INTE!(EN II
- +erisesc incFperea, asigur o temperaturF de %&-%%O , Hi o umiditate de !&-?& .
- +sigur pacientei o po3iGie adecvatF Hi confortabilF En pat
- $asor func iile vitale Hi vegetative= respiraGie, tensiune arterialF, puls,
temperaturF, diure3F, saturaGia oxigenului Hi le note3 in foaia de observaGie
- Recolte3 produse biologice pentru examene de laborator
- Afectue3 bilanGul ingesta @ excreta pe %6 ore
- +sigur igiena corporalF a pacientei, precum Hi a lenJeriei de corp Hi pat
- ;tabilesc raGia alimentarF astfel= proteine 9-5., lipide 9& @ 95., glucide 5&.
pe %6 ore
- 4racGione3 mese mici Hi dese 5-! ' 3i 59 mese principale Hi %-9 gustFri7
- +sigur un regim echilibrat cu scopul de a furni3a raGia caloricF necesarF, de a
reduce hiperglicemia Hi de a menGine o greutate conform vIrstei pacientei
- evalue3 manifestFrile deshidratFrii= aspectul tegumentelor i mucoaselor
- mFsor greutatea corporalF la fiecare %, 9 3ile
- administre3 medica ia prescrisF respectFnd= calea, do3a, ritmul i observ efectul
acestora = insulina $ixtard 5H.$.7 & 5&. insulinF rapidF, M& . insulinF
intermediarF7, care se administrea3F in do3F de &,5 <'kg corp, En % pri3e 3ilnice
5cu 9& minute Enainte de masF7, sub cutanat cu >en, care se pre3intF En cartu de
,5 ml 5&& <'ml7.
- alterne3 locul inJec iei pentru a preveni lipodistrofiile 5fa a externF a bra ului '9
miJlocieD fa a antero-externF a coapsei, '9 miJlocieD flancurile peretelui
abdominal, regiunea subclavicularF, fesierF, superoexternF7
- administre3 medica ie adJuvantF= vitaminoterapie= ,, *, *!, *M, /,l la indica ia
medicului
- sesi3e3 unele modificFri, care au drept cau3F diverse complica ii 5obnubilarea,
transpira iile, respira ia /ussmaul, coma7
- educ pacienta i familia ei cu privire la= alimenta ie, administrarea medica iei la
domiciliu, observarea complica iilor, importan a efortului fi3ic do3at, importan a
odihnei i importan a men inerii unui psihic bun En contextul bolii cronice.
I( / E(ALUA!E
#upF %6 de ore pacienta are riscul de complica ii acute ameliorat, datoritF
faptului cF hiperglicemia s-a redus de la %&& mg. la 95 mg., iar glico3uria de
la &,5 g la &,% g gluco3F En urinF
;tarea generalF de sFnFtate a pacientei este amelioratF prin diminuarea riscului de
complica ii acute i cronice i prin diminuarea numarului mic iunilor de la 5'3i
la -'3i.
>acienta a cFpFtat Encredere En echipa medicalF i dovede te En elegere prin
cooperare la manevrele medicale, prin acceptul la anumite tehnici i investiga ii
i prin reducerea fricii la vederea acelor i seringilor.
>acienta Hi familia ei au EnGeles importanGa alimentaGiei Hi a tratamentului pentru a
putea duce o viaGF cvasinormalF Hi a evita apariGia complicaGiilor acute Hi cronice.
PLAN DE ,N-!I.I!E PENT!U PA0IENTA T*E* 1iua + / 68*68*+659
I 4 0ULE-E!E DE DATE:
Stare fi2ic::
respira ii L M resp.'min
puls L !% b.'min.
"ensiunea +rterialF L M&'!& mmHg
"emperatura L 9? grade ,
glicemie L 95mg .
glico3urie L &,% g gluco3F En urinF
Enal ime L ,9& m
greutate L 9& kg
diure3a L - micGiuni'3i
somn insuficient i nelini tit
Stare de igiena:
tegumente i mucoase uscate, dar curate
fanere curate i integre
0ondi ii 3siho4sociale =
manifestF Entelegere i dorin F de cunoa tere a bolii i a modului de tratament
II 4 ANALI1A I INTE!P!ETA!EA DATEL;!
Diagnostic de nursing= 2ntoleran F la efort din cau3a bolii, manifestatF prin obosealF,
slFbiciune i lipsa interesului pentru Joc
Ne&oi 3rioritare afectate=
Nevoia de a dormi i a se odihni
Nevoia de a se misca Hi a avea o buna posturF
Nevoia de a evita pericolele
Manifest:ri de de3enden : =
intoleran F la efort
obosealF, somnolen F
astenie fi3icF i psihicF
scFdere ponderalF
Pro#le"e de de3enden ::
dificultate En mi care
imposibilitatea ob inerii unui somn calitativ i cantitativ
risc de alterare a stFrii generale
pierdere a masei musculare
risc de complica ii acute i cronice
III / PLANI'I0A!EA ,N-!I.I!IL;!
;#iecti&e:
>acienta sF se poatF odihni corespun3Ftor 5minim - ore-noapte7
>acienta sF creascF En greutate Hi sa fie En limite normale pentru vIrsta ei
>acienta sa-Hi recapete condiGia fi3icF Hi psihicF
>acienta Hi familia ei sF cunoascF manifestFrile bolii Hi regimul de viaGF
>acienta Hi familia ei sF fie conHtienGi cF prin respectarea alimentaGiei Hi a
tratamentului poate duce o viaGF cvasinormalF
>acienta sa- i diminue3e riscul de complica ii
I( 4 INTE!(EN II
- +erisesc incFperea, asigur o temperaturF de %&-%%O , Hi o umiditate de !&-?& .
- +sigur pacientei o po3iGie adecvatF Hi confortabilF En pat
- $asor func iile vitale Hi vegetative= respiraGie, tensiune arterialF, puls,
temperaturF, diure3F, saturaGia oxigenului Hi le note3 in foaia de observaGie
- Recolte3 produse biologice pentru examene de laborator
- KnvF pacienta sF execute tehnici de relaxare pentru a avea un somn odihnitor=
tehnica respira iei,
- KnvF pacienta cum sF- i do3e3e efortul fi3ic pentru a putea avea un tonus bun i
totodatF pentru a nu se obosi prea mult
- +sigur condi ii de mediu relaxante pentru un somn calitativ= camera sa fie bine
aerisitF, lenJeria de pat i corp curatF, lini te sau mu3icF ambientalF, in func ie de
starea pacientei.
- +dministre3 medica ia perscrisF respectFnd do3a, calea, ritmul i observ efectul
acestora= somnifere la nevoie, pe cale oralF
- Aduc pacienta cu privire la= importan a efortului fi3ic, men inerea unui tonus bun,
continuarea tehnicilor de relaxare i la domiciliu
( / E(ALUA!E
>acienta a Enteles importan a somnului i acordF mai multF aten ie odihnei,
dormind cu douF ore mai mult decIt dormea acasa
>acienta si-a asumat cIteva tehnici de relaxare i le executF cu aJutorul mamei=
inspira i expirF lent i isi imaginea3F ca este intr-un loc frumos, pe un fundal de
mu3icF ambientalF.