Diabetes Mellitus  Patient has a blood glucose reading of less than 180 mg/dL; fasting blood

glucose levels of less than <140 mg/dL; hemoglobin A1C level <7%.
Diabetes mellitus (DM) is a chronic disease characterized by insufficient production
of insulin in the pancreas or when the body cannot efficiently use the insulin it produces.
This leads to an increased concentration of glucose in the bloodstream (hyperglycemia). It
is characterized by disturbances in carbohydrate, protein, and fat metabolism.
Sustained hyperglycemia has been shown to affect almost all tissues in the body and is
associated with significant complications of multiple organ systems, including the eyes,
nerves, kidneys, and blood vessels.
Nursing Care Plans
Nursing management of diabetes includes effective treatment to
normalize blood glucoseand decrease complications using insulin replacement, balanced
diet, and exercise. The nurse should stress the importance of complying with the
prescribed treatment program. Tailor your teaching to the patient’s needs, abilities, and
developmental stage. Stress the effect of blood glucose control on long-term health.
Here are 13+ nursing care plans (NCP) for diabetes mellitus:
1. Risk for Unstable Blood Glucose
2. Deficient Knowledge
3. Risk for Infection
4. Risk for Disturbed Sensory Perception
5. Powerlessness
6. Risk for Ineffective Therapeutic Regimen Management
7. Risk for Injury
8. Imbalanced Nutrition: Less Than Body Requirements
9. Risk for Deficient Fluid Volume
10. Fatigue
11. Risk for Impaired Skin Integrity
12. Other Possible Nursing Care Plans
Risk for Unstable Blood Glucose

Risk for Unstable Blood Glucose: At risk for variation of blood glucose levels from the
normal range that may compromise health.
Risk factors
 Inadequate blood glucose monitoring
 Lack of adherence to diabetes management
 Medication management
 Deficient knowledge of diabetes management
 Developmental level
 Lack of acceptance of diagnosis
 Stress
 Sedentary activity level
 Insulin deficiency or excess
Possibly evidenced by
 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs
and symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]
Desired outcomes
 Deficient Knowledge: Absence or deficiency of cognitive information related to specific
topic.
May be related to
 Unfamiliarity with insulin injection
 Dietary modifications
 Exercise for normoglycemia
 Unfamiliarity with information
 Interpretation
Possibly evidenced by
 Requests of information
 Statements of concern
 Inadequate follow-through of instructions
 Development of preventable complications
Desired outcomes
 Before discharge, patient will demonstrate knowledge of insulin injection,
symptoms, and treatment of hypoglycemia and diet.
Nursing Interventions Rationale

Long-acting insulin does not have a peak of

Explain that long-acting insulin (Lantus) only need to be injected
once or twice daily.
Explain that regular prandial insulins (Humulin) should be injected
30 mins before meals.
Rapid acting insulins (Novolog, Humalog) may be
injected before or after eating.
Explain that insulin dosages may need to be adjusted.
Teach patient to rotate insulin injection sites.
Explain the importance of inserting the needle perpendicular to the
skin.
Verify that the patient understands and demonstrates the technique
and timing of home monitoring of glucose.
Teach patient to follow a diet that is low in simple sugars, low in
fat, and high in fiber and whole grains.
action. Insulin glargine is effective over 24
hours.
Dosage may be adjusted based on the actual
amount of food ingested because rapid acting
insulins can be given after a meal.
Insulin dosage should be reduced when
fasting for surgery, when not eating, or when
hypoglycemia occurs. Illness
or infection may increase insulin
requirements.
Multiple injections in the same site may
cause fat deposits.
This ensures deep subcutaneous
administration of insulin.
Monitoring provides data on the degree of
glucose control and identifies the need for
changes in the insulin dosage.
A diet low in fat and high in fiber helps to
control cholesterol and triglycerides. Three
daily meals and an evening snack is
recommended. Refined and simple sugars
should be reduced, and complex
carbohydrates, such as cereals, rice, should be
increased.

Deficient Knowledge Teach patient that anxiety, tremors, and slurred speech are signs of These are indicators of hypoglycemia, which
hypoglycemia. causes seizures, coma, and death.

Teach patient to treat hypoglycemia with crackers, a snack,
or glucagon injection.
Risk for Infection
Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Nursing Diagnosis
 Risk for Infection
Risk factors may include
 High glucose levels, decreased leukocyte function, alterations in circulation
 Preexisting respiratory infection, or UTI
Possibly evidenced by
 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs
and symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]
Desired Outcomes
 Identify interventions to prevent/reduce risk of infection.
 Demonstrate techniques, lifestyle changes to prevent development of infection.
Nursing Interventions
Observe for the signs of infection and inflammation: fever, flushed
appearance, wound drainage, purulent sputum, cloudy urine.
Teach and promote good hand hygiene.
Maintain asepsis during IV insertion, administration of medications,
and providing wound or site care. Rotate IV sites as indicated.
Provide catheter or perineal care. Teach female patients to clean
from front to back after elimination.
Provide meticulous skin care: gently massage bony areas, keep skin
dry. Keep linens dry and wrinkle-free.
Auscultate breath sounds.
Place in semi-Fowler’s position.
Hypoglycemia should be treated with a
carbohydrate snack. If the patient is
unconscious, glucagon should be given IM by
a caregiver.
Rationale
Patients with DM may be admitted with
infection, which could have precipitated the
ketoacidotic state. They may also develop
nosocomial infection.
Reduces risk of cross-contamination.
Increased glucose in the blood creates an
excellent medium for bacteria to thrive.
Minimizes risk of UTI. Comatose patient
may be at particular risk if urinary
retention occurred before hospitalization.
Note: Elderly female diabetic patients are
especially prone to urinary tract and/or
vaginal yeast infections.
Peripheral circulation may be ineffective or
impaired, placing the patient at increased
risk for skin breakdown and infection.
Rhonchi may indicate accumulation of
secretions possibly related to pneumonia or
bronchitis. Crackles may results from
pulmonary congestion or edema from rapid
fluid replacement or heart failure.
Facilitates lung expansion; reduces risk
of aspiration.
Nursing Interventions Rationale
Reposition and encourage coughing or deep breathing if patient is Aids in ventilating all lung areas and
alert and cooperative. Otherwise, suction airway using sterile mobilizing secretions. Prevents stasis of
technique as needed. secretions with increased risk of infection.
Provide tissues and trash bag in a convenient location for sputum
and other secretions. Instruct patient in proper handling of To minimizes spread of infection.
secretions.
Encourage and assist with oral hygiene. Reduces risk of oral/gum disease.
Decreases susceptibility to infection.
Increased urinary flow prevents stasis and
aids in maintaining urine pH/acidity,
Encourage adequate dietary and fluid intake (approximately 3000
reducing bacteria growth and flushing
mL/day if not contraindicated by cardiac or renal dysfunction),
organisms out of system. Note: Use of
including 8 oz of cranberry juice per day as appropriate.
cranberry juice can help prevent bacteria
from adhering to the bladder wall, reducing
the risk of recurrent UTI.
Administer antibiotics as appropriate. Early treatment may help prevent sepsis.
Risk for Disturbed Sensory Perception
Risk for Disturbed Sensory Perception: At risk for change in the amount or patterning
of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired
response to such stimuli.
Nursing Diagnosis
 Risk for Disturbed Sensory Perception
Risk factors may include
 Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance
Possibly evidenced by
 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs
and symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]
Desired Outcomes
 Maintain usual level of mentation.
 Recognize and compensate for existing sensory impairments.
Nursing Interventions Rationale
To provide baseline from which to compare
Monitor vital signs and mental status.
abnormal findings.
Call the patient by name, reorient as needed to place, person, and Decreases confusion and helps maintain
time. Give short explanations, speak slowly and enunciate clearly. contact with reality.
To provide uninterrupted rest periods and
Schedule and cluster nursing time and interventions. promote restful sleep, minimize fatigue and
improve cognition.
Keep patient’s routine as consistent as possible. Encourage Helps keep patient in touch with reality and
participation in activities of daily living (ADLs) as able. maintain orientation to the environment.

Nursing Interventions
Protect patient from injury by avoiding or limiting the use of
restraints as necessary when LOC is impaired. Place bed in low
position and pad bed rails if patient is prone to seizures.
Evaluate visual acuity as indicated.
Observe and investigate reports of hyperesthesia, pain, or sensory
loss in the feet or legs. Investigate and look for ulcers, reddened
areas, pressure points, loss of pedal pulses.
Provide bed cradle. Keep hands and feet warm, avoiding exposure to
cool drafts and/or hot water or use of heating pad.
Assist patient with ambulation or position changes.
Monitor laboratory values: blood glucose, serum osmolality,
Hb/Hct, BUN/Cr.
Carry out prescribed regimen for correcting DKA as indicated.
Powerlessness
Powerlessness: The lived experience of lack of control over a situation, including a
perception that one’s actions do not significantly affect an outcome.
Nursing Diagnosis
 Powerlessness
May be related to
 Long-term/progressive illness that is not curable
 Dependence on others
Possibly evidenced by
 Reluctance to express true feelings; expressions of having no control/influence
over situation
 Apathy, withdrawal, anger
 Does not monitor progress, nonparticipation in care/decision making
 Depression over physical deterioration/complications despite patient
cooperation with regimen
Desired Outcomes
 Acknowledge feelings of helplessness.
 Identify healthy ways to deal with feelings.
 Assist in planning own care and independently take responsibility for self-care
Rationale
activities.
Disoriented patients are prone to injury,
Nursing Interventions Rationale
especially at night, and precautions need to
be taken as indicated. Seizureprecautions Encourage patient and/or SO to express feelings about Identifies concerns and facilitates problem
need to be taken as appropriate to prevent hospitalization and disease in general. solving.
physical injury, aspiration, and falls.
Recognition that reactions are normal can
Retinal edema or detachment, hemorrhage, help patient problem-solve and seek help as
presence of cataracts or temporary paralysis Acknowledge normality of feelings. needed. Diabetic control is a full-time job that
of extraocular muscles may impair vision, serves as a constant reminder of both presence
requiring corrective therapy and/or of disease and threat to patient’s health.
supportive care.
Knowledge of individual’s style helps
Peripheral neuropathies may result in severe determine needs for treatment goals. Patient
discomfort, lack of or distortion of tactile whose locus of control is internal usually
sensation, potentiating risk of dermal injury Assess how patient has handled problems in the past. Identify locus looks at ways to gain control over own
and impaired balance. of control. treatment program. Patient who operates with
Reduces discomfort and potential for dermal an external locus of control wants to be cared
injury. for by others and may project blame for
circumstances onto external factors.
Promotes patient safety, especially when
Enhances sense of being involved and gives
sense of balance is affected. Provide opportunity for SO to express concerns and discuss ways in
SO a chance to problem-solve solutions to
Imbalances can impair mentation. Note: If which he or she can be helpful to patient.
help patient prevent recurrence.
fluid is replaced too quickly, excess water
Unrealistic expectations or pressure from
may enter brain cells and cause alteration in
others or self may result in feelings of
the level of consciousness (water Ascertain expectations and/or goals of patient and SO.
intoxication). frustration and loss of control. These can
impair coping abilities.
Alteration in thought processes or potential
for seizure activity is usually alleviated once Constant energy and thought required for
hyperosmolar state is corrected. diabetic control often shifts the focus of a
Determine whether a change in relationship with SO has occurred. relationship. Development of psychological
concerns affecting self-concept may add
further stress.
Encourage patient to make decisions related to care: ambulation, Communicates to patient that some control
schedule for activities, and so forth. can be exercised over care.
Support participation in self-care and give positive feedback for
Promotes feeling of control over situation.
efforts.
Risk for Ineffective Therapeutic Regimen Management
Ineffective Therapeutic Regimen Management: At risk for pattern of regulating and
integrating into daily living a program for treatment of illness and the sequelae of illness
that is unsatisfactory for meeting specific health goals
Risk factors
 New-onset diabetes
 Lack of knowledge about diabetes and its management
 Complex medical regimen
Desired Outcomes
 Patient demonstrates knowledge of diabetes self-care measures.
Nursing Interventions Rationale
 Can provide an important
starting point in understanding
any complexities or difficulties
the patient perceived in his
diabetes management regimen.
The patient may report
Investigate the patient’s prior efforts to manage the diabetes care regimen.
experiences of being
overwhelmed by attempts to
manage medications, diet,
exercise, blood glucose
monitoring, and other measures
to prevent complications.
Self-management skills
Evaluate the patient’s self-management skills, including the ability to perform determine the amount and type
procedures for blood glucose monitoring. of education that needs to be
provided.
Limited vision may impair the
patient’s ability to prepare and
administer insulin accurately.
Assess for factors that may negatively affect success with following the Limited mobility and the loss of
regimen. fine motor control can interfere
with skills needed for insulin
administration and blood glucose
monitoring.
Cost of medication and supplies
for blood glucose monitoring
Assess the patien’s financial resource for health care. may become barriers to the
patient with limited financial
resources.
Elevated blood glucose levels in
patients with previously
Determine and ensure that patient’s knowledge about the symptoms, causes,
diagnosed diabetes indicate the
treatment, and prevention of hyperglycemia.
need to evaluate diabetes
management.
Risk for Injury
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting
with the individual’s adaptive and defensive resources, which may compromise health.
Risk Factors
 Hyperglycemia
 Peripheral sensory neuropathy
 Autonomic neuropathy
 Immune system deficit
 Vascular insufficiency
Desired Outcomes
 Patient is free of injury to feet.
Nursing Interventions Rationale
Foot lesions and associated wound infections are teh most common
reason for hospitalization of the patient with DM. The patient’s feet
Assess the general appearance of the should be meticulously inspected at every visit. The patient may be
foot. unaware of injuries to the feet as a result of decreased sensation from
peripheral neuropathy. Impaired vision from DM may decrease the
ability to inspect the feet.
Fungal infections in nails serve as a portal of entry for bacteria. The
patient with diabetes has an increased risk for infectionbecause of
Assess the status of the nails.
impaired immunity. Patients with thickened or deformed nails should
be referred for treatment.
Autonomic neuropathy leads to decreased perspiration, causing
Assess the patient’s skin integrity. excessive dryness and fissuring of the skin. Skin breakdown
predisposes the patient to infection.
Note the presence of callus formation or Pressure over bony prominences lead to callus formation; may lead to
corns. the development of skin breakdown.
Infection may be the initiating even for eventual amputation.
Assess for evidence of infection. Symptoms of painand tenderness may be absent because of
neuropathy. Look for redness, drainage, and swelling.
Edema is a major predisposing factor to ulceration. Autonomic
Assess for edema. neuropathy results in the loss of vasomotor reflexes and swelling in the
foot.
Instruct the patient in the principle of
hygiene: wash the feet daily in warm
Maceration between the toes predisposes the patient to infection. The
water using mild soap; avoid soaking
use of lotion replaces the moisturizing effects lost by autonomic
the feet. Dry carefully and gently,
neuropathy. The patient should select a lotion with low alcohol content
especially between toes. Use
to prevent drying.
moisturizing lotion at least once daily.
Avoid the area between the toes.
Instruct the patient to inspect the feet
daily for cuts, scratches, and blisters. A All surfaces of the foot need to be examined, including the skin
mirror may be necessary to assess the between toes. Touch will identify skin surface alterations that are not
bottom of the foot. Instruct to use both evident by sight.
visual inspection and touch.
Teach the patient to inspect the shoes
daily by feeling the inside of the shoe Reduces the risk for injury to the foot.
for irregularities or sharp objects.
Instruct the patient to always wear
protective footwear; never go barefoot.
Keeping the feet covered prevent injuries to the foot.
Instruct the patient to trim nails straight
across and to file sharp corners to Helps avoid injury to the toes when self-care cannot be provided.
match the contour of the toe.
Instruct the patient to wear clean, well-
fitting stockings made from soft cotton,
Soft cotton or wool absorbs moisture from perspiration and
synthetic blend, or wool.
discourages an enviroment in which fungus can thrive.
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient Nursing Interventions Rationale
to meet metabolic needs. Provide liquids containing nutrients
Nursing Diagnosis and electrolytes as soon as patient can tolerate Oral route is preferred when patient is alert and
 Imbalanced Nutrition: Less Than Body Requirements oral fluids then progress to a more solid food as bowel function is restored.
May be related to tolerated.
 Insulin deficiency (decreased uptake and utilization of glucose by the tissues, If patient’s food preferences can be incorporated
resulting in increased protein/fat metabolism) Identify food preferences, including ethnic and
into the meal plan, cooperation with dietary
 Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; cultural needs.
requirements may be facilitated after discharge.
altered consciousness
To promote sense of involvement and provide
 Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, information to the SO to understand the nutritional
and growth hormone), infectious process needs of the patient. Note: Various methods
Possibly evidenced by Include SO in meal planning as indicated.
available or dietary planning include exchange list,
 Increased urinary output, dilute urine point system, glycemic index, or pre selected
 Reported inadequate food intake, lack of interest in food menus.
 Recent weight loss; weakness, fatigue, poor muscle tone Hypoglycemia can occur once blood glucose level is
 Diarrhea reduced and carbohydrate metabolism resumes and
 Increased ketones (end product of fat metabolism) Observe for signs of hypoglycemia: changes in
insulin is being given. If the patient is comatose,
Desired Outcomes LOC, cold and clammy skin, rapid pulse, hunger,
hypoglycemia may occur without notable change in
 Ingest appropriate amounts of calories/nutrients. LOC. This potentially life-threatening emergency
irritability, anxiety, headache, lightheadedness,
should be assessed and treated quickly per protocol.
 Display usual energy level. shakiness.
Note: Type 1 diabetics of long standing may not
 Demonstrate stabilized weight or gain toward usual/desired range with normal display usual signs of hypoglycemia because normal
laboratory values. response to low blood sugar may be diminished.
Nursing Interventions Rationale Beside analysis of serum glucose is more accurate
Weighing serves as an assessment tool to determine than monitoring urine sugar. Urine glucose is not
Weigh daily or as ordered.
the adequacy of nutritional intake. sensitive enough to detect fluctuations in serum
Ascertain patient’s dietary program and usual Identifies deficits and deviations from therapeutic levels and can be affected by patient’s individual
pattern then compare with recent intake. needs. renal threshold or the presence of urinary retention.
Perform fingerstick glucose testing.
Note: Normal levels for fingerstick glucose testing
Ascertain understanding of individual nutritional To determine what information to be provided to may vary depending on how much the patient ate
needs. client or SO. during his last meal. In general: 80–120 mg/dL
Discuss eating habits and encourage diabetic diet To achieve health needs of the patient with the (4.4–6.6 mmol/L) before meals or when waking up;
(balanced diet) as prescribed by the doctor. proper food diet for his condition. 100–140 mg/dL (5.5–7.7 mmol/L) at bedtime.
Document actual weight, do not estimate. Note Regular insulin has a rapid onset and thus quickly
Patients may be unaware of their actual weight or
total daily intake including patterns and time of helps move glucose into cells. The IV route is the
weight loss due to estimation of weight. Administer regular insulin by intermittent or
eating. initial route of choice because absorption from
continuous IV method: IV bolus followed by a
Consult dietician and/or physician for further To reveal changes that should be made in the subcutaneous tissues may be erratic. Many believe
continuous drip via pump of approximately 5–10
assessment and recommendation regarding food client’s dietary intake. For greater understanding the continuous method is the optimal way to
U/hr so that glucose is reduced by 50 mg/dL/hr.
preferences and nutritional support. and further assessment of specific foods. facilitate transition to carbohydrate metabolism and
reduce incidence of hypoglycemia.
Hyperglycemia and fluid and electrolyte
disturbances can decrease gastric motility and/or Glucose solutions may be added after insulin and
Auscultate bowel sounds. Note reports of function (due to distention or ileus) affecting choice fluids have brought the blood glucose to
Administer glucose solutions: dextrose and half-
abdominal pain, bloating, nausea, vomiting of of interventions. Note: Chronic difficulties with approximately 400 mg/dL. As carbohydrate
normal saline.
undigested food. Maintain NPO status as decreased gastric emptying time and poor intestinal metabolism approaches normal, care must be taken
indicated. motility may suggest autonomic neuropathies to avoid hypoglycemia.
affecting the GI tract and requiring symptomatic Provide diet of approximately 60% Complex carbohydrates (apples, broccoli, peas,
treatment. carbohydrates, 20% proteins, 20% fats in dried beads, carrots, peas, oats) decrease glucose
designated number of meals and snacks. levels/insulin needs, reduce serum cholesterol
 Nursing Interventions Rationale Nursing Interventions Rationale
levels, and promote satiation. Food intake is
scheduled according to specific insulin Monitor vital signs:
characteristics and individual patient Hypovolemia may be manifested by hypotension and
response. Note: A snack at bedtime of complex tachycardia. Estimates of severity of hypovolemia may be
carbohydrates is especially important (if insulin is made when patient’s systolic BP drops more than 10 mmHg
given in divided doses) to prevent hypoglycemia  Note orthostatic BP changes. from a recumbent to a sitting then a standing position. Note:
during sleep and potential Somogyi response. Cardiac neuropathy may block reflexes that normally
May be useful in treating symptoms related to increase heart rate.
Administer other medications as
autonomic neuropathies affecting GI tract, thus Lungs remove carbonic acid through respirations, producing
indicated: metoclopramide (Reglan); tetracycline.
enhancing oral intake and absorption of nutrients. a compensatory respiratory alkalosis for ketoacidosis.
Instruct the patient to exercise regularly.  Respiratory pattern: Kussmaul’s Acetone breath is due to breakdown of acetoacetic acid and
respirations, acetone breath. should diminish as ketosis is corrected. Correction of
 Refer the patient to an exercise hyperglycemia and acidosis will cause the respiratory rate
physiologist, physical therapist, or Specific exercises can be prescribed based on any and pattern to approach normal.
cardiac rehabilitation nurse for physical limitations the diabetic patient may have.
In contrast, increased work of breathing, shallow, rapid
specific exercise instructions.  Respiratory rate and quality, use of respirations, and presence of cyanosis may indicate
 Instruct to do warm-ups and cool- Warm-ups and stretching helps prevent muscle accessory muscles, periods of apnea, respiratory fatigueand/or that patient is losing ability to
downs for at least 30 to 60 minutes. injury. and appearance of cyanosis. compensate for acidosis.
 Instruct patient in the methods to Dehydration can hasten hypoglycemia, especially in Although fever, chills, and diaphoresis are common with
maintain hydration and avoid hot weather. Patients may need to add a snack  Temperature, skin color, moisture, infectious process, fever with flushed, dry skin and decreased
hypoglycemia during exercise. before exercising if they experience hypoglycemia. and turgor. skin turgor may reflect dehydration.
Assess peripheral pulses, capillary refill, and Indicators of level of hydration, adequacy of circulating
Risk for Deficient Fluid Volume mucous membranes. volume.
Provides ongoing estimate of volume replacement
Risk for Deficient Fluid Volume: At risk for decreased intravascular, interstitial, Monitor I&O and note urine specific gravity.
needs, kidney function, and effectiveness of therapy.
and intracellular fluid.
Nursing Diagnosis Provides the best assessment of current fluid status and
Weigh daily.
adequacy of fluid replacement.
 Risk for Deficient Fluid Volume
Risk factors Maintain fluid intake of at least 2500 mL/day within
Maintains hydration and circulating volume.
 Osmotic diuresis (from hyperglycemia) cardiac tolerance when oral intake is resumed.
 Excessive gastric losses: diarrhea, vomiting Promote comfortable environment. Cover patient
Avoids overheating, which could promote further fluid loss.
 Restricted intake: nausea, confusion with light sheets.
Possibly evidenced by Changes in mentation can be due to abnormally high or low
 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs glucose, electrolyte abnormalities, acidosis, decreased
and symptoms, as the problem has not occurred and nursing interventions are Investigate changes in mentation and LOC. cerebral perfusion, or developing hypoxia. Regardless of the
directed at prevention.] cause, impaired consciousness can predispose patient
Desired Outcomes to aspiration.
 Demonstrate adequate hydration as evidenced by stable vital signs, palpable Provides for accurate ongoing measurement of urinary
peripheral pulses, good skin turgor and capillary refill, individually appropriate output, especially if autonomic neuropathies result in
urinary output, and electrolyte levels within normal range. Insert and maintain indwelling urinary catheter. neurogenic bladder (urinary
retention/overflow incontinence). May be removed when
Nursing Interventions Rationale patient is stable to reduce risk of infection.
Fatigue
Assists in estimation of total volume depletion. Symptoms
Assess patient’s history related to duration or
may have been present for varying amounts of time (hours to
intensity of symptoms such as vomiting, excessive
days). Presence of infectious process results in fever and Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for
urination.
hypermetabolic state, increasing insensible fluid losses. physical and mental work at usual level
Nursing Diagnosis
  Fatigue
May be related to
 Decreased metabolic energy production
 Altered body chemistry: insufficient insulin
 Increased energy demands: hypermetabolic state/infection
Possibly evidenced by
 Overwhelming lack of energy, inability to maintain usual routines, decreased
performance, accident-prone
 Impaired ability to concentrate, listlessness, disinterest in surroundings
Desired Outcomes
 Verbalize increase in energy level.
 Display improved ability to participate in desired activities.
Nursing Interventions
Discuss with patient the need for activity. Plan schedule
with patient and identify activities that lead to fatigue.
Alternate activity with periods of rest and uninterrupted
sleep.
Monitor pulse, respiratory rate, and BP before and after
activity.
Discuss ways of conserving energy while bathing,
transferring, and so on.
Increase patient participation in ADLs as tolerated.
Assess response to activity.
Assess muscle strength of patient and functional level of
activity.
Discuss with patient the need for activity.
Alternate activity with periods of rest or uninterrupted
sleep.
Monitor pulse, respiration rate and blood pressure before
and after activity.
Perform activities slowly with frequent rest periods.
Promote energy conservation techniques by discussing
ways of conserving energy while bathing, transferring and
performing ADLs.
Provide adequate ventilation.
Instruct patient to perform deep breathing exercises.
Provide comfort and safety measures.
Rationale
Education may provide motivation to increase
activity level even though patient may feel too weak
initially.
To prevent excessive fatigue.
Indicates physiological levels of tolerance.
Patient will be able to accomplish more with a
decreased expenditure of energy.
Increases confidence level, self-esteem and tolerance
level.
Response to an activity can be evaluated to achieve
desired level of tolerance.
To determine the level of activity.
Education may provide motivation to increase
activity level even though patient may feel too weak
initially.
Prevents excessive fatigue. Indicates physiological
levels of tolerance.
Tolerance develops by adjusting frequency, duration
and intensity until desired level is achieved.
Interventions should be directed at delaying the onset
of fatigue and optimizing muscle efficiency.
Symptoms of fatigue are alleviated with rest. Also,
patient will be able to accomplish more with a
decreased expenditure of energy.
For proper oxygenation.
Helps promote relaxation.
To be free from injury during activity.
Nursing Interventions Rationale
Administer oxygen as ordered. To provide proper ventilation.
Risk for Impaired Skin Integrity
Risk for Impaired Skin Integrity: Altered epidermis and/or dermis.
Risk factors
 Decreased circulation and sensation caused by peripheral neuropathy and
arterial obstruction.
Possibly evidenced by
 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs
and symptoms, as the problem has not occurred and nursing interventions are
directed at prevention.]
Desired outcomes
 Patient’s skin on legs and feet remains intact while the patient is hospitalized.
 Patient will demonstrate proper foot care.
Nursing Interventions Rationale
These are assessments for neuropathy. Skin on
Assess integrity of the skin. Assess knee and deep tendon
lower extremity pressure points is at great risk for
reflexes and proprioception.
ulceration.
Use foot cradle on the bed. Use space boots on ulcerated
To prevent pressure on pressure-sensitive points.
heels, elbow protectors, and pressure-relief mattresses.
Wash feet daily with mild soap and warm water. Check water
Decreased sensation increases the risk for burns.
temperature before immersing feet in the water.
Inspect feet daily for erythema or trauma. These are signs that the skin needs preventive care.
Change socks or stockings daily. Encourage the patient to To prevent infection from moisture. White fabric
wear white cotton socks. enables easy visualization of blood or exudates.
Moisturizers soften and lubricate dry skin,
Use gentle moisturizers on the feet.
preventing skin cracking.
Cut toenails straight across after softening toenails with a This action prevents ingrown toenails, which could
bath. cause infection.
This is a high risk for trauma and may result in
The patient should not walk barefoot.
ulceration and infection.
Other Possible Nursing Care Plans
Here are other possible nursing care plans:
 Risk for risk-prone behavior—risk factors may include all-encompassing
changes in lifestyle, self-concept requiring lifelong adherence to therapeutic
regimen, and internal/altered locus of control.
 Compromised family coping—may be related to inadequate or incorrect
information or understanding by primary persons, other situation crises or
situations the SO’s may be facing, lifelong condition requiring behavioral
changes impacting family.