Name: D.O.

Room #: 419

Age/sex: 60/M

CC: Wound @ R leg

Attending Physician: Dr. Arao

Dx: Main Condition: Community Acquired pneumonia. Moderate risk; erythroderma ; Others: HCVD; Type 2 DM
Date
&
time
June
26,
2015
@
8 am

Cues

Need

S: Taas kayo
akong sugar.
As verbalized
by the
patient.

N
U
T
R
I
T
I
O
N
A
L

O:
-c observed
weakness
-increased
urinary output

-increased
food intake
- on Diabetic
diet
-c CBG
monitoring q6

M
E
T
A
B
O
L

Nursing diagnosis

Imbalanced Nutrition
r/t insulin deficiency
secondary to type 2
DM.
R: Due to decrease
of / lack of insulin in
the body, the
glucose level
continuously rises
because
glucose cant be
utilized without the
presence of insulin.
Glucose is the
source of energy,
while
insulin is the vehicle
to transport glucose
to the body tissues.
Because of

Objective of care

After my 5 hours
span of care the
patient will be able
to display improved
nutrition aeb:
A. CBG result
maintained
@ normal
range (80120 mg/dl)
B. Promotion of
adequate
rest and
sleep
C. Improved
vital signs
and
maintained
to normal
range
D. Intake of

Nursing interventions

1. Weigh pt. daily or as

ordered.
R: Weighing serves as an
assessment tool to
determine the adequacy of
nutritional intake.
2. Discuss eating habits
and encourage
diabetic diet as
prescribed by the
Doctor.
R: To achieve health needs
of the patient with the proper
food diet for his/her disease.

3. Ascertain patients
dietary program and
usual pattern then
compare with recent

Evaluation

June 26, 2015

@ 1 pm
Goal partially met.
After my 5 hrs. span
of care the patient
was able to display
improved nutrition
aeb:
A. CBG result
maintained @
normal range
(115 mg/dl)
B. Patient was
able to rest
and sleep
appropriately
C. VS:
BP= 140/90
mmHg
C= 88 bpm

Result:
110mg/dl

I
C

-Glucose:
6.6mmol/L
Normal: 4.15.9mmol/L

P
A
T
T
E
R
N

-BMI: 30.3obese
Range:
Underweight:
< 18.5
Normal
weight: 18.5 24.9
Overweight:
25 - 29.9
Obese: 30
-SGPT (ALT):
89 U/L
Normal: 1763 U/L
-c medication
of Janumet
50/500mg i
tab BID

decrease insulin
level in
the blood stream,
the cells starved,
leading to alteration
of metabolism. The
body needs glucose
for metabolism;
there will be a
breakdown of
energy reserved
from adipose tissue,
muscles and
liver (glucagons).
This will result to
weight loss. But the
energy breaks
down, the glucose
level
continuously
increase because
there is less amount
of insulin. The body
tissues need to be
fed,
this will lead to
polyphagia and
polydipsia because
the tissue are not

appropriate
amount of
calories and
nutrients.

intake.
R: Identifies deficits and
deviations from therapeutic
needs.
4. Auscultate bowel
sounds. Note reports
of abdominal pain,
bloating, nausea,
vomiting of
undigested food.
R: Hyperglycemia and fluid
and electrolyte disturbances
can decrease gastric motility
and/or function (due to
distention or ileus) affecting
choice of interventions. Note:
Chronic difficulties with
decreased gastric emptying
time and poor intestinal
motility may suggest
autonomic neuropathies
affecting the GI tract and
requiring symptomatic
treatment.
5. Observe for signs of
hypoglycemia:
changes in LOC, cold

P= 85 bpm
R= 21 cpm
T= 36.9 *C
D. Pt. avoids
eating sweet
food and
minimizes
intake of rice
and other
high caloric
food.

Cazze Lynn Sunio

St.N

-VS:
BP = 140/90
C=85 bpm
P=83 bpm
R=23 cpm
T= 38.6 *C

being fed and need

glucosefor
metabolism.

and clammy skin,

rapid pulse, hunger,
irritability, anxiety,
headache,
lightheadedness,
shakiness.
R: Hypoglycemia can occur
once blood glucose level is
reduced and carbohydrate
metabolism resumes and
insulin is being given. If the
patient is comatose,
hypoglycemia may occur
without notable change in
LOC.
6. Perform glucose
testing before letting
the patient eat.
R: to determine the clients
blood glucose level and to
know if it is necessary to
administer RI as indicated.
7. Administer regular
insulin if there is high
glucose level as
ordered.
R: Regular insulin has a

rapid onset and thus quickly

helps move glucose into
cells.
8. Administer glucose
solutions: dextrose
and half-normal saline
as indicated.
R: As carbohydrate
metabolism approaches
normal, care must be taken
to avoid hypoglycemia.
9. Administer other
medications as
indicated: metoclopra
mide (Reglan);
tetracycline.
R: May be useful in treating
symptoms related to
autonomic neuropathies
affecting GI tract, thus
enhancing oral intake and
absorption of nutrients.
10. Consult
dietician/physician for
further assessment
and recommendation

regarding food
preferences and
nutritional support
R:To reveal changes that
should be made in clients
dietary intake- For greater
understanding and further
assessment of specific
foods.