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I. INTRODUCTION
Diabetes mellitus or simply Diabetes, is a group of metabolic diseases in which a person
has high blood sugar, either because the body does not produce enough insulin, or because
cells do not respond to the insulin that is produced. This high blood sugar produces the classical
symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia
(increased hunger).
There are three main types of diabetes mellitus (DM). Type 1 DM results from thebody's failure to produce insulin, and presently requires the person to inject insulin or wear an
insulin pump. This form was previously referred to as "insulin-dependent diabetes mellitus"
(IDDM) or "juvenile diabetes". Type 2 DM results from insulin resistance, a condition in which
cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This
form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adult-
onset diabetes". The third main form, gestational diabetes occurs when pregnant women
without a previous diagnosis of diabetes develop a high blood glucose level. It may precede
development of type 2 DM.
Other forms of diabetes mellitus include congenital diabetes, which is due to genetic
defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high
doses of glucocorticoids, and several forms ofmonogenic diabetes.
http://en.wikipedia.org/wiki/Blood_sugarhttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Polydipsiahttp://en.wikipedia.org/wiki/Polyphagiahttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2http://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Gestational_diabeteshttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/MODYhttp://en.wikipedia.org/wiki/MODYhttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/Gestational_diabeteshttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_2http://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Polyphagiahttp://en.wikipedia.org/wiki/Polydipsiahttp://en.wikipedia.org/wiki/Polyuriahttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Blood_sugar7/30/2019 Bka Case Final
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carbohydrates), and endocrinopathies (e.g., Addison's disease). These phenomena are believed
to occur no more frequently than in 1% to 2% of persons with type 1 Diabetes.
Type 2 diabetes mellitus is characterized by insulin resistance, which may be combined with
relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is
believed to involve the insulin receptor. However, the specific defects are not known. Diabetes
mellitus cases due to a known defect are classified separately. Type 2 diabetes is the most
common type. The most common form of diabetes is Type II, It is sometimes called age-onset
or adult-onset diabetes, and this form of diabetes occurs most often in people who are
overweight and who do not exercise
Individuals who are at high risk of developing Type II diabetes mellitus include people who:
are obese (more than 20% above their ideal body weight) have a relative with diabetes mellitus belong to a high-risk ethnic population (African-American, Native American, Hispanic, or
Native Hawaiian)
have been diagnosed with gestational diabetes or have delivered a baby weighing morethan 9 lbs (4 kg)
have high blood pressure (140/90 mmHg or above) have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a
triglyceride level greater than or equal to 250 mg/dL
have had impaired glucose tolerance or impaired fasting glucose on previous testing
http://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Insulin_receptorhttp://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/gestational-diabetes/http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/gestational-diabetes/http://en.wikipedia.org/wiki/Insulin_receptorhttp://en.wikipedia.org/wiki/Insulin_resistance7/30/2019 Bka Case Final
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Diagnostic Tests:
1. Fasting Plasma Glucose Test- this test is to measure bloods plasma-glucose after fastingfor at least 8 hours, thus the name fasting plasma glucose test. This test is useful to
detect all types of diabetes.
2. Oral Glucose Tolerance Test- which measures blood glucose after 8 hours of fasting and2 hours after the person drinks a glucose-containing beverage. This test is effective to
diagnose all types of diabetes.
3. Random Plasma Glucose Test- also called a casual plasma glucose test, because there isno fasting required or worry about what we have eaten. This test, along with anassessment of symptoms, is used to diagnose diabetes but not pre-diabetes. However,
once random plasma glucose test confirms diabetes needs to be reconfirming by FPG or
OGTT
Causes:
The cause of diabetes depends on the type:
Type 1 diabetes is partly inherited, and then triggered by certain infections, with someevidence pointing at Coxsackie B4 virus. A genetic element in individual susceptibility tosome of these triggers has been traced to particular HLAgenotypes (i.e., the genetic
"self" identifiers relied upon by the immune system). However, even in those who have
inherited the susceptibility, type 1 DM seems to require an environmental trigger. The
onset of type 1 diabetes is unrelated to lifestyle.
Type 2 diabetes is due primarily to lifestyle factors and genetics.
http://en.wikipedia.org/wiki/Coxsackie_B4_virushttp://en.wikipedia.org/wiki/Human_leukocyte_antigenhttp://en.wikipedia.org/wiki/Human_leukocyte_antigenhttp://en.wikipedia.org/wiki/Human_leukocyte_antigenhttp://en.wikipedia.org/wiki/Coxsackie_B4_virus7/30/2019 Bka Case Final
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Urinary incontinence, over active bladder, bladder problems are all cause by nervedamage due to prolonged high blood-glucose.
Urinary tract infection is also due to nerve damage, but it is not directly relating with anerve cause. Due to Diabetic Gastroparesis, there is a delay in the food emptying, which
in-turn starts bacterial growth, and causes urinary tract infection. Furthermore, due to
long term of diabetes, immune system losses it capacity thereby it is not able to fight
the infection.
Diabetes Management:
1. Food - What you eat directly influences your blood-glucose levels. Follow the foodpyramid for effective diabetes control or management. Take food at the same time also
the same volume and never skip your food or even snack.
2. Physically active try to make your busy in your daily life routine or spent some timefor physical exercises such as walking, swimming, exercising and playing. It produces
positive results in blood-glucose control as well as a drop in medicine (pills or insulin)
requirements.
3. Lose weight if you are obese or overweight, try to reduce weight by following foodpyramid and increasing physical activity or exercising. Losing weight has a direct positive
impact in your blood-glucose control.
4. Monitor glucose level closely monitor your blood-glucose, check your blood-glucoseusing home glucose monitor, and make a record. If you maintain your blood-glucose
l h id di b i li i
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Nursing Responsibilities:
Advice patient about the importance of an individualized meal plan in meeting weeklyweight loss goals and assist with compliance.
Assess patients for cognitive or sensory impairments, which may interfere with theability to accurately administer insulin.
Demonstrate and explain thoroughly the procedure for insulin self-injection. Helppatient to achieve mastery of technique by taking step by step approach.
Review dosage and time of injections in relation to meals, activity, and bedtime basedon patients individualized insulin regimen.
Instruct patient in the importance of accuracy of insulin preparation and meal timing toavoid hypoglycemia.
Explain the importance of exercise in maintaining or reducing weight. Advise patient to assess blood glucose level before strenuous activity and to eat
carbohydrate snack before exercising to avoid hypoglycemia.
Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses,dryness, hair distribution, pulses and deep tendon reflexes.
Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce
vasoconstriction and enhance peripheral flow.
II. NURSING HISTORY
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PRESENT HISTORY:
Patient BKA never knew that her condition will lead her to amputation. She vieweddiabetes as a simple disease that can be treated by simple medications. Because of her
oblivious attitude regarding her condition, it complicates until she begun to have non-healing
wounds which causes her to undergone debridement on her left foot then followed by her
right. When her right foot doesnt heal on debridement, she undergone below the knee
amputation.
FAMILY HISTORY:
According to patient BKA, her family has history of diabetes which caused her mothers
death. She is aware that she inherits her condition from her mother which was inherited by her
daughter to her.
GORDONS 11 FUNTIONAL PATTERN
HEALTH PERCEPTION
BEFORE: patient BKA considered diabetes as a simple disease only. She ignored the fact
that it may result into many complications. She seldom goes to hospital for check-up until one
day she collapsed following body malaise and dizziness that makes her family to rush her to the
hospital only to find out that her diabetes was being triggered. When she was diagnosed with
diabetes the doctor recommended her to take medications such as insulin and placil. She also
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COGNITIVE AND PERCEPTUAL PATTERN
BEFORE: patient BKA decides in her own as she told us and goes for check-up all byherself. She only consulted her family if it requires family decision. Patient BKA experienced
blurring of vision only when looking from distant places.
PRESENT: she has still sharp memory that she can still able to manage in decision
making and remembered past events. Her vision remains the same, experiencing blurring of
vision form a distant area.
SLEEP-REST PATTERN
BEFORE: patient BKA sleeps 5 hours per day starting 10pm-3am. She seldom had rest
due to her occupation being a vendor working whole day in the market. She only rested when
she sold all her manufactured goods already or if theres no customer. She is aware of her
sleeping pattern and considered it normal rationalizing that its a part of aging and she need to
do that for her work.
PRESENT: when she was diagnosed of diabetes and had undergone debridement, shetried to cope up in her sleeping pattern. She told us that she sleep earlier compared before.
Aside from that, she also tried to look for time to give herself a rest even when she is at work.
ROLE RELATIONSHIP PATTERN
BEFORE: patient BKAs husband is a farmer though her husband earned enough money
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DATE: 08-01-12; TIME: 2:45pm
GENERAL APPEARANCE: the patient looks weak, feels dizzy, irritable with the IFC, andcomplains that she still doesnt feel her left leg, the patient still smiles while she talks to
her relative but hardly to cooperate due to weakness and under the presence of
anesthesia.
PHYSICAL ASSESSMENT:
T: 36.9o
C RR: 20 cpm
PR: 96 bpm BP: 110/80 mmhg
IFC: 100cc
PARTS TECHNIQUE USE ABNORMAL FINDINGS ANALYSIS
HAIR Inspection White strands Dry
Due to aging
HEAD Inspection OilyPalpation Round, symmetry; no mass
or nodules
NormalFACE Inspection Facial grimace, irritable Due to post-operative
Palpation Cold to touch Due to
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TEETH Inspection Incomplete Due to aging
VAGINA Inspection Presence of polyps Due to complication of
diabetesUPPER EXTREMITIES
NAILS Inspection Dirty fingernails Due to poor hygieneSKIN Inspection
Palpation
Dry skin Pale nail bed
Due to increaseurination
Due to poor bloodcirculation or
anemiaPALM Inspection Pale Due to anemia or
poor blood
circulation
LOWER EXTREMITIES
SKIN Inspection
Inspection
Dry skin BKA right leg
Debridement left leg
Due to poor hygiene Due to unhealing
wound and impaired
skin integrity
Due to impaired skinintegrity
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Endocrine- The endocrine gland, which consists of the islets of Langerhans, secretes hormones
into the bloodstream.
Functions of the Pancreas:
The pancreas has digestive and hormonal functions:
The enzymes secreted by the exocrine gland in the pancreas help break downcarbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down
the pancreatic duct into the bile duct in an inactive form. When they enter the
duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to
neutralize stomach acid in the duodenum. The hormones secreted by the endocrine gland in the pancreas are insulin and glucagon
(which regulate the level of glucose in the blood), and somatostatin (which prevents the
release of the other two hormones).
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Pathophysiology:
Precipitating factor:
Eating sweets and fatty
foods
Decrease insulin production of pancreas
Diabetes mellitus Type II
Predisposing factor:
Genetics
Age45 years old
Gender: female
Accumulation of glucose in the blood
stream
Glucose is not metabolize by the body
Fat is broken down in
adipose tissue
Releases fatty acid
in the blood
stream.
Fatty acids
convert into
ketones by
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Gestational
diabetes
Body malaise,
nausea and
vomiting,
pale.
Non healing
wound
Debridement
on the left
and right foot
BKA on the
right foot
Infectious
vaginitis
Peripheral
neuropathy
Diabetic
retinopath
Deteriorationsmall blood
vessels that
nourish retin
Opacity in thelens
Blurred visionosteomyelitis
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IV. LABORATORY RESULTS
August 01 2012
Tests Normal Values Results Interpretation
Hemoglobin F (12-18 g/dl) 10.2 Due to anemia
Monocyte F (37-47%) 30.0 Due to bacteria
White blood
cell
4.0-10.0 18.4 Due to infection
Granulocyte 44.2-80.2% 76 Normal
Lymphocyte 28.0-48.0% 24 Due to the presence of
wound
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VI. COURSE IN THE WARD
August 01,2012
POST-OP ORDERED
DATE TIME DOCTORS ORDER RATIONALE NURSING RESPONSIBILITIES
8/1/12 11:45am To ward/ status post BKA rightunder SAB
For the patient recovery Endorse to ward. Diabetic diet, if with full motor
and sensory
To prevent aspiration Check for the full motor and sensory VS q 15mins. until stable To monitor baseline V/S and any
changes after operation
Monitored V?S q15min For Hgb- now, then q 8 hours
thereafter
To prevent blood loss Request for laboratory IVF:PNSS 1Lx8 hours x 3 cycles
Meds:
1. Ketorolac2. Tramadol3. Metoclopromide
To maintain fluid and electrolyteimbalances
To alleviate sign and symptoms IV hooked and regulated and meds
administered and recorded
Start- diabetic meds andantibiotic once on DAT
To prevent the occurrence of infectionand for maintenance
Give diabetic meds and antibiotic once onDAT
Elevate with one pillow operativesite
To prevent for bleeding Elevate with one pillow atoperative site Watch out for bleeding on
operative site
To check for infection Watch out for bleeding on operative sitethen report.
I & O q 1 hour and record For urine elimination monitoring I and O monitored q1hr Refer as needed To inform ROD Referred
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VIII. NURSING CARE PLAN
August 01, 2012
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
hindi mabilis
gumaling ang sugat
ko. As verbalized
by the patient.
Objective:
Alteredsensation
Delayedwound
healing
Ineffective peripheral
tissue perfusion related
to decreased blood flow
to the area of non
healing wound due to
obstruction of blood
vessels
After 3o
minutes of
nursing
interventions
the patient will
be able to
verbalize
understanding
of condition,therapy
regimen, side
effects of
medications
and when to
conduct health
care provider.
Get vital signsand record.
Establish rapport. Educate client in
active range of
motion exercise.
Elevate head ofbed at night.
Discouragewearing
constrictive
clothing, crossing
legs.
Provide otherpost-op teaching
appropriate for
the situation.
For base line data. To gain the patient
trust.
To promote circulationof blood.
To increasegravitational blood
flow.
To promote bloodcirculation.
Goal met.
After 3o minutes of nursing
interventions the patient was
able to verbalize
understanding of condition,
therapy regimen, side effects
of medications and when to
conduct health care provider.
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Encourage earlyambulation when
possible.
Discuss care offoot care as
appropriate.
To promote peripheralcirculation and limit
mplication associated
with poor perfusion.
When circulation isimpaired, changes in
sensation place client
at risk for
development of lesions
or ulcerations that are
often slow to heal.
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August 01, 2012
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:ang alam ko
noon sa diabetes
simpleng sakit lang,
pero hindi pala as
verbalized by the
patient.
Deficient knowledgeabout the disease
process, diet, care
and treatment
related to lack of
information.
After 3 hours of nursinginterventions the patient
will be able to verbalized
importance of having
healthy lifestyle and
correctly perform
prescribed health
behaviors.
Get vital signs andrecord. Establish rapport. Provide information
to support self-
efficacy, self
regulation and self
management by
focusing on problem
solving and decision
making.
Tailor the delivery ofinstructions to the
clients cognitive level
by accessible words.
Provide healthteaching related to
disease condition.
Evaluate learningoutcomes using
verbalizations.
For base linedata. To gain the
patient trust.
Evaluationserves as an
assessment.
After 3 hours of nursinginterventions the patient
was able to verbalized
importance of having
healthy lifestyle and
correctly performs
prescribed health behaviors.
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August 01, 2012
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
OBJECTIVE:
Increase WBC Presence ofwound due to
operation
Risk for Infection
related to post
operative surgery
After 8 hours of
implementing the
nursing intervention thepatient will be able to
manifest the decrease
of infection.
Check vital signs q15
Observe forlocalized signs of
infection at
insertion site of
wound
Stress proper handhygiene by all
caregivers between
therapies and
clients before
cleaning the wound
Change surgicalwound dressing, as
indicated, using
proper technique
for changing/
disposing of
contaminated
materials.
For baseline data
To prevent crosscontamination of
the infection
To reduce infection
To reduce infectionAnd prevent
contamination
After 8 hours of nursing
intervention the patient was able
to reduce/lessen the infection
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Encourage theclient to increase
protein intake
Administerceftriaxone as
prescribe
To promote woundhealing
To reduceinfection
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VIII. DRUGS STUDY
DRUG NAME INDICATION ACTION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
KETORALAC
Classification:
Nonsteroidal anti-
inflammatory and
non opioid
analgesic
Route: IV every 6
hours
Dosage: 30 mg- 4
doses
Short term
management of
pain.
Inhibits prostaglandin
synthesis, producing
peripherally mediated
analgesia. Also have
antipyretic and anti-
inflammatory
properties.
Therapeutic effects:
decrease pain.
Hypersensitivity; cross
sensitivity with other
NSAIDs may exist.
CNS: drowsiness, dizziness,
headache
Respiratory: dyspnea
CV: edema, pallor,
vasodilation
GI: oliguria
1. Assess for rhinitisincreased risk for
developing
hypersensitivity reactions.
2. Assess pain (note type,location and intensity)
prior to 1-2 hours
following administration.
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DRUG NAME INDICATION ACTION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
TRAMADOL
Classification:
Analgesic
Route: slow IV
push
Dosage: 50 mg- 4
doses
Moderate to
severe pain
Binds to mu-opioid
receptors. Inhibits
reuptake of
serotonin and
norepinephrine in
the CNS.
Therapeutic
effects: decrease
pain
Hypersensitivity; cross
sensitivity with opioids
may exist.
CNS: dizziness, headache
GI: constipation, nausea
1. Assess type, pain location,intensity of pain and 2-3
(peak) after administration.
2. Assess BP and respiratoryrate before and periodically
during administration.
3. Prolonged use may lead to,physical and psychological
dependence and tolerance.
If tolerance develops,
changing to an opiod may be
required to relieve pain.
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DRUG NAME INDICATION ACTION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
METOCLOPROMI
DE
Classification:
antiemetics
Route: IV
Dosage: 10 mg
PRN
-Treatment pi post
surgical and diabetic
gastric stasis.
-Treatment and
prevention post
operative nausea and
vomiting.
Block dopaminre
receptors in
chemoreceptor trigger
zone of the CNS.
Motilates motility of the
ipper G.I. tract and
accelerates gastric
emptying.
Therapeutic effects:
decrease nausea and
vomiting and decrease
symptoms of gastric
stasis.
Hypersensitivity; possible
G.I. obstruction/
hemorrhage.
CNS: drowsiness,
extrapyramidal
reactions,
restlessness.
GI: constipation,
nausea
1. Assess patient for nauseavomiting, abdomina
distention, and bowe
sounds before and afte
administration.
2. Assess for extrapyramidareactions.
3. Monitor for tardivedyskinesia.
4. Assess patient for signs odepression periodically
throughout therapy.
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DRUGS INDICATION ACTION CONTRAINDICATION SIDE EFFECT NURSING RESPONSIBILITIES
Drug name:
Metformin
Classification:
Anti
diabetic
ROUTE:
P.O
DOSAGE:
500mg x a
day with meal
l
Managementof type 2
diabetesmellitus; may
be used with
diet,insulin, or
sulfonylurea
oral
hypoglycemic.
Decreasehepatic
glucose
production
THERAPEUTICEFFECTS:
Maintenance
of blood
glucose
Hypersensitivity; metabolic
acidosis;
dehydration,sepses,hypoxemia, hepatic
impairment.
1. Nausea and vomiting,hypoglycemia
2. Decrease vitamin B121. Obtain baseline and periodic
kidney and liver function tests;
drug contraindicated in the
presence of renal or hepatic
insufficiency. Monitor blood
glucose and HbA1C, and lipid
profile periodically.
2. Assess renal function beforeinitiating.
3. monitor serum folic acid andvitamin B12.
4. Encourage patient to followprescribed diet, medication,
and exercise regimen to
prevent hyperglycemic or
hypoglycemic.
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DRUGS INDICATION ACTION CONTRAINDICATION SIDE EFFECT NURSING RESPONSIBILITIES
Drug name:
INSULIN
Classification:
Anti
diabetics
Route:
sub cut
Dosage:
0.5 to 1 unit/
kg per day
Control ofhyperglyce
mia in
patients
with type
1 or type 2
diabetes
mellitus
lower bloodglucose uptake in
skeletal muscle
and fat,
inhibiting hepatic
glucose
production.
THERAPEUTICEFFECTS: Control
of hyperglycemia
in diabetic
effects.
hyperglycemia, allergy or
hypersensitivity to a
particular type of insulin.
erythema, lipodystrophy,
prurutis, swelling
1. Monitor body weightperiodically. Changes in
weight may necessities
changes in insulin dose.
2. Monitor blood glucose every6 hours during therapy, more
frequently in times of stress.
3. Notify physician promptly forpresence of acetone with
sugar in the urine; may
indicate onset of ketoacidosis.
Acetone without sugar in the
urine usually signifies
insufficient carbohydrate
intake.4. Monitor for hypoglycemia
(see Appendix F) at time of
peak action of insulin. Onset
of hypoglycemia (blood sugar:
5040 mg/dL) may be rapid
and sudden.
5. Check BP, I&O ratio, andblood glucose and ketones
every hour during treatment
for ketoacidosis with IV
insulin.6. .Emphasize the importance of
compliance with nutritional
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guidelines and regular
exercise as directed by health
care professional.