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Kelompok 2 : Program A10 1. Diagnosa 1 Deficit fluid Volume related to hiperglikemia Subyektif data : a. Pasient was taking 48 unit insulin everyday Obyektif data: a. Breathing is deep and rapid b. Aceton smell on breath c. Blood glucose level of 730 mg/dl d. Blood ph 7,26 e. Vomiting Objective : a. Homeostasis can be depended b. stabiled blood glucosa level c. avoid the complication criteria results: a. Patient breath normally b. Smell on breath is not aceton c. Blood glucosa level of 90-120 d.
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  Kelompok 2 : Program A101.Diagnosa 1 Deficit fluid Volume related to hiperglikemiaSubyektif data :a.Pasient was taking 48 unit insulin everydayObyektif data:a.Breathing is deep and rapid b.Aceton smell on breathc.Blood glucose level of 730 mg/dld.Blood ph 7,26e.VomitingObjective :a. Homeostasis can be depended b. stabiled blood glucosa levelc. avoid the complicationcriteria results:a.Patient breath normally b.Smell on breath is not acetonc.Blood glucosa level of 90-120d.Blood pH 7,35-7,45 NoInterventionRationale1. for vital signMonitor for positive plasma keton, aseton breathMaintain frequency and facility of breathing, usingaccesories muscles, there is apnea periode and showingsianosisGive fluid minimum 5-8L/day in the heart capacitytoleranceMonitor the menthal changing, monitor GCSWrite the result of assesment such as anorexia,abdomen pain and vomiting.Hypovolemia can be showed by hipotensi and takikardia.Hipovolemia can be checkedits heavy when patientsistolik blood pressure downuntil 10mmHg from fowler  position to sit or stand up positionWhen insulin is not available, blood glucose levels rise andthe body metabolish fat for energy producing keton bodiesHiperglikemia and asidosiscan make frequency and rateof breathing is abnormal because that is indicationfrom difficulty of breathingand patientMaintenance fluid sirculationThe menthal changing can berelated to hyperglycemi or hipoglycemy, accidocis.Recognizing altering can be predispotition of aspiration in patien.Deficiency of fluid andelectrolit can change gastrik motility which will oftenmake vomiting and potentialyit can make deficiency fluidor electrolit  2.Diagnosa 2 Altered nutrition related to less food intake.Subjective data:Patient was vomiting and anorexia for 1 week Objective: The nutritional requirements can be metCriteria results:1. patient is not vomiting and anorexia2. Patients adhere to her diet. Action Plan:1. Assess the nutritional status and eating habits.Rational: To know about the circumstances and the patient's nutritional needsso it can be given acts and setting adequate diet.2. Instruct the patient to adhere to a diet that has been programmed.Rationale: Compliance with the diet can prevent the occurrence of complications hypoglycemia / hyperglycemia.3. Weigh weight every week.Rational: Knowing the development of patient body weight (body weight is oneindication to determine the diet).4. Identify dietary changes.Rational: To determine whether the patient has been carrying out a diet programdetermined.5. Cooperation with other health team for delivering insulin and diet diabetic.Rational: Delivery of insulin to increase glucose entry into in the network sothat the blood sugar decreases, providing an appropriate diet can accelerate thedecline in blood sugar and prevent complications.
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