(A) Nursing evaluation
1. Medical history, physical assessment, patients complained of eating more, drinking more, urinating more, losing weight, poor wound healing, frequent infections, etc. They should be asked about their lifestyle, eating habits, food intake, family history of diabetes, weight and number of pregnancies. Patients with chronic complications of diabetes have cardiovascular and nervous system abnormalities. Patients with ketoacidosis have deep breathing, dehydration symptoms and consciousness changes.
2. Laboratory tests showed that fasting urine glucose was positive, fasting and postprandial blood glucose increased beyond the normal range, and blood triglyceride, cholesterol and lipoprotein increased; Patients with acidosis may have abnormal changes in urine ketone positive, electrolyte, blood ph and carbon dioxide binding capacity.
3. Psychological and social data Diabetes is a lifelong disease. The stress caused by the long course of disease and the dysfunction of multiple organs and tissues on patients' body and mind is likely to make patients feel anxious and depressed, lack confidence in the disease, or adopt an indifferent attitude towards the disease, thus failing to effectively cope with chronic diseases. Social environment, such as the response and support of patients' relatives and colleagues, is an important factor related to whether patients can adapt to chronic diseases and should be evaluated.
(2) Nursing diagnosis nursing plan and evaluation
1. Malnutrition and emaciation are related to the disorder of glucose, protein and fat metabolism caused by absolute or relative insufficiency of insulin secretion.
(1) The symptoms of polydipsia, polyuria and polyphagia in the target patients were relieved, and their weight increased, and their blood sugar was normal or tended to be normal.
(2) Nursing measures
1) diet care
Daily calorie calculation: according to the patient's gender, age and height, look up the table or calculate the ideal weight [ideal weight (kg)= height (cm)- 105], and then refer to the ideal weight and activity intensity to calculate the total daily calories required. Adult rest people are given 105- 125 kJ (25-30 calories) per kilogram of standard weight every day; Light manual workers 125- 146 kJ (30-35 kcal); Manual workers 146- 167 kilojoules (35-40 kilocalories); Heavy manual workers167 kj (above 40kcal).
Children, pregnant women, nursing mothers, malnutrition or wasting diseases should be increased as appropriate, and obese people should be reduced as appropriate, so that the patient's weight can be restored to about 5% of the ideal weight.
Protein, the distribution of fat and carbohydrate. The protein content in the diet is calculated as 0.8 ~ 1.2g per kilogram of adult's standard weight, and it can be increased to 0.2 ~1.5g per kilogram for children, pregnant women, wet nurses, malnourished people or people with wasting diseases. Fat is 0.6 ~1.0g per kg of standard weight per day; The rest are carbohydrates. According to the above calculation, protein accounts for about 12% ~ 15% of the total calories, fat accounts for about 30%, and carbohydrate accounts for about 50% ~ 60%.
Distribution of three meals: the above calories are converted into recipes according to the food composition table, and the distribution of three meals is generally 1/5, 2/5, 2/5 or 1/3, 1/3, l/3. The contents of three meals should be balanced, with carbohydrates, fat and protein in each meal, and should be quantified regularly, which is beneficial to slow down the absorption of glucose and increase the release of insulin. After eating this recipe for 2 ~ 3 weeks, blood sugar should drop. If it is not good, it is necessary to make necessary adjustments.
In recent years, the food exchange method has been widely used. In this method, food is divided into six categories: grain, milk, meat, fat, fruit and vegetables, with a unit of 80 kcal, such as 25g of grain rice, 30g of raw noodles and 25g of green (red) beans. Milk milk 1 10ml, milk powder 159, and soybean milk 200ml are each a unit; 25 grams of lean pork, 50 grams of lean beef, 55 grams of eggs and 50 grams of abalone are each a unit; 9g of fatty soybean oil, one unit of peanut 15g each; 200 grams of fruit apples and 750 grams of watermelons as a unit; 500~750g of spinach and 350g of radish, each of which is a unit. The same amount of food in each food is interchangeable, and the nutritional value is basically the same. Patients can make recipes according to the contents of different heat exchange parts. This method is rough, but it can increase the selectivity of food and make it convenient for patients to learn and master.
Patients should give up drinking. The staple food advocates coarse rice, flour and moderate miscellaneous grains, and avoids eating glucose, sucrose, honey and its products. The daily intake of animal protein in protein should be 1/3 of the total to ensure the supply of essential amino acids. Eat vegetable oil containing unsaturated fatty acids, avoid animal fat to reduce the intake of saturated fatty acids, and the amount should be less than 10% of total calories. Obese people should eat low-fat food (
2) Physical Exercise According to age, physical strength, illness and complications, guide patients to have regular physical exercise for a long time.
Physical exercise includes walking, jogging, cycling, aerobic exercise, Tai Ji Chuan, swimming and housework. The suitable activity intensity is that the patient's heart rate should reach 50% of the individual's maximum oxygen consumption, and the individual's heart rate at 50% of the maximum oxygen consumption is 0.5 (individual's maximum heart rate-basal heart rate)+basal heart rate, in which the individual's maximum heart rate can be roughly estimated to be 220 years old, and the basal heart rate can be estimated by the pulse rate measured before getting up in the morning. The activity time is 20 ~ 40 minutes, which can be gradually extended to stop or longer, once a day, and it is best for those who use insulin or oral hypoglycemic drugs to exercise regularly every day; Obese patients can appropriately increase the number of activities.
The side effects of physical exercise include ① hypoglycemia; Its occurrence is related to activity intensity, time, meal time before activity, food type, blood sugar level before activity and drug use. Blood type diabetics who simply control their diet generally do not have hypoglycemia. ② Hyperglycemia and ketosis: The blood sugar level of diabetic patients treated with insulin is higher (> 13.3~ 16.7mmol/l). At the initial stage of exercise, sympathetic nerve is over-excited, catecholamine release increases, and blood sugar concentration can rise sharply. Insufficient insulin can cause ketosis or ketoacidosis. ③ Inducing cardiovascular accidents: Exercise can increase the burden on heart and brain, increase plasma volume, reduce vasoconstriction, and may induce angina pectoris, myocardial infarction and arrhythmia. ④ Motor system injury: including bone, joint, muscle or skin injury, foot skin ulceration or even ischemia and gangrene.
Matters needing attention in physical exercise are: blood sugar >; 13.3mmol/l or urine ketone positive people should not do the above activities. Patients with type ⅱ diabetes complicated with cardiovascular and cerebrovascular diseases or severe microangiopathy should be properly arranged according to the specific situation, and the systolic blood pressure should be >: 24kpa( 180mmhg). The activity time should be arranged after dinner. Exercise should be moderate, so as not to excite sympathetic nerve and islet A cells, cause glycogen decomposition and gluconeogenesis, and raise blood sugar. People who only rely on diet control or oral hypoglycemic drugs usually don't need to add food to their foreheads. Patients with type I diabetes often fluctuate between relative insulin deficiency and relative insulin excess when receiving insulin therapy, so we should grasp the relationship between insulin dosage, diet and activity. The former can lead to the increase of blood sugar, the increase of free fatty acids and ketone bodies, which has an adverse effect on metabolism because of the obvious increase of liver sugar output but no increase of glucose utilization during exercise. The latter is prone to hypoglycemia. ② Generally, you can supplement a small amount of extra food or reduce the amount of insulin before the activity. Injecting insulin under the abdominal wall before meals can slow down the absorption rate of insulin during activities. ③ The activity should not be too large and the time should not be too long. The appropriate time is 15 ~ 30 minutes. Attention to the above three points can prevent the occurrence of hypoglycemia after 1 diabetes. Check your feet before and after activities, and pay attention to the surrounding environment and buildings during activities to avoid injury. Take dessert with you and a card with your name, home address and illness in case of emergency.
3) Nursing and educating patients with oral hypoglycemic drugs to take medicine on time according to the dosage, and shall not increase or decrease at will.
Observe adverse drug reactions: The main side effect of sulfonylureas is hypoglycemia, especially in patients with hepatic and renal insufficiency and elderly patients. Other side effects include gastrointestinal reactions and occasional drug allergies, such as leukopenia, anemia, itchy skin and rash. The common adverse reactions of biguanides include anorexia, nausea, vomiting, bitter taste, metallic taste and diarrhea. There are occasional allergic reactions. Because biguanides promote anaerobic glycolysis and produce lactic acid, they can induce lactic acidosis in patients with liver and renal insufficiency, shock or heart failure.
The changes of blood sugar, ghb, fa, urine sugar, urine volume and body weight were observed, and the curative effect and drug dosage were evaluated.
4) Nursing observation of insulin therapy and prevention of adverse insulin reactions: ① Hypoglycemia reaction: It is related to excessive insulin dosage, eating disorder or excessive exercise, which is more common in patients with 1 type diabetes. It is characterized by dizziness, palpitation, sweating, hunger and even coma. For those with hypoglycemia, blood sugar should be detected in time, and sugary foods such as candy, biscuits and sugary drinks should be eaten according to the condition, or 20 ~ 30 ml of 50% glucose should be injected intravenously. Ensuring the effective dose and time of insulin, regular quantitative eating and moderate exercise are the keys to prevent hypoglycemia, including the preservation temperature of islets should not exceed 30℃ and avoiding violent shaking; There are two commonly used preparations in China: 40 or 100u per ml. Pay attention to the matching of syringe and islet concentration when using, and generally use lml syringe to extract liquid medicine to ensure accurate dosage. Ordinary insulin was injected subcutaneously before meals 1/2 hours, and protamine zinc insulin was injected subcutaneously 1h before breakfast. When long-acting insulin and short-acting insulin are mixed, short-acting insulin should be pumped first, then long-acting insulin should be pumped, and then mixed evenly. Reverse operation is not allowed to avoid mixing long-acting insulin with short-acting insulin, which will affect its quick effect. Patients should learn to eat according to the prescribed time and quantity, and reasonably arrange the daily exercise time and quantity. If the meal time is postponed, they can have some biscuits first. ② Insulin allergy: The main manifestations are local itching and urticaria after injection, and systemic rash is rare. Rare severe allergic reactions such as serum sickness and anaphylactic shock. ③ Atrophy or hyperplasia of subcutaneous fat at the injection site can cause insulin malabsorption, but it is rare in clinic. After stopping the injection at this site, you can slowly recover. Changing the injection site frequently to avoid injecting twice in the same site within two weeks can prevent the tissue at the injection site from shrinking or proliferating.
Teach patients the method of self-injection of insulin, and understand the adverse reactions of insulin and matters needing attention in use.
(3) The diabetic symptoms of the patients were significantly improved, their weight increased, and their blood sugar dropped to normal or tended to normal level.
2. The risk of infection is related to hyperglycemia, lipid metabolism disorder, malnutrition and microcirculation disorder.
(l) objectives
1) The patient was not infected.
2) Infected patients can be found and treated in time.
(2) Nursing measures
1) Diet Control the diet reasonably, ensure sufficient calories and protein supply, and enhance the body's resistance.
2) Control the possibility of infection, maintain oral and skin hygiene, scrub frequently and change clothes frequently. When injecting insulin, the local skin should be strictly disinfected to prevent infection.
3) Observe whether there are symptoms and signs related to infection, find them early and handle them in time.
4) The key of diabetic foot (df) care is to prevent skin injury and infection, and its measures include daily foot skin cleaning and massage. Trimmed toenails are slightly bent, equal to toes. Shoes and socks are flat and loose. Observe the changes of color, temperature and humidity of the foot skin dynamically, and check whether there are edema, skin lesions, foot diseases, blood vessel pulsation on the dorsum of the foot, foot skin sensation, etc. Handle in time when the epidermis is broken.
(3) Evaluation
1) The patient was not infected.
2) When the patient is infected, find and treat it in time.
3. Potential complications: ketoacidosis.
(1) target
1) patients should avoid ketoacidosis as much as possible.
2) Patients with ketoacidosis can be found and treated in time.
(2) Nursing measures
1) Patients with obvious fatigue, extreme thirst, increased urine output with anorexia, vomiting, headache and consciousness change on the basis of the original clinical manifestations of diabetes should be alert to the occurrence of ketoacidosis.
2) The first-aid nursing measures for ketoacidosis include ① accurate implementation of doctor's advice and ensuring the input of liquid and insulin. Liquid input should be completed within the specified time, and insulin dosage must be accurate and timely. ② Patients must stay in bed and keep warm to prevent bedsore and secondary infection. Coma patients should be cared according to coma. ③ Closely observe and record the changes of patients' mental state, pupil size, light reflex, respiration, blood pressure, pulse, heart rate and daily fluid volume. During infusion and insulin therapy, urine sugar, urine ketone, blood sugar, blood ketone, blood potassium, blood sodium and carbon dioxide binding force should be sampled every 1 ~ 2 hours.
3) Patient education Educate patients about the inducement of diabetic ketoacidosis and the precursor of ketoacidosis.
Symptoms.
(3) Evaluation
1) The patient had no ketoacidosis.
2) Timely discover and treat patients with ketoacidosis.
4. The potential complication is hypoglycemia.
(1) target
1) patients should try not to have hypoglycemia or hypoglycemia coma.
2) can timely find and treat hypoglycemia or hypoglycemia coma patients.
(2) Nursing measures
1) When hypoglycemia occurs in disease monitoring, patients often feel hungry, accompanied by fatigue, sweating, nausea, palpitations, pale face and even coma. When hypoglycemia occurs during sleep, patients may suddenly wake up with wet skin and sweating, and some patients will feel hungry. All patients with the above symptoms should be alert to hypoglycemia.
2) First-aid nursing measures for hypoglycemia include ① eating sugary food: most patients with hypoglycemia can quickly relieve themselves within 15 minutes after eating sugary food, which can be 2-4 pieces of candy or sugar cubes, 5-6 pieces of biscuits, 1 spoonful of honey, half a cup of juice or sugary drinks, etc. ② Glucose supplement: intravenous injection of 50% glucose 40 ~ 60 ml is the most commonly used and effective first aid method for hypoglycemia. @ glucagon and 1mg intramuscular injection are suitable for those who have difficulty in establishing venous access for a while.
Out-of-hospital first aid or patient self-help.
3) The main contents of patient education include ① educating patients about the common causes of hypoglycemia. One is improper use of insulin, which is mainly seen in diabetic patients treated with insulin, and excessive use of insulin is the most common reason.
Hypoglycemia often occurs within the maximum action time of insulin, such as hypoglycemia caused by short-acting insulin often occurs about 3 hours after meals; Those who use long-acting insulin before meals are prone to hypoglycemia at night. In addition, we can also see that insulin is injected with oral hypoglycemic agents, or the blood circulation is accelerated due to exercise, or the insulin type is changed from animal insulin to human insulin, or the insulin injection method is improper, such as the medium and long-acting insulin are not fully mixed before injection, and the dosage is wrong. The second is that the dosage of sulfonylurea oral hypoglycemic agents is too large. Third, improper diet, including forgetting or delaying meals, insufficient intake or low carbohydrate content in food, not increasing food intake while increasing exercise, reducing the dosage of insulin or oral hypoglycemic drugs, and drinking too much on an empty stomach. ② Take oral hypoglycemic drugs or insulin injection on time according to the dosage, live a regular life, eat regularly and quantitatively, and eat a small amount of biscuits or fruits before meals when delaying meals. Keep the amount of exercise unchanged, eat properly before exercise or reduce the dosage of hypoglycemic agents appropriately. Check blood sugar regularly, especially those who inject insulin and those who often have hypoglycemia at night. ③ Teach patients to know the manifestations of hypoglycemia reaction and master the methods of self-rescue.
(3) Evaluation
1) The patient had no hypoglycemia or hypoglycemia coma.
2) Timely discover and treat patients with hypoglycemia.
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