Nursing care Plans for Cirrhosis hepatic

Nursing care Plans for Cirrhosis, Cirrhosis is a chronic hepatic disease that is characterized by destruction of the functional liver cells, which leads to cellular death. In cirrhosis, the damaged liver cells regenerate as fibrosis areas instead of functional cells, causing alterations in liver structure, function, blood circulation, and lymph damage. The major cellular changes include irreversible chronic injury of the functional liver tissue and the formation of regenerative nodules. These changes result in liver cell necrosis, collapse of liver support networks, distortion of the vascular bed, and nodular regeneration of the remaining liver cells. This disease alters liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.

Pathophysiology of Cirrhosis

Nursing care Plans for Cirrhosis
Treatment of Cirrhosis The goal of Cirrhosis therapy is to remove or alleviate the underlying cause of cirrhosis, prevent further liver damage, and prevent or treat complications:

• Vitamins and nutritional supplements promote healing of damaged hepatic cells and improve the patient's nutritional status. 
• Sodium consumption is usually restricted, and liquid intake is limited to or reduce to help manage ascites and edema. 
• Drug therapy requires special caution detoxify harmful substances efficiently. 
• Antacids may be prescribed to reduce gastric distress and decrease the potential for GI bleeding. 
• Potassium-sparing diuretics, such as furosemide, may be used to reduce ascites and edema. 
• Alcohol is restricted /prohibited,. 
• Sedatives should be avoided. Acetaminophen is especially hepatotoxic, particularly when combined with alcohol. 
• In patients with ascites, paracentesis may be used as a palliative treatment to relieve abdominal pressure. 
• Surgical intervention may be required to divert ascites 
• To control bleeding from esophageal varices or other GI hemorrhage, nonsurgical measures are attempted first. These include gastric intubation and esophageal balloon tamponade. In gastric intubation, a tube is inserted and the stomach is lavaged until the contents are clear. If the bleeding is assessed as a gastric ulcer, antacids and histamine antagonists are administered. 

Patient teaching and home healthcare guide Cirrhosis patients

• Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use exacerbates the Cirrhosis disease. 
• Emphasize to the patient that alcoholic liver disease in its early stages is reversible when the patient abstains from alcohol. but on further stage can be irreversible
• To minimize the risk of bleeding, warn the patient against taking non-steroidal anti-inflammatory drugs, straining to defecate, and blowing his nose or sneezing too vigorously. Suggest using an electric razor and a soft toothbrush. 
• Advise the patient that rest and good nutrition conserve energy and decrease metabolic demands on the liver. 
• Teach the patient to have frequent, small meals. Teach him to alternate periods of rest and activity to reduce oxygen demand and prevent fatigue. 
• Tell the patient how he can conserve energy while performing activities of daily living. For example, suggest that he sit on a bench while bathing or dressing. 
• Stress the need to avoid infections and abstain from alcohol. Refer the patient to Alcoholics Anonymous, if appropriate 
• Encourage the patient to seek frequent medical follow-up. Visits from a community health nurse to monitor the patient’s progress and to help with any questions or problems at home. 
• Refer the patient to an alcohol support group or liver transplant support group 

Nursing care Plans for Cirrhosis
Cirrhosis is a chronic hepatic disease that is characterized by destruction of the functional liver cells, which leads to cellular death. In cirrhosis, the damaged liver cells regenerate as fibrosis areas instead of functional cells, causing alterations in liver structure, function, blood circulation, and lymph damage. The major cellular changes include irreversible chronic injury of the functional liver tissue and the formation of regenerative nodules. These changes result in liver cell necrosis, collapse of liver support networks, distortion of the vascular bed, and nodular regeneration of the remaining liver cells. This disease alters liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.

Causes for Cirrhosis depending on the type for Cirrhosis
Hepatocellular disease, Postnecrotic cirrhosis called portal, nutritional, or alcoholic cirrhosis stems from various types of hepatitis e.g. A, B, C, or D viral hepatitis or toxic exposures. Damage of the Livver results from malnutrition and overuse of alcohol. Fibrous tissue forms in portal areas and around central veins. Autoimmune disease, such as sarcoidosis and chronic inflammatory bowel disease, may result in cirrhosis.
Cholestatic diseases, Cholestatic diseases include diseases of the biliary tree and sclerosing cholangitis.
Metabolic diseases, metabolic diseases include disorders such as Wilson's disease, alpha1- antitrypsin deficiency, and hemochromatosis.
Other types of cirrhosis, other types of cirrhosis include Budd-Chiari syndrome, cardiac cirrhosis, and cryptogenic cirrhosis. Cardiac cirrhosis is rare; the liver damage results from rightsided heart failure. Cryptogenic refers to cirrhosis of unknown cause

Complications for Cirrhosis

• Portal hypertension, 
• Bleeding esophageal varices 
• Hepatic encephalopathy 
• Hepatorenal syndrome. 

Diagnostic tests for Cirrhosis

• Liver biopsy 
• Abdominal X-rays 
• Computed tomography and liver scans 
• Esophagogastroduodenoscopy 
• Blood and Urine and stool studies disclose increased urine levels of bilirubin and urobilinogen; fecal urobilinogen levels decrease

Common Nursing diagnoses found on Nursing care Plans for Cirrhosis

• Activity intolerance 
• Disturbed thought processes 
• Excess fluid volume
• Hopelessness 
• Imbalanced nutrition: Less than body requirements
• Risk for deficient fluid volume 
• Risk for impaired skin integrity 
• Risk for injury Cirrhosis: 

Nursing Outcomes, Nursing Interventions, and Patient Teaching

Cirrhosis is a chronic hepatic disease that is characterized by destruction of the functional liver cells, which leads to cellular death. In cirrhosis, the damaged liver cells regenerate as fibrosis areas instead of functional cells, causing alterations in liver structure, function, blood circulation, and lymph damage. The major cellular changes include irreversible chronic injury of the functional liver tissue and the formation of regenerative nodules. These changes result in liver cell necrosis, collapse of liver support networks, distortion of the vascular bed, and nodular regeneration of the remaining liver cells. This disease alters liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.

Nursing Key outcomes nursing care Plans for Cirrhosis The patient will:

• Perform ADL activities of daily living without excessive fatigue or exhaustion.
• Remain oriented to his environment.
• Show no signs of circulatory overload.
• Participate in decisions about care.
• Maintain adequate caloric intake.
• Patient's fluid volume will remain within normal parameters.
• Patient's skin integrity will remain intact.
• Avoid or minimize complications. 

Nursing interventions nursing care Plans for Cirrhosis

• Monitor vital signs, intake and output, and electrolyte levels to determine fluid volume status.
• Assess fluid retention
• Weigh the patient daily and document his weight. 
• Administer diuretics, potassium, and protein or vitamin supplements as ordered.
• Restrict sodium and fluid intake as ordered.
• Assist and provide oral hygiene before and after meals. 
• Determine food preferences and provide them within the patient's prescribed diet limitations. 
• Provide frequent, small meals. 
• Observe and document the degree of sclera and skin jaundice.  
• Give the patient frequent skin care. 
• Observe for bleeding gums, ecchymosed, epitasis, and petechiae. 
• Inspect stools for amount, color, and consistency. 
• Increase the patient's exercise tolerance by decreasing fluid volumes and providing rest periods before exercise. 
• Use appropriate safety measures to protect the patient from injury.
• Watch for signs of anxiety, epigastric fullness, restlessness, and weakness.
• Observe closely for signs of behavioral or personality changes.
• Observe Report increasing stupor, lethargy, hallucinations, or neuromuscular dysfunction. Arouse the patient periodically to determine level of consciousness. Watch for asterixis, a sign of developing encephalopathy. 
• Allow the patient to express his feelings about having cirrhosis. 
• Provide psychological support and encouragement, when appropriate. 

Patient teaching nursing care Plans for Cirrhosis

• Warn the patient against taking nonsteroidal anti-inflammatory drugs, straining to defecate, and blowing his nose or sneezing too vigorously. To minimize the risk of bleeding, 
• Suggest using a soft toothbrush and a electric razor 
• Advise the patient that rest and good nutrition conserve energy and decrease metabolic demands on the liver. 
• Suggest the patient to eat frequent, small meals. Teach him to alternate periods of rest and activity to reduce oxygen demand and prevent fatigue.
• Tell the patient how he can conserve energy while performing activities of daily living. For example, suggest that he sit on a bench while bathing or dressing. 
• Stress the need to avoid infections and abstain from alcohol. Refer the patient to alcohol abuse treatment Anonymous, if appropriate 
• Alcohol abuse treatment. Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use exacerbates the disease. Stress that alcoholic liver disease in its early stages is reversible when the patient abstains from alcohol. Encourage family involvement in. Assist the patient in obtaining counseling or support for her or his alcoholism. 
• Encourage the patient to seek frequent medical follow-up 
• Refer the patient to an alcohol support group or liver transplant support group.

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Nursing Care Plans for Traumatic Amputation

Nursing Care Plans for Traumatic Amputation. Traumatic amputation the accidental loss of a body part usually involves a finger, toe, arm, or leg. In complete amputation, the member is totally severed; in partial amputation, some soft-tissue connection remains. The prognosis for traumatic amputation has improved because of early, improved emergency and critical care management, new surgical techniques, early rehabilitation, prosthesis fitting, and new prosthesis designs. Amputations can be surgical (therapeutic) or traumatic (emergencies resulting from injury).

Causes for Traumatic Amputation

A traumatic amputation may result from a cutting, tearing, or crushing insult involving the use of factory, farm, or power tools, or from a motor vehicle accident.

Complications for Traumatic Amputation

Hypovolemic shock and sepsis are possible complications in traumatic amputation. If reimplantation is attempted, residual paralysis may occur.

Levels of Amputation

Below the knee

Syme procedure

Transmetatarsal/toe Amputation

Hip disarticulation/extensive hemipelvectomy

Upper extremity Nursing assessment

Nursing Care Plans for Traumatic Amputation

Patient history reveals the type of accident that caused the amputation. Inspection: partially or completely severed body lost, hemorrhage and soft tissue damage, type of wound well-defined edges and damage is local/ crush amputation, damage involves the tissue and arterial. Psychosocial: patient with a traumatic amputation may be in the denial phase of grief

Traumatic Amputation

Treatment Blood loss and hypovolemic shock is the greatest immediate threat in traumatic amputation. Control bleeding, Fluid replacement with sterile normal saline or lactated ringer’s solution, colloids, and Blood replacement as needed. Reimplantation Early prosthesis fitting and rehabilitation.

Nursing diagnosis Nursing Care Plans for Amputation

Common Nursing diagnosis found in Nursing Care Plans for Traumatic Amputation:

Acute pain

Deficient fluid volume

Disturbed body image

Dressing or grooming self-care deficit

Fear

Hopelessness

Impaired physical mobility

Impaired skin integrity

Ineffective coping

Ineffective role performance

Ineffective tissue perfusion: Peripheral

Risk for disuse syndrome

Risk for infection

Risk for post trauma syndrome

Nursing key outcomes, Interventions and patient teaching Nursing Care Plans for Traumatic Amputation

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Nursing Care Plans For Appendicitis

Nursing Care Plans For Appendicitis, Appendicitis is an acute inflammation of the vermiform appendix, a narrow, blind tube that extends from the inferior part of the cecum just below the ileocecal valve. Although the appendix has no known function, it does regularly fill and empty itself of food. Appendicitis occurs when the appendix becomes inflamed from ulceration of the mucosa or obstruction of the lumen. If untreated, this disease is fatal.

Causes For Appendicitis 
Obstruction of the vermiform appendix. Since the appendix is a small, finger-like Appendage of the cecum, it is prone to obstruction as it regularly fills and empties with intestinal contents. obstruction caused by a fecal mass, stricture, barium ingestion, or viral infection. This obstruction sets off an inflammatory process that can lead to infection, thrombosis, necrosis, and perforation.

Complications For Appendicitis 
Common complication of appendicitis: Appendix ruptures or Perforates. Peritonitis. Other complications include: Appendiceal abscess Pyelophlebitis.

Diagnostik tes 
Complete blood count Abdominal ultrasound Abdominal computed tomography (CT) scan

Nursing Assessment Nursing Care Plans For Appendicitis 
Because other disorders can mimic appendicitis in sign and symptoms, diagnosis must rule out illnesses with similar symptoms: bladder infection, gastroenteritis, ileitis, colitis, acute salpingitis, tubo-ovarian abscess, diverticulitis, gastritis, ovarian cyst, pancreatitis, renal colic, and uterine disease
Patients history of midabdominal pain as the disease process progresses, patients usually complain of a constant epigastric or periumbilical pain that eventually localizes in the right lower quadrant of the abdomen. The patient may also report anorexia, nausea, one or two episodes of vomiting, and a low-grade fever. Later signs and symptoms include malaise, constipation and, rarely, diarrhea. Inspection typically shows a patient who walks bent over to reduce right lower quadrant pain. When sleeping or lying in a supine position, he may keep his right knee bent up to decrease pain. Auscultation usually reveals normal bowel sounds. Palpation and percussion disclose no localized abdominal findings except diffuse tenderness in the midepigastric area and around the umbilicus. Tenderness in the right lowers abdominal. There may be pain in the right lower quadrant resulting from palpating the lower left quadrant (Rovsing’s sign).

Appendicitis Treatment 
Appendectomy If peritonitis develops, treatment involves GI intubation, parenteral replacement of fluids and electrolytes, and administration of antibiotics.

Nursing diagnosis Nursing Care Plans For Appendicitis 
Common nursing diagnosis found in Nursing Care Plans For Appendicitis

• Acute pain 
• Imbalanced nutrition: Less than body requirements 
• Impaired skin integrity 
• Ineffective tissue perfusion: GI 
• Risk for deficient fluid volume 
• Risk for infection 
• Risk for injury 

Nursing Key outcomes, Interventions and patients teaching Nursing Care Plans for Appendicitis

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Nursing Care Plans for Pneumonia

Respiratory System

Nursing Care Plans for Pneumonia. Pneumonia, acute infection of the lung parenchyma, interstitial lung tissue in which fluid and blood cells escape into the alveoli. that often impairs gas exchange. Pneumonia classified in several ways. 

Based on microbiological etiology origin: Viral Bacterial Fungal Protozoa Mycobacterium Mycoplasmal Rickettsial 

Based in location, pneumonia can be classified: Bronchopneumonia, Bronchopneumonia involves distal airways and alveoli Lobular pneumonia or lobar pneumonia. In this pneumonia involves part of a lobe; and lobar pneumonia, an entire lobe 

The infection is also classified as one of three types: 

• Primary pneumonia, Primary pneumonia results directly from inhalation or aspiration of a pathogen, such as bacteria or a virus; it includes pneumococcal and viral pneumonia. 
• Secondary pneumonia, Secondary pneumonia may follow initial lung damage from a noxious chemical or other insult (superinfection) or may result from hematogenous spread of bacteria from a distant area. 
• Aspiration pneumonia, Aspiration pneumonia results from inhalation of foreign matter, such as stomach contents vomitus or food particles, into the bronchi. It’s more likely to occur in elderly or debilitated patients, those receiving nasogastric tube feedings, higher prevalence those with an impaired gag reflex, poor oral hygiene, or a decreased level of consciousness 

Causes for pneumonia 

• In bacterial pneumonia, the most common cause of bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniae or Pneumococcus. Usually occurs when the lungs’ defense mechanisms are impaired by such factors as suppressed cough reflex, decreased cilia action, decreased activity of phagocytic cells, and the accumulation of secretions. Pneumococcal pneumonia occurs only in the lobar form.which can occur in any part of the lungs, an infection initially triggers alveolar inflammation and edema. As the alveolocapillary membrane breaks down, alveoli fill with blood and exudate, resulting in atelectasis. In severe bacterial infections, the lungs assume a heavy, liverlike appearance, as in acute respiratory distress syndrome (ARDS). 
• Viral pneumonia occurs when a virus attacks bronchiolar epithelial cells and causes interstitial inflammation and desquamation, which eventually spread to the alveoli 
• In aspiration pneumonia, aspiration of gastric juices or hydrocarbons triggers similar inflammatory changes and inactivates surfactant over a large area. Decreased surfactant leads to alveolar collapse. Acidic gastric juices may directly damage the airways and alveoli. Particles with the aspirated gastric juices may obstruct the airways and reduce airflow. 

Predisposing factors increase the risk of pneumonia. 

For bacterial and viral pneumonia, these include chronic illness and debilitation, Cancer (particularly lung cancer) Abdominal and thoracic surgery Atelectasis Common colds or other viral respiratory infections Chronic respiratory disease (chronic obstructive pulmonary disease, asthma, bronchiectasis, cystic fibrosis), influenza, Smoking, Malnutrition, Alcoholism, Sickle cell disease, Tracheotomy, exposure to noxious gases Immunosuppressive therapy. 

Complications for Pneumonia 

Without proper treatment, pneumonia can lead to such life-threatening complications as Septic shock, Hypoxemia, and Respiratory failure. Empyema or lung abscess. Bacteremia Endocarditi Pericarditis Meningitis 

Diagnostic tests 

Chest X-rays. Sputum specimen for Gram stain and culture and sensitivity. White blood cell count Blood cultures. Arterial blood gas (ABG). Bronchoscopy or transtracheal aspiration. Pleural fluid culture. Pulse oximetry. 

Nursing Assessment Nursing Care Plans for Pneumonia 

Focused Nursing assessment in pneumonia care plans Vital sign: blood pressure, body temperature, the pulse or rate of heartbeats, the respiration or rate of breathing Crackles, wheezing, or rhonchi over the affected lung area Dullness when you percuss Presence of cyanosis, and presence of dyspnea or tachypnea
Patient’s history The patient may have a history of a recent upper respiratory infection, influenza, or a viral syndrome. Elicit a history of a chronic pulmonary disease, such as asthma, bronchitis, or tuberculosis; prolonged immobility; sickle cell anemia; neurological disorders that cause paralysis of the diaphragm; surgery of the thorax or abdomen; smoking; alcoholism; IV drug therapy or abuse; and malnutrition. Establish any history of exposure to noxious gases, aspiration, or immunosuppressive therapy Bacterial pneumonia, the patient may report pleuritic chest pain, a cough, excessive sputum production, and chills. On Nursing assessment, you may note that the patient has a fever. In inspection, you may found that the patient is shaking and coughs up sputum. In advanced cases of all types of pneumonia, you hear dullness when you percuss. Auscultation may disclose crackles, wheezing, or rhonchi over the affected lung area as well as decreased breath sounds and decreased vocal fremitus. 

Nursing diagnosis Nursing Care Plans for Pneumonia 

Common Nursing Diagnosis found in Nursing Care Plans for Pneumonia 

• Ineffective airway clearance 
• Acute pain 
• Anxiety 
• Hyperthermia 
• Imbalanced nutrition: Less than body requirements 
• Impaired gas exchange 
• Ineffective coping 
• Risk for deficient fluid volume 
• Risk for infection 

Nursing Key outcomes, interventions and patient teaching Nursing Care Plans for Pneumonia

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Nursing care plans for Dementia

Nursing care plans for Dementia, Dementia is a chronic disturbance involving multiple cognitive deficits, including memory impairment. Dementia is characterized by chronicity and deterioration of selective mental functions. Onset is insidious over months to years in most cases. Dementia is usually progressive, more common in the elderly, and rarely reversible even if underlying disease can be corrected. Dementia can be classified as cortical or subcortical. 

Type of Dementia 

There are three types of cortical dementia: 

• Primary degenerative dementia (eg, Alzheimer dementia), accounting for about 50–60% of cases. 
• atherosclerotic (multi-infarct) dementia, 15–20% of cases (this figure is probably low because of the tendency to overuse the diagnosis of Alzheimer dementia) 
• Mixtures of the first two types or dementia due to miscellaneous causes, 15–20% of cases . Examples of primary degenerative dementia are Alzheimer dementia (most common) and Pick, Creutzfeldt-Jakob, and Huntington dementias (less common). 

In all types, loss of impulse control (sexual and language) is common. The tenuous level of functioning makes the individual most susceptible to minor physical and psychological stresses. The course depends on the underlying cause, and the general trend is steady deterioration. 

Pseudodementia is a term applied to depressed patients who appear to be demented. These patients are often identifiable by their tendency to complain about memory problems vociferously rather than try to cover them up. They usually say they can’t complete cognitive tasks but with encouragement can often do so. They can be considered to have depression-induced reversible dementia that remits when the depression resolves. 

Causes of dementia 

CNS pathology: head trauma, hypertensive cerebral changes, seizures, tumors 

Endocrinopathies: thyroidism, parathyroidism 

Hypoxemia 

Hypothermia or hyperthermia 

Substance intoxication or abstinence and withdrawal states 

Exposure to certain metals, toxins, or drugs 

Metabolic: diabetic acidosis, hypoglycemia, acid-base imbalances 

Hepatic encephalopathy 

Thiamine deficiency 

Postoperative states 

Psychosocial stressors: relocation stress, sensory deprivation or overload, sleep deprivation, immobilization. 

Pathophysiology

Primary Dementia : 

• Primary dementias are degenerative disorders that are progressive, irreversible, and not due to any other condition. Specific disorders are dementia of the Alzheimer’s type (DAT) and vascular dementia (formerly multi-infarct dementia). DAT demonstrates progression of symptoms from the initial stage, which is characterized by mild cognitive deficits in the area of short-term memory and accomplishment of goal-directed activity, to the final stage in which profound impairment occurs in the areas of cognition and self-care abilities. Research is ongoing; however, DAT is believed to have multiple causative factors. 
• Genetic factors: Familial Alzheimer’s disease is associated with abnormal genes on chromosomes 1, 14, and 21. In particular, with genes located on these chromosomes (1 and 14) that encode for amyloid precursor protein which leads to accumulation of the amyloid beta-peptide in plaques. A specific cholesterol-bearing protein, apolipoprotein E4 (Apo E4), is found on chromosome 19 twice as often in people with DAT as in the general population. 
• Biochemical and brain structural factors: The neurotransmitter acetylcholine has been implicated in terms of relative deficit and/or receptor abnormalities as related to Alzheimer’s disease. Autopsy findings reveal presence of brain changes, that is, the presence of amyloid plaques and neurofibrillary tangles associated with nerve cell destruction. Additional areas of investigation include: 
• Slow viral infection. 
• Autoimmune processes. 
• Head trauma. 

Secondary Dementia: 

Occur as a result of another pathologic process. 

• Infection-related dementias Acquired immunodeficiency syndrome Chronic meningitis Creutzfeldt-Jakob disease Progressive multifocal leukoencephalopathy Postencephalitic dementia syndrome Syphilis Subacute sclerosing panencephalitis Tuberculosis 
• Subcortical degenerative disorders Huntington’s disease Parkinson’s disease Wilson’s disease Thalamic dementia 
• Hydrocephalic dementias 
• Vascular dementias 
• Traumatic conditions, such as posttraumatic encephalopathy and subdural hematoma 
• Neoplastic dementias Glioma Meningioma Meningeal carcinomatosis Metastatic deposits 
• Inflammatory conditions, such as sarcoidosis, systemic lupus erythematosus, and temporal arteritis 
• Toxic conditions, such as alcohol-related syndrome and iatrogenic dementias (anticonvulsant, anticholinergic, antihypertensive, psychotropic drugs) 
• Metabolic disorders Anemias Deficiency states (minerals and vitamins) Cardiac or pulmonary failure Hepatic encephalopathy Porphyria (deficiency in enzymes involved in heme synthesis) Uremia 

Clinical Manifestations for dementia 

Not all of these features will be present in every person, nor will every person go through every stage and phase of dementia Slow, insidious onset, Impaired long- and short-term memory, Deterioration of cognitive abilities judgment, abstract thinking, Often irreversible if untreated, Personality changes, No or slow EEG changes. 

Early dementia 

Appear more apathetic, with less sparkle. Lose interest in hobbies or activities. Be unwilling to try new things. Be unable to adapt to change. Show poor judgement and make poor decisions. Be slower to grasp complex ideas and take longer with routine jobs. Blame others for ‘stealing’ lost items. Become more self-centred and less concerned with others and their feelings. Become more forgetful of details of recent events. Be more likely to repeat themselves or lose the thread of their conversation. Be more irritable or upset if they fail at something. Have difficulty handling money. 

Moderate dementia 

Be very forgetful of recent events. Memory for the distant past seems better, but some details may be forgotten or confused. Be confused regarding time and place. Become lost if away from familiar surroundings. Forget names of family or friends, or confuse one family member with another. Forget saucepans and kettles on the stove. May leave gas unlit. Wander around streets, perhaps at night, sometimes becoming lost. Behave inappropriately – for example, going outdoors in their nightwear. See or hear things that are not there. Become very repetitive. Be neglectful of hygiene or eating. Become angry, upset or distressed through frustration. 

Severe dementia 

Be unable to remember – for even a few minutes – that they have had, for example, a meal. Lose their ability to understand or use speech. Be incontinent. Show no recognition of friends and family. Need help with eating, washing, bathing, using the toilet or dressing. Fail to recognise everyday objects. Be disturbed at night. Be restless, perhaps looking for a long dead relative. Be aggressive, especially when feeling threatened or closed in. Have difficulty walking, eventually perhaps becoming confined to a wheelchair. Have uncontrolled movements. 

Dementia Treatment 

• Treatment is generally community focused; the goal of treatment is to maintain the quality of life as long as possible despite the progressive nature of the disease. Effective treatment is based on: Diagnosis of primary illness and concurrent psychiatric disorders Assessment of auditory and visual impairment Measurement of the degree, nature, and progression of cognitive deficits Assessment of functional capacity and ability for self-care Family and social system assessment 
• Environmental strategies in order to assist in maintaining the safety and functional abilities of the patient as long as possible. 
• Pharmacologic therapy used for the person with DAT is directed toward the use of anticholinesterase drugs to slow the progression of the disorder by increasing the relative amount of acetylcholine. Available drugs include donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon) and tacrine (Cognex). An NMDA-receptor antagonist memantine (Namenda) may be provided in an attempt to improve cognition. Other drugs may be used for behavioral control and symptom reduction. Agitation management: neuroleptic drugs Psychosis: neuroleptic drugs Depression: antidepressants, ECT 
• Hypertension management in vascular dementia is important in reducing the severity of symptoms. 
• Family education is a treatment strategy because statistics indicate that family caregivers provide care for patients with DAT in 7 out of 10 cases. The family and the treatment team collaborate in the delivery of care. 

Complications for dementia 

Without accurate diagnosis and treatment, secondary dementias may become permanent. 

Falls with serious orthopedic or cerebral injuries. 

Self-inflicted injuries. 

Aggression or violence toward self, others, or property. 

Wandering events, in which the person can get lost and potentially suffer exposure, hypothermia, injury, and even death. 

Serious depression is demonstrated in caregivers who receive inadequate support. 

Caregiver stress and burden may result in patient neglect or abuse. 

Nursing Process Nursing Care Plans For Dementia 

Nursing Assessment Nursing Care Plans For Dementia 

Assess the onset and characteristics of symptoms (determine type and stage of disorder). Establish cognitive status using standard measurement tools. Determine self-care abilities. Assess threats to physical safety (eg, wandering, poor reality testing). Assess affect and emotional responsiveness. Assess ability and level of support available to caregivers. 

Nursing Diagnosis Nursing Care Plans for Dementia 

• Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding 
• Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs 
• Risk for Injury related to cognitive impairment and wandering behavior 
• Impaired Social Interaction related to cognitive impairment 
• Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places Interventions and Evaluation 

Nursing Care Plans For Dementia

DIAGNOSIS	OUTCOME	INTERVENTION	EVALUATION
Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding	Demonstrate congruent verbal and nonverbal communication.	·      Speak slowly and use short, simple words and phrases. ·      Consistently identify yourself, and address the person by name at each meeting. ·      Focus on one piece of information at a time. Review what has been discussed with patient. ·      If patient has vision or hearing disturbances, have him wear prescription eyeglasses and/or a hearing device. ·      Keep environment well lit. ·      Use clocks, calendars, and familiar personal effects in the patient's view. ·      If patient becomes verbally aggressive, identify and acknowledge feelings. ·      If patient becomes aggressive, shift the topic to a safer, more familiar one. ·      If patient becomes delusional, acknowledge feelings and reinforce reality. Do not attempt to challenge the content of the delusion.	·        Demonstrates decreased anxiety and increased feelings of security in supportive environment
Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs	Independence in Self-Care	·      Assess and monitor patient's ability to perform ADLs. ·      Encourage decision making regarding ADLs as much as possible. ·      Label clothes with patient's name, address, and telephone number. ·      Use clothing with elastic and Velcro for fastenings rather than buttons or zippers, which may be too difficult for patient to manipulate. ·      Monitor food and fluid intake. ·      Weigh patient weekly. ·      Provide food that patient can eat while moving. ·      Sit with patient during meals and assist by cueing. ·      Initiate a bowel and bladder program early in the disease process to maintain continence and prevent constipation or urine retention	Maintains maximum degree of orientation and self-care within level of ability
Risk for Injury related to cognitive impairment and wandering behavior	Safety appears	·      Discuss restriction of driving when recommended. ·      Assess patient's home for safety: remove throw rugs, label rooms, and keep the house well lit. ·      Assess community for safety. ·      Alert neighbors about the patient's wandering behavior. ·      Alert police and have current pictures taken. ·      Provide patient with a MedicAlert bracelet. ·      Install complex safety locks on doors to outside or basement. ·      Install safety bars in bathroom. ·      Closely observe patient while he is smoking. ·      Encourage physical activity during the daytime. ·      Give patient a card with simple instructions (address and phone number) should the patient get lost. ·      Use night-lights. ·      Install alarm and sensor devices on doors.	Safety precautions and close surveillance maintained; no injury
Impaired Social Interaction related to cognitive impairment	Socialization increase	·      Provide magazines with pictures as reading and language abilities diminish. ·      Encourage participation in simple, familiar group activities, such as singing, reminiscing, doing puzzles, and painting. ·      Encourage participation in simple activities that promote the exercise of large muscle groups.	Attends group activities; sings, exercises with group
Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places	Risk for violence is not appears	·      Respond calmly and do not raise your voice. ·      Remove objects that might be used to harm self or others. ·      Identify stressors that increase agitation. ·      Distract patient when an upsetting situation develops.	Decreased occurrence of acting-out behaviors

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Nursing care plans for Diabetes Mellitus

Nursing care plans for Diabetes Mellitus, Diabetes mellitus is a disorder in which the level of blood glucose is persistently raised above the normal range. Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes mellitus occurs in two primary forms: type 1, characterized by absolute insufficiency, and the more prevalent type 2, characterized by insulin resistance with varying degrees of insulin secretory defects. Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both (ADA], Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003. 

Causes for Diabetes Mellitus 

The cause of both type 1 and type 2 diabetes remains unknown, although genetic factors may play a role. Diabetes mellitus results from insulin deficiency or resistance. Insulin transports glucose into the cell for use as energy and storage as glycogen. It also stimulates protein synthesis and free fatty acid storage. Insulin deficiency or resistance compromises the body tissues’ access to essential nutrients for fuel and storage. The resulting hyperglycemia can damage many of the body’s organs and tissues. 

Type 1 diabetes is due to pancreatic islet B cell destruction predominantly by an autoimmune process, and these patients are prone to ketoacidosis. 

Type 2 diabetes is the more prevalent form and results from insulin resistance with a defect in compensatory insulin secretion 

Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose. 

Risk Factors For Diabetes Mellitus Include: 

• Obesity. 
• Physiologic or emotional stress, which can cause prolonged elevation of stress hormone levels. 
• Pregnancy, which causes weight gain and increases levels of estrogen and placental hormones, which antagonize insulin 
• Metabolic syndrome, which is considered a precursor to the development of type 2 diabetes mellitus 
• some medications that can antagonize the effects of insulin, including thiazide diuretics, adrenal corticosteroids, and hormonal contraceptives 

Classification of Diabetes Mellitus 

There are several different types of diabetes mellitus; they may differ in cause, clinical course, and treatment. The major classifications of diabetes are: 

• Type 1 diabetes (insulin dependent diabetes mellitus) is caused by B-cell destruction, usually leading to absolute insulin deficiency a) Immune mediated b) Idiopathic 
• Type 2 diabetes (previously referred to as non insulin dependent diabetes mellitus) ranges from those with predominant insulin resistance associated with relative insulin deficiency, to those with a predominantly insulin secretory defect with insulin resistance 

PATHOPHYSIOLOGY OF DIABETES 

Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas. Insulin is an anabolic, or storage, hormone. When a person eats a meal, insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells. In those cells, insulin: 

• Transports and metabolizes glucose for energy 
• Stimulates storage of glucose in the liver and muscle (in the form of glycogen) 
• Signals the liver to stop the release of glucose 
• Enhances storage of dietary fat in adipose tissue 
• Accelerates transport of amino acids (derived from dietary protein) into cells 

Insulin also inhibits the breakdown of stored glucose, protein, and fat. During fasting periods (between meals and overnight), the pancreas continuously releases a small amount of insulin (basal insulin); another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and stimulate the liver to release stored glucose. The insulin and the glucagon together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver. Initially, the liver produces glucose through the breakdown of glycogen (glycogenolysis). After 8 to 12 hours without food, the liver forms glucose from the breakdown of noncarbohydrate substances, including amino acids (gluconeogenesis). 

Type 1 Diabetes This form of diabetes is immune-mediated in over 90% of cases and idiopathic in less than 10%. The rate of pancreatic B cell destruction is quite variable, being rapid in some individuals and slow in others. Type 1 diabetes is usually associated with ketosis in its untreated state. It occurs at any age but most commonly arises in children and young adults with a peak incidence before school age and again at around puberty. It is a catabolic disorder in which circulating insulin is virtually absent, plasma glucagon is elevated, and the pancreatic B cells fail to respond to all insulinogenic stimuli. Exogenous insulin is therefore required to reverse the catabolic state, prevent ketosis, reduce the hyperglucagonemia, and reduce blood glucose. 

Immune-mediated type 1 diabetes mellitus (type 1A) 

Most patients with type 1 diabetes mellitus have circulating antibodies to islet cells (ICA), insulin (IAA), glutamic acid decarboxylase (GAD65), and tyrosine phosphatases (IA-2 and IA2-) at the time the diagnosis is made. These antibodies facilitate screening for an autoimmune cause of diabetes, particularly screening siblings of affected children, as well as adults with atypical features of type 2 Diabetes). Antibody levels decline with increasing duration of disease. Also, low levels of anti-insulin antibodies develop in almost all patients once they are treated with insulin. 

This theory is referred to as the hygiene hypothesis. None of these factors has so far been confirmed as the culprit. Part of the difficulty is that autoimmune injury undoubtedly starts many years before clinical diabetes mellitus develops. 

Idiopathic type 1 diabetes mellitus (type 1B)
Less than 10% of subjects have no evidence of pancreatic B cell autoimmunity to explain their insulinopenia and ketoacidosis. This subgroup has been classified as “idiopathic type 1 diabetes” and designated as “type 1B.” Although only a minority of patients with type 1 diabetes fall into this group, most of these are of Asian or African origin.

Type 2 Diabetes Mellitus
Circulating endogenous insulin is sufficient to prevent ketoacidosis but is inadequate to prevent hyperglycemia in the face of increased needs owing to tissue insensitivity (insulin resistance).
The two main problems related to insulin in type 2 diabetes are insulin resistance and impaired insulin secretion. Insulin resistance refers to a decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, thus rendering insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver.
The exact mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 diabetes are unknown, although genetic factors are thought to play a role. Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies. Therefore, DKA does not typically occur in type 2 diabetes.

Prediabetes 
Prediabetes is an abnormality in glucose values intermediate between normal and overt diabetes.
Impaired Fasting Glucose

• A new category adopted by the American Diabetes Association in 1997 and redefined in 2004. 
• Occurs when fasting blood glucose is greater than or equal to 100 but less than 126 mg/dL. 

Impaired Glucose Tolerance 

• Defined as blood glucose measurement on a glucose tolerance test greater than or equal to 140 mg/dl but less than 200 in the 2-hour sample. 
• Asymptomatic; it can progress to type 2 diabetes or remain unchanged. 
• May be a risk factor for the development of hypertension, coronary heart disease, and hyperlipidemias. 

Gestational Diabetes Mellitus 

• Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance occurring during pregnancy. 
• Occurs in approximately 4% of pregnancies and usually disappears after delivery. 
• Women with GDM are at higher risk for diabetes at a later date. 
• GDM is associated with increased risk of fetal morbidity. 
• Screening for GDM for all pregnant women other than those at lowest risk (under age 25, of normal body weight, have no family history of diabetes, are not a member of an ethnic group with high prevalence of diabetes) should occur between the 24th and 28th weeks of gestation. 

Diabetes Associated with Other Conditions

Certain drugs can decrease insulin activity resulting in hyperglycemia corticosteroids, thiazide diuretics, estrogen, phenytoin. 

Disease states affecting the pancreas or insulin receptors pancreatitis, cancer of the pancreas, Cushing’s disease or syndrome, acromegaly, pheochromocytoma, muscular dystrophy, Huntington’s chorea. 

CLINICAL MANIFESTATIONS 

Clinical manifestations of all types of diabetes include the “three Ps”: polyuria, polydipsia, and polyphagia. Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the excess loss of fluid associated with osmotic diuresis. The patient also experiences polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. The onset of type 1 Diabetes may also be associated with sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed. 

DIABETES MANAGEMENT 

The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications. 

Drugs for Treating Hyperglycemia 

The drugs for treating type 2 diabetes fall into several categories: 

1. Drugs that primarily stimulate insulin secretion by binding to the sulfonylurea receptor. Sulfonylureas remain the most widely prescribed drugs for treating hyperglycemia. The meglitinide analog repaglinide and the D-phenylalanine derivative nateglinide also bind the sulfonylurea receptor and stimulate insulin secretion. 
2. Drugs that alter insulin action: Metformin works in the liver. The thiazolidinediones appear to have their main effect on skeletal muscle and adipose tissue. 
3. Drugs that principally affect absorption of glucose: The glucosidase inhibitors acarbose and miglitol are such currently available drugs.
4. Drugs that mimic incretin effect or prolong incretin action: Exenatide and DPP 1V inhibitors fall into this category. 
5. Other: Pramlintide lowers glucose by suppressing glucagon and slowing gastric emptying. 

Insulin

Insulin is indicated for type 1 diabetes as well as for type 2 diabetic patients with insulinopenia whose hyperglycemia does not respond to diet therapy either alone or combined with other hypoglycemic drugs. Therefore, the therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia and without seriously disrupting the patient’s usual lifestyle and activity. 

There are five components of diabetes management 

• Nutritional management 

• Exercise 

• Monitoring 

• Pharmacologic therapy 

• Education Nursing Process 

Nursing Care Plans For Diabetes Mellitus

Nursing Assessment Nursing Care Plans For Diabetes Mellitus

Obtain a history of current problems, family history, and general health history. Has the patient experienced polyuria, polydipsia, polyphagia, and any other symptoms? Number of years since diagnosis of diabetes Family members diagnosed with diabetes, their subsequent treatment, and complications 

Perform a review of systems and physical examination to assess for signs and symptoms of diabetes, general health of patient, and presence of complications. General: recent weight loss or gain, increased fatigue, tiredness, anxiety Skin: skin lesions, infections, dehydration, evidence of poor wound healing Eyes: changes in vision”floaters, halos, blurred vision, dry or burning eyes, cataracts, glaucoma Mouth: gingivitis, periodontal disease Cardiovascular: orthostatic hypotension, cold extremities, weak pedal pulses, leg claudication GI: diarrhea, constipation, early satiety, bloating, increased flatulence, hunger or thirst Genitourinary (GU): increased urination, nocturia, impotence, vaginal discharge Neurologic: numbness and tingling of the extremities, decreased pain and temperature perception, changes in gait and balance 

Nursing Diagnosis Nursing care plans for Diabetes Mellitus 

Common nursing diagnosis found in Nursing care plans for Diabetes Mellitus 

• Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures 
• Fear related to insulin injection 
• Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat 
• Activity Intolerance related to poor glucose control 
• Deficient Knowledge related to use of oral hypoglycemic agents 
• Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities 
• Ineffective Coping related to chronic disease and complex self-care regimen 

Nursing Intervention and Evaluation Nursing care plans for Diabetes Mellitus

Nursing Diagnose	Outcome	Intervention	Evaluation
Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures	Nutrition balance between needs and intake	·         Assess current timing and content of meals. ·         Advise patient on the importance of an individualized meal plan in meeting weight-loss goals. Reducing intake of carbohydrates may benefit some patients; however, fad diets or diet plans that stress one food group and eliminate another are generally not recommended. ·         Discuss the goals of dietary therapy for the patient. Setting a goal of a 10% (of patient’s actual body weight) weight loss over several months is usually achievable and effective in reducing blood sugar and other metabolic parameters. ·         Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life. ·         Explain the importance of exercise in maintaining/reducing body weight. ·         Caloric expenditure for energy in exercise ·         Carryover of enhanced metabolic rate and efficient food utilization ·         Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them. ·         Strategize with patient to address the potential social pitfalls of weight reduction.	Maintains ideal body weight with body mass index less than 25
Fear related to insulin injection	Fear less or discrease	·         Assist patient to reduce fear of injection by encouraging verbalization of fears regarding insulin injection, conveying a sense of empathy, and identifying supportive coping techniques. ·         Demonstrate and explain thoroughly the procedure for insulin self-injection ·         Help patient to master technique by taking a step-by-step approach. ·         Allow patient time to handle insulin and syringe to become familiar with the equipment. ·         Teach self-injection first to alleviate fear of pain from injection. ·         Instruct patient in filling syringe when he or she expresses confidence in self-injection procedure. ·         Review dosage and time of injections in relation to meals, activity, and bedtime based on patient’s individualized insulin regimen.	Demonstrates self-injection of insulin with minimal fear
Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat	Injury is not appears	·         Closely monitor blood glucose levels to detect hypoglycemia. ·         Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid hypoglycemia. ·         Assess patient for the signs and symptoms of hypoglycemia. o    Adrenergic (early symptoms) sweating, tremor, pallor, tachycardia, palpitations, nervousness from the release of adrenalin when blood glucose falls rapidly o    Neurologic (later symptoms) light-headedness, headache, confusion, irritability, slurred speech, lack of coordination, staggering gait from depression of central nervous system as glucose level progressively falls ·         Treat hypoglycemia promptly with 15 to 20 g of fast-acting carbohydrates. ·         Encourage patient to carry a portable treatment for hypoglycemia at all times. ·         Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin. ·         Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia. ·         Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency. ·         Encourage patient to carry a portable treatment for hypoglycemia at all times. ·         Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin. ·         Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia. ·         Encourage patients to wear an identification bracelet or card that may assist in prompt treatment in a hypoglycemic emergency.	Hypoglycemia identified and treated appropriately
Activity Intolerance related to poor glucose control	Normal Activity is appears	·         Advise patient to assess blood glucose level before and after strenuous exercise. ·         Instruct patient to plan exercises on a regular basis each day. ·         Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia. ·         Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia. ·         Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present. Patient should contact health care provider if levels remain elevated. ·         Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised.	Exercises daily
Deficient Knowledge related to use of oral hypoglycemic agents	Knowledge is sufficient	·         Assess level of knowledge of disease and ability to care for self ·         Assess adherence to diet therapy, monitoring procedures, medication treatment, and exercise regimen ·         Assess for signs of hyperglycemia: polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred vision ·         Assess for signs of hypoglycemia: sweating, tremor, nervousness, tachycardia, light-headedness, confusion ·         Perform thorough skin and extremity assessment for peripheral neuropathy or peripheral vascular disease and any injury to the feet or lower extremities ·         Assess for trends in blood glucose and other laboratory results ·         Make sure that appropriate insulin dosage is given at the right time and in relation to meals and exercise ·         Make sure patient has adequate knowledge of diet, exercise, and medication treatment ·         Immediately report to health care provider any signs of skin or soft tissue infection (redness, swelling, warmth, tenderness, drainage) ·         Get help immediately for signs of hypoglycemia that do not respond to usual glucose replacement ·         Get help immediately for patient presenting with signs of either ketoacidosis (nausea and vomiting, Kussmaul respirations, fruity breath odor, hypotension, and altered level of consciousness) or hyperosmolar hyperglycemic nonketotic syndrome (nausea and vomiting, hypothermia, muscle weakness, seizures, stupor, coma).	Verbalizes appropriate use and action of oral hypoglycemic agents
Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities	Impaired Skin Integrity is not appears	·         Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, hammer toe or bunion deformation, hair distribution, pulses, deep tendon reflexes. ·         Maintain skin integrity by protecting feet from breakdown. o    Use heel protectors, special mattresses, foot cradles for patients on bed rest. o    Avoid applying drying agents to skin (eg, alcohol). o    Apply skin moisturizers to maintain suppleness and prevent cracking and fissures. ·         Instruct patient in foot care guidelines ·         Advise the patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral blood flow. Help patient to establish behavior modification techniques to eliminate smoking in the hospital and to continue them at home for smoking-cessation program.	No skin breakdown
Ineffective Coping related to chronic disease and complex self-care regimen	Effective coping	·         Discuss with the patient the perceived effect of diabetes on lifestyle, finances, family life, occupation. ·         Explore previous coping strategies and skills that have had positive effects. ·         Encourage patient and family participation in diabetes self-care regimen to foster confidence. ·         Identify available support groups to assist in lifestyle adaptation. ·         Assist family in providing emotional support.	Verbalizes initial strategies for coping with diabetes

Diabetes Mellitus, Patient Teaching Discharge and Home Healthcare Guide

Because diabetes mellitus is a lifelong disease, patients, family teaching discharge, and home healthcare guide probably the most important responsibility of the nurse who provides Nursing Care plans for Diabetes Mellitus. The best persons to manage diabetes mellitus that is affected so markedly by daily fluctuations in environmental stress, exercise, diet, and infections are the patients self and their families. Patient teaching discharge and home healthcare guide patient with Diabetes Mellitus should include explanations by the physician or nurse of the nature of diabetes and its potential acute and chronic hazards and how they can be recognized early and prevented or treated. 

Patient teaching discharge and home healthcare guide for Diabetes Mellitus: 

• Teach the patient sign and symptoms of hypoglycemia and hyperglycemia 
• Teach the patients about medication purpose, dosage, route, and possible side effects of all prescribed medications. 
• In patients with self-administer insulin, demonstrate patient the appropriate preparation and administration techniques. 
• Teach to the patient signs and symptoms of diabetic neuropathy and emphasize the need for safety precautions because neuropathy decreased sensation can hide sense injuries 
• Tell to the patient the Prognosis of Diabetes Mellitus, Insulin resistance increases with age, After the first few years of treatment, the majority of people with type 2 diabetes require more than one medicine to keep their blood sugar controlled 
• Teach the patient how to manage diabetes when he has a minor illness, such as a cold, or flu. 
• To encourage compliance with lifestyle changes, emphasize how blood glucose control affects long-term health. 
• Teach the patient how to care for his feet. 
• Advise him to wear comfortable, nonconstricting shoes and never to walk barefoot 
• To prevent diabetes, teach people at high risk to avoid risk factors ”for example, maintaining proper weight and exercising regularly, teach to patients you can help to prevent type 2 diabetes by maintaining your ideal body weight, especially if you have a family history of diabetes. Diet and exercise have been shown to delay the onset of diabetes in people who are in the early stages of insulin resistance. If you already have been diagnosis Diabetes Mellitus type 2, you can delay or prevent complications by keeping tight control of your blood sugar. 
• Advise patients to have annual ophthalmologic examinations for early detection of diabetic retinopathy 
• Encourage the patient and his family to obtain additional information about Diabetes mellitus from nearby Diabetic foundations.

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