NURSING IN PATIENTS WITH

TYPE II Diabetes Mellitus

NURSING TASK MEDIKAL

PAPERS

By
Group 1
class F

STUDY PROGRAM OF NURSING

UNIVERSITY OF JEMBER
2017
 NURSING IN PATIENTS WITH
TYPE II Diabetes Mellitus

NURSING TASK MEDIKAL

PAPERS

structured to meet the tasks subjects with the Medical Nursing

Supervisor: Ns. Jon Hafan S, M. Kep., Sp.Kep.MB

By
Rizki Amalia
Abidah Istna Mardiyah
Sindy Arie premature
Mery Eka Yaya Fujianti
NIM 152310101065
NIM 152310101070
NIM 152310101152
NIM 152310101161

STUDY PROGRAM OF NURSING

UNIVERSITY OF JEMBER
2017

i
 VALIDITY SHEET

Medical Nursing Papers task to titles

"NURSING IN PATIENTS WITH

TYPE II Diabetes Mellitus"
Compiled by:

Rizki Amalia NIM 152310101065

Abidah Istna Mardiyah NIM 152310101070
Sindy Arie premature NIM 152310101152
Mery Eka Yaya Fujianti NIM 152310101161
It has been approved for the seminar and collected on:

Date and time:

This paper was prepared with his own thoughts and not the result of plagiarism or
reproduction of papers that have been there.

composer

Group 1
Knowing,
Undertaking courses Supervisor

Ns. Jon Hafan S, M. Kep., Sp.Kep.MB Ns. Jon Hafan S, M. Kep., Sp.Kep.MB
NIP 1002 19840102 201504 NIP 1002 19840102 201504

ii
 Preface

Praise Allah for all His grace and guidance so that we can complete a paper entitled
"Nursing Care in Patients With Diabetes Mellitus Type II," this well. This paper was prepared
to fulfill the tasks subjects Medical Nursing.
In this paper we would like to thank:
1. Ns. Jon Hafan S, M. Kep., Sp.Kep.MB,, as supervisor manufacture of paper; and also as a
lecturer in charge of subject Medical Nursing; and
2. friends students of Nursing at the University of Jember F class that has helped.
Criticisms and suggestions so we expect from the reader for the improvement of this
paper. Hopefully this paper can be useful for future medical nursing and increase knowledge
of the reader,

Jember, September 2017

Author
Group 1

iii
 TABLE OF CONTENTS
Page
TITLE PAGE .................................................................................................. i
VALIDITY SHEET ........................................................................................ ii
Preface ............................................................................................................. iii
TABLE OF CONTENTS ............................................................................... iv
CHAPTER 1 INTRODUCTION................................................................... 1
1.1 Background ................................................................................. 1
1.2 Objectives .................................................................................... 2
1.3 Implications of Nursing.............................................................. 2
CHAPTER 2. REVIEW OF THEORY ........................................................ 3
2.1 Definition...................................................................................... 3
2.2 Etiology ........................................................................................ 4
2.3 Signs and symptoms ................................................................... 5
2.4 Pathophysiology .......................................................................... 6
2.5 Patway ......................................................................................... 9
2.6 Treatment .................................................................................... 11
2.7 Theory of Nursing ...................................................................... 14
CHAPTER 3. NURSING ............................................................................... 30
3.1 Case .............................................................................................. 30
3.2 Assessment .................................................................................. 37
3.3 Diagnosis...................................................................................... 47
3.4 Intervention ................................................................................ 48
3.5 Implementation .......................................................................... 59
3.6 Evaluation ................................................................................... 61
CHAPTER 4. CONCLUSION ...................................................................... 65
4.1 Conclusion ................................................................................... 65
4.2 Recommendations ...................................................................... 65
REFERENCES ............................................................................................... 67
ATTACHMENT ............................................................................................ 68

iv
 CHAPTER 1 INTRODUCTION

1.1 Background

Diabetes mellitus (DM) is a disease where there is impaired metabolism of

carbohydrates, proteins and fats. It is caused by a lack of muscle or tissue sensitivity to
insulin, called insulin resistance or by a lack of insulin or a hormone called insulin-deficient
(Guyton & Hall, 2007). Diabetes mellitus is a group of symptoms that arise in a person caused
by an increase in blood glucose sugar levels due to insulin deficiency both absolute and
relative (Syahbudin, 2009). Diabetes danger very large and can allow the patient became
weak kidney, blind, suffering from leg and a lot of serious complications and lead to a high
mortality rate. People with diabetes face daily danger because blood sugar levels are not
controlled.

There are two types of diabetes mellitus, namely diabetes mellitus type I (insulin-
dependent diabetes mellitus) and diabetes mellitus type II (noninsulin-dependent diabetes
mellitus). Type I diabetes mellitus is characterized by loss of the insulin-producing cells in the
pancreas langhernas islands so that there is a lack of insulin in the body. Diabetes mellitus
type II, caused by the body's inability to respond appropriately for the activity of the insulin
produced by the pancreas (insulin resistance), so it does not achieve normal glucose levels in
the blood. Diabetes mellitus type II is more common and accounts for 90% of all diabetes
cases worldwide (Maulana 2009).

Diabetes mellitus (DM) is one of the major threats to the health of mankind in the 21st
century WHO estimates that by 2025, the number of people with diabetes will swell to 300
million people (Sudoyo, 2006). According to WHO cases of DM in Indonesia in 2000 was 8.4
million people are in the world ranking fourth after India (31.7 million), China (20.8 million),
and the United States (17.7 million), and the WHO estimates will 2 increase in 2030, India
(79.4 million), China (42.3 million), the United States (30.3 million) and Indonesia (21.3
million) (Wild, S., 2004). DM Type II is found (> 90%) compared with type I diabetes type II
diabetes occurs after the age of 30 years whereas Type I diabetes usually occurs before the
age of 30 years. Which is a chronic disease (chronic) can affect men and women,

Diabetes mellitus is often not detected before the diagnosis is made, so that morbidity
(disease or conditions that alter the health and quality of life) and mortality (death) occur early
in the case that this is not detected. Diabetes mellitus is a chronic hyperglycemic state and is
1
slowly but surely going to destroy tissue within the body if not handled properly and serious
(Agus et al, 2011). With the discovery of some of the factors that cause diabetes mellitus,
including genetic factors, environmental factors, obesity factors, demographic factors, and
others, then these factors affect a person will have diabetes mellitus type I or type II diabetes.

1.2 Purpose
1.2.1 General purpose
Students are able to explain the concept and nursing care pada clients with Diabetes
Mellitus Type II.
1.2.2 Special purpose
The purpose of writing this paper that students are able to gain an overview and
explains:
a. Definition of Diabetes Mellitus Type II
b. Etiology of Diabetes Mellitus Type II
c. Signs and symptoms of Type II Diabetes Mellitus
d. Pathophysiology and pathway of Diabetes Mellitus Type II
e. Management of Diabetes Mellitus Type II
f. The concept of nursing care of Diabetes Mellitus Type II
g. Nursing care in Diabetes Mellitus Type II.

1.3 benefit
The benefits that can be obtained, namely, students can understand about:
a. Definition of Diabetes Mellitus Type II
b. Etiology of Type II Diabetes Mellitus
c. Signs and symptoms of Type II Diabetes Mellitus
d. Pathophysiology of Diabetes Mellitus Type II
e. Management of patients with Type II Diabetes Mellitus
f. The concept of nursing care Diabetes Mellitus Type II
g. Nursing care in patients with Type II Diabetes Mellitus.

2
 CHAPTER 2. LITERATURE

2.1. Definition
Diabetes mellitus is a disease caused by a decrease in levels of the hormone insulin
produced by the pancreas gland resulting in increased levels of glucose in the blood. This
resulted in a decrease in glucose consumption by the body can not be perfectly processed so
that the concentration of glucose in the blood will increase. Diabetes Mellitus is divided into
several types, namely type 1 diabetes, type 2 diabetes, secondary diabetes and gestational
diabetes mellitus. Diabetes mellitus is a metabolic disorder adalalah genetically and clinically
heterogeneous manifestations including a loss of carbohydrate tolerance, if fully developed
clinically then diabetes mellitus is characterized by fasting and postprandial hyperglycemia,
atherosclerosis and vascular disease microangiopathy.
According to American Diabetes Association (ADA) of 2005, Diabetes mellitus type 2
is a group of metabolic diseases with characteristic hyperglycemia occurs due to
abnormalities in insulin secretion, insulin action or both. Type 2 Diabetes Mellitus is a
metabolic disorder that is marked by a rise in blood sugar due to a decrease in insulin
secretion by pancreatic beta cells and insulin function or disorder (insulin resistance). Insulin
resistance is the decline in the ability of insulin to stimulate glucose uptake by peripheral
tissues and to inhibit the production of glucose by the liver so that glucose can not enter into
the cell and eventually accumulate in the bloodstream. Β cells are not able to fully
compensate for this insulin resistance, relative insulin deficiency means. This inability is
evident from the reduction in insulin secretion upon stimulation of glucose, as well as the
stimulation of glucose along with insulin secretion stimulants other materials. Means
pancreatic β cells undergo desensitization to glucose.
In type II diabetes mellitus, the pancreas can still make insulin, but the insulin
produced poor quality and can not function properly as a key to enter the glucose into the
cells. As a result of glucose in the blood remains high, causing hyperglycemia. Chronic
hyperglycemia in diabetes is associated with long-term damage, malfunction or failure of
several organs, especially the eyes, kidneys, nerves, heart and blood vessels (Gustaviani,
2006). Because insulin still produced by the beta cells of the pancreas, the diabetes mellitus
type II is considered as non-insulin dependent diabetes mellitus.
Type 2 diabetes usually occurs in adults (WHO, 2014). It usually occurs at age 45, but
can also occur at the age of 20 years. Type 2 diabetes incidence in women is higher than men
laki.Wanita higher risk of diabetes because it is physically a woman has an increased chance
3
of a body mass index greater. Type 2 diabetes is often diagnosed several years after onset,
once complications arose so that the high incidence is about 90% of people with diabetes
worldwide and is largely the result of the deterioration of risk factors such as being
overweight and lack of physical activity (WHO, 2014).
2.2. Etiology
Diabetes Mellitus is called the silent killer because the disease may affect all organs of
the body and cause a variety of complaints. Diabetes mellitus is a disease caused by a
deficiency of insulin relative or absolute. Insulin deficiency can occur through three roads,
namely:
a. The destruction of B cells of the pancreas due to influences from the outside (viruses,
chemicals, etc.)
b. Desensitasi or decrease glucose receptors in the pancreas gland
c. Desensitasi or damage to the insulin receptors in peripheral tissues
An increasing number of people with diabetes, mostly type 2 diabetes, related to
several factors: the risk factors can not be changed, the risk factors that can be changed and
other factors. According to the American DiabetesAssociation (ADA) that DM associated
with risk factors that can not be changed include:
1) Family history of diabetes (first degree relative)
A person who is suffering from diabetes mellitus is thought to have diabetes gene. It
was alleged that talent diabetes is a recessive gene. Only people who are
homozygous with the recessive gene that suffer Diabetes Mellitus.
2) Age ≥45 years
Based on research, the most affected age Diabetes Mellitus is> 45 years.
3) ethnic,
4) A history of having a baby with birth weight infants> 4000 grams or a history of
gestational diabetes mellitus
5) A history of low birth weight (<2.5 kg).

While the risk factors that can be changed on Diabetes mellitus (DM) Type 2 include:
1) Obesity based on BMI ≥25kg / m2 or abdominal circumference ≥80 cm in women
and ≥90 cm in men laki.Terdapat significant correlation between obesity and blood
glucose levels, the degree of obesity with BMI> 23 may cause an increase in blood
glucose levels to 200 mg% ,

4
 2) Lack of physical activity
3) Hypertension is an increase in blood pressure in hypertension is closely linked to
improper storage of salt and water, or an increased pressure of the body on the
circulation of peripheral blood vessels.
4) Dislipidemi adalah conditions characterized by increased levels of blood fats
(triglycerides> 250 mg / dl). There is a relationship between the increase in plasma
insulin with low HDL (<35 mg / dl) is often obtained in patients with diabetes.
5) Unhealthy diets.
Other factors associated with diabetes risk are people with polycystic ovarysindrome
(PCOS), patients with metabolic syndrome have riwatyat impaired glucose tolerance (IGT) or
fasting blood glucose impaired (GDPT) before, had a history of cardiovascular disease such
as stroke, coronary heart disease, or peripheral rrterial Diseases ( PAD), alcohol consumption,
stress factors, smoking, sex, consumption of coffee and caffeine. Alcohol can disrupt blood
sugar metabolism, especially in patients with DM, so it will be difficult for the regulation of
blood sugar and blood pressure increases. Someone will increase blood pressure when
consumed ethyl alcohol is more than 60 ml / day which is equivalent to 100 proof whiskey
ml, 240 ml or 720 ml wine.
2.3. Signs and symptoms
Symptoms of diabetes mellitus can be divided into acute and chronic. Acute symptoms
of diabetes mellitus are poliphagia (much to eat), polydipsia (much to drink), Polyuria (lots of
urine / frequent urination at night), increased appetite but lose weight quickly (5-10 kg within
2-4 weeks) and easily exhausted. While the symptoms of chronic diabetes mellitus are
tingling, skin feels hot or like punctured needles, numbness in the skin, cramps, fatigue,
drowsiness, sight began to blur, dental volatile and easily separated, sexual performance
declined even in men can occur impotence, in pregnant women frequent miscarriage or fetal
death in utero or at birth weight more than 4kg.

The classic symptoms of diabetes such as polyuria, polidipsi, polyphagia, and weight
loss is not always seen in elderly patients with DM because with increasing age there is an
increase renal threshold for glucose so that new glucose excreted in the urine when blood
glucose is high enough. In addition, because the thirst mechanism impaired with aging, then
polidipsi did not happen, so that elderly people with diabetes is hyperosmolar dehydration due
to severe hyperglycemia. DM in elderly generally asymptomatic, even if there are no

5
symptoms, often in the form of non-specific symptoms such as weakness, lethargy, behavioral
changes, decline in cognitive status or functional ability (including delirium, dementia,
depression, agitation, easy to falls and urinary incontinence).
2.4. pathophysiology
In the pathophysiology of type 2 diabetes, there are several circumstances that play a role are:
1. insulin resistance
Diabetes mellitus type 2 is not caused by a lack of insulin secretion, but because
insulin target cells fail or are unable to respond to insulin normally. This situation is
commonly referred to as "insulin resistance". Insulin resistance occurs as a result
many of his obesity and lack of physical activity and aging
2. B cells of the pancreas dysfunction
In the early development of type 2 diabetes mellitus, B cells showed interference with
the first phase insulin secretion, insulin secretion means fail to compensate insulin
resistance. If not handled properly, the subsequent development will be damage to B
cells of the pancreas. B-cells damage will occur progressively pancreas often will lead
to a deficiency of insulin, so that eventually patients require exogenous insulin. In
patients with type 2 diabetes mellitus is generally found two factors, namely insulin
resistance and insulin deficiency.
According to the ADA in 2014, this condition is caused by a deficiency of insulin but
not absolute. This means that the body is unable to produce enough insulin to meet the needs
that are marked withlack of beta cells or peripheral insulin resistance in insulin deficiency
(ADA, 2014). Peripheral insulin resistance means there is damage to the insulin receptors,
causing insulin becomes less effective usher biochemical messages to the cells (CDA, 2013).
In most cases of type 2 diabetes, when oral medications fail to stimulate the release of insulin
is adequate, then the administration of drugs by injection can be an alternative.
Insulin resistance in muscle and liver and pancreatic beta cell failure have been known
as the central destruction of the pathophysiology of type 2 DM. Later revealed that the beta
cell failure occurs much earlier and more severe than previously thought. In addition to
muscle, liver and beta cells, other organs sepert fat tissue (increased lipolysis), gastrointestinal
(deficient incretin), cell alpha pancreas (hiperglukagonemia), kidney (increased glucose
absorption), and brain (insulin resistance), all of which contribute to the cause the occurrence
of impaired glucose tolerance in type 2 DM.

6
 DeFronzo in 2009 has informed that not only muscles, liver and pancreatic beta cells
are a central role in the pathogenesis of type 2 DM patients, but there is another organ that
acts he describes as the Ominous octet (Figure-1)

Picture 1. The Ominous octet, eight organs that play a role in

pathogenesis of hyperglycemia in type 2 diabetes mellitus
(Ralph A. DeFronzo. From the Triumvirate to the Ominous Octet: A New
Paradigm for the Treatment of Type 2 Diabetes Mellitus. Diabetes. 2009;
58: 773-795)

Broadly speaking, the pathogenesis of type 2 DM is caused by the eight (omnious

octet) below:
1) The failure of pancreatic beta cells
At the time of diagnosis of type 2 DM enforced, beta cell function has been
significantly reduced. Anti-diabetic drug that works through this pathway is
sulfonylureas, meglitinid, GLP-1 agonists and DPP-4 inhibitors.
2) liver
In patients with type 2 DM occurs severe insulin resistance and thus triggers
gluconeogenesis glucose production by the liver in the basal state (HGP = hepatic

7
 glucose production) increases. Drugs that work through this pathway is metformin,
which suppress the process of gluconeogenesis.
3) Muscle
In patients with type 2 DM obtained multiple interference performance in
intramioselular insulin, due to interference causing disruption tyrosine
phosphorylation of glucose transport in muscle cells, a decrease in glycogen synthesis
and decreased oxidation of glucose. Drugs acting on this pathway is metformin, and
thiazolidinediones.
4) fat cells
Fat cells are resistant to the effects of insulin antilipolisis, causing an increase in the
process of lipolysis and free fatty acid (FFA = Free Fatty Acid) in plasma. Penigkatan
FFA will stimulate gluconeogenesis, and trigger insulin resistance in the liver and
muscles. FFA will also interfere with insulin secretion. Disruptions caused by FFA is
referred to as lipotoxocity. Drugs acting on track are the thiazolidinediones.
5) gut
Ingested glucose trigger the insulin response is much greater than if administered
intravenously. Effect known as incretin effect is played by two hormones GLP-1
(glucagon-like polypeptide-1) and GIP (glucose-dependent insulinotrophic
polypeptide or also known as gastric inhibitory polypeptide). In patients with type 2
DM deficiency obtained GLP-1 and GIP resistant. Beside that incretin soon broken by
the presence of the enzyme DPP-4, so it only works in a few minutes. Drugs that
inhibit the performance of DPP-4 is a group of DPP-4 inhibitor. The digestive tract
also have a role in the absorption of carbohydrates through the performance of the
enzyme alpha-glucosidase which breaks down polysaccharides into monosaccharides
are then absorbed by the intestines and result in increased blood glucose after a meal.
6) Alpha cells Pancreas
B cells of the pancreas is an organ-6 plays a role in hyperglycemia and has been
known since 1970. The function of cells in the synthesis of glucagon in the fasting
state levels in the plasma will increase. This increase is caused in a state of basal HGP
significantly increased compared to normal individuals. Drugs that inhibit glucagon
secretion or inhibiting the glucagon receptor include GLP-1 agonists, DPP-4
inhibitors, and amylin.
7) Kidney

8
 The kidneys are known to play a role in the pathogenesis of type 2 DM. Kidney
memfiltrasi about 163 grams of glucose per day. Ninety percent of this filtered glucose
to be absorbed back through the role of SGLT-2 (sodium glucose co-transporter) in the
proximal tubule convulated. Average 10% will be in absorption through the role of
SGLT-1 in the descending and ascending tubules, so that ultimately there is no
glucose in urine. In patients with diabetes increased SGLT-2 gene expression. Drugs
that inhibit the SGLT-2's performance will inhibit re-absorption of glucose in the
kidney tubules so that glucose will be removed through the urine. Drugs acting on this
pathway is a SGLT-2 inhibitor. Dapaglifozin is one example of a cure.
8) Brain
Insulin is a powerful appetite suppressant. In obese individuals both DM and non-DM,
obtained hyperinsulinemia which a compensatory mechanism of insulin resistance. In
this class of food intake has increased as a result of insulin resistance also occurs in
the brain. Drugs acting on this pathway is a GLP-1 agonist, amylinand bromocriptine.

2.5. Pathway

Source: https://www.scribd.com/doc/120249475/Pathway-DM

9
2.6. Management
Management of type 2 DM require aggressive therapy to achieve glycemic control and
control of cardiovascular risk factors. This is done because of the chronic complications that
occur. In the Consensus Management and Prevention of type 2 DM in Indonesia in 2011, the
management and the management of DM emphasis on the four pillars of the management of
diabetes, namely education, medical nutrition therapy, physical exercise and pharmacological
interventions.

1) Education
The health team with the patient in health behavior change which requires the active
participation of patients and their families. Educational effort carried komphrehensif
and seeks to increase the motivation of patients to have sehat.Tujuan behavior of
diabetes education is to support the efforts of patients with diabetes to understand the

10
 natural history of the disease and its management, identify health problems /
complications that may arise early / time is still reversible, obedience behavior
monitoring and self-management of the disease, and changes in behavior / health
habits needed. Educating people with diabetes include self glucose monitoring, foot
care, adherence to the use of drugs, smoking cessation, increased physical activity, and
reduce the intake of calorie and high-fat diet.
2) Medical Nutrition Therapy
Regulatory principles namely diabetic meal on a balanced diet, according to the
caloric needs of each individual, taking into account the regularity of feeding
schedule, type and amount of food. The recommended dietary composition consisting
of 45% -65% carbohydrates, 20% -25% fat, 10% protein and 20%, Sodium less than
3g, and dietary fiber enough about 25g / day.
3) Physical Exercise
Regular physical exercise 3-4 times a week, each for about 30 minutes. Recommended
physical exercise is aerobic such as walking, jogging, cycling and swimming. Physical
exercise in addition to maintaining fitness can also lose weight and improve insulin
sensitivity.
4) Pharmacologic interventions
Pharmacologic therapy is given along with increased knowledge of patients, setting
eating and physical exercise. Pharmacological therapy consists of oral drugs and
injection form. Drugs that currently exist include:
A. Oral hypoglycemic agents (OHO)
Triggers the secretion of insulin:
a) sulfonylureas
1. The main effect increases the secretion of insulin by the beta cells of
the pancreas
2. The main options for patients with normal weight or less
3. Long working sulfonylurea is not recommended in the elderly,
impaired liver and kidney physiology and malnutrition
b) Glinid
1. Consisting of repaglinide and nateglinid
2. How cooperation with sulfonylureas, but more emphasis on the first-
phase insulin secretion.

11
 3. These drugs either to cope with postprandial hyperglycemia
Boosting insulin sensitivity:
(a) biguanide
1. Biguanide class of the most widely used is metformin.
2. Metformin lowers blood glucose through
3. the impact on insulin action at the cellular level, distal to the insulin
receptor, and decrease liver glucose production.
4. Metformin is the main option for obese diabetics, with dyslipidemia,
and accompanied by insulin resistance.
(b) Thiazolidinediones
1. lDecrease insulin resistance by increasing the amount of glucose
transporter proteins thereby increasing peripheral glucose uptake.
2. Thiazolidinediones are contraindicated in heart failure due to fluid
retention.
Gluconeogenesis inhibitors:
(a) Biguanide (Metformin).
1. In addition to lowering insulin resistance, metformin also reduces
liver glucose production.
2. Metformin is contraindicated in impaired renal function with a serum
creatinine> 1.5 mg / dL, impaired liver function, as well as the
tendency of patients with hypoxemia as in sepsis
3. Metformin does not have side effects like hypoglycemia sulfonylurea
class.
4. Metformin has side effects on the gastrointestinal tract (nausea), but
can be overcome by administering after meals.
Alpha glucosidase inhibitors:
(a) acarbose
1. Work by reducing the absorption of glucose in the small intestine.
2. Acarbose also has no side effects like hypoglycemia sulfonylurea
class.
3. Acarbose have side effects on the gastrointestinal tract of bloating and
flatulence.

12
 4. Inhibitors of dipeptidyl peptidase-4 (DPP-4) Glucagon-like peptide-1
(GLP-1) is a peptide hormone produced ole L cells in the intestinal
mucosa. This peptide is secreted when food intake. GLP-1 is a potent
inhibitor of the insulin and glucagon. However, GLP-1 is rapidly
converted into inactive metabolites by the enzyme DPP-4. DPP-4
inhibitors may increase the release of insulin and inhibiting the release
of glucagon.
B. DRUG INJECTION
Insulin
1. Fast-acting insulin
2. Short-acting insulin
3. Intermediate-acting insulin
4. Long-acting insulin
5. Insulin mix of fixed
Agonists GLP-1 / incretin mimetic
1. Working as a stimulant release of insulin without causing
hypoglycemia, and inhibits the release of glucagon
2. Does not promote weight loss such as insulin and sulfonylureas
3. Side effects include gastrointestinal disturbances such as nausea and
vomiting.
2.7 Treatment of Type 2 Diabetes Mellitus

Essential in the management of Type 2 diabetes mellitus is a change of lifestyle that a

good diet and regular exercise. With or without pharmacologic therapy, a balanced diet and
exercise regularly (if no contraindications) should still be executed.

1. glycemic targets
The results of clinical and epidemiological research shows that by lowering glucose
levels then the incidence of microvascular and neuropathic complications will decrease.
Target blood glucose levels are best based daily checks and A1C as an index of chronic
glycemia has not been studied systematically. But the results of the DCCT (in patients with
Type 1 diabetes) and UKPDS (in patients with type 2 diabetes) directs the achievement of
glycemic goals in the nondiabetic range. However, in both studies even in group patients
receiving intensive treatment, A1C levels can not be maintained in the non-diabetic range.

13
The study reached the average level of A1C ~ 7% which is above the average 4SD non-
diabetic.
The most recent glycemic targets are ADA (American Diabetes Association) which is
based on practicality and the projected reduction in the incidence of complications, namely
A1C <7%. This consensus states that A1C alarm to initiate or change therapy with the goal of
A1C <7%. Factors such as life expectancy, the risk of hypoglycaemia and the presence of
CVD should be considered in every patient before providing more intensive treatment
regimens.
2. metformin

The main effect of metformin is lowered "hepatic glucose output" and lower fasting
glucose levels. Monotherapy with metformin lowered A1C by ~ 1.5%. In general, metformin
can be tolerated by the patient. The undesirable effects of the most frequent complaints are
gastrointestinal complaints. Metformin monotherapy is rarely accompanied by hypoglycemia;
and metformin can be used safely without causing hypoglycemia in prediabetes. Nonglikemik
important effect of metformin is not cause weight gain or cause A decrease in weight a little.
Renal dysfunction is a contraindication to the use of metformin as it will increase the risk of
lactic acidosis; These complications are rare but fatal.

3. sulfonylureas

Sulfonylureas lower blood glucose levels by increasing the secretion of insulin.Dari terms
of efficacy, no different sulfonylurea with metformin, which lowers A1C ~ 1.5%. Undesirable
effect is hypoglycemia, which can be long and life threatening. Episodes of severe
hypoglycemia is more common in older people. Greater risk of hypoglycemia with
chlorpropamide and glibenclamide as compared with other second-generation sulfonylurea.
Sulfonylureas often lead to weight gain ~ 2 kg. Excess sulfonylurea to improve blood glucose
levels has a maximum at half the maximum dose and a higher dose should be avoided.

4. Glinide

As with sulfonylurea, glinide stimulate insulin secretion but this group has a half-life in
the circulation much shorter than the sulfonylurea and should be consumed in greater

14
frequency. Glinide group can merunkan A1C by ~ 1.5% risk of weight gain in glinide
resembles a sulfonylurea, hypoglycemia but the risk is smaller.

5. resistor  -glukosidase

resistor -glukosidase work polisakharida inhibit the breakdown in the small intestine so
monosakharida that can be absorbed is reduced; thus inhibited postprandial glucose levels.
Monotherapy with inhibitors-glukosidase not lead to hypoglycemia. This group is not as
effective as metformin and sulfonylurea in lowering blood glucose levels; A1C can be
decreased from 0.5 to 0.8%. Increased carbohydrate in the colon resulting in increased gas
production and gastrointestinal complaints. In clinical studies, 25-45% of participants stop
taking these drugs because of the side effects.

6. Thiazolidinedione (TZD)

TZD works to increase the sensitivity of muscle, fat and liver to either endogenous or
exogenous insulin. Data on the effects of TZDs in lowering blood glucose levels in the use of
monotherapy is a decrease in A1C of 0.5 to 1.4%. Side effects The most frequent complaints
are weight gain and fluid retention resulting in increased incidence of peripheral edema and
congestive heart failure.

7. Insulin

Insulin is the oldest medication for diabetes, the most effective in lowering blood glucose
levels. When used in adequate doses, insulin can lower A1C to approach each therapeutic
targets. Unlike other antihyperglycemic medications, insulin does not have a maximal dose.
Insulin therapy is associated with weight gain and hypoglycaemia.

8. Dipeptidyl peptidase four inhibitor (DPP4 inhibitors)

DPP-4 is a membrane protein that diexpresikan in various tissues including immune cells.
DPP-4 inhibitors are small molecules that enhance the effects of GLP-1 and GIP are
increasing "glucose- mediated insulin secretion" and mensupres glucagon secretion. Clinical
studies indicate that DPP-4 inhibitors lowered A1C by 0.6 to 0.9%. This class of drugs is not
meninmbulkan hypoglycemia when used as monotherapy.

9. Algorithms management of Diabetes Mellitus Type 2 according to the ADA / EASD

15
 The algorithm is made by taking into account the characteristics of individual
intervention, synergism and costs. The goal is to achieve and maintain an A1C <7% and
change the intervention as soon as possible if the target is not reached glikekemik.

10. Tier 1: "well validated core therapy"

This intervention is the best way and the most effective, as well as a therapeutic strategy
"cost-effective" to achieve glycemic targets. Tier1 algorithms is the main choice of therapy of
type 2 diabetes patients.

Following the steps of providing therapy in diabetes mellitus type 2, namely:

a) The first step: lifestyle intervention and metformin.

Based on the evidence of short-term benefits and long-term if weight loss and physical
activity improved can be achieved and maintained as well as "cost effectiveness" if
successful, then this consensus 20 states that intervention lifestyles should be implemented as
the first step in the treatment of type 2 diabetes patients the new one. Lifestyle intervention
also to improve blood pressure, lipid profile, and weight loss or at least prevent weight gain,
should always underlie the management of type 2 diabetes patients, even when it has been
given the drugs.

For patients who are obese or overweight, the modification of the composition of the diet
and physical activity levels still play a supportive treatment. Metformin therapy should be
initiated concurrently with lifestyle intervention at diagnosis. Metformin is recommended as
initial pharmacological therapy, on the absence of specific contraindications, because the
immediate effects on glycemia, without the weight gain and hypoglycemia in general, side
effects are slight, acceptable to patients and the relatively cheap price. Extra blood glucose
lowering drugs else should be considered when there is a persistent symptomatic
hyperglycemia.

b) Step two: add a second drug

When the lifestyle intervention and metformin maximum dosage tolerated glycemic
targets are not achieved or can not be maintained, other medicines should be added after 2-3
months of starting treatment or any time when A1C targets are not achieved. If there are
contraindications to metformin or patients can not tolerate metformin then be given another
drug. Consensus recommends the addition of insulin or sulfonylureas. Which determines
16
which drugs are selected is the value of A1C. Patients with A1C> 8.5% or with clinical
symptoms of hyperglycemia should be given insulin, starts with basal insulin (intermediate-
acting or long -acting). However, many patients with type 2 diabetes a new still respond to
oral medication.

c) The third step: adjustment lajut

When lifestyle intervention, metformin and a sulphonylurea or basal insulin does not
generate the target glycemia, the next step is intensified insulin therapy. Intensification of
insulin therapy is usually in the form of an injection of "short-acting" or "rapid-acting" given
before meals. When insulin injections starting the insulin secretagogues should be
discontinued.

d) Tier 2: less well-validated therapies

In certain clinical conditions of the second stage of this algorithm can be considered.
Specifically when the very dreaded hypoglycemia (eg those who do dangerous work), then
the addition of exenatide or pioglitazone can be considered. If the weight loss is an important
consideration and the A1C close to the target (<8%), exenatide is an option. When inervensi
is not effective in achieving the target A1C, or such treatment can not be tolerated by the
patient, then the addition of sulfonylurea may be considered. Another alternative is that the
"tier 2 intervention" stopped and restarted basal insulin.

2.8 Supporting investigation

Investigations For the diagnosis of type II diabetes is by examination of blood glucose and oral
glucose tests (OGTT). Meanwhile, to differentiate DM type II and type I diabetes mellitus with an
examination of C-peptide.

1. Blood glucose tests

a) Plasma Glucose When Vena
Venous blood sugar tests while in patients with type II diabetes mellitus in patients with type
II diabetes bleak classic symptoms of polyuria, polydipsia and polyphagia. Random blood
glucose is defined any time regardless of the last meal. With random blood glucose checks
can already be enforcing the diagnosis of type II diabetes. When blood glucose levels as ≥ 200
mg / dl then the patient can be called diabetes. In these patients is not necessary to check
the glucose tolerance test.

17
 b) Fasting Plasma Glucose Vena
On fasting venous plasma glucose tests, patients fasted for 8-12 hours before the test by
stopping all drugs used, if there are drugs that must be given needs to be written in the form.
Interpretation examination, fasting blood sugar as follows: fasting plasma glucose levels <110
mg / dl otherwise normal, ≥126 mg / dl is diabetic, while between 110 to 126 mg / dl is called
impaired fasting blood glucose (GDPT). The fasting blood sugar is more effective than the
oral glucose tolerance test examination.
c) 2 hours Post-prandial glucose (GD2PP) test is done when there is suspicion of DM.
Patients eat foods containing 100g of carbohydrates before the fast and stopping smoking
and exercising. Post-prandial glucose 2 hours indicates diabetes when blood glucose levels ≥
200 mg / dl, whereas the normal value ≤ 140. Impaired Glucose Tolerance (IGT) when glucose
levels> 140 mg / dl but <200 mg / dl.
d) Glucose 2 hours in the Oral Glucose Tolerance Test (OGTT)
Examination Oral Glucose Tolerance Test (OGTT) performed when the glucose when blood
sugar levels ranging from 140-200 mg / dl to ensure diabetes or not. According to the
agreement the WHO in 2006, the OGTT test procedures by dissolving 75gram glucose in
adults, and 1.25 mg in children then dissolved in 250-300 ml water and finished within 5
minutes. OGTT performed at least the patient has fasted for at least 8 hours. Ratings are as
follows: 1) normal glucose tolerance when ≤ 140 mg / dl; 2) Impaired glucose tolerance (IGT)
when glucose levels> 140 mg / dl but <200 mg / dl; and 3) tolerance of glucose ≥ 200 mg / dl
is called diabetes mellitus.
2. HbA1c

HbA1c is a reaction between glucose and hemoglobin, stored and survive in the red blood cell
for 120 days in accordance with the age of the erythrocytes. HbA1c levels depend on the levels of
glucose in the blood, so that HbA1c represent average blood sugar levels over three months. While
blood sugar tests reflect only when questioned, and does not describe the long-term control. Blood
sugar checks required for pengelolaaan diabetes complications due mainly to cope with changes in
glucose levels change suddenly.

Table Category HbA1c namely:

HbA1c <6.5% Good glycemic control

HbA1c 6.5 -8% Glycemic control was

18
HbA1c> 8% Poor glycemic control

2.9 Nursing care

2.9.1 assessment
Nursing care at the first stage of the assessment. In the assessment of patient needs in the data
biographical data and other data to support the diagnosis. These data must be as accurate as-
accurate, so that can be used in the next tahp. For example, includes the patient's name, age, main
complaint, and many more.
a. Medical history
Current medical history:
Usually the client into the hospital with complaints of pain, tingling in the lower
extremities, wounds that are difficult to heal, the skin dry, red, and eyes sunken,
Headache, declared as wanted vomiting, numbness, muscle weakness,
disorientation, lethargy, coma and confusion.
Past medical history
DM clients usually have a history of hypertension, cardiovascular diseases such as
myocardial infarction
Family medical history
There is usually a history of family members with diabetes
b. Pattern Assessment Gordon
1. pattern perception
In patients with gangrene of diabetic foot there is a change of perception and
management of healthy life due to lack of knowledge about the effects of gangrene
of the feet diabetuk causing a negative perception of him and the tendency to not
comply with the procedures of treatment and care of the old, more than 6 million
people with diabetes are unaware diabetic foot of the risk they even fear amputation
(Debra Clair, journal february 2011).
2. Metabolic nutritional patterns
As a result of inadequate insulin production or insulin deficiency then blood sugar
levels can not be maintained, giving rise to complaints of frequent urination, plenty
to eat, lots to drink, weight loss and tiredness. These circumstances may result in
nutritional and metabolic disorders that can affect the patient's health status.
Nausea, vomiting, weight loss, poor skin turgor, nausea / vomiting.
19
3. patterns of elimination
The presence of hyperglycemia causes osmotic diuresis that causes the patient to
frequent urination (polyuria) and expenditure of glucose in the urine (glucosuria).
At elimination Alvi relatively no disturbance.
4. Activity and exercise patterns
Weakness, difficulty walking / moving, muscle cramps, rest and sleep disorders,
tachicardi / tachipnea at the time of activity and even to occur coma. Their
gangrenous wounds and weakness of the muscles - the muscles of the lower limbs
causes the sufferer unable to perform daily activities optimally, the patient
susceptible to fatigue.
5. Patterns of sleep and rest
Break is not effective presence of polyuria, pain in the injured leg, so clients have
trouble sleeping.
6. cognitive perception
Patients with gangrene tends to neuropathy / numbness in the wound that is not
sensitive to pain. The tasting decline, impaired vision.
7. Perception and self-concept
A change in the function and structure of the body will cause sufferers experience a
disruption in self-image. Wounds that are difficult to heal, the duration of
treatment, the number of the cost of care and treatment of patients with depression
and anxiety caused disruption on the role of family (self esteem).
8. The role of relationship
Gangrenous wounds that are difficult to heal and smelled cause patients
embarrassment and withdrawn.
9. sexuality
Angiopathy can occur in the vascular system in the reproductive organs, causing
potential disruption sek, disorders and erectile quality, as well as the impact on the
process of ejaculation and orgasm. An inflammation of the vaginal area, as well as
decreased orgasm and impotence in men occur. a higher risk of prostate cancer
associated with nephropathy. (Chin-Hsiao Tseng on Journal, March 2011)
10. Koping tolerance
The length of time of treatment, chronic disease course, the feeling of helplessness
because of the dependency causes a negative psychological reactions such as anger,

20
 anxiety, irritability and other - other, can cause the sufferer is unable to use
constructive coping mechanisms / adaptive.
11. value keprercayaan
A change in health status and decreased function of the body and foot injuries do
not hinder the patient in performing religious worship but affects the pattern of the
patient.

c. Physical examination
Include the state of the patient, consciousness, speech sounds, height, weight and
signs - vital signs.
1. Head and neck
Assess the shape of the head, the state of the hair, is there any enlargement of the
neck, ears sometimes ringing, is there a hearing impairment, tongue often feels
thick, saliva becomes more viscous, dental volatile, easy gum swelling and
bleeding, whether blurred vision / double, diplopia, cloudy eye lens.
2. Integumentary system
Decreased skin turgor, their wounds or scars blackish color, moisture and shu skin
in the area around the ulcer and gangrene, redness of the skin around the wound,
texture, hair and nails.
3. Respiratory system
Is there shortness of breath, cough, sputum, chest pain. In patients with DM easy
infection.
4. The cardiovascular system
Decreased tissue perfusion, weak or diminished peripheral pulses, tachycardia /
bradycardia, hypertension / hypotension, arrhythmia, kardiomegalis.
5. gastrointestinal system
There polifagi, polidipsi, nausea, vomiting, diarrhea, constipation, dehidrase,
weight changes, increased abdominal girth, obesity.
6. urinary system
Polyuria, urinary retention, urinary incontinence, burning sensation or pain during
urination.
7. musculoskeletal system

21
 Fat distribution, muscle mass deployment, perubahn height, rapid fatigue,
weakness and pain, presence of gangrene in the extremities.
8. neurological system
There was a decrease of sensory, parasthesia, anesthetics, lethargy, drowsiness,
slow reflexes, chaotic mental disorientation.
Pathway

Source: https://www.scribd.com/doc/120249475/Pathway-DM

22
 2.9.2 Nursing diagnoses
Nursing diagnoses that appear in patients with diabetes mellitus:
1. Nutrition less than body requirements bd insulin balance disorders, diet and physical activity.
2. The risk of blood glucose instability bd less knowledge of diabetes management tenatang
3. Bd peripheral tissue perfusion, decrease in blood circulation to peripheral disease processes
(DM).
4. Risk of fluid volume deficiency bd osmotic diuresis.
5. Fatigue bd physical metabolism for energy production due to severe high blood sugar levels.
6. Tissue integrity bd necrosis of tissue damage (necrosis sores gengrene).
7. Acute pain bd peripheral tissue damage due to hypoxia.
8. Risk of infection bd trauma to the tissue, the disease (diabetes mellitus).
9. Deficiency of knowledge about the disease process, diet, care, and treatment bd lack of
information
10. Anxiety bd lack of knowledge about the disease

2.9.3 Intervention

DIAGNOSI
NO NOC NIC
S
1 Domain 2. (00179) imbalance Nutrition Management (1100)
Nutrition nutrition, less than Definition: supply and increase the
Class 1. Eat body requirements intake of a balanced nutrition
Nutritional After nursing care, activity:
imbalance, patient nutrition is 1. Instruct patients about
less than expected to be fulfilled. nutritional needs
body (1004) Nutritional 2. Determine the number of
requirements Status calories and types of nutrients
(00002) 1. The intake of food needed by the patient to meet
and fluids on a scale the nutritional needs
of 2 (much deviate 3. Create an environment that is
from the normal optimal when consuming food
range) increased to a 4. Monitor the calories and food

23
 scale of 4 (slightly intake of patients
deviates from the 5. Monitor tendency of increase or
normal range) decrease in weight in patients

(1622) Behavioral
comply: the
recommended diet

1. Choosing foods
according to
prescribed diet of
scale 2 (rarely show)
increased to 4 scale
(often shows)
2. Choosing a beverage
in accordance with
the prescribed diet
of scale 2 (rarely
show) ditingkatka
into 4 scale (often
shows)

(1854) Knowledge: a
healthy diet

1. Intake of nutrients in
accordance with the
individual needs of
the scale 2 (limited
knowledge)
upgraded to 4 scale
(much knowledge)
2 Domain 2. (00002) The risk of Hyperglycemia Management
Nutrition instability in blood (2120)
Class 4. glucose levels 1. Monitor daraah sugar levels,

24
 Metabolism according to indications
The risk of After nursing, 2. Monitor for signs and symptoms
instability of expectedinstability of of hyperglycemia: polyuria,
blood glucose blood glucose levels polidipsi, polifagi, weakness,
levels (00179) normal, latergi, malaise, blurred vision
(2300) Blood glucose or headaches.
levels 3. Monitor ketourin, as indicated.
4. Brikan insulin as prescribed
1. Blood glucose on a
5. Encourage oral fluid intake
scale of 2 (a sizeable
6. Limit activity when blood
deviation from the
glucose levels over 250 mg / dl,
normal range) increased
especially if ketourin happen
to 4 scale (mild
7. Encourage self-monitoring of
moderate deviation
blood glucose levels
from the normal range)
8. Instructed the patient and family
(2111) Severity regarding diabetes management
Hyperglycemia 9. Facilitating adherence to a diet
and exercise regimen
1. Increased blood
Teaching: Prescribing Diet (5614)
glucose on a scale of 2
1. Assess the patient's level of
(by weight) increased to
knowledge about the
4 scale (mild)
recommended diet
(1619) Self- 2. Assess the patient's diet today
management: diabetes and previously, including the
preferred food
1. Monitor blood
3. Teach the patient make a diary
glucose on a scale of 2
of food consumed
(rarely show) increased
4. Provide examples of appropriate
to 4 scale (often shows)
food menu
5. Involve patients and families
3 Domain 4. (00 204) Peripheral Checking Skin (3590)
Activities and tissue perfusion, 1. Use assessment tools to identify
rest. Class 4. patients at risk for skin

25
Response After nursing, expected breakdown.
Cardiovascul ineffectiveness of patient 2. Monitor the color and
ar / peripheral tissue temperature of the skin
PulmonaryPe perfusion can be reduced. 3. Check the clothing that is too
ripheral tissue (0401) Status tight
perfusion (00 circulation 4. Monitor the skin and mucous
204) membranes of the area of
1. Paresthesias of the
discoloration, bruises, and
scale 2 (quite heavy)
broken.
increased to 4 scale
5. Teach member family /
(mild)
caregivers about the signs of
2. Ascites of scale 2
skin damage, appropriately.
(quite heavy)
Management of Peripheral
increased to 4 scale
Sensation (2660)
(mild)
1. Monitor sensation blunt or sharp
(0407) Perfusion and hot and cold (which is felt
tissue: peripheral by the patient)
2. Monitor their exact parasthesia
1. Parestsia of scale 2
3. Intruksikan patient and family to
(quite heavy) increased
check the skin every day
to 4 scale (mild)
4. Place the pads on the affected
(0409) Blood body part to protect these
Coagulation areas
Foot Care (1660)
1. The formation of
1. Discuss with patients and
clots on a scale of 2
families on routine foot care
(big enough deviation
2. Instruct the patient and family
from the normal range)
about the importance of foot
increased to 4 scale
care
(mild deviation from
3. Examine the skin to determine
the normal range)
their irritation, cracks, lesions,
(0802) Vital signs etc.

1. The body 4. Drain on the sidelines of a

26
 temperature of the scale finger carefully
2 (big enough deviation
from the normal range)
increased to 4 scale
(mild deviation from
the normal range)
4 Domain 4. (00 093) Exhaustion Energy Management (0180)
Activity / 1. Assess the patient's physiological
Rest Class 3. After nursing, the status that causes fatigue
Energy expected fatigue on 2. Instruct the patient to express
Balance. patients can be feelings about the limitations
Fatigue (00 reduced. experienced secaraverbal
093) (0002) Energy 3. Determine the perception of the
conservation patient / person closest to the
patient about the cause of fatigue
1. Maintaining adequate
4. Select interventions to reduce
nutrition intake of scale
fatigue both pharmacologic and
2 (rarely show)
nonpharmacologic
increased to 4 scale
Nutrition Management (1100)
(often shows)
1. Determine the nutritional status
(0005) Tolerance of of the patient and the patient's
activity ability to meet the nutritional
needs
1. The power of the
2. Intruksikan patients about
upper body of the scale
nutritional needs
2 (much disturbed)
3. Set the necessary diet
increased to a scale of 4
4. Instruct the patient regarding
(slightly annoyed)
diet modifications needed
2. The strength of the 5. Instruct the patient associated
lower body of the scale with dietary needs for pain
2 (much disturbed) conditions.
increased to a scale of 4
(slightly annoyed)

27
 (0007) The level of
fatigue

1. Exhaustion of scale 2
(sizeable) increased to 4
scale (mild)

2. Loss of appetite on a
scale of 2 (sizeable)
increased to 4 scale
(mild)

(0008) Fatigue:
disruptive effect

1. Energy reductions of
scale 2 (sizeable)
increased to 4 scale
(mild)
2. Changes in
nutritional status of
the scale 2 (sizeable)
increased to 4 scale
(mild)
5 11. Domain (00044) Tissue integrity Checking leather (3590)
Security / After nursing, expected 1. Use assessment tools to identify
Protection damage to the integrity of patients at risk for skin
Class 2. the network can be breakdown.
Physical reduced. 2. Monitor the color and
Injury (0401) Status temperature of the skin
(continued) circulation 3. Check the clothing that is too
Damage to the tight
1. The power of the
integrity of the 4. Monitor the skin and mucous
dorsal pedis pulse right
network (000 membranes of the area of
on the scale 2 (big
444) discoloration, bruises, and
enough deviation from
28
the normal range) broken.
increased to 4 scale 5. Teach member family /
(mild deviation from caregivers about the signs of
the normal range) skin damage, appropriately.

2. The power of the

dorsal pedis pulse left
of the scale 2 (big
enough deviation from
the normal range)
increased to 4 scale
(mild deviation from
the normal range)

(0407) Perfusion
tissue: peripheral

1. Charging capillary
finger on the scale 2 (a
sizeable deviation from
the normal range)
increased to 4 scale
(mild deviation from
the normal range)

2. The capillary refill

the toes of the scale 2 (a
sizeable deviation from
the normal range)
increased to 4 scale
(mild deviation from
the normal range)

(1101) The integrity of

tissue: skin and

29
 mucous membranes

1. Perfusion network of
scale 2 (much
disturbed) increased to
a scale of 4 (slightly
annoyed)

2. The integrity of the

skin of the scale 2
(much disturbed)
increased to a scale of 4
(slightly annoyed)

(1102) Wound
healing: primary

1. Estimating the
condition of the wound
edges of the scale 2
(limited) dotingkatkan
menajdi scale 4 (large)

6. 12. Domain (00132) Acute pain Pain Management (1400)

Comfort Definition: Reduction or reduction
Class 1. After nursing care, of pain to a level of comfort that is
Physical acute pain in a patient is acceptable to the patient.
comfort expected to be reduced. activity:
Acute Pain (1605) Control of pain 1. Perform a comprehensive
(00132) assessment of the patient's pain
1. Recognize when pain
2. Observation of nonverbal clues
occurs on a scale of 2
regarding ketidakanyamanan
(rarely show) increased
3. Dig a patient's knowledge and
to 4 scale (often shows)
beliefs about pain
2. Describe the causes 4. Evaluation of the patient's pain
30
 of scale factor 2 (rarely experience in the past that
show) increased to 4 includes a history of chronic
scale (often shows) pain patients and families
5. Determine the frequency needs
(3016) Client
to conduct a study patient
satisfaction: Pain
discomfort
management
6. Reduce factors that may
1. Pain control of scale increase the patient's pain
2 (somewhat satisfied) 7. Use pain control measures
increased to a scale of 4 before the pain in patients gain
(very satisfied) weight
8. Encourage the patient to rest or
2. The level of pain are
sleep to reduce pain
monitored regularly on
the scale 2 (somewhat
satisfied) increased to a
scale of 4 (very
satisfied)
7 11. Domain (00004) The risk of Infection Control (6540)
Security / infection Definition: Reduces Infection
Protection 1. Replace equipment appropriate
Class 1. After nursing care, is patient care per institutional
Infection not expected to protocol
Risk of happeninfection on the 2. Instruct the patient regarding
infection patient. proper hand washing techniques
(00004) (1908) Detection risk 3. Make sure the aseptic handling
of all channels IV
1. Recognize the signs
Infection Protection (6550)
and symptoms that
Definition: Prevention and early
indicate risiki of scale 2
detection of infection in patients at
(rarely mnunjukkan)
risk
increased to 4 scale
1. Monitor susceptibility to
(often shows)
infection
2. Monitor changes in 2. Give klit proper care of skin and
31
 health status scale 2 mucous membranes Check for
(rarely mnunjukkan) redness, extreme warmth, or
increased to 4 scale drainage
(often shows) 3. Teach the patient and family
how to avoid infection
(1902) Control risk

1. Identify the risk

factors of scale 2 (rarely
mnunjukkan) increased
to 4 scale (often shows)

2. Identify risiki scale

factor 2 (rarely
mnunjukkan) increased
to 4 scale (often shows)
8 Domain 5. (00126) deficiency of Facilitation of Learning (5520)
Perception / knowledge 1. Emphasize the importance of
Cognition following medical evaluation,
After nursing, expected
4th grade. and review of symptoms that
patient knowledge on
Knowledge require immediate reporting to
diabetes mellitus type 2
deficit the doctor
increases.
(00124) 2. Diskusikam signs / symptoms of
(1820) Knowledge:
diabetes, for example
diabetes management
polydipsia, polyuria, weakness,
1. Prevention of weight loss
hyperglycemia on the 3. Use language that is commonly
scale 2 (limited used
knowledge) upgraded to 4. Provide information in
4 scale (much accordance with the locus of
knowledge) control patients
5. Provide information according
2. The procedure to be
to the level of the patient's
followed in treating
progress
hoperglikemia of scale
Modification of Behavior (4360)
32
2 (limited knowledge) 1. Determine the patient's
upgraded to 4 scale motivation to change behavior
(much knowledge) 2. Help the patient to identify
strengths
(1621) Behavioral
3. Support to change unwanted
comply: a healthy diet
habits with the desired habits
1. Finding information 4. Offer positive reinforcement in
tenyang raw nutritional making independent decisions
guidelines of the scale 2 patients
(rarely) be increased to
4 scale (often done)

(1622) Behavioral
comply: the
recommended diet

1. Using the nutritional

information on the label
to determine the choice
of scale 2 (rarely show)
increased to 4 scale
(often shows)

2. Following the
recommendation for the
number of meals per
day on a scale of 2
(rarely show) increased
to 4 scale (often shows)

(1632) Behavioral
comply: the suggested
activity

1. Discuss the activity

of a health professional
33
 recommendation from a
scale of 2 (rarely show)
increased to 4 scale
(often shows)
9 Domain 9. (00146) Anxiety Reduction of anxiety (5820)
Coping / Definition: Reduce stress, fear,
Stress After nursing care, feelings, and discomfort associated
Tolerance patient anxiety is with sources of hazards identified
Class 2. expected to be reduced. akivitas:
Response (1211) The level of 1. Use a calm approach and
Koping anxiety convince
Anxiety 2. Declare premisesn clear
1. Not to rest on a scale
(00146) expectations of behavior of the
of 2 (quite heavy)
client
increased to 4 scale
3. Understand the crisis situation
(mild)
from the client's perspective
2. Feeling restless of 4. Give factual information tekait
scale 2 (quite heavy) diagnosis, treatment and
increased to 4 scale prognosis
(mild) 5. Being client side to improve
safety and reduce the fear
3. Sleep disorders from
6. Encourage the family to
scale 2 (quite heavy)
accompany clients in a proper
increased to 4 scale
manner
(mild)
7. Give the object that indicates a
(0907) Processing of secure feeling
information 8. Praise / reinforce good behavior
appropriately
1. Shows organized
9. Identification of the time of the
thought processes of the
change in the level of anxiety
scale 2 (much
10. Help clients identify situations
disturbed) increased to
that trigger anxiety
a scale of 4 (slightly
11. Supports the use of appropriate

34
 annoyed) coping mechanisms
12. Consider the client's ability to
(3009) Client
make decisions
satisfaction:
13. Instructed the client to use
Psychological
relaxation techniques
treatment
14. Assess for signs of verbal and
1. Information is given non-verbal anxiety
about the course of the Improved Coping (5230)
disease on a scale of 2 Definition: Facilitation of cognitive
(somewhat satisfied) effort to meneglola perceived
increased to a scale of 4 stressor, change, or in threats that
(very satisfied) interfere in order to meet the
necessities of life and the role
2. Information is given
Activity:
about the common
1. Help the patient in breaking
emotional response to
down the complex into smaller
the disease on a scale
objectives, and steps that can be
of 2 (somewhat
managed
satisfied) increased to a
2. Support the patient's attitude
scale of 4 (very
associated with realistic
satisfied)
expectations as an attempt to
overcome the feeling of
powerlessness
3. Find a way to understand the
patient's perspective on the
situation
4. Get to know the background of
cultural / spiritual patient
5. Encourage patients to clarify
misunderstandings

2.9.4 Evaluation

35
 Evaluation in nursing is an activity in assessing the nursing actions that have been
determined, to determine the optimal fulfillment of client needs and measure the results
of the nursing process. In the evaluation of nursing using SOAP or subjective data, objective
analysis and future planning. If the problem is solved such interventions can be stopped, if not
resolved needs to create re planning to address the problem.
Nursing Evaluation in Patients with Diabetes Mellitus
Evaluation is expected in patients with diabetes mellitus are as follows.
1. The patient's condition is stable, does not occur gangrene, pain does not occur
2. Normal skin turgor, no lesions or network integrity
3. Normal vital signs
4. Weight can be increased with a normal laboratory values and no signs of
malnutrition.
5. Fluid and electrolyte normal diabetic patients.
6. Infections and complications do not occur
7. Tiredness or fatigue is reduced / decrease fatigue
8. Patients expressed his understanding of the condition suffering from diabetes
mellitus, the effect of the procedure and the treatment process.

This evaluation is the evaluation of patients with diabetes mellitus and if from point
one to point 8 has been achieved by a patient, it can be concluded that the patient has been
healthy and able to leave the hospital. But patients should consider gulu levels in the blood,
by eating a healthy, nutritious and low in sugar.

36
 CHAPTER 3. NURSING

3.1 Case

Tn. W, 31 years old, a widower, with complaints of leg tingling and numbness since 1
month ago accompanied by body felt limp. Walking is often tingling, especially after sitting
cross-legged or squatting for a long time. Patients were also admitted to sometimes does not
hurt when he tripped over the object. Patients were also admitted their complaints often thirst,
often feel hungry and often urinate at night more than 3 times (do not pay attention to how
much pee comes out). Impaired vision began to be felt the patient, the patient feels a rotating
view and feel objects around sway. Clients admitted to the client initially did not know the
disease and high blood sugar levels. Clients continue to consume foods that are sweet.
Routine patient went to the doctor to take medicine diabetes. However, in the first month
admitted patients stop taking the drug. Daily work as parking attendants in the market. Late
sleeping habits, coffee consumption behaviors, like eating foods that are sweet, eat smaller
meals every night, smoking 10 cigarettes per day, and never exercise regularly do not refute.
Mr. biological mother. W has the same history of diseases such as diabetes, high blood history
while in older people does not exist. For family health issues, family rarely went to the doctor.
Since 8 months ago are known to have a history of diabetes. It is known for having a history
of frequent urination, a lot of drinking and a lot of eating while weight tends to decrease as
well as from blood sugar checks during that time reached 333 mg / dl. KDK have brought him
to White Wood and given the diabetes drug is metformin (3x1) and glibenclamide (1x1).
Patients say before pain patients eat 3 times a day. While in hospital patients eat only half
portions. Patients felt sick and wanted to vomit. Patients admitted to not regularly drink
accompanied diabetes drugs have diets and lifestyles that are less good. In addition patients
admitted to a recently completed his TB treatment since 1.5 months ago and declared cured
by a doctor. The patient's physical examination on September 5, 2013, awareness of the
compost mentis, weight 58 kg, height 168 cm, normal nutritional impression (BBI / Weight
Idaman), BMI (Body Mass Index) is normal (20.5), the pressure darah120 / 80 mmHg,
nadi100 x / min, pernapasan20 x / minute, temperature 36.5 ° C. Status generalist patients had
head, eyes, nose, mouth, neck, chest (heart and lung) patients in the normal range.
Neurological status showed hypesthesia in the region of dextra and sinistra pedis. Patient
fasting blood sugar of 256 mg / dl. Working diagnosis of these patients is Diabetes Mellitus
Type II diabetic neuropathy (Wicaksono, 2013).

37
3.2 Pengkajian

I. IDENTITAS
Nama : Tn. W
Jenis Kelamin : Laki-laki
Usia : 31 tahun
Alamat : Jl. Pondasi No.22, RT.2/RW.17, Kayu Putih.
Tanggal Masuk : 17 September 2017
Tanggal Pengkajian : 18 September 2018
Agama : Islam
Pendidikan : SLTA
Pekerjaan : Tukang Parkir
No. RM : 78175

II. ANAMNESIS
A. Keluhan Utama : kaki kesemutan dan mati rasa sejak 1 bulan yang lalu disertai
dengan badan terasa lemas.
B. Riwayat Penyakit Sekarang
Klien datang ke rumah sakit KDK kayu putih pada tanggal 11 September 2017
dengan keluhan kaki kesemutan dan mati rasa sejak 1 bulan yang lalu disertai dengan
badan terasa lemas. Kaki sering kesemutan terutama saat setelah duduk bersila atau
jongkok dalam waktu lama. Pasien juga mengaku terkadang tidak terasa sakit jika
kakinya tersandung benda. Pasien juga mengaku adanya keluhan sering haus, sering
terasa lapar dan sering BAK malam hari lebih dari 3 kali (tidak memperhatikan
seberapa banyak kencing yang keluar).
C. Alergi (obat, makanan, plester, dll)
Pasien mengatakan bahwa pasien tidak mempunyai riwayat alergi obat, makanan,
serta plester.
D. Riwayat Penyakit Dahulu
Pasien mengaku baru menyelesaikan pengobatan TB parunya sejak 1,5 bulan yang
lalu dan dinyatakan sembuh oleh dokter.
E. Riwayat Penyakit Keluarga
Ibu kandung Tn. W memiliki riwayat penyakit yang sama berupa diabetes,
sedangkan riwayat darah tinggi pada orang tua tidak ada.

38
 F. Kebiasaan/polahidup/life style
Keluarga mengatakan bahwa pasien mempunyai kebiasaan merokok, serta pasien
mempunyai kebiasaan minum kopi dengan banyak gula, pasien juga tidak menjaga pola /
menu makanan dan minuman yang di konsumsi, makanan camilan yang paling di gemari
pasien adalah camilan yang manis-manis.
G. Obat-obat yang digunakan
Keluarga mengatakan bahwa pasien pernah mengkonsumsi obat TB, dan sudah tidak
mengkonsumsi obat sejak 1.5 bulan lalu. Dan semenjak itu pasien tidak pernah
mengkonsumsi obat lain.

Genogram:

Keterangan :
: laki-laki
: perempuan
: tinggal satu rumah
: meninggal
: Pasien
III. Pengkajian Keperawatan
1. Persepsi kesehatan & pemeliharaan kesehatan
Jika ada anggota keluarga yang sakit, jarang berobat ke dokter.
Interpretasi :
Keluarga mengatakan bahwa ke dokter itu hanya jika sakitnya sudah parah.
2. Pola nutrisi/ metabolik
a. Antropometeri

39
 BB sebelum sakit = 62 kg
BB saat ini = 58 kg
TB: 168 cm
IMT= BB/(Tb(m)2) =58/2,82=20,5
Kategori IMT
Underweight < 18,5
Normal 18,5-24,9
Overweight >25
Interpretasi: berdasarkan rumus IMT, pasien termasuk kategori normal
b. Biomedical sign :
Albumin : 3,54 g/dl; 2,64 g/dl ; 2,27 g/dl
Globulin : 2,55 g/dl; 2,85 g/dl ; 3,46 g/dl
Hemoglobin : 13,6 gr%
Gula darah sewaktu : 333 mg/dl
Gula drah puasa : 256 mg/dl
Kategori Glukosa darah normal:
Gula darah puasa : 80-99 mg/dl
Gula darah sewaktu : 80-145 mg/dl
Interpretasi :
Pada hasil lab didapatkan nilai normal pada nilai Albumin, Globulin, dan
Hemoglobin tetapi gula darah sewaktu dan gula darah puasa tinggi dalam batasan
tidak normal.
3. Pola eliminasi:
a. BAK
1) Frekuensi : 1800cc/jam
2) Jumlah : >1200-1500 cc/jam
3) Warna : berwarna kuning jernih
4) Bau : berbau khas
5) Kemandirian : mandiri/dibantu
b. BAB
1) Frekuensi : 1x/hari
2) Jumlah : normal
3) Warna : kuning

40
 4) Bau : bau khas
5) Karakter : berbentuk
6) Kemandirian : mandiri/dibantu
Interpretasi :
Pola eliminasi yang dialami oleh klien terganggu, karena feses dan urine yang
dikeluarkan tidak sesuai atau tidak normal.
4. Pola aktivitas dan latihan
Pasien dalam melakukan ADL perlu dibantu.
Aktivitas harian (Activity Daily Living)
Kemampuan perawatan diri 0 1 2 3 4
Makan / minum √
Toileting √
Berpakaian √
Mobilitas di tempat tidur √
Berpindah √
Ambulasi / ROM √
Ket: 0: tergantung total, 1: dibantu petugas dan alat, 2: dibantu keluarga, 3: dibantu alat,
4: mandiri
5. Pola tidur dan istirahat
Durasi : Klien mengatakan tidur pada pukul 23.30 WIB-04.00 WIB (4,5 jam) dan siang
hari tidur selama 1 jam.
Interpretasi : klien mengalami gangguan tidur karena cemas.
6. Pola kognitif dan perseptual
Fungsi Kognitif dan Memori :
Mampu berkomunikasi dan berorientasi dengan baik saat dilakukan pengkajian.
Penglihatan klien kurang berfungsi dengan baik karena mengalami gangguan. Gangguan
penglihatan yang dirasakan adalah pandangan berputar dan merasa benda-benda sekitar
bergoyang. Pendengaran , pengecapan dan penciuman, klien berfungsi dengan baik.
Sensori, klien masih mampu membedakan sensori tajam dan tumpul sekalipun harus
dengan tekanan yang kuat.

Interpretasi :
Pasien mengalami gangguan pada penglihatannya.

41
7. Pola persepsi diri
a. Gambaran diri : Klien mengatakan tidak bisa bekerja mencari uang.
b. Identitas diri : Pasien merupakan seorang suami dan ayah yang sudah
memiliki dua anak.
c. Harga diri : Pasien percaya dirinya dapat sembuh dan segera melakukan
aktivitas sehari hari yaitu menjalani hidup dengan keluarga kecilnya.
d. Ideal Diri : Pasien ingin segera sembuh dan ingin segera bekerja kembali
agar bisa menghidupi keluarganya.
e. Peran Diri : Pasien mengatakan dirinya tidak bisa melakukan kegiatan
yang terlalu berat
Interpretasi :
Pola persepsi diri pasien tidak mengalami gangguan, gambaran diri pasien tidak
mengalami gangguan
8. Pola seksualitas & reproduksi
Pasien mengatakan sudah mempunyai 2 anak. Klien mengatakan tidak pernah memiliki
riwayat gangguan reproduksi.
Interpretasi:
Tidak ada masalah
9. Pola peran dan hubungan
Klien mengatakan perannya klien ada seorang suami sekaligus kepala rumah tangga yang
harus mencari nafkah untuk keluarganya dengan bekerja sebagai tukang parkir di pasar.
Hubungan klien dengan orang terdekat tidak mengalami masalah. Setelah dirawat di
rumah sakit klien akan menjaga kondisinya saat ini dan akan selalu periksa ke dokter.
Saat di rumah sakit klien juga berinteraksi baik dengan keluarga pasien lain, perawat dan
juga tenaga medis lainnya.
Interpretasi :
Pasien mengalami gangguan peran saat sakit.
10. Sistem nilai dan keyakinan
Klien mengatakan klien beragama Islam dan selalu taat dalam menjalankan kewajiban
sholatnya walaupun di tempat tidur
11. Pola koping dan stres

42
 Klien mengatakan apabila ada masalah pasti didiskusikan dengan keluarganya dan
saudara terdekatnya. Klien menyelesaikan masalahnya dengan musyawarah. Klien
terlihat cemas dan stres akan penyakitnya.
IV. PEMERIKSAAN FISIK
A. Pemeriksaan Tanda-Tanda Vital
N : 100x/menit,
RR : 20x/menit,
TD : 120/80 mmHg,
S : 36,5 C
GCS : E4V5M6
B. Pemeriksaan Kepala
Bentuk Kepala: Mesochepal, tidak terdapat deformitas
Rambut : Dominan hitam dan tidak mudah rontok
C. Pemeriksaan Mata
Konjungtiva : Pada mata kanan dan kiri tidak terlihat anemis.
Sklera : Pada mata kanan dan kiri terlihat ikterik
Pupil : Isokor kanan-kiri, diameter 3 mm, reflek cahaya( + / + )
Palpebra : Tidak edema
Visus : Baik
D. Pemeriksaan Hidung
Bentuk : normal, tidak terdapat deformitas
Nafas cuping hidung : tidak ada
Sekret : tidak terdapat sekret hidung
E. Pemeriksaan Mulut
Bibir : Tidak sianosis, tidak kering
Lidah : Tidak kotor, tepi tidak hiperemi
Tonsil : Tidak membesar
Faring : Tidak hiperemis
Gigi : Lengkap
F. Pemeriksaan Telinga
Bentuk : normal, tidak terdapat deformitas
Sekret : tidak ada
Fungsional : pendengaran baik

43
G. Pemeriksaan Leher
JVP : tidak meningkat
Kelenjar tiroid : tidak membesar
Kelenjar limfonodi : tidak membesar
Trakhea : tidak terdapat deviasi trakhea
H. Pemeriksaan Thorak
1. Paru-paru
Inspeksi : simetris kanan kiri, tidak ada retraksi, tidak ada sikatrik.
Palpasi : vocal fremitus kanan sama kiri
Perkusi : sonor pada seluruh lapang paru, batas paru hepar pada SICV LMC dextra
Auskultasi : suara dasar vesikuler, tidak ada suara tambahan di semua lapang paru
2. Jantung
Inspeksi : Ictus cordis tidak terlihat
Palpasi : Ictus cordis tidak teraba
Perkusi : Batas jantung
Kanan atas : SIC II LPS dextra
Kanan bawah : SIC IV LPS dextra
Kiri atas : SIC II LMC sinitra
Kiri bawah : SIC IV LMC sinistra
Auskultasi : S1- S2, reguler, tidak ada mur-mur, tidak ada gallop
I. Pemeriksaan Abdomen
Inspeksi : tampak asites, sikatrik akibat bekas luka operasi apendiksitis,
Auskultasi : peristaltik normal
Perkusi : pekak pada region abdomen kanan atas sampai 3 jari dibawah arcus costae
dan tympani di abdomen kanan bawahdan abdomen kiri
Palpasi :supel, terdapat nyeri tekan pada regio bagian atas, teraba adanya pembesaran
hepar dan lien tidak teraba. Tes undulasidan pekak beralih positif.
J. Pemeriksaan Ekstremitas
Superior : tidak ada deformitas, tidak ada edema, perfusi kapiler baik, tidak
anemis, akral hangat.
Inferior : tidak ada deformitas, tidak ada edema, CRT bagian ujung lebih dari 3
detik, perfusi kapiler buruk, tidak anemis, akral dingin.

44
Analisa data
Data Etiologi Masalah keperawatan
Ds : Pola hidup tidak sehat Risiko ketidakstabilan kadar
-Riwayat penyakit diabetes glukosa darah
sejak 8 bulan lalu Sel beta di pankreas
-klien mengeluh kaki terganggu
kesemutan dan badan lemas
-sering BAK Defisiensi insulin
-klie suka mengonsumsi
kopi, makan manis,
merokok 10 batang per hari Retensi insulin
-pasien mengatakan tidak
pernah berolahraga
Do: Hiperglikemia
-pasien tampak lemas
-Gula darah sewaktu : 333
mg/dl Kadar glukosa darah tidak
-gula darah puasa : 256 terkontrol
mg/dl
-urine output : >1500 cc/jam
Ketidakstabilan kadar
glukosa darah
Ds : Penurunan pemakaian Gangguan pemenuhan
-Klien mengatakan selama glukosa oleh sel nutrisi kurang dari
di rumah sakit klien makan kebutuhan tubuh
2x sehari dan hanya makan
separuh porsi kurang lebih Proteolisis
sekitar 2 sendok makan.
-Pasien mengatakan merasa
mual dan ingin muntah Asam amino meningkat

Do :
45
BB sebelum sakit : 62 kg Glukoneugenesis
BB setelah sakit : 58 kg
TB : 168
Indeks Masa Tubuh (IMT) : Ketogenesis
20,5 Ketonemia

Penurunan BB
Ds : Defisiensi insulin absolute Risiko infeksi
-Pasien mengatakan kakinya
kesemutan terutama saat
setelah duduk bersila atau Penurunan pemakaian
jongkok dalam waktu lama. glukosa oleh sel
-Pasien mengaku terkadang
tidak terasa sakit jika
kakinya tersandung benda Hiperglikemia
Do :
-Gula darah sewaktu 333
mg/dl Hiperosmolalitas
-Gula darah puasa pasien
256 mg/dl.

Ds : Defisiensi insulin absolute Ansietas

-klien mengatakan cemas
tentang penyakit yang di
deritanya Perubahan status kesehatan
-Klien mengaku sering BAK
malam hari lebih dari 3x.
Do : Kurangnya pengetahuan ttg
-Klien terlihat cemas dan penyakit
gelisah
-TD : 120/80
-RR : 20x/menit

46
- Suhu : 36,5 C

Ds : Defisiensi insulin absolute Kurangnya pengetahuan

-Klien mengaku klien tidak tentang proses penyakit,
mengetahui penyakitnya diet, dan pengobatan
-Klien mengatakan tidak Perubahan status kesehatan
mengetahui kadar gula
darahnya tinggi
-Klien tetap mengonsumsi Hospitalisasi
makanan yang manis.
-Klien mengatakan sudah 1
bulan ini pasien mengaku Informasi in adekuat
berhenti minum obat
tersebut.
Do :
Saat pasien ditanya tentang
diabetes pasien hanya tau
diabees itu penyakit kencing
manis

Ds : Defisiensi insulin absolute Keletihan

-Pasien mengatakan kaki
kesemutan saat setelah
duduk dan jongkok Lipolisis
-Badan terasa letih dan
lemas
Do : Keletihan otot
-tampak berbaring di tempat
tidur
-Albumin : 3,54 g/dl; 2,64
g/dl ; 2,27 g/dl
-Globulin : 2,55 g/dl; 2,85
g/dl ; 3,46 g/dl

47
-Hemoglobin : 13,6 gr%
-Gula darah sewaktu : 333
mg/dl
-Gula drah puasa : 256
mg/dl

Ds : Kadar glukosa darah Ketidakefektifan Perfusi

-Pasien mengatakan kaki meningkat Jaringan Perifer
terasa kesemutan dan saat
tersandung tidak merasa
sakit Defisiensi insulin
Do :
- CRT bagian ujung lebih dari
3 detik, perfusi kapiler buruk, Aliran darah ke perifer
akral dingin, terganggu
- TD : 120/80
- Nadi : 100x/menit
- RR : 20x/menit Ketidakefektifan Perfusi
- Suhu : 36,5 C Jaringan Perifer
Ds: Diabetes Mellitus Tipe II Risiko jatuh
-Pasien mengatakan badan
lemas dan kaki kesemutan
-Saat tersandung pasien Perubahan kadar gula darah
tidak merasakan apa-apa
-pasien mengatakan
gangguan penglihatan pasien Gangguan penglihatan
terganggu
-bayangan kabur dan seperti
berputar-putar Risiko jatuh
-klien sering ke kamar
mandi BAK pada malam
hari

48
Do:
Pupil : Isokor kanan-kiri,
diameter 3 mm, reflek
cahaya( + / + )
Ds: Diabetas Mellitus tipe II Gangguan pola tidur
-Klien merasa tidak bisa
tidur karena memikirkan
penyakitnya Sering terjaga ketika malam
-klien sering bolak-balik ke
kamar mandi untuk BAK
Do: Pola tidur tidak
-klien tidur pada pukul menyehatkan
23.30 WIB-04.00 WIB (4,5
jam) dan siang hari tidur
selama 1 jam. Gangguan pola tidur

3.3 Diagnosa keperawatan

1. Risiko ketidakstabilan kadar glukosa darah berhubungan dengan kadar glukosa darah
tidak terkontrol.
2. Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh berhubungan dengan intake
makanan yang kurang.
3. Risiko infeksi berhubungan dengan tingginya kadar gula darah.
4. Ansietas berhubungan dengan kurangnya pengetahuan tentang penyakitnya.
6. Kurang pengetahuan tentang proses penyakit, diet, perawatan, dan pengobatan
berhubungan dengan kurangnya informasi.
7. Keletihan berhubungan dengan keletihan otot.
8. Ketidakefektifan Perfusi Jaringan Perifer berhubungan dengan penurunan sirkulasi
darah ke perifer, proses penyakit (DM).
9. Nyeri
10. Gangguan pola tidur
11. Risiko jatuh

49
 3.4 Intervensi
NO DIAGNOSA NOC NIC
1 Domain 2. (00002) Resiko Manajemen Hiperglikemi (2120)
Nutrisi ketidakstabilan kadar 1. Monitor kadar gula daraah,
Kelas 4. glukosa darah sesuai indikasi
Metabolisme 2. Monitor tanda dan gejala
Resiko Setelah dilakukan hiperglikemi: poliuria, polidipsi,
ketidakstabilan asuhan keperawatan, polifagi, kelemahan, latergi,
kadar glukosa diharapkanketidakstabila malaise, pandangan kabur atau
darah (00179) n kadar glukosa darah sakit kepala.
normal. 3. Monitor ketourin, sesuai
(2300) Kadar glukosa indikasi.
darah 4. Brikan insulin sesuai resep
5. Dorong asupan cairan oral
1. Glukosa darah dari
6. Batasi aktivitas ketika kadar
skala 2 (deviasi yang
glukosa darah lebih dari
cukup besar dari
250mg/dl, khusus jika ketourin
kisaran normal)
terjadi
ditingkatkan menjadi
7. Dorong pemantauan sendiri
skala 4 (deviasi ringan
kadar glukosa darah
sedang dari kisaran
8. Intruksikan pada pasien dan
normal)
keluarga mengenai manajemen
(2111) Keparahan diabetes
Hiperglikemia 9. Fasilitasi kepatuhan terhadap
diet dan regimen latihan
1. Peningkatan glukosa
Pengajaran: Peresepan Diet
darah dari skala 2
(5614)
(berat) ditingkatkan
1. Kaji tingkat pengetahuan pasien
menjadi skala 4
mengenai diet yang disarankan
(ringan)
2. Kaji pola makan pasien saat ini
(1619) Manajemen dan sebelumnya, termasuk

50
 diri : diabetes makanan yang di sukai
3. Ajarkan pasien membuat diary
1. Memantau glukosa
makanan yang dikonsumsi
darah dari skala 2
4. Sediakan contoh menu makanan
(jarang menunjukkan)
yang sesuai
ditingkatkan menjadi
5. Libatkan pasien dan keluarga
skala 4 (sering
menunjukkan)
2 Domain 2. (00179) Manajemen Nutrisi (1100)
Nutrisi Ketidakseimbangan 1. Instruksikan kepada pasien
Kelas 1. nutrisi, kurang dari mengenai kebutuhan nutrisi
Makan kebutuhan tubuh 2. Tentukan jumlah kalori dan
Ketidakseimba Setelah dilakukan jenis nutrisi yang dibutuhkan
ngan nutrisi, asuhan keperawatan, oleh pasien untuk memenuhi
kurang dari diharapkan nutrisi kebutuhan gizi
kebutuhan pasien terpenuhi. 3. Ciptakan lingkungan yang
tubuh (00002) (1004) Status Nutrisi optimal pada saat
2. Asupan makanan mengkonsumsi makanan
dan cairan dari skala 4. Monitor kalori dan asupan
2 (banyak makanan pasien
menyimpang dari 5. Monitor kecenderungan
rentang normal) terjadinya kenaikan atau
ditingkatkan penurunan berat badan pada
menjadi skala 4 pasien
(sedikit
menyimpang dari
rentang normal)

(1622) Perilaku
patuh : diet yang
disarankan

3. Memilih makanan
yang sesuai dengan
diet yang ditentukan
51
 dari skala 2 (jarang
menunjukkan)
ditingkatkan
menjadi skala 4
(sering
menunjukkan)
4. Memilih minuman
yang sesuai dengan
diet yang ditentukan
dari skala 2 (jarang
menunjukkan)
ditingkatka menjadi
skala 4 (sering
menunjukkan)

(1854) Pengetahuan :
diet yang sehat

1. Intake nutrisi yang

sesuai dengan
kebutuhan individu
dari skala 2
(pengetahuan
terbatas) ditingkatkan
menjadi skala 4
(pengetahuan banyak)
3 Domain 11. (00004) Resiko infeksi Kontrol Infeksi (6540)
Keamanan/ 1. Ganti peralatan perawatan per
Perlindungan Setelah dilakukan pasien sesuai protokol institusi
Kelas 1. Infeksi asuhan keperawatan, 2. Anjurkan pasien mengenai
Resiko infeksi diharapkan tidak teknik mencuci tangan dengan
(00004) terjadiinfeksi pada tepat
pasien. 3. Pastikan penanganan aseptik
(1908) Deteksi risiko dari semua saluran IV

52
 1. Mengenali tanda dan Perlindungan Infeksi (6550)
gejala yang 1. Monitor kerentanan terhadap
mengindikasikan risiki infeksi
dari skala 2 (jarang 2. Berikan perawatan klit yang
mnunjukkan) tepat Periksa kulit dan selaput
ditingkatkan menjadi lendir untuk adanya kemerahan,
skala 4 (sering kehangatan ektrim, atau
menunjukkan) drainase
3. Ajarkan pasien dan keluarga
2. Memonitor
bagaimana cara menghindari
perubahan status
infeksi
kesehatan skala 2
(jarang mnunjukkan)
ditingkatkan menjadi
skala 4 (sering
menunjukkan)

(1902) Kontrol risiko

1. Mengidentifikasi
faktor risiko dari skala
2 (jarang mnunjukkan)
ditingkatkan menjadi
skala 4 (sering
menunjukkan)

1. Mengenali faktor
risiki skala 2 (jarang
mnunjukkan)
ditingkatkan
menjadi skala 4
(sering
menunjukkan)
4 Domain 9. (00146) Ansietas Pengurangan kecemasan (5820)
Koping/ 1. Gunakan pendekatan yang

53
Toleransi Setelah dilakukan tenang dan menyakinkan
Stress asuhan keperawatan, 2. Nyatakan dengan jelas harapan
Kelas 2. diharapkan ansietas terhadap perilaku klien
Respon pasien berkurang. 3. Pahami situasi krisis yang
Koping (1211) Tingkat terjadi dari perspektif klien
Ansietas kecemasan 4. Berikan informasi faktual tekait
(00146) diagnosa, perawatan dan
1. Tidak dapat
prognosis
beristirahat dari skala 2
5. Berada disisi klien untuk
(cukup berat)
meningkatkan rasa aman dan
ditingkatkan menjadi
mengurangi ketakutan
skala 4 (ringan)
6. Dorong keluarga untuk
2. Perasaan gelisah dari mendampingi klien dengan cara
skala 2 (cukup berat) yang tepat
ditingkatkan menjadi 7. Berikan objek yang
skala 4 (ringan) menunjukkan perasaan aman
8. Puji/kuatkan perilaku yang baik
3. Gangguan tidur dari
secara tepat
skala 2 (cukup berat)
9. Identifikasi saat terjadinya
ditingkatkan menjadi
perubahan tingkat kecemasan
skala 4 (ringan)
10. Bantu klien mengidentifikasi
(0907) Memproses situasi yang memicu kecemasan
informasi 11. Dukung penggunaan mekanisme
koping yang sesuai
1. Menunjukkan proses
12. Pertimbangkan kemampuan
pikir yang terorganisir
klien dalam mengambil
dari skala 2 (banyak
keputusan
terganggu) ditingkatkan
13. Intruksikan klien untuk
menjadi skala 4 (sedikit
menggunakan teknik relaksasi
terganggu)
14. Kaji untuk tanda verbal dan non
(3009) Kepuasan verbal kecemasan
klien : perawatan Peningkatan koping (5230)
psikologis 1. Bantu pasien dalam memecah

54
 1. Informasi di berikan tujuan kompleks menjadi lebih
tentang perjalanan kecil, dan langkah yang dapat
penyakit dari skala 2 dikelola
(agak puas) 2. Dukung sikap pasien terkait
ditingkatkan menjadi dengan harapan yang realistis
skala 4 (sangat puas) sebagai upaya untuk mengatasi
perasaan ketidakberdayaan
2. Informasi di berikan
3. Cari jalan untuk memahami
mengenai respon
prespektif pasien terhadap
emosional yang biasa
situasi
terhadap penyakit dari
4. Kenali latar belakang
skala 2 (agak puas)
budaya/spiritual pasien
ditingkatkan menjadi
5. Dukung pasien untuk
skala 4 (sangat puas)
mengklarifikasi
kesalahpahaman
5 Domain 5. Setelah dilakukan Fasilitasi Pembelajaran (5520)
Persepsi/ asuhan keperawatan, 1. Tekankan pentingnya mengikuti
Kognisi diharapkan evaluasi medik, dan kaji ulang
Kelas 4. pengetahuan pasien gejala yang memerlukan
Defisiensi mengenai diabetes pelaporan segera ke dokter
pengetahuan mellitus tipe 2 2. Diskusikam tanda/gejala DM,
(00124) bertambah. contoh polidipsia, poliuria,
1. Pengetahuan: kelemahan, penurunan berat
manajemen diabetes badan
dari skala 2 3. Gunakan bahasa yang umum
ditingkatkan digunakan
menjadi skala 4 4. Berikan informasi yang sesuai
2. Perilaku patuh: diet dengan lokus kontrol pasien
yang sehat dari skala 5. Berikan informasi sesuai tingkat
2 ditingkatkan perkembangan pasien
menjadi skala 4 Modifikasi Perilaku (4360)
3. Perilaku patuh: 1. Tentukan motivasi pasien
Aktivitas yang untuk perubahan perilaku

55
 disarankan dari 2. Bantu pasien untuk
skala 2 ditingkatkan mengidentifikasi kekuatan
menjadi skala 4 3. Dukung untuk mengganti
4. Perilaku patuh: Diet kebiasaan yang tidak
yang disarankan dari diinginkan dengan kebiasaan
skala 2 ditingkatkan yang diinginkan
menjadi skala 4 4. Tawarkan penguatan yang
positif dalam pembuatan
keputusan mandiri pasien
6 Domain 4. (00093) Keletihan Manajemen Energi (0180)
Aktifitas/ 1. Kaji status fisiologis pasien yang
Istirahat Kelas Setelah dilakukan menyebabkan kelelahan
3. asuhan keperawatan, 2. Anjurkan pasien mengungkapkan
Keseimbangan diharapkan keletihan perasaan secaraverbal mengenai
Energi. pada pasien dapat keterbatasan yang dialami
Keletihan dikurangi. 3. Tentukan persepsi pasien/orang
(00093) (0002) Konservasi terdekat dengan pasien mengenai
energi penyebab kelelahan
4. Pilih intervensi untuk mengurangi
1. Mempertahankan
kelelahan baik secara
intake nutrisi yang
farmakologis maupun
cukup dari skala 2
nonfarmakologis
(jarang menunjukkan)
Manajemen Nutrisi (1100)
ditingkatkan menjadi
1. Tentukan status gizi pasien dan
skala 4 (sering
kemampuan pasien untuk
menunjukkan)
memenuhi kebutuhan gizi
(0005) Toleransi 2. Intruksikan pasien mengenai
terhadap aktivitas kebutuhan nutrisi
3. Atur diet yang diperlukan
1. Kekuatan tubuh
4. Anjurkan pasien mengenai
bagian atas dari skala 2
modifikasi diet yang diperlukan
(banyak terganggu)
5. Anjurkan pasien terkait dengan
ditingkatkan menjadi
kebutuhan diet untuk kondisi
skala 4 (sedikit
56
terganggu) sakit.

2. Kekuatan tubuh
bagian bawah dari skala
2 (banyak terganggu)
ditingkatkan menjadi
skala 4 (sedikit
terganggu)

(0007) Tingkat
kelelahan

1. Kelelahan dari skala

2 (cukup besar)
ditingkatkan menjadi
skala 4 (ringan)

2. Kehilangan selera
makan dari skala 2
(cukup besar)
ditingkatkan menjadi
skala 4 (ringan)

(0008) Keletihan : efek

yang menganggu

1. Penurunan energi
dari skala 2 (cukup
besar) ditingkatkan
menjadi skala 4
(ringan)
2. Perubahan status
nutrisi dari skala 2
(cukup besar)
ditingkatkan
menjadi skala 4

57
 (ringan)
7. Domain 4. (00204) Pengecekan Kulit (3590)
Aktivitas dan Ketidakefektifan 1. Gunakan alat pengkajian untuk
istirahat. Kelas perfusi jaringan perifer mengidentifikasi pasien yang
4. Respon berisiko mengalami kerusakan
Kardiovaskule Setelah dilakukan kulit.
r/ pulmonal asuhan keperawatan, 2. Monitor warna dan suhu kulit
Ketidakefektifa diharapkan 3. Periksa pakaian yang terlalu
n perfusi ketidakefektifan perfusi ketat
jaringan perifer jaringan perifer pasien 4. Monitor kulit dan selaput lendir
(00204) dapat berkurang. terhadap area perubahan warna,
(0401) Status sirkulasi memar, dan pecah.
5. Ajarkan anggota
3. Parestesia dari skala
kelurga/pemberi asuhan
2 (cukup berat)
mengenai tanda-tanda kerusakan
ditingkatkan
kulit, dengan tepat.
menjadi skala 4
Manajemen Sensasi Perifer
(ringan)
(2660)
4. Asites dari skala 2
1. Monitor sensasi tumpul atau
(cukup berat)
tajam dan panas dan dingin
ditingkatkan
(yang dirasakan pasien)
menjadi skala 4
2. Monitor adanya Parasthesia
(ringan)
dengan tepat
(0407) Perfusi 3. Intruksikan pasien dan keluarga
jaringan : perifer untuk memeriksa kulit setiap
harinya
1. Parestsia dari skala 2
4. Letakkan bantalan pada bagian
(cukup berat)
tubuh yang terganggu untuk
ditingkatkan menjadi
melindungi area tersebut
skala 4 (ringan)
Perawatan Kaki (1660)
(0409) Koagulasi 5. Diskusikan dengan pasien dan
darah keluarga mengenai perawatan
kaki rutin
1. Pembentukan bekuan

58
 dari skala 2 (deviasi 1. Anjurkan pasien dan keluarga
cukup besar dari mengenai pentingnya perawatan
kisaran normal) kaki
ditingkatkan menjadi 2. Periksa kulit untuk mengetahui
skala 4 (deviasi ringan adanya iritasi, retak, lesi, dll
dari kisaran normal) 3. Keringkan pada sela-sela jari
dengan seksama
(0802) Tanda-tanda
vital

1. Suhu tubuh dari

skala 2 (deviasi cukup
besar dari kisaran
normal) ditingkatkan
menjadi skala 4
(deviasi ringan dari
kisaran normal)

3.5 Implementasi
No. Hari/ Waktu Implementasi Ttd
Tanggal
1. Senin, 08.00- 1. Memonitor kadar gula darah, sesuai
18/09/17 09.00 indikasi
WIB 2. Memonitor tanda dan gejala hiperglikemi:
poliuria, polidipsi, polifagi, kelemahan,
latergi, malaise, pandangan kabur atau sakit
kepala.
3. Memberikan insulin sesuai resep
4. Mengintruksikan pada pasien dan keluarga
mengenai manajemen diabetes
5. Mengajarkan pasien membuat diary
makanan yang dikonsumsi

59
2. Senin 10.30- 1. Memonitor kalori dan asupan makanan
18/09/17 11.30 pasien
WIB 2. Memonitor kecenderungan terjadinya
kenaikan atau penurunan berat badan pada
pasien
3. Menentukan jumlah kalori dan jenis nutrisi
yang dibutuhkan oleh pasien untuk
memenuhi kebutuhan gizi
3. Senin, 14.00- 1. Menimbang berat badan setiap hari dan
18/09/17 14.30 monitor satus pasien
WIB 2. Memonitor tanda-tanda vital pasien
3. Memberikan cairan dengan tepat
4. Mendistribusikan asupan cairan selama 24
jam
5. Memonitor berat badan

4. Senin, 16.00- 1. Mengganti peralatan perawatan per pasien

18/09/17 16.30 sesuai protokol institusi
2. Menganjurkan pasien mengenai teknik
mencuci tangan dengan tepat
3. Memastikan penanganan aseptik dari
semua saluran IV
4. Mengajarkan pasien dan keluarga
bagaimana cara menghindari infeksi

60
 5. Senin, 18.30- 1. Menggunakan pendekatan yang tenang dan
18/09/17 19.00 menyakinkan
2. Memahami situasi krisis yang terjadi dari
perspektif klien
3. Memberikan informasi faktual tekait
diagnosa, perawatan dan prognosis
4. Mendampingi klien untuk meningkatkan
rasa aman dan mengurangi ketakutan

6. Senin, 20.00- 1. Mengkaji status fisiologis pasien yang

18/09/17 20.15 menyebabkan kelelahan
2. Memilih intervensi untuk mengurangi
kelelahan baik secara farmakologis maupun
non farmakologis

7. Senin, 1. Memonitor warna dan suhu kulit

18/09/17 2. Memeriksa pakaian yang terlalu ketat
3. Memonitor sensasi tumpul atau tajam dan
panas dan dingin (yang dirasakan pasien)
1. Memonitor adanya Parasthesia dengan
tepat
2. Mengintruksikan pasien dan keluarga
untuk memeriksa kulit setiap harinya
3. Menganjurkan pasien dan keluarga
mengenai pentingnya perawatan kaki

3.6 Evaluasi
Hari, Tanggal, Diagnosa Par
No Evaluasi
Jam keperawatan af

1 19 September 2017 Risiko ketidakstabilan S : Pasien mengatakan sudah

kadar glukosa darah tidak merasa lemas dan

61
 kesemutan di kakinya

O:

-Gula darah puasa : 99 mg/dl

-Gula darah sewaktu : 144

mg/dl

A : Masalah teratasi sebagian

P : Lanjutkan diet makan,

dan pantau pemenuhan
nutrisi pasien

2 19 September 2017 Gangguan pemenuhan S : pasien mengatakan nafsu

nutrisi kurang dari makan meningkat dan badan
kebutuhan tubuh tidak terasa lemas

O:

-klien makan 3x sehari

-klien menghabiskan satu

porsi makanan dari rumah
sakit

-BB naik 0,5 kg dari 58

menjadi 58,5

A : masalah kebutuhan
nutrisi kurang dapat teratasi
sebagian

P : lanjutkan diet makanan

sehat dan pantau asupan
nutrisi untuk pasien

3 19 September 2017 Risiko defisit volume S : klien mengatakan masih

sering BAK pada malam

62
 cairan hari, klien masih merasa
sering haus

O:

-urine output klien 1300

cc/hari

-BAK 7-8 x/hari

A : masalah belum teratasi

P : lanjutkan intervensi untuk

mengurangi diuresi

4 19 September 2017 Risiko infeksi S : klien mengatakan tidak

terasa kesemutan di kakinya

O : tidak ada luka di tubuh

klien terutama di kaki

A : masalah risiko infeksi

klien teratasi

P : pantau agen penyebab

infeksi klien untuk
mengurangi terjadinya
infeksi

5 19 September 2017 Ansietas S : klien mengatakan sudah

tidak cemas memikirkan
penyakitnya

O : klien tampak tenang dan

bisa tidur pada malam hari

A : masalah kecemasan klien

dapat teratasi

63
 P : hentikan intervensi

6 19 September 2017 Kurang pengetahuan S : klien mengatakan sudah

tentang proses penyakit, mengerti penjelasan dari
diet, perawatan, dan perawat tentang penyakitnya
pengobatan
O : klien dapat menjawab
pertanyaan dari perawat dan
dapat menjelaskan ulang
penjelasan dari perawat

A : masalah sudah teratasi

P : hentikan intervensi

7 19 September 2017 Keletihan S : klien mengatakan sudah

tidak lemas lagi

O : klien terlihat dapat

beraktivitas.

A : masalah teratasi sebagian

P : lanjutkan intervensi untuk

mengurangi keletihan

8 19 September 2017 Ketidakefektifan S:

Perfusi Jaringan Perifer -Klien mengatakan kaki
klien tidak terasa kesemutan
lagi
-Klien mengatakan kaki
klien masih tidak terasa
ketika disentuh
O:
-CRT klien <3 detik
-Akral dingin
-warna sudah tidak pucat
A:
64
 -masalah belum teratasi
sepenuhnya
P:
-Lanjutkan intervensi
perawatan kaki dan senam
kaki

65
 BAB 4. PENUTUP

4.1 Kesimpulan
Diabetes mellitus adalah penyakit yang disebabkan oleh penurunan kadar hormon
insulin yang diproduksi oleh kelenjar pankreas yang mengakibatkan meningkatnya kadar
glukosa dalam darah. Penurunan ini mengakibatkan glukosa yang dikonsumsi oleh tubuh
tidak dapat diproses secara sempurna sehingga konsentrasi glukosa dalam darah akan
meningkat. Diabetes Mellitus terbagi menjadi beberapa tipe, yaitu DM tipe 1, DM tipe 2, DM
Sekunder dan DM gestasional. Diabetes melitus tipe 2 merupakan suatu kelompok penyakit
metabolik dengan karakteristik hiperglikemia yang terjadi karena kelainan sekresi insulin,
kerja insulin atau kedua-duanya. Diabetes Mellitus Tipe 2 adalah penyakit gangguan
metabolik yang di tandai oleh kenaikan gula darah akibat penurunan sekresi insulin oleh sel
beta pankreas dan atau ganguan fungsi insulin.
Faktor resiko yang tidak dapat diubah untuk penderita DM tipe 2 diantaranya adalah
riwayat keluarga dengan DM, usia lebih dari 45 tahun, riwayat melahirkan bayi dengan berat
badan lahir bayi lebih dari 4000 gram, dan riwayat lahir dengan berat badan rendah. Gejala
dari DM 2 sendiri ada 2 yaitu gejala akut dan gejala kronik. Gejala akutnya diantaranya
poliphagia, polidipsia, poliuria, nafsu makan bertambah namun berat badan turun dengan
cepat (5-10 kg dalam waktu 2-4 minggu), dan mudah lelah. Sedangkan gejala kronik diabetes
melitus yaitu kesemutan, kulit terasa panas atau seperti tertusuk tusuk jarum, rasa kebas di
kulit, kram, kelelahan, mudah mengantuk, pandangan mulai kabur, gigi mudah goyah dan
mudah lepas. Penatalaksanaan dan pengelolaan DM dititik beratkan pada 4 pilar
penatalaksanaan DM, yaitu edukasi, terapi gizi medis, latihan jasmani dan intervensi
farmakologis.
4.2 Saran
a. Bagi penderita Diabetes Mellitus Tipe II
Bagi penderita Diabetes Mellitus Tipe II diharapkan lebih dapat memeperhatikan
kesehatannya, terutama untuk pola makan dan aktivitas yang dilakukan.
b. Bagi keluarga
Bagi keluarga diharapkan dapat mengawasi atau memperhatikan klien yang sedang
menderita penyakit Diabetes Mellitus Tipe II, karena dukungan dari keluarga adalah yang
paling penting bagi klien.
c. Bagi perawat atau tenaga kesehatan

66
Bagi perawat ataupun tenaga kesehatan lain diharapkan dapat memberikan pelayanan
kesehatan atau keperawatan yang baik terhadap klien dan bisa bertugas sesuai dengan
fungsinya masing-masing.

67
 DAFTAR PUSTAKA

Adi, Soebagijo Soelistijo. 2015. Konsensus Pengelolaan Dan Pencegahan Diabetes Melitus
Tipe 2 Di Indonesia 2015. Jakarta: PB. Perkeni

Ed. Herman T.H., & Komitsuru. S. 2014. Nanda Internasional Nursing Diagnosis, Definition
and Clasification 2015-2017. EGC. Jakarta.

Guyton, A. C., Hall, J. E., 2007. Buku Ajar Fisiologi Kedoktera. Jakarta : EGC, 1022

Haida, Nurlaili Kurnia Putri & Atoillah, Nurlaili Isfandiari. Hubungan Empat Pilar
Pengendalian Dm Tipe 2 dengan Rerata Kadar Gula Darah. Average Blood Sugar and
Diabetus Mellitus Type II Management Analysis. Surabaya: Departemen Epidemiologi
Fakultas Kesehatan Masyarakat Universitas Airlangga

Harfika, Meiana. Karakteristik Penderita Diabetes Melitus Tipe 2 Di Instalasi Rawat Inap
Penyakit dalam Rumah Sakit Mohammad Hoesin Palembang.

Kurniawan, Indra. 2010. Diabetes Melitus Tipe 2 pada Usia Lanjut. Volum: 60, Nomor: 12,
Desember 2010.

Noor, Restyana Fatimah. 2015. Diabetes Melitus Tipe 2. Volume 4 Nomor 5, Februari 2015.

Notoatmodjo, S. 2007. Promosi Kesehatan dan Ilmu Perilaku. Jakarta: Penerbit Rineka Cipta.

PB PAPDI, 2009. Panduan Pelayanan Medik. Jakarta: Interna Publishing: Hlm 9-15.

PERKENI, 2011. Konsensus Pengendalian dan Pencegahan DM Tipe 2 di Indonesia. Jakarta:

Hlm 1-7 & 14-30.

PERKENI. Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia

2006. Jakarta: PB.PERKENI. 2006

Soebardi, S., & Yunir E, 2007. Terapi Non Farmakologis Pada DiabetesMelitus dalam Buku
Ajar Ilmu Penyakit Dalam. Edisi ke-4. Jakarta: Pusat Penerbitan FKUI: Hlm 1864-186.

Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiati S. 2006. Buku Ajar Ilmu Penyakit
Dalam. Jilid III Edisi V. Jakarta : Interna Publishing

Syahbudin, S. 2009. Diabetes Melitus dan Pengelolaannya. Cetakan 2, PusatDiabetes &amp;

Lipid RSUP Nasional Dr. Cipto Mangunkusumo. Jakarta: FKUI

Wicaksono, M. T. P. 2013. Diebetes Mellitus Tipe II Gula Darah Tidak Terkontrol dengan
Komplikasi Neuropati Diabetikum. Medula. Volume 1. Nomor 3. Fakultas Kedokteran
Universitas Lampung.

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LAMPIRAN

69