Ralph Kenneth M.

Manzanilla

BSN III-B

Name of Patient: Emelita Valladolid

NURSING CARE PLAN

Cues Nursing Diagnosis Background Goal Intervention Rationale Evaluation
Cbg result 323 Risk for unstable Blood glucose is At the end of the Discuss home to identify and
mg/dl blood glucose the main sugar that shift the patient glucose-monitoring manage glucose
related to lack of the body makes will maintain according to fluctuations
v/s taken as diabetes from the food in glucose in individual
follow: management the diet. Glucose is satisfactory range parameters (e.g.,
t: 36.6 carried through 6x/day for
p: 87 the bloodstream to normal day and
r: 24 provide energy to more frequently
bp: 160/80 all cells in the during times of
body. Cells cannot stress)
use glucose
without the help of Discuss how client’s Drugs and
insulin. Type 2 antidiabetic combinations of
diabetes: results medication(s) work. drugs work
from insulin in varying ways
resistance, a with different blood
condition in which glucose control and
cells fail to use side effects.
insulin properly, Understanding drug
sometimes actions can help
combined with an client avoid/reduce
absolute insulin risk of potential for
deficiency. hypoglycemic
reactions
Patient verbalizes Activity At the end of the Ascertain ability to Helps to
fatigue and intolerance related shift the patient will sit, stand, and move differentiate
weakness to sedentary participate in about as desired. between problems
lifestyle necessary/desired Note degree of relating to
 activities assistance movement
necessary, and problems with
and/or use of oxygen supply and
assistive equipment. demand
characterized by
fatigue and
weakness.
Assist with Enables client to
activities and maintain mobility
provide/monitor while protecting
client’s use of from injury.
assistive devices.

Assist/direct Promotes improved

client/SO to plan for or more normal
progressive increase activity level,
of activity level stamina,
aiming for maximal and conditioning.
activity within the
client’s ability
Patient seeks for Readiness for At the end of the Determine stressors Accurate
knowledge of new enhanced coping shift the patient that may be identification of
strategies will identify affecting client. situation that client
effective coping is dealing with
behaviors currently provides
being used. information for
planning
interventions to
enhance coping
abilities.
Identify social Available support
supports available to systems, such as
client. family/friends,
can provide client
with ability to
handle current
stressful events, and
“talking it out” with
an
empathic listener
 will help client
move forward to
enhance coping
skills.
Patient Health-seeking At the end of the Problem-solve Helps identify
demonstrated lack behaviors shift the patient options for change. actions to be taken
of knowledge in will express desire to achieve desired
health-promotion to change specific Improvement
behaviors habit/lifestyle
patterns to Instruct in helps client
achieve/maintain individually comprehensively
optimal appropriate wellness manage
health behaviors. healthcare practices
Patient verbalizes Ineffective At the end of the Advice client or SO Intake of proper
intake of protection related shift the patient to intake proper nutrition will
improper to inadequate will demonstrate nutrition strengthen our
nutrition such as nutrition intake of proper immune system
chocolates nutrition