POSSIBLE NURSING CARE PLAN

Assessment Need Nursing Diagnosis Objective of Care Nursing Intervention

Subjective: P Unstable Blood Glucose After 4 hours of Independent:
“Pirmi nako H nursing  Monitoring the rapid blood
level, related to Insulin
mabatian ug Y interventions sugar at regular intervals as
kakapoy” as S Resistance or decreased unstable glucose prescribed. R: to identify the
verbalized. I will no longer imbalance in glucose levels
production or utilization of
O manifested as  Daily Weight Recording. R: to
Objective data: L the insulin as evidenced by evidence by: determine weight loss or weight
 Triple P’s O gain.
hyperglycemia.
 RBS- 180 G  Maintain  Advice to reduce
mg/dl I blood sugar carbohydrate like sugars in
 FBS- 39. 1 C Rationale: as normal as diet. (Low fat diet) as
mmol/L Needs/ Scientific explanation possible prescribe. R: To prevent
 Creatinine- Nutrition type 2 diabetes mellitus is without hyperglycemia and high sodium
169.1 and fluid previously known as adult- serious high content.
umol/L onset diabetes, maturity-onset or low blood  Monitor intake and output
 Impaired diabetes, or non-insulin sugars chart daily. R: to identify the
Glucose dependent diabetes mellitus  Prevent fluid volume status.
Tolerance (NIDDM) - is due to a tissue  Advice to take adequate bed
Test combination of defective damage rest especially when the
 Glycosuria insulin secretion and defective caused by too blood glucose level is more
responsiveness to insulin much sugar that 250mg/dl. R: Activity can
(often termed insulin in the blood increase the need of more glucose
resistance or reduced insulin stream to the tissues whereas in diabetic
sensitivity), almost certainly  No evidence patients the Glucose uptake by
involving the insulin receptor of triple P’s the tissues is decreased due to
in cell membranes. In early  RBS lower at lack of insulin action.
stages, the predominant 139 mg/dl  Administer Insulin therapy or
abnormality is reduced insulin  FBS reach at oral hypoglycemic agents (RI
sensitivity, characterized by normal level drip 100 units via infusion
elevated levels of insulin in the
blood. In the early stages,
hyperglycemia can be reversed
by a variety of measures and
medications that improve
insulin sensitivity or reduce
glucose production by the
liver, but as the disease
progresses the impairment of
insulin secretion worsens and
therapeutic replacement of
insulin often becomes
necessary.
(4.11-5.89 pump) as prescribed. R: To
mmol/l) decrease the blood glucose level.
 Crea (59-104  Administer IV fluids of PNSS
umol/L) 1L @ 80 cc/hr. (While
choosing IV fluids do not
administer glucose containing
solutions like dextrose
solutions). R: to improve fluid
volume status and prevent
increasing the blood glucose
levels.
 Obtain labs CBC, ABG and
electrolytes as prescribe.
 Advice the client on the need
for the regular treatment. R:
to prevent complications of the
disease.
Dependent
a. Metoclopramide 5 mg q 6hrs
IV x 4 doses
b. Ketoanalogue 600-gram TID
c. c. Furosemide 40 mg IV
now for creatinine now
 Assessment Need Nursing Diagnosis Objective of Care Nursing Intervention
Subjective: P Ineffective tissue perfusion, After 2 hours of nursing Independent:
“Naa koy mabatian H interventions acute pain  Assess feet and legs for
peripheral r/t decreased
ug banhod” as Y will no longer skin temperature,
verbalized. S arterial flow as evidenced manifested as evidence sensation, soft tissue
I by: injuries, corns, calluses,
by numbness and tingling
Objective data: O dryness, hammer toe or
 Delayed L of the feet secondary to Short Term: bunion deformation, hair
capillary O Promote tissue distribution, pulses, deep
diabetic left foot.
refill time in G perfusion to the tendon reflexes. R: This
the lower I affected area will prevent further damage
extremities C Rationale: -Increase perfusion to tissues in the patient’s
 RBS levels Needs/ Diabetes sometimes affects the until adequate -client foot.
increased Pain nerves of the feet, causing a will verbalize  Elevate feet when up in a
 Decreased avoidance loss of sensation. Therefore, understanding of the chair. Avoid putting the
pulse rate in when a person with decreased relationship between feet in a dependent
the affected sensory perception in the feet diabetes and position. R: Minimizes
extremities is wounded, the wound is left circulatory changes interruption of blood flow
 Loss of unnoticed and may develop -demonstrate and reduces venous pooling.
sensation of an infection, when the awareness of safety  Reinforce safety
the pancreas produces factors and foot care. precautions regarding use
ulcerative insufficient amounts of the of heating pads, hot water
foot hormone insulin and/or the Long Term: bottles, and soaks. R: Heat
body’s tissues become Keep tissue perfusion increases metabolic demands
resistant to normal or even adequate. Maintain on compromised tissues.
high levels of insulin. This adequate level of  Vascular insufficiency
causes high blood glucose hydration to alters pain sensation,
(sugar) levels, which can lead maximize perfusion increasing risk of injury.
to a number of complications  Discuss complications of
if untreated. the disease that result
from vascular changes.
 Instruct patient in foot
care guidelines. R:
Educating the patient will
help promote cooperation.
 Antidiabetics as ordered
by physician. R: Taking
care of the underlying
disease will help alleviate the
effects.
 Assessment Need Nursing Diagnosis Objective of Care Nursing Intervention
Subjective: P Imbalanced Nutrition: After the nursing Independent:
“Taas kayo akong H
less than body
interventions  Weight daily or as indicated.
sugar.” as Y Imbalanced R: Assesses adequate of nutritional
verbalized. S requirements related to Nutrition will no intake by absorption and utilization
I longer manifested as of nutrients.
inability to utilize
Objective data: O evidence by:  Identify food preferences,
 observed L nutrients secondary to including ethnic/cultural needs.
weakness O  Promotion of R: If patient’s food preferences can be
insulin deficiency.
 increased G adequate rest incorporated into the meal plan.
urinary I and sleep Discuss proper distribution of meals
output C Rationale:  RBS result that the client prefers but may
 increased Needs/ Due to decrease of / lack of maintained @ contribute in maintaining normal
food intake Nutrition insulin in the body, the normal range body weight. cooperation with
 on Diabetic and fluid glucose level continuously (80- 120 mg/dl) dietary requirements may be
diet rises because glucose can’t  Improved vital facilitated.
 CBG be utilized without the signs and  Ascertain patient’s dietary
monitoring q presence of insulin. maintained to program and usual pattern then
6 Glucose is the source of normal range compare with recent intake. R:
 Glucose: energy, while insulin is  d. Intake Identifies deficits and deviations from
6.6mmol/L the vehicle to transport appropriate therapeutic needs.
Normal: 4.1- glucose to the body number of  Ascertain patient’s dietary
5.9mmol/L tissues. Because of calories and program and usual pattern then
-BMI: 30.3- decrease insulin level in nutrients. compare with recent intake. R:
Obese the blood stream, the cells Identifies deficits and deviations from
starved, leading to therapeutic needs.
 BP: 140/90
alteration of metabolism.  Auscultate bowel sounds. Note
The body needs glucose reports of abdominal pain,
for metabolism; there will bloating, nausea, vomiting of
be a breakdown of energy undigested food. R: Hyperglycemia
reserved from adipose and fluid and electrolyte disturbances
tissue, muscles and liver
(glucagon’s). This will
result to weight loss. But
the energy breaks down,
the glucose level
continuously increases
because there is less
amount of insulin. The
body tissues need to be
fed, this will lead to
polyphagia and polydipsia
because the tissue is not
being fed and need
glucose for metabolism.
can decrease gastric motility and/or
function (due to distention or ileus)
affecting choice of interventions.
Note: Chronic difficulties with
decreased gastric emptying time and
poor intestinal motility may suggest
autonomic neuropathies affecting the
GI tract and requiring symptomatic
treatment.
 Perform glucose testing before
letting the patient eat. R: to
determine the client’s blood glucose
level and to know if it is necessary to
administer RI as indicated.
 Administer regular insulin if there
is high glucose level as ordered.
R: Regular insulin has a rapid onset
and thus quickly helps move glucose
into cells.
 Consult dietician/physician for
further assessment and
recommendation regarding food
preferences and nutritional support
R: To reveal changes that should be
made in client’s dietary intake- For
greater understanding and further
assessment of specific foods.
 DRUG STUDY
Date/ Generic Brand Classific Indication Mechanism Dosage & Adverse
Time Name Name ation of Action Nursing Considerations
Frequency Reactions
9-3-21 Piperacillin Zosyn Anti- Treatment Antibacterial 4.5-gram CNS: seizures,  Obtain history of
/Tazobacta infective; of moderate combination IVTT q 12 confusion, hypersensitivity to
m to severe product hours dizziness, penicillin or other
Beta- appendicitis consisting of ANST (-) headache, drugs prior to
the
lactam ; skin and insomnia, administration.
semisynthetic
antibiotic skin piperacillin and
lethargy.  Monitor patient
; structure the beta- GI: diarrhea, carefully during the
Antipse infections. lactamase constipation, first 30 min after
udomona Gynecologic inhibitor drug-induced initiation of the
l infections. tazobactam. hepatitis, infusion for signs of
Penicillin Community Piperacillin: nausea, hypersensitivity
-acquired Binds to vomiting. including pulmonary
and bacterial cell GU: interstitial symptoms (tightness
nosocomial wall nephritis. Derm: in the throat and
membrane,
pneumonia rashes, urticaria. chest, wheezing,
causing cell
caused by death.
Hemat: cough dyspnea) or
piperacillin- Spectrum is bleeding, skin reactions (rash,
resistant, extended leukopenia, pruritus, urticaria).
beta- compared with neutropenia, Notify physician or
lactamase– other penicillin. thrombocytopen nursing staff
producing Tazobactam: ia. Local: pain, immediately if these
bacteria. Inhibits beta- phlebitis at IV reactions occur.
lactamase, an site.  Monitor hematologic
enzyme that Misc:
can destroy status with
hypersensitivity prolonged therapy
penicillin.
Death of
reactions, (Hct and Hgb, CBC
susceptible including with differential and
bacteria. anaphylaxis and platelet count).
serum sickness,
fever.
Date/Ti Generic Brand Classifi Indication Mechanism Dosage & Adverse
me Name Name cation of Action Nursing Considerations
Frequency Reactions
9-17-21 Merope Merom Antibact Prescribed Inhibits cell 1g IV CNS: seizures,  Determine history of
nem ax IV erial for wall infusion q dizziness, hypersensitivity reactions to
Trihydr bacterial synthesis in 12 hrs. headache. Resp: other beta-lactams,
Merre infections apnea. GI: cephalosporins, penicillin, or
ate bacteria,
m IV like skin pseudomembra other drugs.
and thereby
and skin nous colitis,  Lab tests: Perform C&S tests
leading to
structure constipation, prior to therapy. Monitor
infections, cell death. diarrhea, periodically liver and kidney
bacterial glossitis function.
meningitis, (increased in
 Monitor for seizures
serious children),
especially in older adults
nosocomial nausea, thrush
and those with renal
infections (increased in
insufficiency.
like children),
septicemia, vomiting. Derm:
 Report S&S of
febrile moniliasis superinfection.
neutropeni (children only),  Discontinue drug and
a, pruritus, rash. immediately report S&S of
intraabdom Local: hypersensitivity.
inal and inflammation at  Assess respiration, and
pelvic injection site, notify physician
infections. phlebitis. Misc: immediately if patient
allergic exhibits any interruption in
reactions, respiratory rate (apnea) or
including other signs of respiratory
anaphylaxis. failure (rapid labored
breathing, cyanosis,
confusion, irritability,
sleepiness, headache, oxygen
desaturation).
 Monitor injection site for
pain, swelling, and irritation.
 Date/ Generic Brand Classific Indication Mechanism Dosage & Adverse
Nursing Considerations
Time Name Name ation of Action Frequency Reactions
9-8-21 Insulin Basaglar Anti- Indicated Lowers 22 units CNS: headache,  Close monitoring of
glargine KwikPen, diabetics to improve blood pyrexia. vital signs including
Lantus, SQ OD blood sugar level.
glycemic glucose by CV: peripheral
Lantus control in stimulating edema.  Adjust dosages
Solostar, regularly depending in
adults and glucose EENT:
Toujeo patient specific glucose
pediatric uptake in pharyngitis,
Solostar measurements.
patients skeletal rhinitis.
with type 1 muscle and GI: abdominal  Inform patients that
hypoglycemia is the
diabetes fat, pain,
most common adverse
mellitus inhibiting gastroenteritis,
reaction with insulin.
and in hepatic diarrhea, nausea,  Monitor signs and
adults with glucose vomiting. symptoms of
type 2 production. Metabolic: hypoglycemia and
diabetes hypoglycemia, hyperglycemia.
mellitus. sodium Common symptoms
retention, weight include tingling in hands,
gain. feet, lips; chills and cold
sweats; confusion;
MUSCU: back
difficulty in concentration;
pain. drowsiness; excessive
RESP: URI, hunger; headache;
bronchitis, irritability; nervousness;
cough. tremor; weakness;
unsteady gait.
SKIN: injection-
 Instruct patient in self-
site reactions,
management, including
lipodystrophy.
glucose monitoring,
pruritus, rash. injection technique,
Misc: allergic proper storage of
reactions, flulike insulin and
symptoms. management of
hypoglycemia and
 hyperglycemia.

Date/ Generic Brand Classifi Indication Mechanism Dosage & Adverse Nursing Considerations
Time Name Name cation of Action Frequency Reactions
9-4-21 Ketoanal Ketobest Essenti Prevention Normalizes 600 mg Hyper Before:
ogue Ketosteril al and therapy metabolic tab, 2tab calcemia 1.Assess electrolyte levels
of damages process, TID 2.Explain therapeutic value of
Amino drug
due to faulty promotes
acids/S or deficient 3.Assess allergy to the drug
recycling 4.Caution patient of the different
upplem protein
product side effects
ents metabolism
5. Assess vital signs
in chronic exchange.
Reduces ion 6. Proper preparation of the drug
renal in-
concentratio During:
sufficiency in
1. Verify patient’s identity
connection n of
2. Administer with food to
with limited potassium,
prevent GI upset
protein food magnesium 3. Administer drug at right
of ≤40 g/day and
(for adults).
time, route, and dosage
phosphate. 4. Advise to swallow the tablet
Supplements whole
indicated for 5. Monitor vital signs
patients After:
having 1. Document administration of
urologic drug
problems like 2. Instruct patient to report
chronic immediately if symptoms of
kidney hypercalcemia occur like muscle
disease weakness, constipation
3. Monitor calcium levels.
4. Monitor for signs of
hypercalcemia and electrolyte
levels.
5. Monitor vital signs especially
cardiac changes.
Date/ Generic Brand Classifi Indication Mechanism Dosage & Adverse Nursing
Time Name Name cation of Action Frequency Reactions Considerations
9-7-21 Kalium Potassi Fluid To prevent and Supplement 2 tabs q 3hrs x Metabolism:  Assess vital signs
Durules um treat potassium al 3 doses Hyperkalemia.
and
deficits
 Monitor I&O
Chlorid potassium Gastrointestinal
Electrol secondary to  Monitor serial
e in the form : Abdominal
yte diuretic or pain, diarrhea, serum potassium
of high
Balance corticosteroid nausea. levels before and
potassium
Agent therapy. Skin: Rash. during therapy.
food or
Also, indicated potassium  Administer oral
Replace
when potassium chloride drug after meals
ment is depleted by may be able or with food and a
solutio severe vomiting, full glass of water
to restore
n diarrhea; to decrease GI
normal
intestinal upset
drainage, potassium
fistulas, or levels.  Instruct patient
malabsorption; not to chew or
diabetic crush tablets; have
acidosis. patient swallow
tablet whole.
 Monitor cardiac
rhythm carefully
during IV
administration.
 Document
administration of
drug