PATIENT’S DEMOGRAPHIC INFO

NAME: Rodrigo OCCUPATION: Farmer

AGE: 76 y/o HEALTH hx: diabetes (deceased mother); stroke (deceased father); adult-onset DM (2 younger brothers)

NURSING CARE PLAN #1: High Priority: Ineffective peripheral tissue perfusion related to vasoconstriction secondary to high glucose level.
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: High Priority: After 48 hours of nursing Independent Nursing After 48 hours of nursing
intervention, the patient will Intervention: intervention, the patient
Primary subjective data: Ineffective peripheral be able to have an was able to have an
tissue perfusion related to improved peripheral tissue Encourage pt to eat low Eating low glycemic foods improved peripheral tissue
● Pt experience vasoconstriction secondary perfusion as evidenced by glycemic index foods such can help control a patient's perfusion as evidenced by
numbness and to high glucose level. a lower glucose level as: vegetables (Peppers, blood glucose level. a lower glucose level
tingling sensation reading within the range of Broccoli, Tomatoes, reading within the range of
200 mg/dl to 170 mg/dl. Lettuce, Eggplants) and 200 mg/dl to 170 mg/dl.
● Pt reports tiredness fruits (Strawberries,
few hours after Apples, Pears)
waking up After 48 hours, the patient Eating regularly can help in
will demonstrate proper managing a patient's After 48 hours, the patients
● Pt complains of management to decrease Encourage the patient to weight, blood glucose level demonstrated proper
cloudy vision tingling sensation and eat regularly with the and risk of cardiovascular management techniques to
decrease numbness. proper meal plan. diseases such as decrease tingling sensation
Secondary subjective data: hypertension. and decrease numbness.

● Increased irritability
as reported by the
patient's wife. Perform and educate the pt Information about
on how to perform self performing self glucose
glucose monitoring monitoring helps the
Objective Data: patient to monitor their
glucose sugar at home.
● Random Glucose
level - 400 mg/dl

● Bp rate - 150/100
 Dependent Nursing Blood glucose monitoring
Intervention: can help in finding patterns
of its fluctuation and
Monitor blood glucose level control it within the 200
as ordered by the mg/dL to 170 mg/dL range.
physician.

Collaborative Nursing A balanced meal plan can

Intervention: help ensure that a patient
acquires needed nutrients
Collaboration with a while maintaining low
nutritionist in creating a glucose level.
meal plan that consists of
foods high fiber, protein
and low fat and
carbohydrate.

REFERENCES:
American Diabetes Association. (2004). Physical activity/exercise and diabetes. Diabetes care, 27 (suppl 1), s58-s62. https://doi.org/10.2337/diacare.27.2007.S58
Fletcher, J. (2020). How can you lower your blood sugar? Retrieved from: https://www.medicalnewstoday.com/articles/320738#lowering-blood-sugar-levels
Ralph, S., & Taylor, C. (2014). Nursing Diagnosis Pocket Guide (2nd ed., pp. 419). Lippincott Williams & Wilkins.
Vera, M. (2022, March 18). 2 Cataract Nursing Care Plans. Nurseslabs. Retrieved June 8, 2022, from
https://nurseslabs.com/2-cataracts-nursing-care-plans/?fbclid=IwAR2iRYULxDGdAKPTG8QmGbwWuR3ouzGXn6ncCuEMKK7yC-iYgyXGOWF3NQI
Elsevier. (2021, September 15). Elsevier – Patient Education Blood Glucose Monitoring, Adult. Elsevier's Healthcare Hub. Retrieved June 8, 2022, from
https://elsevier.health/en-US/preview/blood-glucose-monitoring-adult
NURSING CARE PLAN #2: Medium Priority: Deficient fluid volume related to osmotic diuresis from hyperglycemia
Assessment Nursing Diagnosis Planning
Subjective Data: Medium Priority: After 48 hours of nursing
intervention, the patient will
Primary data: Deficient fluid volume be able to have improved
related to osmotic diuresis fluid volume as evidenced
Pt complains of increased from hyperglycemia by demonstration of
thirst, hunger, and often adequate hydration and
urination. improved fluid volume
through oral fluid intake of
2L/day.
Objective Data:
After 48 hours of nursing
Random Glucose level - intervention, the patient will
400 mg/dl be able to have improved
fluid volume as evidenced
BP rate - 150/100 by achieving urine output
range of 30-60 cc/hr.
wt. - 110 kgs
After 48 hours of nursing
intervention, the patient will
be able to have improved
fluid volume as evidenced
by identifying interventions
to prevent or reduce risk of
hyperglycemia.
Intervention
Independent Nursing
Intervention:
Position the patient
properly to provide
physiologic safety and
ventilation.
Explain reasons for fluid
loss, educate and
demonstrate to pt how to
monitor fluid volume. (i.e.
recording daily weight and
measuring intake and
output)
Dependent Nursing
Intervention:
Encourage the patient to
drink the prescribed
amount of fluids.
Rationale
Maintaining proper patient
positioning prevents
complications of injury and
immobility.
This encourages patient
involvement in personal
care. Monitoring of fluid
intake ensures the
patient’s proper intake of
fluid and other nutrients.
Monitoring of output
determines if there is
adequate output of urine
as well as normal
defecation.
Patients in their older years hyperglycemia.
have a diminished sense of
thirst and may require
constant reminders to
drink. Fluid replacement
can be made easier by
being creative with fluid
sources.
Evaluation
After 48 hours of nursing
intervention, the patient
has improved fluid volume
as evidenced by
demonstration of adequate
hydration and improved
fluid volume through oral
fluid intake of 2L/day.
After 48 hours of nursing
intervention, the patient
has improved fluid volume
as evidenced by achieving
urine output range of
30-60 cc/hr.
After 48 hours of nursing
intervention, the patient
has improved fluid volume
as evidenced by identifying
interventions to prevent or
reduce risk of
REFERENCES
Salleh, A. (2014). The intake-output chart. Retrieved from: https://drdollah.com/monitoring/the-intake-output-chart/
Wayne, G. (2022). Fluid volume deficit (dehydration) nursing care plan. Retrieved from:
https://nurseslabs.com/deficient-fluid-volume/#nursing_assessment_and_rationales_for_fluid_volume_deficit

NURSING CARE PLAN #3: Low Priority: Impaired Skin integrity related to extensive wounds as manifested by delay in wound healing.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Low Priority: Independent Nursing

*No subjective data*
Impaired Skin integrity
related to extensive
wounds as manifested by
delay in wound healing.
After 8 hours of nursing
intervention, the patient will
be able to have an
improved skin integrity as
manifested by an
improvement in wound
healing.
Intervention:
Initiate topical therapy Topical therapy or
treatment is simply
cleansing of wound, should
be done to nourish the skin
and to protect wound from
harm and further infection
After 8 hours of nursing
intervention, the patient
was able to have an
improved skin integrity as
manifested by an
improvement in wound
healing.

Promote proper wound Accurate and enough

care which includes information given to the
Objective Data: handwashing, wound patient increases his ability
cleansing, wound dressing to manage therapy
● Extensive wound etc. independently, since
on right foot. cleaning of wounds
properly will help reduce
● Wound on right the risk of infection and
knee improves the healing

Protect the extremity from
injury using bed cradle and
position extremity at or
lower than level of heart.
Encourage and educate
patient about proper meal
plans consisting of
proteins, vitamins, iron,
and calories that will help
improve the wound
healing.
Dependent Nursing
Intervention:
Dress wounds as needed,
avoiding tight, constricting,
and sticky dressings
Collaborative Nursing
Intervention:
Administer antibiotics as
prescribed by the doctor.
Ensure that the patient
finishes the course of
antibiotics prescribed by
the physician.
process.
To ensure patient’s
comfort, promote collateral
blood flow, and improve
venous blood flow.
Nutrition plays a vital role
in maintaining intact skin
and in promoting wound
healing. Proteins help grow
new healthy tissue.
As needed, wound will
need to be dressed and
cleaned. Sticky dressings
may be difficult to remove
and cause further damage
Infected wounds are
generally treated through
the use of antibiotic
therapy. If the infection is
mild and has not spread to
other areas of the body.
 Communicate with a
dietician for an appropriate
meal plan to improve the
wound healing process.
The dietician could help in
providing proper food
preferences for the patient
and family to meet
adequate nutritional levels.

References:

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: diagnoses, interventions, & outcomes. Retrieved from: https://nursestudy.net/impaired-skin-integrity-nursing-diagnosis/
National Library of Medicine (2017). Using medication: topical medications. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK361003/
Wayne, G. (2022). Risk for impaired skin integrity nursing care plan. Retrieved from:
https://nurseslabs.com/risk-for-impaired-skin-integrity/#:~:text=Nursing%20Interventions%20for%20Impaired%20Skin%20Integrity,-Use%20the%20following&text=Encourage%2
0the%20use%20of%20lifting,use%20of%20a%20lift%20sheet.