NURSING CARE PLAN

Name of the Patient: Santiago, Mildred Ramos Age: 48 years old Sex: Female Name of Student: Casilao, Mike Arone H.
Civil Status: Married Religion: Catholic Rm/Bed No. Rm. 304 Area: Sagrada Familia Hospital (Med-Ward) Level/ Block: BSNIV-B
Address: Manggahan San Jose San Luis Pampanga Date Submitted: June 29, 2023
Date of Admission: June 27, 2023 Diagnosis: Diabetes Mellitus Type Rating: _____________________________________________

CUES Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Expected Outcomes
Subjective/ Objective
Subjective: Risk for Unstable Blood After 1 hour of Independent Intervention Independent Intervention After 1 hour of
 Glucose Level related to lack Independent Nursing Independent Nursing
“Nahihilo at masakit of knowledge in blood glucose Intervention the client will  Establish rapport to the  To obtain trust on the client Intervention the goal was
ang ulo ako bago management as evidenced by: be able to: client and to her guardian and guardian to allow them met as evidenced by:
ko pumunta dito sa be more comfortable
hospital” as Subjective: discussing or raising any  The client was able to
verbalized by the   Acknowledge factors issues. acknowledge factors
patient. “Nahihilo at masakit that may lead to that may lead to
 “Nanghihina din ang ulo ako bago ko unstable glucose.  Assess client’s learning  To determine how the unstable blood
katawan ko” as pumunta dito sa needs and abilities; note client will accept and glucose
verbalized by the hospital” as verbalized  Verbalize plan for barriers in accepting integrate the health
patient. by the patient. modifying factors to information. education.  The client was able to
Objective:  “Nanghihina din prevent or minimize devise a plan in
 Body Malaise katawan ko” as shifts in glucose level.  Ascertain client’s/SO’s  This will enlighten her to be modifying factors to
 Dizziness verbalized by the knowledge and able to maintain her blood prevent or minimize
 Headache patient. understanding of condition glucose level to normal spike in blood glucose
CBG: 165 mg/dl Objective: and treatment needs. level
 Body Malaise
 Dizziness  Determine client’s  Age, maturity, current
 Headache awareness and ability to health status, and
 CBG: 165 mg/dl be responsible for dealing developmental stage all
with situation. affect a client’s ability to
provide for their own
safety.
Definition:
- At risk for variation of blood
glucose/sugar
levels from the normal range
that may compromise
health
Nursing Diagnosis Handbook.
Ackley, Ladwig, & Makic. 11
ed
 Assess family/SO(s)
support of client.  Client may need
assistance with lifestyle
changes (e.g., food
preparation or
consumption, timing of
intake and/or exercise, or
administration of
medications).
 Discuss home glucose
monitoring to SO  To identify and manage
according to individual glucose variations.
parameters
 Refer to appropriate
community resources,  For lifestyle modification,
diabetic educator, and/or medical management,
support groups, as referral for insulin pump or
needed, glucose monitor, financial
assistance for supplies,
and so forth.