Part XI

(Nursing Care Plan)

Assessment
Subjective: Pakiramdam ko lagi akong nauuhaw tsaka nanghihina. as verbalized by the patient Objective: Urine Specific Gravity: 1.030 Increase hct: .50 Weakness VS - BP: 100/70 - T: 37.0C - P:110 bpm - R: 20 cpm

Diagnosis
Fluid Volume

Planning
STG After 1 hour of nursing intervention patients hydration will be improved. LTG During the patients stay in the hospital and up to discharge, patient will be able to maintain an adequate hydration.

Interventions & Rationales

Independent Monitor VS to have a baseline data. Monitor I & O to provide estimation of volume replacement needs and effectiveness of therapy. Review lab results like urine specific gravity and hct to monitor for improvement of therapy and could assess for patients hydration status as well. Encourage patient to increase fluid intake to provide adequate hydration. Regulate IVF to provide proper rendition of fluids and electrolytes to the patient. Provide comfortable environment. Avoid overheating, which could promote further fluid loss. Assess skin turgor, capillary refill and mucous membrane for this are indicators of hydration

Evaluation
After 1 hour of

deficit related to osmotic diuresis from hyperglycemi a as manifested by verbal cues and signs and symptoms

nursing intervention patients hydration has improved.

During the

patients stay at the hospital patient was able to maintain adequate hydration as manifested by normal urine specific gravity of 1.015.
Goal Met

status of the patient. Dependent Administer medications on time as doctors order to be relief from symptoms of the disease. Give IVF as doctors order to maintain and regain patients fluid volume. Collaborative: Collaborate with the dietician of proper diet for the patients condition to improve her health status.

Assessment

Diagnosis

Planning

Interventions & Rationales

Evaluation

Subjective: Mataas ang blood sugar ko as verbalized by the patient. Objective:

HGT: 11.2

mmol/L Family History of diabetes mellitus No compliance to diet regimen and medication Sedentary lifestyle (Smoking, Alcohol consumption)

Unstable blood glucose related to lack of adherence to diabetes management as manifested by sedentary lifestyle, excessive intake of food, no compliance to diet regimen and medication and an increase in HGT of 11.2 mmol/L

STG After 1 hour of nursing intervention patient will verbalize understanding of the disease process and importance of strict compliance to diet regimen and medication that is required for her. LTG During the patients stay in the hospital and up to discharge, patient will be able to adhere to strict diet and exercise regimen and maintain a stable blood glucose level.

Independent
Establish rapport to have

After 1 hour of

credibility to the patient and will be able to follow health teachings. Assess patients level of understanding to allow proper communication process. Provide environment conducive to learning Health Teaching: - Encourage client to reduce intake of rice and sweets for it may worsen the clients existing condition of diabetes. - Encourage patient to consult a medical advice whenever she experiences symptoms of the said existing condition which is diabetes. - Encourage patient to exercise and decrease alcohol consumption, and to quit smoking to aid in her recovery and maintain a healthy lifestyle. - Provide information about self-monitoring blood glucose levels to allow cooperation of the patient in the treatment regimen.

nursing intervention patient has verbalize understanding of the disease process

During the

patients stay at the hospital patient wasnt able to maintain a stable blood glucose level as manifested by 17.5 mmol/L or 316 mg/dL and wasnt able to adhere to strict diet and exercise regimen.
Goal Unmet

Instruct patient about possible complications of his existing conditions for the patient to be aware of the possible risks it may bring him. Instruct the patient about proper insulin administration and its importance to allow adherence to the treatment regimen and cooperation of the patient in maintaining a stable blood glucose level.

Dependent Administer medications on time as doctors order to be relief from symptoms of the disease. Collaborative:
-

Provide information on community resources (check ups) and that will help the patient maintain his treatment regimen.

Assessment

Diagnosis

Planning

Interventions & Rationales

Evaluation

Subjective: Madaming problema sa bahay. Naglayas nga ako eh, kaya di ako nakapag-inject ng insulin ko for 1 week. madalas din ako gumimik tsaka uminom. As verbalized by the patient. Objective:
HGT: 17.5

Ineffective

After 1 hour of

Independent
Establish rapport to have

mmol/L or 316 mg/dL Sedentary Lifestyle: Drinking alcoholic beverages, Smoking, No exercise Lack of control in the diet (loves sweets) Family problems Lack of adherence to treatment regimen (insulin injection)

health maintenance related to ineffective family coping as manifested by verbal cues sedentary lifestyle, lack of control in diet, lack of adherence to treatment regimen and HGT of 17.5 mmol/L or 316 mg/dL

nursing intervention patient will identify potential health risks created by lifestyle and noncompliance to treatment regimen.
During the

patients stay at the hospital and up to discharge, patient will demonstrate awareness that healthy behavior requires some effort and confidence in ability to manage her existing condition; patient will be able to prioritize health other than some factors that could affect her health and verbalize willingness to change her lifestyle as well.

credibility to the patient and be able to follow health teaching. Assess patients level of understanding to allow proper communication process. Provide environment conducive for learning to properly absorb health teachings. Identify factors that affect clients belief in maintaining health for us to determine the causative factors and develop appropriate plan to eliminate it. Encourage patient and family to ask questions regarding health services or any health related matters for clarification Encourage patient to verbalize feelings to parents and discuss matters that bother her to help her cope with stress that is in her.

After 1 hour of nursing intervention patient has identified the potential health risks created by lifestyle and non-compliance to treatment regimen. During the patients stay at the hospital patient has demonstrated awareness that healthy behavior requires some effort and confidence in ability to manage her existing condition and patient is able to resolve factors that affects her health. Goal Met

 Encourage mother of the patient to talk to her daughter to allow bonding and verbalization of feelings. Health Teaching: - Encourage discussion of preventive health measures specific to patients needs, such as dietary changes, cessation of smoking, stress reduction, and implementation of exercise program to help patient adhere to the treatment regimen and for her to eliminate those aggravating factors systematically. Dependent

Administer medications as ordered to maintain her normal functioning.

Collaborative Consult with social services to plan for health maintenance needs on discharge to allow follow up care.