ST.

PAUL UNIVERSITY SURIGAO

Cor. San Nicolas; Rizal Streets
8400 Surigao City, Philippines

Pt’s Name: R.P

Date and time of Interview:

ASSESSMENT NURSING DX PLANNING INTERVENTION

Subjective: Risk for unstable blood glucose After 7 hour of appropriate -Build Rapport
Rezel verbalize a sudden increase level r/t Pre-existing Type 2 intervention the pt will be able -Provide Rezel with a blood glucose monitor and educate
in thirst, frequent urination, and Diabetes Mellitus amb increased to maintain blood glucose her on proper usage.
unexplained weight loss over the thirst, frequent urination, within target range for optimal -Instruct on a schedule for monitoring, including pre and
past few weeks. With a known elevated random blood glucose maternal and fetal healt post-meal readings.
history of Type 2 diabetes, she levels. -Refer Rezel to a dietitian for a detailed assessment of her
expresses concerns about the current dietary habits and formulation of a tailored meal
potential impact on her plan.
pregnancy and the well-being of -Emphasize the importance of carbohydrate counting and
her unborn child. portion control.
-Collaborate with an endocrinologist to determine the
VS appropriate insulin regimen.
BP: 130/85 mmHg -Educate Rezel on insulin administration techniques,
HR: 92 bpm potential side effects, and the importance of adherence.
RR: 20 breaths per minute -Schedule bi-weekly ultrasounds to monitor fetal growth
TP: (37.1°C) and well-being.
Random Blood Glucose Level: -Integrate non-stress tests into the monitoring plan to
190 mg/dL assess the baby's response to movement.
-Increase the frequency of fetal monitoring to assess the
baby's well-being and adjust management strategies as
needed
CASE PROBLEM
Rezel Pobe a 28-year-old woman at 28 weeks of gestation, presents with increased thirst, frequent urination, and
unexplained weight loss over the past few weeks with a history of Type 2 diabetes, her concern for potential complications
during pregnancy is evident and the potential impact on her pregnancy well/ being Objective findings include a blood
pressure of 130/85 mmHg, heart rate of 92 bpm, respiratory rate of 20 breaths per minute, temperature of (37.1°C), a blood
glucose level of 190 mg/d