Assessment

Nursing
diagnosis
S-kumain
Noncomplianc
ako ng
e r/t deficient
dalawang
knowledge
slice ng
relevant to
gardenia
regimen
bread kanina behavior
kasi na
gutom ako
as
verbalized
by the
patient
O-Cbg- 210
mg/dl
-instructed
to NPO prior
to cbg
recording

Inference

Planning

Intervention

Behavior of
person and/or
caregiver that
fails to
coincide with
a healthpromoting or
therapeutic
plan agreed
on by the
person (and/or
family and/ or
community)
and
healthcare
professional.
In the
presence of
an agreed-on
healthpromoting or
therapeutic
plan, persons
or care givers
behavior is
fully or
partially non
adherent and
may lead to
clinically
ineffective or

Short term
After 4 hours of nursing
intervention the client will
be able to demonstrate
willingness

Independent

-to learn about and

participate in treatment
plan and care
Long term
After 8 hours of nursing
intervention the client will
be able to
-State an understanding
of the implications of not
following the prescribed
treatment plan.

1.) Assess beliefs

about current illness.
2.) Determine
reasons for
noncompliance
3.) Establish rapport
with client and
relatives
4.) Explain the
importance of NPO
prior to cbg recording

Rationale

Evaluation

1.)this is to determine the

knowledge of the client to
her disease

Short term
After 4 hours of nursing
intervention the client
is able to demonstrate
willingness

2.) to identify the factors

that influences for noncompliance

-to learn about and

participate in treatment
plan and care

3.) having an trust to

nurse on duty may
increase the level of
compliance

Long term
After 8 hours of nursing
intervention the client
is able to
-State an understanding
of the implications of
not following the
prescribed treatment
plan.

4.) this is for the client to

clearly understand

5.) Instruct client not

to take anything prior 5.) to determine the level
to the cbg monitoring of Glucose to the body
6.) Teach significant
others not to give
any food to patient
prior to monitoring

dependent

6.) instruct client

diversion if client may feel
hunger

ACTUAL

partially
ineffective
outcomes

7.) Notify physician

about the
noncompliance
behavior of client to
prior to procedure
8.) administer apidra
if qualified to the
prescribe coverage

ACTUAL

7.) to inform the physician

about the attitude of the
client in to care plan

Assessment
S- bakit
tumaas
nanaman
ang sugar
ko as
verbalized
by the
patient
O
-CBG
monitoring
of 210 mg/dl

-3 units of
apidra
insulin

Nursing
diagnosis
Deficient
knowledge
related to
unfamiliarity
to disease
process

Inference

Planning

Intervention

Verbalization
of the
problem;
inaccurate
follow-through
of instruction;
inaccurate
performance
of test;
inappropriate
or
exaggerated
behaviors
(e.g.,
hysterical,
hostile,
agitated,
apathetic)
Related
Factors: Lack
of exposure;
lack of recall;
information
misinterpretati
on; cognitive
limitation; lack
of interest in

Short term
After 4 hours of nursing
intervention the client
will demonstrate
understanding of the
diseases process

Independent

Long term
After 8 hours of nursing
intervention the client
will be able to initiate
necessary changes in
lifestyle

2.) Assess clients

readiness for learning

1.)Assess clients level

of knowledge and
anticipatory needs

3.) Provide information

related only to the
current situation and
to its disease process
4.) Provide positive
reinforcement

rationale

1.) to determine the

extent of
understanding and the
attention adherence of
the client
2.) to determine if
client is willing to
listen in discussion
about the disease
process
3.) this is to avoid the
overload of
information being
infuse to the client

5.) Discuss to client

the adherence to
instruction given by
the health care
providers

4.) encourage our

client to fully give
attention about the
disease process

6.) Avoid using medical

terms while explaining
the disease or even in

5.)for client to fully

understand
consequences if not

Evaluation
Short term
After 4 hours of nursing
intervention the client is
demonstrate
understanding of the
diseases process
Long term
After 8 hours of nursing
intervention the client is
able to initiate necessary
changes in lifestyle

ACTUAL

learning;
unfamiliarity
with
information
resources

giving instruction to
client
7.) Respond to clients
inquiries regarding to
disease.

adhering to care plan

6.)this is to avoid
confusion and also for
the client to fully
understand the
discussion

dependent
8.) administer Apidra if
CBG in above 181
mg/dl

7.) to clarify if there

are some things that
are still confusing to
the client

8.) as ordered by the

physician if the result
of cbg monitoring
exceeds to the
coverage administer
unit of apidra

ACTUAL

Assessment
S: nako
mahirap talaga
iwasan kumain
ng masasarap
as verbalized
by the patient
mahilig talaga
kami kumain
kasi may
canteen kami
as verbalized
by the
patients
significant
others

Nursing
diagnosis
ineffective
self-health
management
related to
mistaken
perception

Inference

Planning

Intervention

Rationale

Evaluation

History of lack of
health-seeking
behavior; reported
or observed lack of
equipment,
financial, and/or
other resources;
reported or
observed
impairment of
personal support
systems; expressed
interest in
improving health
behaviors;
demonstrated lack
of knowledge

Short term
After 4 hours of
nursing intervention
the patient will be able
to adopt lifestyle
changes

Independent

1.) this is to assess

the factors
influencing the
clients lifestyle

Short term
After 4 hours of nursing
intervention the patient is
able to adopt lifestyle
changes

Long term
After 8 hours of
nursing intervention
the client will be able
to assume readiness in
taking care of own
health

2.) Assess clients

ability and desired to
learn

1.)Identify risk
factors in clients
personal and family
history

3.) Assess clients

perception about the
current disease
4.) Note clients
family culture

2.) to determine the

willness of the client
to learn
3.) to determine if
client is
knowledgeable
about her disease
4.) this may
influence the
perception of client

Long term
After 8 hours of nursing
intervention the client is
able to assume readiness in
taking care of own health

ACTUAL

O:
CBG: 210 mg/dl

regarding basic
health practices;
demonstrated lack
of adaptive
behaviors to
internal and
external
environmental
changes; reported
or observed
inability to take
responsibility for
meeting basic
health practices in
any or all functional
pattern areas
Related Factors:
Disabled family
coping, perceptualcognitive
impairment
(complete or partial
lack of gross or fine
motor skills); lack
of or significant
alteration in
communication
skills (written,
verbal, or gestural);
unachieved
developmental
tasks; lack of
material resources;

about health care

5.) encourage pt and
pts significant others
to have a healthier
diet, state diet,
6.) provide client
materials that will
give them ideas in
healthy diet
7.) discuss client
about having a wellbalanced diet

5.) eating healthy

foods might be a
start of having
stable blood sugar
6.) this may help the
client to appreciate
and fully understand
some tips or
regimens about
health care
maintenance

dysfunctional
grieving; disabling
spiritual distress;
inability to make
deliberate and
thoughtful
judgments;
ineffective coping

Assessment

Nursing diagnosis

Inference

Planning

Intervention

Rationale

Evaluation

S:
Hindi gumagaling
ang sugat ko
as
verbalized by the
Patient.
O
Flushed
Appearance
.
CBG: 210 mg/dl
V/S taken as
follows:
T:37.4
P:87
R:19
BP: 120/90

Risk for
infection
related to high
glucose levels.

Type 2 diabetes
mellitus occurs
when the
pancreas
produces
insufficient
amounts of the
hormone insulin
and/or the body's
tissues become
resistant to normal
or even high
Levels of insulin.
This causes high
blood glucose
(sugar) levels,
which can lead to
a number of
complications if
Untreated.

Short term
After 8 hours
of nursing
interventions,
the patient
will identify
interventions
to prevent or
reduce risk
Of infection.

Independent:
Observe for signs
of infection and
Inflammation.
Promote good
hand washing by
Nurse and patient.
Maintain aseptic
technique for IV
insertion
procedure,
administration of
medications, and
providing
maintenance and
Site care. Rotate
IV sites as
Indicated.
Provide catheter
Or perineal care.
Teach the female
patient to clean
from front to back
After elimination.
Provide
conscientious
skin care, gently
massage bony

Patient may be
admitted with
infection, which
could have
precipitated the
ketoacidosis
state, or may
develop a
nosocomial
Infection.
Reduces the
risk of cross
contamination
High glucose in
the blood
creates an
excellent
medium for
bacterial
Growth.
Minimizes the
risk for
Infection.
Peripheral
circulation may
be impaired,
placing patient
at increased

After 8
hours of
nursing
intervention
s, the
patient was
able to
identify
intervention
s to prevent
or reduce
risk of
infection

RISK

Areas. Keep the

skin dry, linens
dry and wrinkle
Free.

risk for skin

irritation or
breakdown and
Infection.

Place in semi
Fowlers position.

Facilitates lung
expansion and
reduces risk of
Aspiration.

Encourage
adequate dietary
and fluid intake of
3000 ml per day.

Decrease
susceptibility to
Infection.

Collaborative:
Obtain specimen
for culture and
sensitivities as
Indicated.

Identifies
organisms so
that most
appropriate
drug therapy
can be
Instituted.

Assessment
O.
CBG: 210 mg/dl
DM Diet
(+) flavored
breads (ube
Cheese Gardenia)
(+) Flavored
beverages
( minute made
orange juice)

Nursing diagnosis
Risk for unstable
blood glucose
related to dietary
intake

Inference
Type 2 Diabetes
Mellitus occurs
when the pancreas
produces
insufficient amounts
of hormone insulin
and/or the bodys
tissues become
resistant to normal
or even high levels
of insulin. This
causes high blood
glucose levels,
which can lead to a
number of
complications if
untreated.

Planning
After 4 hrs. of
nursing intervention
the client will be
able to maintain
glucose in
satisfactory range

Intervention
Determine
individual factors
that may contribute
to unstable glucose
as listed risk factors

Rationale
1. clients family
history of diabetes
known diabetic with
poor glucose control

Assess clients
family support

2. client need as an
assistance in
lifestyle change

Discuss glucose
monitoring

3. to inform client
the proper
regulation of
glucose

Review clients diet

specially
carbohydrate intake

Provide reading
materials for
patient regarding to
the control of
glucose intake
Advice client to
adhere to the diet
prescribed by
physician

4. glucose balance
is determine by the
amount of
carbohydrates
consumed

5. this may help the

client to understand
the importance of
having a balance
diet
6. this is to met the
goal of the diet
prescribed

Evaluation
After 4 hrs of
nursing intervention
the client is able to
maintain glucose in
satisfactory range

RISK

Patients Information

Name: NKP
Age:
Sex: Female
Religion: Roman Catholic
Initial diagnosis: Uncontrolled DM
Usual source of income: Canteen Owner

Nursing Care Plan

Uncontrolled
DM

Submitted by: Ylron John A.

Tapar
Submitted to: Maria Veronica