NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Unstable blood Short-term Goal: Independent: Independent: Short-term Goal:
“I feel weak and glucose level 1. Assess for signs of 1. The signs are the results of
drowsy” as verbalized maybe related After 20 minutes of nursing hypoglycemia. both increased adrenergic After 20 minutes of nursing
by the patient. to insulin interventions, the patient 2. Assess activity and decrease interventions, the patient
deficiency will be able to: medications taken glucose delivery to the will be able to:
Objective:  Have a blood regularly. brain. The patient may feel  Have a blood
 CBG; 51 glucose level of 3. Monitor blood dizziness, headache, glucose level of
mg/dl less than 160 glucose level. fatigue, tremors, less than 160
mg/dl. 4. Assess blood diaphoresis, hunger, and mg/dl.
V/S taken; Long-term Goal: glucose level visual changes. Long-term Goal:
BT: 37.3˚C/axilla before meals and 2. A lot of drugs can cause
BP: 140/100 mmHg After 24 hours of nursing before bedtime. fluctuations in blood After 24 hours of nursing
PR:76 bpm interventions, the patient 5. Monitor serum glucose as side effect. interventions, the patient
RR:25 cpm will be able to: insulin levels. Regular use of salicylates, will be able to:
02 Sat: 94-95%  Acknowledge 6. Assess eating disopyramide, pentamidine  Acknowledge
factors that leads patterns. can cause hypoglycemia. factors that leads
to unstable 7. Assess the patient 3. Normal fasting blood to unstable
glucose and DKA. knowledge and glucose for an adult is 70- to glucose and DKA.
 Verbalize understanding 105 mg/dl. Critical  Verbalize
understanding of about the hypoglycemia is less than understanding of
body and energy prescribed diet. 40-60 mg/dl. body and energy
needs. 8. Discuss the 4. Blood glucose should be needs.
 Verbalize plan to importance of between 140 to 180 mg/dl.  Verbalize plan to
minimize or balance exercise 5. Hyperinsulinemia occurs minimize or
prevent with food intake. early in the development of prevent
complications. 9. Instruct the patient type 2 diabetes. complications.
experiencing 6. Non adherence to dietary
hypoglycemia guidelines for a specific
GOAL WAS MET
about appropriate clinical condition can result
actions to raise in fluctuations in blood
blood glucose. glucose.
Dependent: 7. An individualized patient
1. Administer plan is recommended.
insulin as
directed.
2. Treat 8. Exercises blood glucose
hypoglycemia level by facilitating uptake
with 50% of glucose into cells.
dextrose. 9. Food intake is appropriate
3. Administer in most cases of
hypertensive hypoglycemia to raise
drugs as blood glucose levels.
prescribed. Dependent:

1. Insulin is required to lower

the blood glucose levels in
type 1 diabetes.
2. There are signs of
hypoglycemia that D50 can
treat.
3. Hypertension is commonly
associated with diabetes.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Objective: Altered sensory Short-term Goal: Independent: Independent: Short-term Goal:
 Stupor perception 1. Administer fast – 1. Fast-acting sugar or simple
 Unconscious maybe related After 20 minutes of nursing acting sugar- sugars are easily digested After 20 minutes of
 CBG of 51 to interventions, the patient containing food. and absorbed compared to nursing interventions, the
mg/dl hypoglycemia will be able to: 2. Raised side rails. complex sugars. patient will be able to:
 GCS result evidenced by  Regain his 3. Facilitate proper 2. To facilitate the safety of the  Regain his
of 8/15 (M: stuporous consciousness ventilation. patient. consciousness
8, V:2, E: 2) appearance  GCS will become 4. Check blood sugar 3. To make sure the patient has  GCS will become
and GCS of stable at 12-13/15 level on the onset a calm and enough air to stable at 12-13/15
V/S taken; 8/15 (M: 5, V: 4, E: 3- of symptoms and facilitate his breathing. (M: 5, V: 4, E: 3-
BT: 37.3˚C/axilla 4) recheck again 4. Monitoring the blood 4)
BP: 140/100 mmHg  Maintain usual after treatment glucose level signifies the  Maintain usual
PR:76 bpm level of mentation. within 15-30 need for more or just enough level of
minutes. to intake of carbohydrate.
RR:25 cpm  Recognize for
5. Encourage patient 5. Individuals my feel varying
mentation.
02 Sat: 94-95% existing sensory  Recognize for
to verbalize the symptoms of hypoglycemia
impairments. existing sensory
signs and and it may be the same every
impairments.
symptoms he felt time it occurs.
during the onset. 6. It could help in times
6. Educate patient to symptoms of hypoglycemia GOAL WAS MET
monitor blood may occur.
glucose regularly Dependent:
Dependent: 7. There are signs of
1. Administered hypoglycemia that D50 can
D50-50 IV 1 ½ treat.
now. 8. It can improve the quality of
2. Administered life of the patient.
02support via
nasal cannula at
2-3 LPM.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective data: Ineffective Short-term Goal: 1. Obtain a blood 1. Blood glucose should Short-term Goal:
“I cannot breathe and cerebral glucose reading be between 140 to 180
I feel dizzy” as perfusion After 8 hours of nursing before meal, mg/dl. After 8 hours of nursing
verbalized by the related to intervention, the patient before bed and 2. An individualized intervention, the patient
patient. diabetes will be able to: PM. patient plan is will be able to:
mellitus type 2  Maintain his 2. Maintain a recommended.  Maintain his
Objective Data: as evidenced by HbA1c of 4-5%. consistent diet 3. To assess the mental HbA1c of 4-5%.
 Lethargic elevated blood  Maintain his blood plan as indicated. status of the patient  Maintain his
 Weak glucose level of glucose level 3. Monitor 4. To have baseline data. blood glucose
 CBG of 213 213 mg/dl, FBS between 70-140 neurological status 5. Hypertension and level between 70-
mg/dl of 31.14 mg/dl. of the patient. hypotension is 140 mg/dl.
mmol/L, and  Maintain his FBS 4. Monitor vital commonly associated  Maintain his FBS
V/S taken: HbA1C of of 70-115 mg/dl. signs. with diabetes. of 70-115 mg/dl.
BT: 37.3 °C/axilla 9.57% 5. Administer 6. Absolute bed rest may
BP: 140/90 mmHg Long-term Goal: medications for be needed to relax the Long-term Goal:
PR: 68 bpm hypertensive patient and prevent
RR: 18 cpm After 24 hours of nurisng drugs. reoccurrence of severe After 24 hours of nurisng
intervention, the patient 6. Maintain adequate symptoms. intervention, the patient
will be able to: bedrest, provide 7. To reduce onset of will be able to:
 Verbalizes quiet hypoxemia.  Verbalizes
knowledge of environment. knowledge of
treatment 7. Administer treatment
regimen, oxygen if regimen,
including indicated. including
appropriate appropriate
exercise and exercise and
mediactions and mediactions and
their actions and their actions and
possible side possible side
effects. effects.
 Identifies changes  Identifies changes
in lifestyle that are in lifestyle that are
needed to increase needed to increase
tissue perfussion. tissue perfussion.