Problem: Weight gain Diagnosis: Type 2 Diabetes Mellitus

Prioritization: Date:

Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective: Imbalanced Short – term Independent: Short – term Goal:
 The client Nutrition: More Goal: 1. Obtain initial weight, - For baseline data. Goal Met.
verbalize that he than Body After 30 minutes to height and BMI of The client
was unable to Requirements 1 hour of nursing the client. demonstrate
lose more than 2- related to excessive intervention the appropriate changes in
3 lb. consumption of client will 2. Assess risk and - To determine lifestyle including
 Excessive intake carbohydrates as demonstrate presence of factors or treatments and eating pattern and
of carbohydrates evidenced by client appropriate conditions associated interventions that exercise program as
in the form of verbalizes that he changes in lifestyle with obesity. may be indicated in evidenced by:
bread and pasta. never seen a including eating addition to weight a. Decrease his
 The client dietician and a pattern and management. consumption of
verbalize that he BMI of 32.6 kg/m2 exercise program. carbohydrates.
has never seen a 3. Assess client’s - Being overweight or b. He cooperated
dietician. Long – term Goal: knowledge of own having large body with dietician
After 2 weeks of body weight and size may not be for his plan
Objective: nursing nutritional needs, and viewed negatively by about his diet.
 Weight: 178 lb. intervention the determine cultural individual, because it c. He is able to
 Height: 5’3” client will display expectations is considered within measure his
 BMI: 32.6 kg/m2 weight loss with regarding size. relationship to family food in a
optimal eating patterns, peer normal portion
 Vital signs as
maintenance of and cultural sizes.
follows:
health. influences.
BP: 154/96
mmHg (lying,
4. Explore and - Helps identify when Long – term Goal:
right arm),
discuss emotions and patient is eating to Goal Met.
140/90 mmHg
events associated satisfy an emotional The client display
(sitting, right
with eating. need, rather than weight loss with
arm)
PR: 88 bpm physiological hunger. optimal maintenance
RR: 20 cpm of health.
5. Formulate an eating - It is helpful to keep a. He is
plan with the patient, the plan as similar to participating in
using knowledge of patient’s usual eating weight loss
individual’s height, pattern as possible. A program.
body build, age, plan developed with b. Increase his
gender, and and agreed to by the activity level
individual patterns of patient is more likely through
eating, energy, and to be successful. exercises and
nutrient playing golf.
requirements. c. He is able to
decrease his
6. Discuss need to give - Denying self by weight to 4 lbs.
self-permission to excluding desired or d. He is able to
include desired or favorite foods results monitor his
craved food items in in a sense of weight once a
dietary plan. deprivation and week.
feelings of guilt and
failure when
individual “succumbs
to temptation.” These
feelings can sabotage
weight loss.

7. Determine current - Exercise furthers

activity levels and weight loss by
plan progressive reducing appetite;
exercise program increasing energy;
(walking) tailored to toning muscles; and
the individual’s goals enhancing cardiac
and choice. fitness, sense of well-
being, and
 accomplishment.

8. Emphasize the - Reducing tension

importance of provides a more
avoiding tension at relaxed eating
mealtimes and not atmosphere and
eating too quickly. encourages more
leisurely eating
patterns. This is
important because a
period of time is
required for the
appestat mechanism
to know
the stomach is full.

9. Develop an appetite - Signals of hunger and

reeducation plan with fullness often are not
patient. recognized, have
become distorted, or
are ignored.

Dependent:
1. Administer - For pharmacologic
medication as effect
prescribed by the
physician for weight
loss.

Collaborative:
1. Consult with dietitian - Individual intake can
to determine caloric be calculated by
and nutrient several different
 requirements for formulas, but weight
individual’s weight reduction is based on
loss. the basal caloric
requirement for 24
hr., depending on
patient’s sex, age,
current and desired
weight, and length of
time estimated to
achieve desired
weight.

2. Refer to a community - To provide role

support groups or models, address
psychotherapy, as issues of body image
indicated. and self-worth.

Problem: Deficient knowledge Diagnosis: Type 2 Diabetes Mellitus

Prioritization: Date:
 Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation
Subjective: Deficient knowledge Short – Term Goal: Independent: Short – term Goal:
 The client stated related to insufficient After 30 – 60 1. Render physical - Ensuring physical Goal Met.
that he has limited knowledge about minutes of nursing comfort for the comfort allows the The client are able to
knowledge diabetes mellitus as intervention the patient. patient to verbalize
regarding diabetes evidenced by client will verbalize concentrate on what understanding of his
self-care misinterpretation of understanding of is being discussed condition, disease
management and information and lack condition, disease or demonstrated. process, and
states. of instruction to the process, and treatment and
 The client stated client treatment and 2. Grant a calm and - A calm environment perform necessary
that he does not perform necessary peaceful allows the patient to procedures correctly,
understand why he procedures correctly, environment concentrate and and explains reasons
has diabetes since and explains reasons without focus more for the actions as
he never eats for the actions. interruption. completely. evidenced by:
sugar. a. He is able to
 The spouse of the Long – Term Goal: 3. Provide an - Conveying respect understand
client stated that After 1-2 days of atmosphere of is especially about his
she has nursing interventions respect, openness, important when condition by
encouraging him the client will exhibit trust, and providing education reinstating what
to treat his progress on the collaboration. to patients with is Type 2
diabetes with understanding the different values and diabetes
herbal remedies conditions and able beliefs about health mellitus, the
and weight loss to perform self- and illness. complication,
supplements, she monitoring blood the risk factors,
frequently scans glucose. 4. Include the patient - Goal setting allows and also the
the internet for the in creating the the learner to know treatment.
latest diabetes teaching plan, what will be b. He is able to
remedies. beginning with discussed and verbalize the
 The client stated establishing expected during the importance of
that he has never objectives and goals session.  his medication
been instructed in for learning at the and the possible
self-monitoring of beginning of the side effects of
blood glucose session. its.
 (SMBG). c. He is able
 The client also has 5. Involve patient in - Patient involvement participate in
never had a foot writing specific improves any program
exam as part of his outcomes for the compliance with for diabetic
primary care teaching session, health regimen and management.
exams, nor has he such as identifying makes teaching and
been instructed in what is most learning a Long – term Goal:
preventive foot important to learn partnership. Goal Met.
care. from their The client is
 The client stated viewpoint and exhibiting progress
that he stopped lifestyle. on understanding his
taking his conditions and able
medication 6. Use the teach- - The teach-back to perform self-
because he back technique technique consists monitoring blood
experiencing of specific steps in a glucose as evidenced
to determine the
dizziness, repetitive order to by:
patient’s evaluate the a. He is still be
sweating, and
agitation. understanding of recipient’s able to
what was taught: knowledge of the understand
Objective: content discussed. what was
 Weight: 178 lb.  The nurse Patients who are not taught by him.
 Height: 5’2” able to do this b. He still
gives method after attending the
 BMI: 32.6 kg/m2
informatio multiple cycles is program about
 Vital signs as
follows: n in a considered diabetic
BP: 154/96 mmHg caring cognitively management.
(lying, right arm), manner, impaired. c. He is able to
perform self-
140/90 mmHg using plain
(sitting, right arm) monitoring
language. blood glucose 4
PR: 88 bpm
 Ask the times a week.
RR: 20 cpm
patient to
explain in
 his or her
own
words.
 Rephrase
the
informatio
n if unable
to repeat it
accurately.
 Again ask
the patient
to teach-
back the
informatio
n using his
or her own
words until
the nurse
is
- Questions facilitate
comfortabl open
e that is communication
understoo between patient and
d. health care
 If the professionals and
allow verification of
patient still
understanding of
does not given information.
understan
d, consider - Monitoring
 other provides data on the
strategies. degree of glucose
control and
7. Encourage identifies the need
questions about for changes in the
Type 2 Diabetes insulin dosage.
Mellitus, treatment,
and self-monitoring - Reinforces learning
blood glucose. and convey the
maximum amount
of information.

8. Verify that the - The blood glucose

patient understands monitoring device is
and demonstrates a handy and
the technique and accurate way of
timing of home assessing blood
monitoring of glucose levels.
glucose. Proper usage of this
device is essential
9. Provide written in detecting
information about unstable blood
diabetes glucose levels.
management for the
patient to refer to. - Essential in
ensuring the client’s
10. Ensure client is understanding of his
knowledgeable treatment regimen
about using his own to ensure his
blood glucose compliance and
monitoring device. adherence.
 - For client’s access
to additional
resources for
diabetes
management.
11. Discuss how the
client’s anti-diabetic
medications work.

Collaborative:
1. Collaborative with
community
resources, support
groups and diabetic
educators.