University of St.
La
Salle College of
Nursing
Nursing Care Plan
Name of Student: Gavaran, Gersalia, Gonzales, Hulguin Section and Group:BSN2-E
Name of CI: Ms. Gemmarie Cabrera Area of Exposure: USLS
Rationale/Pathophysiologic Goals/Desired
Assessment Cues Nursing Diagnosis Nursing Intervention Rationale Evaluation
Basis Outcome
Subjective Cues: Risk for unstable Predisposing Precipitating After 8 hours of After 8 hours of
blood glucose level nursing intervention, nursing
- Type 2 - Food
● Client states “I related to lack of diabetes preferences the client will be able intervention, the
experienced adherence to - Hypertensive - Obesity (BMI: to: client and
slight tingling diabetes - Age: 71 y/o 30) significant other
and numbness management. - Unhealthy Independent was able to:
in my feet and diet Short-term Goals intervention:
has a history
of frequent ↓ 1. Acknowledge ● Determine ● To assess The client was
High glucose level factors that individual risk/contribu able to
bladder
may lead to factors that ting factors. acknowledge the
infections”. ↓ unstable factors that may
may
Lack of adherence to diabetes lead to unstable
● “My wound is Definition: glucose and contribute to
management
increased unstable glucose and
not healing on At risk for variation
my right foot of blood
↓ cholesterol glucose. increased
Diagnosis of type 2 Diabetes and levels. cholesterol levels
between the glucose/sugar levels Hypertension “I should eat
second and from the normal
↓ foods like leafy
third digits”, range that may Dependent
Risk for unstable blood glucose greens, broccoli,
as verbalized compromise health. intervention:
level related to lack of adherence to berries, lean
by the client.
diabetes management. meat, and protein
● Ascertain ● To know such as fish” as
● In the last client the verbalized by
24 hours, knowledge of understandi the client.
the client condition and ng of the GOAL MET.
recalls Source/Reference: treatment. client.
eating NANDA
"Breakfast:
2-3 slices of
toast with
margarine Independent
(about 1 intervention:
tbsp); coffee
with milk, 2. Demonstrate ● Educate the ● To The client was
Lunch: 1 can understanding client about understand able to
tomato soup of diabetes diabetes and the demonstrate and
prepared with and its proper how it affects importance
understand the
water; saltine management. the body. of managing
crackers (12) their proper
with peanut condition. management of
butter (about diabetes. "It is
2 tbsp) and ● Discuss the ● To important that I
Dinner: pork importance of understand eat food that are
chop 3 oz; 1 diet, exercise, and perform
good for my
cup of corn; and weight the key to
cornbread, 1 management manage body. I realized
slice and in managing diabetes. that not eating
applesauce, 1 diabetes. sweets and fast
cup of corn.” food doesn't
Dependent mean that I'm
intervention: already healthy.
Objective Cues:
I am starting to
● Refer the ● To keep
● Serum blood client to a cholesterol, modify my
glucose of 325 dietician for blood lifestyle and diet
mg/dl personalized pressure by strictly
● Height: 5’0 dietary and blood following the diet
● Weight: 155 counseling. glucose plan prescribed
lbs level within
by my dietician"
● Cholesterol: the normal
300 mg/dl range said the client.
● HDL: 35 mg/dl GOAL MET.
● Administer ● To help
Strength: medications manage
● Prepares own prescribed by blood sugar
meal and the physician. levels
rarely eats
at
restaurants
● Avoids Independent
sugary foods intervention:
3. Verbalize ● Discuss the ● To The client was
Weakness: understanding importance of maintain a able to
● Old age: 71 of body and balancing food healthy understand the
years old energy needs. intake, and weight and
importance of
physical optimizing
activity to the body’s energy needs in
meet the energy the human body.
body’s energy. utilization. GOAL MET.
Independent
Long-term Goals: interventions:
1. Maintain ● Assess the The client was
glucose with pattern of ● Physical able to maintain
satisfactory physical activity glucose level in.
range. activity. helps lower
satisfactory
blood
glucose range.
levels. GOAL MET.
Regular
exercise is a
core part of
diabetes
managemen
t and
reduces risk
for
cardiovascul
ar
complicatio
ns.
● Discuss the ● Allows for
target blood early
glucose range intervention
and to address
encourage to any
maintain their deviation
levels within from the
this range. target range
Dependent
Intervention:
● Monitor the
client’s blood
glucose levels
regularly and ● It
provide empowers
feedback as individuals
needed. to take
control of
their health
and reduce
Independent the risk of
intervention: complicatio
ns.
2. Verbalize a ● Educate the
dietary plan patient about
The client was
as modifying the
importance of able to
factors to
carbohydrates ● To make understand the
prevent or
minimize counting and informed importance of
complications. its roles in dietary meal planning to
diabetes choices. prevent or
management.
minimize
complications.
Dependent GOAL MET.
Intervention:
● Review the
patient’s
current
dietary intake ● To reveal
and identify potential
areas of areas for
improvement. modification
to align with
diabetes
managemen
t.
