Bulacan State University

COLLEGE OF
NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: Age: 34 Gender: F Date Handled: March 15, 2024

Medical Diagnosis: Gestational Diabetes Mellitus Clinical Area: R. De C. Galvez Medical Center
Chief Complaint: Increase of body weight

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Disturbed Body Image in Short Term Goal: Independent: Short Term Goal:
“Ako’y nag-aalala sa relation to alteration to After 8 hours of nursing After 3 hours of nursing
pagtaas ng aking self- perception as interventions, the client ➣ Determine client’s view of being ➣ Mental image includes our ideal interventions, the goals were:
timbang” as verbalized evidenced by reporting will be able to: overweight or “fat” and what it and is usually not up- to-date. She or
by the client. negative feelings does for the individual. he may experience mixed feelings of Met
towards body ➣ Verbalize an fear and shame or compensate for Partially Met
Objective: understanding of psychological trauma by developing Unmet
body changes a strong or “big” personality.
 Weight: 80 kg. As evidenced by:
 Height: 1.60 m ➣ Recognize and ➣ Determine client perception of ➣ Client’s perception of what ➣ The patient was able to
 BMI: 31.25 incorporate body image threat to self. problem weight poses are more verbalize an understanding
 Temp: 36.6 C change into self-concept important than what the threat really of body changes
 BP: 120/80 in an accurate manner is and needs to be dealt with before
(mmHg) without negating self- reality can be addressed. ➣ The patient was able to
 HR: 104 (bpm) esteem recognize and incorporate
 RR: 22 (rpm) ➣ Promote open communication, ➣ Providing open communication body image change into self-
 Gestational ➣ Seek information and avoiding criticism or judgment and an environment that is free from concept in an accurate manner
Diabetes actively pursue growth. about client’s behavior. without negating self-esteem
judgement will allow the patient to
Mellitus
feel more comfortable and will
 Obesity Long-Term Goal: ➣ The patient was able to seek
increase the patient’s sense of
After 7-10 days of nursing control and willingness to engage in information and actively pursue
interventions, the client will activities with the nurse. growth.
be able to:
➣ Outline and clearly state ➣ It is helpful for each individual to Long-Term Goal:
➣ Verbalize acceptance of responsibilities of client and nurse. understand area of own responsibility After 7-10 days of nursing
self in a situation in the program so that interventions, the goals were:
misunderstandings do not arise.
➣ Verbalize relief of anxiety Met
 and adaptation to ➣ Encourage client to use imagery ➣ Mental rehearsal is very useful in Partially Met
actual/altered body image to visualize self at desired weight. helping the client plan for Unmet
and deal with anticipated change in
self- image As evidenced by:
➣ The patient verbalized
➣ Advise a moderate physical ➣ Exercise helps in maintaining acceptance of self in a situation
activity as per obstetric guidelines blood glucose levels
➣ The patient verbalizes relief of
anxiety and adaptation to
Collaborative: actual/altered body image

➣ Refer to community support ➣ Weight- loss groups can provide

and/or therapy group companionship, enhance motivation,
decrease loneliness and social
ostracism, and give practical
solutions to common problems.
Group therapy can be helpful in
dealing with under lying
psychological concerns.

Student’s Name: Yr&Sec/Group No.

 Bulacan State University
COLLEGE OF
NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: Age: 34 Gender: F Date Handled: March 15, 2024

Medical Diagnosis: Gestational Diabetes Mellitus Clinical Area: R. De C. Galvez Medical Center
Chief Complaint: Increase of body weight

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for unstable blood Short Term Goal: Independent: Short Term Goal:
“Madalang lang ako glucose level in relation to After 8 hours of nursing After 3 hours of nursing
makapag-check ng gestational diabetes interventions, the client ➣ Determine factors that increase ➣ Lack of access to medications, interventions, the goals were:
sugar level dahil na mellitus as evidenced by will be able to: the risk of unstable glucose over or undereating, morbid obesity,
rin sa kakulangan ng inadequate blood glucose lack of exercise or overexercising, Met
pera” as verbalized by monitoring ➣ Identify factors that growth spurts in adolescence, and Partially Met
the client. lead to unstable glucose pregnancy are common causes of Unmet
unstable glucose.
Objective: ➣ Demonstrate proper As evidenced by:
technique for monitoring ➣ Assess if the patient has a ➣ GDM can occur in women ➣ The patient was able to identify
 Weight: 80 kg. blood glucose level history of diabetes prior to without a history of diabetes pre- factors that lead to unstable
 Height: 1.60 m pregnancy. pregnancy glucose
 BMI: 31.25 ➣ Verbalize plan for
 Gestational modifying factors to prevent ➣ Assess the patient’s ➣ Allow time for open-ended ➣ The patient demonstrated
Diabetes or minimize complications understanding of their disease questions and discussion to assess the proper technique for
Mellitus patient’s knowledge of diabetes. This monitoring blood glucose level
 Obesity ➣ Blood Glucose reading of allows the nurse to assess for a
 10.6 (mmol/L) less than 180 mg/dL knowledge deficit and educate ➣ The patient verbalizes plan for
 Inadequate accordingly. modifying factors to prevent or
Blood Glucose Long-Term Goal: minimize complications
Monitoring After 5-7 days of nursing ➣ Discuss any concerns that the ➣ Anxiety and stress are quite
interventions, the client will patient may have related to her common in pregnant women and ➣ Blood Glucose reading less
be able to: condition. they usually have a lot of questions. than 180 mg/dL
Taking time to discuss these
➣ Maintain blood glucose in concerns can help identify the areas Long-Term Goal:
satisfactory range that need further teaching and After 5-7 days of nursing
discussion. interventions, the goals were:
➣ Increase frequency in
 blood sugar monitoring ➣ Review client’s dietary program ➣ Identifies deficits and deviations Met
and usual pattern; compare with from therapeutic plan, which may Partially Met
recent intake. precipitate unstable glucose and Unmet
uncontrolled hyperglycemia.
As evidenced by:
➣ Perform blood glucose testing. ➣ All available glucose monitors ➣ The patient was able to
will provide satisfactory readings if maintain blood glucose in
properly used and maintained and satisfactory range
routinely calibrated.
➣ Increased frequency in blood
➣ Maintain blood glucose ➣ Regular monitoring helps in sugar monitoring
monitoring by also teaching the maintaining glycemic control and
patient how to monitor blood adjusting treatment.
glucose level and maintains a log

➣ Educate on signs and symptoms ➣ To prevent further complication

of hyperglycemia/hypoglycemia and determine appropriate treatment.

➣ Advise a moderate physical ➣ Exercise lowers glucose and

activity as per obstetric guidelines makes the body more sensitive to
insulin.

Dependent:

➣ Monitor the patient’s HbA1c- ➣ To determine how well the

glycosylated hemoglobin. diabetes has been controlled over the
last few months

➣ Administer medication as ➣ To cure or treat the condition and

ordered to get the desired outcomes for the
patient

Collaborative:

➣ Refer to nutritionist or dietician ➣ Dieticians can instruct on specific

dietary changes and provide
resources on which foods to eat,
what
to limit, and how to read food labels.

Student’s Name: Yr&Sec/Group No.