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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
Rationale
Evaluation
Short term
After 4 hours of nursing
intervention the client
is able to demonstrate
willingness
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.
dependent
ACTUAL
partially
ineffective
outcomes
ACTUAL
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
rationale
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.
dependent
8.) administer Apidra if
CBG in above 181
mg/dl
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
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
1.)Identify risk
factors in clients
personal and family
history
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;
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
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
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
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
Uncontrolled
DM