Nursing Care Plan

Name of Patient: SM Age/Sex: 25/F Room/Bed#: 1

Chief Complaint: Gestational Diabetes Miletus Physician: Dr. Anna Ellena

Nursing Nursing
Date/Time Cues Need Objective of Care Evaluation
Diagnosis Interventions
A S: Verbalization H That within 1.) Establish
P of "Gi resetahan E Risk for injury 6hours of rapport GOAL MET
R man ko ug A r/t high nursing R- To gain 4/18/17
I insulin sauna L glucose level intervention, patient's trust 9pm
L kaso gistop T patient will and cooperation
18, nako" H R:Vulnerable be able to 2.)Assess and After 6hrs of nursing
2 Verbalization of for injury as a monitor for intervention, patient
0 "hilig ko pirmi P result of A.) signs of edema was able to
1 mukaon ug E environmental maintain R-Because of A.) Maintain VS
7 pansit ug rice" R conditions VS within vascular within normal range:
C interacting normal changes, the BP:120/80
@ O: E with the range diabetic client is Temp:36.6
VS: P individuals (RR-15-30, prone to excess CR:85
3 Temp: T adaptive and Temp-35.5- fluid retention PR:83
P 36.4degC I defensive 37, CR-80- and PIH RR:20
M CR:86bpm O resources, 120, BP- 3.)Monitor VS
PR:84bpm N which may 90/70- R-To establish B.) Client was able to
RR:19cpm compromise 120/80) baseline and to do activities of daily
BP:120/90mmH A health. detect sudden living for exercise
g N change in such as
D Reference: B.)Do client's ambulating/walking
Positive OGTT Leifer, activities of condition
result: H G.(2014). daily living 4.)Help patient C.)Client was able to
190.8mg/dL E Introduction to for exercise identify factors identify factors that
 A maternity and such as that may may aggravate
With Medication L pediatric walking aggravate gdm condition GDM such
-Calcium + Vit D T nursing 5th such as as high carbohydrate
H edition. C.) Identify uncontrolled diet as evidenced by
Elseveir; factors that food verbalization of the
M United States. may consumption client "gani control
A contribute R-Uncontrolled najud ko ani sa
N to the consumption pagkaon ug kanon"
A condition may result to
G and ways to unstable
E prevent glucose level
M progress of 5.) Teach
E condition patient to divide
N such as her
T controlling carbohydrate
carbohydrat intake
P es intake throughout the
A day
T R-
T All carbohydrat
E es will have an
R impact on your
N blood glucose
levels so be
aware of how
much you eat.
6.)Encourage
client to follow
treatment
regimen
R-Not following
treatment
regimen may
aggravate
condition
7.)Encourage
client to
ambulate and
do ROM
exercises
R-Exercise can
help lower
glucose
concentration
8.)Administer
meds as
ordered
R-to treat
underlying
condition

Reference:

Leifer,
G.(2014).
Introduction to
maternity and Michael E. Puente
pediatric Stn.
nursing 5th
edition.
Elseveir; United
States.