CHAPTER 5 : Nursing Care Management

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

Subjective Data:
October 3 gidala ko sa
ako friend diri sa hospital
kay luya daw kaayo akong
nawong, ug kapoy sab ang
paminaw nako sa akong
lawas. Wala naman gani
ko namista pag petsa 4 kay
gi admit naman ko, as
verbalized by the pt.
Risk for - After 8 hours of Assess for signs of -After 8 hours of nursing
Unstable nursing intervention the hyperglycemia. interventions, the patient
Blood Glucose patient will understand was able to identify the
the signs and sypmtoms Assess the patients signs and symptoms of
of hyperglycemia and current knowledge and hyperglycemia
she will take her understanding about -the patient understand
medications religiously the prescribed diet. the importance of taking
to avoid episodes of the medication.
condition.
Assess the pattern of
physical activity.

Report BP of more than

Objective Data: 160 mm HG (systolic).
Administer hypertensive
Vital Signs: as prescribed.
T 36.7 C
P 90 bpm
R 19 bpm Assess feet for
BP 140/80 mmHg temperature, pulses,
color, and sensation.
Assessment :
- Weak
- distress
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

Laboratory Result: Risk for After 8 hours of Observe for the signs of After 8 hours of
Infection nursing infection and nursing
WBC : 11.97 inerventions, the inflammation: fever, interventions, the
HGB : 131 g/l patient will flushed appearance, patient was able
HCT : 38.4 % identify wound drainage, purulent to identify
PLT : 343 interventions to sputum, cloudy urine. interventions, to
BUN : 16 mg/dl prevent or reduce prevent or
Sodium : 140 mg/d risk of infection. Teach and promote reduce risk for
Potassium : 3.4mg/dl good hand hygiene. infection.
Calcium -: 8.2mg/dl
FBS : 368.22 Maintain asepsis during IV
HbA1C : > 14 insertion, administration of
CREATININE : 0.74 mg/dl medications, and providing
wound or site care. Rotate
IV sites as indicated.

Provide tissues and trash

bag in a convenient
location for sputum and
other secretions. Instruct
patient in proper handling
of secretions.

Encourage adequate
dietary and fluid intake (
approximately 3000 ml/day
if not contraindicated by
cardiac or renal
dysfunction), including 8 oz
of cranberry juice per day
as appropriate.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

Deficient After 8 hours of Explain that long-acting After 8 hours of

Knowledge nursing insulin (Lantus)only nursing
interventions need to be injected interventions, the
the patient will once or twice daily. patient will be
demonstrate able to identify
knowledge of Teach patient to rotate the interventions
insulin injection, insulin injection sites. to prevent
symptoms and hypoglycemia.
treatment of Teach patient to follow
hypoglycemia a diet that is low in
and diet. simple sugars, low in fat,
and high fiber and
whole grains.

Teach patient that

anxiety, tremors, and
slurred speech are signs
of hypoglycemia.

Teach patient to treat

hypoglycemia with
crackers, a snack.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

 Risk for Injury After 8 hours Assess the general After 8 hours of
of nursing appearance of the nursing
interventions, foot. interventions the
the patient will Assess the status of patient will be
be free of the nails. able to identify
injury to feet Instruct the patient to interventions to
and the trim nails straight reduce risk for
principle of across and to file injury to feet and
hygiene to sharp corners to principle of
feet. match the contour of hygiene.
the toe.
Instruct the patient in
the principle of
hygiene: wash the
feet daily in warm
water using mild soap;
avoid soaking the
feet. Dry carefully and
gently, especially
between toes. Use
moisturizing lotion at
least once daily. Avoid
the area between the
toes.
Instruct patient to
always wear
protective footwear;
never go barefoot.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

 Fatigue After 8 hours Discuss with patient After 8 hours of nursing
of nursing the need for activity. interventions, the patient
interventions, was able to identify
the patient will Increase patient interventions for ADLs.
be able to participation in ADLs
identify the as tolerated.
need for
activity . Assess response to
activity.

Discuss with patient

the need to activity.

Instruct patient to
perform deep
breathing exercises

Provide comfort and

safety measures.