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Nursing Diagnosis # 1: Ineffective Tissue Perfusion related to interruption of blood flow secondary to Hypertension and Diabetes Mellitus Type

2 as evidenced by cyanosis and poor capillary refill Goal: to improve circulation Expected Outcomes: At the end of 8 hours of nurse client interaction, the client should be free from signs of ineffective tissue perfusion as manifested by: Demonstrate behaviors/lifestyle changes to improve circulation Demonstrate increased perfusion as individually appropriate Participate in measures to correct/compensate for defects Interventions Evaluation Promotive/Preventive
Vital Signs Blood pressure Pulse Rate Respiratory Rate Temperature 120/80 mmHg 70 bpm 20 cpm 36C

o Monitored vital signs. Rationale: to assess patients condition

o Patient has Diabetes Mellitus Type II and history of Guillane Barre Syndrome o Determined factors related to individual situation. Rationale: to assess causative/ o Creatinine Dec.21, 2011: 4.46mg/dL (N.V. 0.50-0.95 mg/Dl) o BUN Dec. 21, 2011: 40.74 mg/dl (N.V. 8-23 mg/dL);

contributing factors o Reviewed laboratory studies. Rationale: to provide objective data

regarding nutritional status

o (+) cyanosis, (+) cold clammy skin, (+) poor capillary refill

o Inspected for pallor, cyanosis, mottling, clammy skin etc Rationale: to note strength of peripheral pulses.

o Patient is under Low Salt, Low Fat, Low Cholesterol diet

o Provided for diet restrictions providing adequate calories Rationale: to meet the bodys needs.

while

o Patient was able to fully rest and sleep.

Nursing Diagnosis # 2: Imbalanced Nutrition: More than body requirements related to excessive food intake as evidenced by overweight Goal: To correct metabolic abnormalities Expected Outcomes: At the end of 8 hours of nurse client interaction, the client should be free from signs of Imbalanced Nutrition: Less than body requirements, as manifested by: ingestion of appropriate amounts of calories or nutrients verbalize understanding on the importance of proper diet enumerate foods to be excluded /included in her diet Interventions Evaluation Promotive/Preventive o Establish rapport. Ascertain understanding of individual nutritional needs Rationale: monitor patients condition
Vital Signs Blood pressure Pulse Rate Respiratory Rate Temperature 120/80 mmHg 70 bpm 20 cpm 36C

o Determine the clients attitude towards eating Rationale: Psychological factors towards eating may affect one persons appetite and also to know the clients eating habits. o Ascertain clients diet Rationale: To achieve health needs of the patient with the proper food diet for her disease o Instructed the client to follow the prescribed number of servings in her diet Rationale: to identify deficit and deviations from therapeutic needs

o (+) good appetite

o Patient is under low salt low fat, low cholesterol diet

o Added to diet specification: 0.8 grams protein, 2 grams sodium, 2 grams potassium and low phosphorus

Nursing Diagnosis # 3: Risk for Unstable Blood Glucose related to poor compliance manifested by frequent heavy meals Goal: To maintain normal blood glucose levels Expected Outcomes: At the end of 8 hours of nurse client interaction, the client should: Have normal blood glucose levels Have proper diet Proper diet Interventions Evaluation Promotive/Preventive o Monitor patients blood glucose level. Rationale: to assessed patients condition
Vital Signs Blood pressure Pulse Rate Respiratory Rate Temperature 120/80 mmHg 70 bpm 20 cpm 36C

o Determine the clients attitude towards eating Rationale: Psychological factors towards eating may affect one persons appetite and also to know the clients eating habits. o Ascertain clients diet Rationale: To achieve health needs of the patient with the proper food diet for her disease o Instructed the client to follow the prescribed number of servings in her diet Rationale: to identify deficit and deviations from therapeutic needs Rehabilitative o Encouraged frequent monitoring of blood glucose. Rationale: to monitor patients condition o Instructed on activities that help control blood glucose Rationale: to monitor patients condition o Emphasized the importance of balanced diet and drug compliance for effective management of blood glucose level. Rationale: to monitor patients condition

o (+) good appetite

o Patient is under low salt low fat, low cholesterol diet o Added to diet specification: 0.8 grams protein, 2 grams sodium, 2 grams potassium and low phosphorus

Patient appreciated the health teachings.