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NCP-diabetes mellitus

NCP-diabetes mellitus

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Published by junard
ncp of my care study diabetes mellitus
ncp of my care study diabetes mellitus

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Categories:Types, Research, Science
Published by: junard on Oct 18, 2010
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10/24/2013

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APPENDIX D:
NURSING CARE PLAN
Patient¶s Name : M.F.T. Hospital No. : 100022598622Age : 41 years old Room No. : 6B-654Impression/ Diagnosis : Hyperglycemia-Type II Diabetes Mellitus with Essential HypertensionPhysician : Dr. Albert Lim Rafaran
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 CLINICAL PORTRAIT PERTINENT DATA
Received patient lying on bed, awake, responsive, afebrile, coherent, with easerespirations and shows willingness to participate in assessment process, with PNSSinserted @ left hand infusing well @ 80 cc/hr.Significant findings noted are as follow:
 
Patient seems to be always tired.
 
Patient takes most of the time sleeping.
 
Patient has a family member with diabetes mellitus.
 
Patient loves to eat sweet foods.
 
Patient tends to use sodas and sweet juices as water substitute.Vital signs taken are as follows:BP: 130/70 mmHg HR: 87 bpmTEMP: 36.3 ºC RR: 17 cpmPAIN: 0HPI:3hrs PTA, patient complains of polyuria and severe headache, thus brought them tovisit Chong Hua Emergency Department. In the emergency department, patient came polydipnic, polyphagic, polyuric with volvovaginal itcheness.CHIEF COMPLAINS:Patient¶s chief complaints are weight loss, and blurring of eye vision.VITAL SIGNS:BP: 140/80 mmHg RR: 20 cpm height: 157 cmTEMP: 36.5 ºC HR: 98 bpm weight: 81.1 kgHEALTH HISTORY RELATED TO PRESENT ILLNESS:Patient¶s father is positive for diabetes mellitus making her a positive recipient of thisdisease. The patient¶s lifestyle is slightly sedentary adding the possibility of having thedisease. On the other hand, patient enjoys eating sweet foods and uses sweet sodas and juices as substitute for water giving her a big chunk to have the disease.
 
CUES NURSINGDIAGNOSISSCIENTIFICBASISGOAL & OUTCOMECRITERIA NURSINGACTIONS & NURSINGORDERSRATIONALE OF NURSINGORDERSEVALUATION
S-³Pirme lang gamayakong makaon diri kaydili jud ko ganahan satimpla sa mga pagkaonnga i-rasyon.´ asverbalized by the patient.O-
 
W
eight loss
 
Lethargic
 
W
eak 
 
Vital signs takenas follows:BP: 130/70 mmHgTemp: 36.3 ºCHR: 87 bpmRR: 17 cpm
W
t: 78 kg from81.1 kgImbalance Nutrition: Lessthan bodyrequirementsrelated tounwillingness toeat.Adequate nutrition isnecessary to meet the body¶s demand. Nutritional status can beaffected by disease or injury state.In the case of my patient, her imbalancednutrition is due to her unwillingness to eat dueto unusual taste.Because of her medicalcondition, food preparations arechanged appropriate for her, but the change intaste is not easilymasked by the patient.(Gulanick/Myers; 2007; p. 134)After 3 days of nurse-patientinteraction, the patient will be able to demonstrate behaviour, lifestyle changesto regain appropriate weight.Specifically the patient will be able to:1)
 
Verbalizeunderstanding withcausative factors whenknown and necessaryintervention.The nurse will assistthe patient indemonstrating behaviour, lifestylechanges to regainappropriate weight.The nurse will:a)
 
Ascertainunderstanding of individual nutritionalneeds. b)
 
Discuss eating habitsincluding food preferences,intolerance andaversion.c)
 
Promote pleasantrelievingenvironmentincludingsocialization when possible.To determineinformational needs of the patient. ( Doenges,Morrhouse,Murr; 2009; p. 565)To appeal to client¶stasks. ( Doenges,Morrhouse, Murr; 2009; p. 565)To enhance intake.( Doenges,Morrhouse, Murr;2009; p. 565)GOAL METPatient was able todemonstrate behaviour, lifestylechanges to regainappropriate weight.GOALPARTIALLY METPatient was able to partiallydemonstrate behaviour, lifestylechanges to regainappropriate weight.GOAL NOT METPatient was notable to demonstrate behaviour, lifestylechanges to regainappropriate weight.
47
 
 
2)
 
Demonstrate progressive weightgain toward goal.3)
 
To promote wellnessafter interventions has been done.a)
 
Assess weight,measure or calculate body fat. b)
 
Evaluate total dailyfood intake.c)
 
Encourage clientto choose food or have familymember to bringfood that seamsappealing.a)
 
W
eight at regular intervals anddocument results. b)
 
Consult withdietician andnutritional supportteam as necessary.c)
 
Refer to homehealth resources.To establish baseline parameters.( Doenges, Morrhouse,Murr; 2009; p. 565)To reveal possible causeof malnutrition changesthat could be made inclient¶s intake. (Doenges, Morrhouse,Murr; 2009; p. 566)To stimulate appetite. (Doenges, Morrhouse,Murr; 2009; p. 567)To monitor effectivenessof dietary plan.( Doenges, Morrhouse,Murr; 2009; p. 568)To have an accuratedietary intake for longterm needs. ( Doenges,Morrhouse, Murr; 2009; p. 568)For initiation andsupervision of homenutrition therapy whenused. ( Doenges,Morrhouse, Murr; 2009; p. 569)
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