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James E.

Scales LPN Transition Class N1007 June 7th - June 13th Week 2 - Nursing Care Plan - Diabetes Ms. Ammie D. Humphrey

NURSING CARE PLAN Student Name: James E. Scales Patient Initials: T.A. Assessment Needs/Nursing Diagnoses Assessment:
Subjective: During discussion of blood sugar levels, patient became very defensive regarding questions about what he had eaten recently. Objective: Patient was observed eating potato chips and drinking a can of sprite in the waiting room. In addition, Patients blood sugar registered 505 once taken Short Term:
y Patient will describe the consequences of continued noncompliance with the treatment regimen y Patient will discuss feelings toward noncompliance with peer person y Student will increase understanding of the pathophysiology of diabetes and develop the skills necessary to manage diabetes. y Student will improve self-care management skills. y Make the Patient an active partner in his own healthcare management. y Treat him with respect, acknowledging his missteps. y Increase Patient perception of control over whether he follows the regimen. If the Patient feels respected and involved with the decision making, compliance will be better y Listen non-judgmentally y Embolden self control and self confidence y Attempted to discuss treatment regimen and expectations with client. y Monitor blood glucose levels at school y Arrange space and time for student to perform blood glucose levels, insulin injection, diet inventory and snack consumption. y Maintain blood glucose record and send to physician as needed y Hyperglycemia can cause water to be pulled from intracellular fluid and placed in the extracellular compartment, causing dilution of serum sodium. y Continued high blood sugar will result in poor turgor, dry membranes and excessive thirst, all could lead to dehydration. y Glucose has a high osmotic pull. Glucose levels needs to be reduced gradually for the fluid balance. y Patient able to maintain weight. y Intake equal to output y Membranes pink and moist, no discoloration y Patient able to state 3 signs of hyperglycemia y Patient states the importance of taking medications and proper diet. y Patient able to state 3 signs of hypoglycemia y Patient states when to take insulin in relationship to meals y Patient able to demonstrate appropriate techniques regarding rotation sites with each injection. y Will keep insulin in refrigerator.

Patient-Centered Goals

Room Number: N1007 Interventions

Date: 06/13/2011 Scientific Principle Evaluation

Physiological/psychological Needs
y Identify stresses that can interfere diet compliance y Eliminating anxiety, angry, and other factors which may contribute to noncompliance

Long Term:
y Patient will list treatment regimens and expectations and agree to follow through for the first 6 month, then revisit for follow up evaluation

Nursing Diagnosis
y Risk of Noncompliance y Risk of apathy toward compliance with diet regimen y Risk for infection due to high glucose levels which will provide medium for bacterial or fungal growth y Risk for delayed healing due to possible fluid imbalance and high glucose y Knowledge deficit related to prevention