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Palawan State University

COLLEGE OF NURSING AND HEALTH SCIENCES


Puerto Princesa City

NURING CARE PLAN


Name: Castaneda, Glenda A.
Age: 48 years old
Civil Status: Married
Address: Dagohoy, Narra, Palawan
Chief Complaint: + vomiting, weakness
Medical Diagnosis: Hyperosmolar, Hyperglycemia, DM2 uncontrolled

DOA: October 9, 2015


Ward: Female Medical Ward
Diet: Diabetic Diet
CI: Ma. Zendria Catacutan,RN,MSN
Attending Physician: Dr. Densen/ Dr. Acharon

Present Illness:
According to the patients husband, two hours prior to admission, around 2:00am, he arrived at home and when he was about to enter their room on the first
floor of their two story house, he heard his wife moaning and he saw Glenda on floor at sitting position and had already vomited and urinated. He asked Glenda of
what happened but she cannot speak clearly, she cannot even stand alone. He called his daughter on the second floor to ask for help. They just thought that Glenda
had hypoglycemic attack without checking her blood glucose level and so they had Glenda drank a half cup of Milo with two table spoons of sugar as an emergency
management. Then, they borrowed a tricycle from their neighbor and went to Ospital ng Palawan for medical help. They arrived at Ospital ng Palawan emergency
room around 4:00 am. A blood test was done and so they found out that the patient didnt experienced hypoglycemia but a hyperglycemia with a blood glucose level
of 206 mg/dL. Then, she was admitted in the female medical ward.
Past Health History:
The patient had experienced childhood illnesses such as chicken pox and measles. She also experienced cough, common colds and fever and she would take
over-the-counter drugs for his therapeutic regimen. They have heredofamilial disease such as diabetes, her mother also had diabetes and she herself was diagnosed
with diabetes last 2004. She was taking insulin therapy before but she was fed up and stopped the therapy about several months ago. This was her second
hospitalization, her first was last 2013 when she had hypoglycemic attack with her blood glucose level of 25 mg/dL and she was admitted at Cooperative Hospital.
She had no known food and drug allergies.

NURSING CARE PLAN


ASSESSMENT
Subjective cues:
Nakita ko sya sa
sahig kaninang
madaling-araw,
nakaihi na at sumuka.
Objective cues:
Diaphoresis
Skin warm to
touch
Dry skin
Drowsy
Weakness
Polyuria
Elevated
temperature38.1C
Hyperventilation
Increased
respiratory rate30 cpm
BP: 140/100
Contraptions:
PNSS 1L x 8h @
350cc 42 gtt/min

DIAGNOSIS

RATIONALE

PLAN

INTERVENTION

Hyperthermia r/t
dehydration 2
hyperglycemic
hyperosmolar
nonketotic syndrome

Vomiting and polyuria

STG:
At the end of 2 hours
nursing intervention,
patient will be able to
maintain body
temperature within
normal range between
36.5-37.5C

Independent:
1. Monitor axillary
temperature every
15 minutes, until
stable, then every
1-2 hours.
2. Monitor hear rate
and rhythm.

Excessive loss of body


fluids

Alteration in
maintaining normal
boy temperature

Increased body
temperature

Hyperthermia

LTG:
At the end of 8 hours
nursing intervention,
patient will be free of
complications such as
seizure activity.
3. Promote surface
cooling by means
of changing lighter
clothes, fan, TSB.
4. Encouraged fluid
intake and
regulated and
monitored IV
fluid.
5. Encouraged to
take adequate rest

RATIONALE

1. Monitors
effectiveness of
treatment.
2. Dysrhythmias are
common due to
electrolyte
imbalance,
dehydration, and
direct effects of
hyperthermia to
blood and cardiac
tissues.
3. Promote heat loss
by radiation,
conduction
convection and
evaporation.
4. To support
circulating volume
and tissue
perfusion.

5. To reduce

EVALUATION

Body temp-37.0C
RR- 24 cpm
BP- 130/100
-no complications

period.
Dependent:
6. Administered
paracetamol as
prescribed by the
physician.

Submitted by: Dhonabelle Vanessa F. Adona

metabolic
demands/oxygen
consumption.
6. Aids in reducing
fever.