Name: IEC

Age: 83 y/o

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

S> Risk for unstable Short Term:
blood glucose After 2 hours of nursing
O> Continuous related inadequate intervention the client will
intake of blood glucose be able to:
medication monitoring and -Verbalize understanding of
medication body and energy needs.
management. - Acknowledge factors that
may lead to unstable
glucose.
Long Term:
After 3 days of nursing
intervention the client will
be able to:
- Verbalize plan for
modifying factors to
prevent/minimize shifts in
the glucose level.
-Maintain glucose in
satisfactory range.
Independent:
-Determine individual factors
that may contribute to
unstable glucose.
-Ascertain whether client/SOs
are adept at operating client’s
home glucose monitoring.
-Provide information on
balancing food intake,
antidiabetic agents, and energy
expenditure.
-Discuss home glucose
monitoring according to
individual parameters.
-Client or family history of
diabetes; known diabetic with
poor glucose control; eating
disorders; poor exercise habits.
-All available machines will
provide satisfactory readings if
properly used and maintained and
routinely calibrated.
-To assist client to develop
preventative strategies to avoid
glucose instability.
-To identify and manage glucose
variations.
Goal was met,
After 2 hours of nursing
intervention the client was be
able to:
-Verbalize understanding of
body and energy needs.
- Acknowledge factors that may
lead to unstable glucose.
After 3 days of nursing
intervention the clienasill be
able to:
- Verbalize plan for modifying
factors to prevent/minimize
shifts in the glucose level.
-Maintain glucose in
satisfactory range.

-Review client’s diet especially -Glucose balance is determined by

carbohydrate intake. the amount of carbohydrates
consumed, which should be
determined in needed grams/day.
 -Encourage client to read labels -These foods produce a slower rise
and choose foods prescribed as in blood glucose.
having low glycemic index (GI),
higher fiber, and low fat
content.

-Discuss how client’s

antidiabetic medications work.
-Drugs and combinations of drugs
work in varying ways with
different blood glucose control
and side effects. Understanding
drug actions can help client
avoid/reduce risk of potential for
hyperglycemic reactions.

Name: IEC
Age: 83 y/o

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

S> Risk for infection Short term: Independent: Goal was met,
related to After 1 hour of nursing Note risk factors for occurrence -To assess causative/contributing After 1 hour of nursing
inadequate primary intervention the client will of infection (extremes of age, factors. intervention the client was be
defenses (broken be able to: skin/tissue wounds, able to:
O> foot ulcer at skin) as manifested -verbalize understanding of immunocompromised host). -verbalize understanding of
the right foot by foot ulcer at the individual causative/risk individual causative/risk
right foot. factors. -Observe localized signs of factors.
-Identify interventions to infection at wounds. -Identify interventions to
prevent/reduce risk of -To assess causative/ prevent/reduce risk of
infection. -Change wound dressings, as contributing factors. infection.
indicated using proper
Long Term: technique for
After 2 days of nursing changing/disposing of -To reduce/correct existing risk After 2 days of nursing
intervention the client will contaminated materials. factors. intervention the client was able
able to: to:
-Demonstrate techniques, -Review individual nutritional -Demonstrate techniques,
lifestyle changes to needs, appropriate exercise lifestyle changes to promote
promote safe environment. program, and need for rest. safe environment.
-Achieve timely wound -Achieve timely wound healing;
healing; be free of purulent -Instruct client/SOs in be free of purulent drainage or
drainage or erythema; be techniques to protect the -To promote wellness. erythema; be afrebrile.
afrebrile. integrity of skin, care for
lesions, and prevention of
spread of infection.

-Emphasize necessity of taking

antivirals/antibiotics, as -To promote wellness.
directed.

-Discuss importance of not

 taking antibiotics/using -Premature discontinuation of
“leftover” drugs unless treatment when client begins to
specifically instructed by feel well may result in return of
healthcare provider. infection and drug-resistant strain.

-Inappropriate use can lead to

development of drug resistant
strains/secondary infection.

Name: IEC
Age: 83 y/o

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

S> “Medyo Deficient knowledge Short Term: Independent: Goal was met,
madami na (Learning Needs) After 2 hours of nursing -Determine client’s -Individual may not be physically, After 2 hours of nursing
akong regarding disease intervention the client will ability/readiness and barriers emotionally or mentally capable intervention the client wasl be
nararamdaman, process/treatment be able to: to learning. of this time. able to:
namamanhid and individual care -Verbalize understanding -Verbalize understanding of
ung mga kamay needs related to of condition/disease -Client may need to suffer condition/disease process and
ko, ganun ba unfamiliarity with process and treatment. consequences of lack of treatment.
talaga?” as information/lack of -Participate in learning -Be alert to sign of avoidance. knowledge before he or she is -Participate in learning process.
verbalized by recall as evidenced process. ready to accept information. -Exhibit increased
the client. by request for -Exhibit increased interest/assume responsibility
information. interest/assume -To determine other factors for own learning by beginning to
O> inaccurate responsibility for own pertinent to the learning process. look for information and ask
follow-through learning by beginning to questions.
of look for information and -Note personal factors
instruction/perf ask questions. (age/developmental level,
ormance test. gender, social/cultural
Long Term: influences, religion, life After 3 days of nursing
After 3 days of nursing experiences, level of education, intervention the client was be
intervention the client will emotional stability). able to:
be able to: -To prevent overload. -Identify relationships of sign
-Identify relationships of -Provide information relevant and symptoms to disease
sign and symptoms to only to the situation. process and correlate symptoms
disease process and -Can encourage continuation of and causative factors.
correlate symptoms and -Provide positive reinforcement efforts. -Perform necessary procedures
causative factors. and avoid negative reinforces. correctly and explain reasons for
-Perform necessary -State objectives clearly in -To meet learner’s need. actions.
procedures correctly and learner’s terms. -Initiate necessary lifestyle
explain reasons for changes and participate in
actions. -Determine client’s method of --To facilitate learning/ recall. treatment regimen.
-Initiate necessary lifestyle accessing information (visual,
changes and participate in auditory, kinesthetic, and
treatment regimen. gustatory/ olfactory) and
includes teaching plan.
 -Use short, simple sentences
and concepts. Repeat and
summarize as needed. -To facilitate learning.

-Begin with information the

client already knows and move
to what the client not know,
progressing from simple to -Can arouse interest/limit sense
complex. of being overwhelmed.

NURSING PRIOPRIZATION:

NURSING DIAGNOSIS PRIORITY RATIONALE

 1. Risk for unstable blood glucose related inadequate
blood glucose monitoring and medication
management.
2. Risk for infection related to inadequate primary
defenses (broken skin) as manifested by foot ulcer
at the right foot.
CONCLUSION:
High Priority It is considered as high priority because according to ABCs
of life, excessive glucose from the blood can affect
the circulation of the blood throughout the body. Thus
affecting the homeostasis. The blood cannot give
sufficient amount of blood especially in the peripheral
area.
Medium Priority It is considered as a medium priority because according to
the Maslow’s hierarchy of needs physical aspects of an
individual belong to safety and security needs, which
is the second level. Skin is a large part of it. This is the
reason why it is considered as a medium priority.
 Diabetes mellitus, often simply referred to as diabetes—is a group of metabolic diseases in which a person has high blood sugar, either because the body does not
produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination),
polydipsia (increased thirst) and polyphagia (increased hunger).

In making this case study, we really appreciated how vital our organs are, we need to be careful of doing action because it may affect our life. Diabetes mellitus is a very
complex disease process if not treated appropriately. It can be lessen by having an appropriate and by controlling our lifestyle, correct diet, and the avoidance to the factors that
can be worsen its condition like smoking.

We have concluded in making this case study that we can avoid this kind of disease by taking care of our body. Everything that is too much is bad. Through this case
study we learned many things that are necessary and have a relevance to our future career.