Cynthialyn Castro, 29 year old Female: with a Diagnosis of Pre-eclampsia severe, to consider diabetic, to consider Sub-involution

Anemia Secondary.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Knowledge Objective Independent Intervention: The patient is

Data: deficit To participate Assess Vital signs To determine the current able to verbalize
“Di ko alam related to in learning status of the patient. the
na diabetic lack of process. Explain to the client the procedure and To reduce anxiety of the understanding of
na pala ako. exposure to its purpose regarding to Capillary patient. individual
Ngayon lang the disease Short term Blood glucose. therapeutic
nung na secondary goal: interventions,
admit ako” as to Diabetes The patient Monitor the capillary blood glucose of To check the condition of medications and
manifested will be able to the patient. her diabetes. its purposes.
by the verbalize the
mother. understanding Instruct patient to fasting or maintain To avoid inaccurate Long term goal:
of individual NPO (nothing per orem) for 6 hours reading of the result. The patient will
Objective therapeutic prior to CBG (capillary blood glucose be able to
Data: interventions, measurement) verbalize her
Alert, medications understanding
conscious and its Instruct patient to avoid sugar-rich To prevent risk in regarding to rich
and able to purposes. foods (e.g. chocolate) hyperglycemia in iron Diabetic
sit and stand. diet
Long term Instruct patient to eat Iron rich foods To prevent anemia and to
Vital signs: goal: (e.g. liver or animal organs, egg, fish, help in producing more
T: 36.3’ C The patient poultry, leafy vegetables and dried red blood cells.
RR: 24 bpm will be able to fruits) for her anemia.
PR: 82 cpm verbalize her
BP: 120/80 understanding Give the importance of ambulation or To promote blood
mm Hg regarding to exercise. circulation.
rich in iron
Diabetic diet. Explain to the client facts, causes and To educate the client
information regarding to her disease. regarding to her status
Explain also the purpose of the and acquired disease.
treatment and therapeutic regimen
given by her doctor.

Provide Oral care For patient’s comfort

Instruct the Family to bathe the patient To provide optimal skin

every other day. care and comfort.

Dependent Intervention:
Give/administer medications as To promote wellness of
instructed by the doctor. the patient and to
stabilize her health.
Collaborative Intervention:
Refer patient to Med. Tech for For further evaluation
Laboratory Examination of her Hggt, and analysis of the
TID patient’s disease.