NURSING CARE PLAN
ASSESSMENT
SUBJECTIVE:Complainin
g of her blood sugar levels
have been rising for the past
week. she noted polyuria,
polydipsia, and rising
fingerstick glucose values,
higher than 200 mg/dL.
She denies having any
fever, chills, cough, nasal
congestion, chest pain,
abdominal pain, or dysuria.
OBJECTIVE:Both her
parents had diabetes, and at
the time of her diagnosis
she weighed 278 pounds.
Four months later, with
weight loss and exercise,
her blood sugar levels were
consistently under 100
mg/dL, and metformin was
discontinued. She did well
until 1 week ago. She has
been eating well, with no
nausea, vomiting, or
symptoms of dehydration.
she has hypertension, for
OBJECTIVE OF CARE PLANNED RATIONALE IMPLEMENTATION EVALUATION
INTERVENTION
Goals Expected Outcomes
-Assess -Participates in the
-Determine client’s -Client may not be -Demonstrates basic After 8 hrs of nursing interventions,
readiness to learning process
readiness as well as physically, understanding to the patient was able to verbalize
learn and – exhibits signs of
his barriers to emotionally or Diabetes Mellitus type understanding of the disease process.
individual taking responsibility
learning. mentally capable at II. participates in the learning process
learning for own learning
-Look for signs of this time which – exhibits signs of taking
needs – verbalizes
avoidance to learn. will call for the responsibility for own learning by
understanding of
-Identify client’s need to reschedule asking questions
condition and
support person that diabetic health – verbalizes understanding of
treatment
may also need teaching plans. condition and treatment
– correlates signs
information about -Reflects the need – correlates signs and symptoms of
and symptoms of the
the planned diabetes to stress the the disease process and identify
disease process and
regimen. consequences that corresponding management
identify
may happen in lieu – perform demonstrated procedures
corresponding
of lack of correctly and explain reasons for
management
knowledge. actions
– perform
-Client’s support
demonstrated
persons like
procedures correctly
parents, spouse and
and explain reasons
caregivers also
for actions
need to be provided
with right
information as they
also take part in the
client’s treatment.
which she takes losartan
(Cozaar); hyperlipidemia, -Establish
for which she takes priorities in -Provide information -To prevent -Assist the client in
atorvastatin (Lipitor); and learning relevant only to the information establishing priorities in
gout, for which she takes situation. overload. learning.
allopurinol (Zyloprim). Her -Provide positive -This can
blood pressure is 148/70 reinforcement. encourage
mm Hg, pulse 100, and -Determine client’s continuation of
weight 273 pounds, and she most urgent learning efforts.
is afebrile. On examination, need both from the -Client’s and
her skin, head, eyes, ears, client’s and nurse’s nurse’s identified
nose, throat, lungs, heart, point of view. most urgent need
and abdomen are normal. may differ and
Urinalysis in the clinic require adjustments
shows large amounts of in teaching plan.
glucose and ketones

-Identify
teaching -Determine client’s -To personalize -Let the client perform
methods fit preferred method of teaching plan and and verbalize the
for the accessing facilitate learning promotion of wellness
client. information like or recall of in relation to individual
visual, auditory and information and community.
kinesthetic means. provided.
-Assist in mutual -Clarifies the
goal setting and expectations of the
learning contracts. learner and the
teacher.
-Promote
wellness -Provide information -For concerns and
on how to contact a clarifications post-
healthcare provider discharge.
after hospitalization. -For healthcare
-Educate about management
nearby community resources post-
resources or support discharge.
groups. -To assist with
-Educate about further learning and
additional learning promote client’s
resources like learning at own
diabetes care pace.
websites, videos, etc