Date and Cues Need Nursing Objective of Nursing Intervention Evaluation

Time Diagnosis Care

S: P Imbalanced Short term: Independent: Short term:
Client’s son H nutrition: After 8 hours After 8 hours of
verbalized that client Y Less than of nursing -Discuss eating habits and encourage a nursing
was diagnosed with S body intervention, diabetic diet as prescribed. intervention, Goal
Diabetes Mellitus I requirements the client is R: To achieve health needs of the patient was partially met
Type II 15 years ago O related to expected to: with the proper food diet for her condition. as evidenced by:
L insulin
O: O deficiency as -Ingest -Observe signs of hypoglycemia: -Willingness to
Diagnostic test G evidenced appropriate changes in LOC, cold and clammy skin, cooperate of client
results: I by weakness amounts of rapid pulse, hunger, irritability, anxiety, is present during
C and FBS of calories and headache, lightheadedness, and health teaching,
FBS – 7mmol/L NEED 7mmol/L nutrients, shakiness.
HbA1C- 6.5% and HbA1C R: Hypoglycemia can occur once blood -Usual energy
Homeostasis of 6.5%. -Display usual glucose level is reduced and carbohydrate increased but not
energy levels, metabolism resumes and insulin is being back to usual
R: Type II and given. levels, and
Diabetes
occurs as -Demonstrate Dependent: -Client was
insulin stabilized cooperative in
production weight or gain -Administer Metformin 500mg/tab stabilizing her
continue to toward usual twice a day as ordered by physician. desire to reach
decrease as or desired R: Metformin decreases the hepatic glucose normal laboratory
body range with production which decreases the values.
resistance to normal gastrointestinal glucose absorption to
insulin laboratory increase cell insulin sensitivity.
increases after values.
 an excess in Long term: Collaborative: Long term:
insulin After 2 to 3 After 3 days of
production in days of -Assist in minimal walking while nursing
the pancreas nursing avoiding the stairs as ordered. intervention, goal
fails to move intervention, R: Walking improves glucose control and was met as
glucose into the client exercise helps the muscle absorb blood sugar evidenced by:
the cells for manifests: while preventing glucose buildup in the
fuel. This bloodstream -FBS – 5.6mmol/L
leads to an -Prediabetes to
increase of normal FBS -HbA1C – 5.9%
glucose level values
in the body.
-Prediabetes to
-healthline, normal HbA1C
2017 values

Date and Cues Need Nursing Objective of Nursing Intervention Evaluation

Time Diagnosis Care
S: P Fatigue Short term: Independent: Short term:
Report of non- H related to After 4 hours of After 4 hours of
productive cough, Y Class III nursing -Assess vital signs q4 hours. nursing
hypotension, and S heart failure intervention, R: To evaluate fluid status and intervention, Goal
tachycardia upon I as evidenced the client is cardiopulmonary response to activity was met as
admission. O by expected to evidenced by:
L cardiomegal participate in -Determine presence of degree of sleep.
O: O y with LR activities that R: Fatigue can be a consequence of sleep -Client was able to
Bipedal edema G ventricular reduce the deprivation participate in
I hypertrophy workload of activities that
VS: C the heart Dependent: reduce heart
RR – 23CPM NEED R: Heart workload and
failure is Long term: -Administer Digoxin 0.25μg once a day willing to apply
Diagnostic test Rest and described as After 2 to 3 as ordered by physician. health teachings.
results: Sleep the inability of days of nursing R: Digoxin increase the force of myocardial
BNP: 453pg/mL the heart to interventions, contraction which increases cardiac output Long term:
Troponin (+) support the the patient will and lowers heart rate. After 3 days of
Potassium – 2.9mEq organs and be able to nursing
Cardiomegaly with tissues for display Collaborative: intervention, goal
LR ventricular oxygen and stability in was met as
hypertrophy nutrients. hemodynamics -Administer oxygen @3Lpm via nasal evidenced by:
This leads to a . cannula.
decreased R: O2 administration improves -RR – 17CPM
cardiac output oxygenation of diseased myocardial tissue
which renders which prevents problems caused by low
the amount of oxygen such as damages to the heart and
blood that the the brain.
heart pumps
 be inadequate
to circulate
the blood
returning to
the heart from
the body and
lungs. This
inadequacy of
oxygen and
nutrients then
causes
impaired
bodily
functions and
fatigue.

-MedicineNet,
2020

Date and Cues Need Nursing Objective of Nursing Intervention Evaluation

Time Diagnosis Care
S: P Excess fluid Short term: Independent: Short term:
Client’s son H volume After 4 hours of After 4 hours of
verbalized that client Y related to nursing -Monitor and calculate 24-hour intake nursing
was diagnosed with S reduced intervention, and output balance intervention, Goal
hypertension 6 years I glomerular the client is R: Diuretic therapy may result in sudden was met as
ago. O filtration expected to: increase in fluid loss even though edema or evidenced by:
L (decreased ascites remains.
O: O cardiac -Participate in -Client was
Presence of fluid in G output) as diet and fluid -Evaluate urine output in response to participative in
lower lung fields I evidenced by restrictions. diuretic therapy diet and fluid
Bipedal edema grade C presence of R: Focus is on monitoring the response to restrictions
2+ NEED fluid in lower Long term: the diuretics rather than the actual amount
lung fields After 1 week of voided Long term:
VS: Nutritio and bipedal nursing After 1 week of
RR – 23CPM n and edema. interventions, -Weigh daily on the same time of the nursing
Fluid the patient will day. intervention, goal
Diagnostic test R: Pulmonary be able to: R: A gain of 5lb represents approximately 2L was met as
results: edema occurs of fluid. Diuretics can also result in evidenced by:
BNP: 453pg/mL when the heart -Have reduced excessive fluid shifts and weight loss
Troponin (+) is not able to pitting on -Reduced pitting
Potassium – 2.9mEq pump bipedal edema of edema to grade
Cardiomegaly with efficiently 1
LR ventricular which causes a -Normalize
hypertrophy change of potassium level -Potassium level –
pressure in the between 3.5 3.7mEq/L
blood vessels and 5.5 mEq
and fluid is Dependent:
pushed into the
air spaces in the -Administer Furosemide 40mg tab twice
lungs. a day as ordered by physician.
R: Furosemide is a diuretic and it increases
Bipedal edema renal excretion of water, sodium chloride,
is caused by magnesium, potassium, and calcium.
excess fluid
trapped in the -Administer Digoxin 0.25μg once a day
body’s tissue as ordered by physician.
caused by R: Digoxin increases cardiac output
decreased therefore reducing edema by reducing the
cardiac output amount of blood backflow.
which causes
blood to Collaborative:
accumulate in
the legs, ankle, -Controlled low sodium with potassium
and feet. diet.
R: Sodium increases the risk of having edema
-MedlinePlus, as sodium attracts water, if accumulated on
2020 one spot, water follows which causes edema.
-Mayo Clinic,
2017 Potassium helps in the cardiac output of the
heart by increasing it.