NURSING CARE PROCESS

Name of Patient: Aubrey Age: _19 Sex: __F Civil Status: __Single Room/Bed No. ________
Medical /Surgical Diagnosis: Risk of Acquiring Diabetes Mellitus and Hypertension Assessment date: July 15,2021
Prepared by: Angelica Mae R. Valera Section/Grp No. 14 CI/Supervisor: Toni M. Notario
Cues Nursing Analysis Goals and Implementation Rationale Evaluation
Diagnosis Objective

Subjective cues: Stem: SCIENTIFIC ANALYSIS Long-term Goal:

Aubrey Risk of Acquiring The impact of The client will be able to The client and the nurses
mentioned that Diabetes Mellitus diabetes and high educate herself by providing will achieve the goal and
she has no known and Hypertension. blood pressure can proper education about objectives with the said
allergies. increase the risk of health supplements and nursing role given.
cardiovascular proper learning about
She states that “I Related to disease, kidney Lacto-Ovo Vegetarian diet
am lacto-ovo Weight loss and disease, and other that she has been taking
vegetarian. Most gain, essential of health problems such daily and giving proper
of the time I hang taking as having a risk of medication to reduce stress,
out with my friend supplements, and excess weight and anxiety, and health
for a tea or family history of body fact, stress, diseases.
coffee.” the client. having a low level of
essential Objectives: Independent Intervention
“I still would like AEB supplemental
to be active and Risk factor of vitamins. 1. To provide proper 1. Monitory and document 1. Monitoring blood 1. The client manifested
do activities that dietary intake, (Prelipcean,2019) physical activity to the the vital signs of the client pressure can normal vital signs such as
won’t take up so lack of diabetes client to improve health especially the blood determine whether blood pressure.
much of my time management, and Lacto-Ovo Vegetarian condition. pressure. you are at risk for GM
but help me lose risk of prone Diet increases the risk heart disease and PM ✓
few pounds to behavior of the of having high blood stroke. It will also UM
45kg.” client. pressure and give a sense of
considering this, it has security about the
“I walk to church an excessive salt, client’s health.
every Thursday, sugar, and variety of (Center for Disease
Friday, and unhealthy fats. It Control and
Sunday for 15 increases the anxiety Prevention, 2020)
minutes. Last level related to weight
month, during the gain. (Doheny, 2019)
enhanced 2. To provide proper 2. Provide measures of 2. Providing 2. The client stated he learned
community education about Lacto-Ovo nutritional intake before it measure of about proper nutritional intake
Vegetarian diet about the nutritional intake to control her blood glucose.

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 quarantine, I SITUATIONAL risks and proper dietary becomes a risk of having helps you control GM ✓
ganed 2 kg.” ANALYSIS: procedure. diabetes. your blood sugar PM
(glucose) and UM
CBC and X-ray Having a family manage your
results were history of diabetes weight. (Mayo
reviewed by the increases the risk of Clinic, 2021)
doctor and noted having diabetes.
with normal (Prelipcean, 2019) Collaborative Intervention
findings. 3. To give information 3. Ascertain healthy body 3. Experts like a 3. The client manifested
A nutritional about nutrition by weight for age and height. dietician can balance health nutrition by
deficiency occurs providing essential Refer to a dietitian for determine nitrogen taking her proper Lacto-Ovo
Objective cues: when the body does supplements or vitamins nutritional support. balance as a Vegetarian Diet knowledge as
not absorb or get from while doing the Lacto-Ovo measure of the the dietician provided.
Family History of food the necessary Vegetarian Diet. nutritional status of GM ✓
Illness: Father (+) amount of nutrient. the patient. A PM
Hypertension Deficiencies can lead negative nitrogen UM
(HPN), and to a variety of health balance may mean
Diabetes Mellitus problems such as protein
(DM) digestion problems, malnutrition. The
dementia, etc. (Olsen, dietician can also
Present Health 2019) determine the
History: patient’s daily
requirements of
Never specific nutrients to
experienced to promote sufficient
get hospitalized. nutritional intake.
(Wayne,2020).
Her mother
ensures that she
takes daily 4. To adequate reassure of 4. Plan a meal plan and 4.Nursing 4. The client was able to do
supplemental any anxiety related to the schedule a physical activity assistance with proper physical activities that
vitamins such as client’s weight gain or loss. for the client and if the activities of daily fits on her dietary plan as the
vitamin C and B patient lacks knowledge living (ADLs) will nurses provide proper meal
complex, and and strength schedule a conserve the plan as scheduled.
every year she rest period. patient’s energy for GM ✓
gets flu vaccine activities the PM
from their family patient values. UM
doctor. (Wayne, 2020)

5. To make the client’s low 5. Decrease in

sugar level to normal as her circulating blood

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 V/S taken as existing blood pressure of volume can cause
follows: 100/70 mmHg should hypotension and
become into a normal tachycardia and can
T: 37.2C state. increase the risk of
PR: 95 having diabetes.
RR: 12 Psychomotor Objectives are (Wayne,2020)
BP: 100/70mmHg shown in the said goals, as
per the patient will practice
new proper nutritional Efficiency
intake including the The strategies/interventions
essential supplements that were suitable within a given
should be taken regularly. time frame to solve the client’s
health problem.
GM✓
PM
UM

Appropriateness
The strategies/interventions
were appropriate to solve the
client’s HP.
GM
PM ✓
UM

Adequacy
The number of
strategies/objectives were
enough to solve the client’s HP.
GM
PM ✓
UM

Acceptability
The strategies/interventions
were acceptable to the client.
GM
PM ✓
UM

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 References
Barhum, L. (2019, May 28). Diabetes and hypertension: What are the relationship? Medical and health
information. https://www.medicalnewstoday.com/articles/317220.

Belleza, M. (2020, June 4). Diabetes mellitus: Simplified study guide & nursing care management. Nurseslabs. https://nurseslabs.com/diabetes-mellitus/.

Doheny, K. (2019, November 4). Are there health downsides to vegetarian diets? WebMD. https://www.webmd.com/diet/obesity/news/20191104/are-there-
health-downsides-to-vegetarian-diets.

Mayo Clinic Staff. (2021, March 25). Diabetes diet: Create your healthy-eating plan Print. Mayo Clinic. https://www.mayoclinic.org/diseases-
conditions/diabetes/in-depth/diabetes-diet/art-20044295.

National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. (2021, February 23). Measure your
blood pressure. Centers for Disease Control and Prevention. https://www.cdc.gov/bloodpressure/measure.htm.

The Healthline Editorial Team. (2019, March 8). Nutritional deficiencies (Malnutrition): Symptoms and treatment.
Healthline. https://www.healthline.com/health/malnutrition.

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