Plan of Care
Day 1
S> “Ang sama ng pakiramdam ko,
malimit din akong uhaw tapos mayat
maya ang pagihi ko” as verbalized by the
patient.
O>
 CBG – 291 mg/dl
 Total cholesterol 256 mg/dL
 Triglycerides 346 mg/dL
 LDL 155 mg/dL
 HDL 32 mg/dL
 UA +glucose, − ketones
 Weight=173lb
 Height=5’2’’
 BMI=31.6, Obese
 Bp -150/90mm Hg
 Polyuria
 Seen drinking sugary beverages,
1bottle(coke)
A> Unstable Blood Glucose related to
lack of adherence to diabetes management
as manifested by increased blood sugar
level.
P>After 8 hours of nursing
interventions,the patient will be able to
display behavioral changes regarding to
diet modification like avoid drinking
beverages that are high in sugar like coke,
Day 2 Day 3
S> “Hindi ko kayang bumangon para S> “Hindi ko alam, kung anong dapat
umuhi.” as verbalized by the patient. kong kainin” as verbalized by the patient.
Chronic fatigue.
O> O>
 CBG – 291 mg/dl  CBG – 291 mg/dl
 Weight=173lb  Total cholesterol 256 mg/dL
 BMI=31.6, Obese  Triglycerides 346 mg/dL
 T – 36.5 C  LDL 155 mg/dL
 P – 73 bpm  HDL 32 mg/dL
 R – 21 bpm  Weight=173lb Height=5’2’’
 Bp -150/90mm Hg BMI=31.6, Obese
 Looks exhausted  Bp -150/90mm Hg
 Abdominal discomfort  Confused expression
 Seen drinking sugary beverages, 1
bottle(coke)
A> Fatigue related to Altered body A> Deficient Knowledge related to
chemistry: insufficient insulin as Dietary modifications
evidenced by Impaired ability to maintain
usual physical activity
P> After 8 hours of nursing P> After 8 hours of nursing
interventions,the patient will be able to interventions,the patient will be able to
display improved ability to participate in exhibit understanding of hyperglycemia
desired activities. treatment and nutrition.
etc.
I>
● Assess for signs of hyperglycemia.
● Assess the pattern of physical
activity.
● Monitor blood glucose level.
● Educate the patient about the risks
and complications of diabetes.
● Educate the patient about ways to
lower blood sugar level like
lessening the consumption of
sugary beverages like coke.
● Stress the importance of achieving
blood glucose control.
● Administer medication as ordered
by the physician.
E> After 8 hours of nursing interventions,
the patient was able to change her desired
beverage from coke to pineapple juice.
Fully met
I>
● Assess response and tolerance to
activity.
● Assess muscle strength of patient.
● Monitor pulse, respiration rate and
blood pressure before and after
activity.
● Identify activities that lead to
fatigue.
● Discuss ways of conserving energy
while moving to different
positions.
● Educate the patient about the
importance of exercise in diabetes
management.
● Instruct the patient to perform
range of motion exercises, like
swinging of arms, as tolerated.
● Perform activities slowly with
frequent rest periods.
E> After 8 hours of nursing interventions,
the patient was able to display improved
ability to participate in desired activity as
evidenced by desire to urinate in the
bathroom with guidance.
I>
● Asses the patient’s knowledge
about diabetes and its
management.
● Educate patient about foods rich in
fiber like oats and avocado.
● Teach patient to follow a diet that
is low in simple sugars, low in fat,
and high in fiber and whole grains.
● Explain the importance of weight
loss to obese patients with
diabetes.
● Explain the importance of having
consistent meal content or timing.
● Provide written information about
diabetes management.
● Refer to dietitian for dietary
modifications.
E> After 8 hours of nursing
interventions,the patient was able to
exhibit understanding of hyperglycemia
treatment and nutrition by Stating 8 out of
10 foods that are rich in fiber; stating the
importance of weight loss for obese
patients.