NURSING CARE PLAN

Name of Patient: A.L. Age: 59 y.o. Sex: Male Civil Status: Married Room/Bed No.: 331
Medical/Surgical Diagnosis: Spinal Cord Compression Papillary CA Stage IV Admission Date: October 7, 2021 Shift: 7am –3pm
Prepared by: Section/Grp No.: CI/Supervisor:
Cues Nursing Analysis Goals and Objective Implementation Rationale Evaluation
Diagnosis

SCIENTIFIC Short-term Goal

Risk for Unstable Blood
Subjective Cues:
hormones secondary to
- The client verbalized,
“Diabetic po ako and
umiinom ako ng
maintenance. Hindi po
ba ito maapektuhan ng
mga gamot na
pinapainom niyo sakin
para sa cancer ko?”
Objective Cues:
- Decreased appetite
- Presence of anxiety
- Numbness of insulation
process to toes
Measurements:
CBG Results:
October 8, 2021:
a.) 5:32 AM - 245 mg/dl
b.) 12:05 AM - 245 mg/dl
c.) 17:00 PM - 375 mg/dl
October 9, 2021
a.) 6:10 AM - 349 mg/dl
b.) 22:20 PM - 189-349
ANALYSIS:
Glucose RT altered After a 2 hour sequence
According to the of nursing interventions,
diabetes definition of NANDA, the patient will achieve
Risk for unstable blood and maintain glucose in a
glucose is “Vulnerable to satisfactory range of 65 -
change in blood 110 mg/dl.
glucose/sugar levels from
the normal range, which
may compromise health".
Hyperglycemia, or high Objectives:
blood sugar, can arise in a
number of clinical Cognitive:
settings. Diabetes
mellitus is the most
frequent condition Independent Intervention:
characterized by high 1. The client will
blood glucose levels. verbalize and MET. The client was able
Hypoglycemia, on the - Educating the
explain the ● Teach the following to to verbalize and explain
other hand, is most patient on how to
importance of the client: the importance of
commonly caused by a interpret glucose
maintaining - Normal and maintaining satisfactory
person with diabetes levels allows them
satisfactory blood abnormal range of blood glucose level after
mellitus taking too much to identify and
glucose level. blood glucose levels 2 hours of nursing
insulin. Excessive alcohol regulate their
for diabetic patients glucose levels more intervention.
use, protracted fasting - Importance of
and starvation situations, effectively. (Belleza,
achieving and 2020)
adrenal insufficiency, and maintaining a
eating disorders such as healthy blood
anorexia nervosa are all glucose level.
risk factors. Low blood
glucose levels after meals
are a result of increased
mg/dl insulin production and
may be connected to
gastric bypass surgery or
excessive consumption of
refined carbs.
Diabetes mellitus (DM) is
a chronic condition Independent intervention:
2. The client will
marked by inadequate
independently
insulin synthesis in the ● Teach the following to - The most important MET. The client was able
perform home
pancreas or inefficient the client: thing you can do to to independently perform
blood glucose
insulin use by the body. - how to perform control type 1 or home blood glucose
monitoring.
As a result, the home glucose type 2 diabetes is to monitoring after 2 hours
concentration of glucose monitoring using a monitor your blood of nursing intervention.
in the circulation rises glucometer sugar levels on a
(hyperglycemia). - measuring capillary regular basis. You'll
Disturbances in blood glucose be able to observe
carbohydrate, protein, - How to read blood what causes your
and lipid metabolism glucose levels statistics to rise or
define it. Sustained fall, such as
hyperglycemia has been changing your diet,
demonstrated to impact taking your
nearly all of the body's prescription, or
tissues. Multiple organ exercising. With this
systems, including the information, you
eyes, nerves, kidneys, and and your health-care
blood arteries, are linked team can decide on
to substantial difficulties. the optimal diabetes
SITUATIONAL treatment strategy
ANALYSIS: for you. (CDC,
2021)
The client is a 59 year old
Psychomotor:
male, diagnosed with
stage IV Papillary
Thyroid Carcinoma.
Dependent Intervention:
As stated by the client, he 3. The client will MET. The client was able
has Diabetes and is adhere to the - The patient's
● Refer to a registered to adhere to the
currently taking prescribed physique, weight,
dietitian for prescribed appropriate
maintenance medicines. appropriate meal blood glucose
Upon assessment, the
client is showing signs of
decrease in appetite,
presence of anxiety, and
numbness of the
insulation process to toes.
The client’s CBG test
results from October *
and 9 have shown that
his CBG levels are above
the normal range.
(NANDA
International, 2016)
(Wayne, 2017)
(Vera, 2021)
plan for diabetic individualized diet levels, exercise meal plan to the patient
patients. instruction. habits, and unique after 2 hours of nursing
clinical condition all intervention.
factor into a tailored
Independent Intervention: food plan. Blood
glucose levels will
● Assist the patient in be stabilized as a
identifying eating result of changes in
patterns that need to be the patient's diet.
modified. (Wayne, 2017)
● Discuss the following to - This information
the client: serves as the
- Importance of foundation for
weight loss to obese personalised dietary
patients with advice related to the
diabetes. clinical condition
- Importance of that causes blood
having consistent glucose levels to
meal content or fluctuate.
timing. Understanding the
- Significance of food nutritional
consistency and the composition of
approximate time meals and how
intervals between varied meal patterns
meals. affect diet quality
- Monitor blood might aid in the
glucose levels discovery of key
before and after diet–disease links.
meals. (Leech, et. al. 2015)
- Preventing
hypoglycemia
symptoms and
maintaining overall
blood glucose
management
requires a regular
amount of food and
 time gap between
meals. (Wayne,
2017)

- Three meals of
equal size,
appropriately spaced
meal times (5-6
hours apart), and
one or two snacks
are recommended.
Food consumption
should be spread out
throughout the day
to make the
pancreas' workload
more tolerable.
(Vera, 2021)

Dependent Intervention:

● Refer the patient to an - Specific exercises MET. The client was able
4. The client will
exercise physiologist, can be prescribed to adhere to the exercise
adhere to the
physical therapist, or based on any program appropriate for
exercise program
cardiac rehabilitation physical limitations obese and diabetic
appropriate for
nurse for specific the patient may patients after 2 hours of
obese and diabetic
exercise instructions. have. (Wayne, 2017) nursing intervention.
patients.
Independent intervention: - Weight reduction is
an important part of
● Explain the following diabetes therapy.
to the client: Weight loss of
- Health benefits 5-10% of total body
 and importance of weight can
exercise in the minimize or
management of eliminate the
diabetes. requirement for
- Exercise drugs while also
precautions for improving blood
patients taking glucose levels
insulin. dramatically. (Vera,
2021)

- Exercise helps to
keep glucose levels
in check by boosting
glucose absorption
into cells. Exercise,
food consumption,
and blood glucose
levels must all be
understood by the
patient. (Wayne,
2017)

Affective:

5. The client will Independent Intervention:

express concerns - The patient's
about his ● Provide a safe MET. The client was able
environment for the health-related result to express concerns about
condition. has been shown to
client to openly express his condition after 2
concerns about his be influenced by hours of nursing
condition. nurse-patient intervention.
● Attend to the client’s interactions.
questions and concerns Showing empathy,
regarding his condition creating trust,
advocating for the
patient, offering
informative
 feedback, and
responding to the
patient's unmet
6. The client will be Independent Intervention: needs are all
able to participate examples of MET. The client was able
and cooperate ● Encourage the client to excellent therapeutic to participate and
with the nursing participate during the interactions. This cooperate with the
interventions performance of nursing form of professional nursing interventions
provided. interventions. interaction can help provided after 2 hours of
● Maintain nurse-client patients feel more nursing intervention.
relationship satisfied.

(Bennett, 2020)

References:
- Vera, M. (2021). Nursing Care Plans for Diabetes Mellitus. Retrieved from https://nurseslabs.com/diabetes-mellitus-nursing-care-plans/
- Wayne, G. (2017). Risk for Unstable Blood Glucose Level Nursing Care Plan. Retrieved from https://nurseslabs.com/risk-unstable-blood-glucose-level/
- Leech, R. et.al. (2015). Understanding meal patterns: definitions, methodology and impact on nutrient intake and diet quality. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501369/
- Bennett, A. (2020, September 2). Patient And Nurse Relationship: Why It's Important. Host Healthcare. Retrieved November 5, 2021, from
https://www.hosthealthcare.com/blog/patient-and-nurse-relationship-why-its-important/
- Belleza, R. M. N. (2020, June 4). Diabetes Mellitus. Nurseslabs. Retrieved November 5, 2021, from https://nurseslabs.com/diabetes-mellitus/#nursing_interventions
- Monitoring Your Blood Sugar. (2021). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/diabetes/managing/managing-blood-sugar/bloodglucosemonitoring.html