III.

NURSING CARE PLAN CUES NURSING DIAGNOSI S Subjective: kanina pa ako pinagpapawisan at uhaw na uhaw ako palagi Objective: elevated temperature of 38.4C/axilla increased urine output. sweating of the skin thirst A1: Deficient Fluid Volume r/t intracellular DHN 2 the DM II After 2 days of NI, the patient shall have maintained fluid volume at a functional level as evidenced by P1: At the end of the 8hour shift. The patient shall have verbalized understandin g of
Monitor the temperature Take and record vital signs Establish rapport Friendly

LONG TERM

SHORT TERM

INTERVENTIONS

RATIONALE

EVALUATION

individual good causative skin turgor, moist mucous membrane factors and purpose of individual

Short relationship with Term:After the 8-hour shift, patient and to patient will be able to each have verbalized others concern understanding To obtain of causative factors and baseline data purpose of individual therapeutic interventions To monitor and changes in medications.
temperature

Long Term:
Assess skin turgor and mucous membranes for signs of Dry skin and mucous membranes are signs of dehydration

and stable vital therapeutic signs. interventions and medications.

After 2 days of NI, the patient will have maintained fluid volume at a functional level as

exhaustion weight loss dry skin

dehydration Encourage the patient to increase fluid intake Administer IVF as ordered by the Doctor Administer anti-pyretic as prescribed by the Doctor. To replace fluid loss and prevent dehydration To replace electrolytes and fluid loss To decrease body temperature and will have less occurrence of dehydration.

evidenced by individual good skin turgor, moist mucous membrane and stable vital signs

Subjective: nanghihina pa din ako ngayon tsaka kanina pa ako ihi ng ihi Objective: A2: Imbalanced Nutrition: less than body requirement To facilitate the maintenance of nutrition of all body cells. After 1 week, P2: At the end of the 8hour shift, patient shall have verbalized Establish rapport Friendly relationship with patient and to be able Short Term: After the 8hour shift, patient will

to each others have concern verbalized

 poor muscle tone generalized weakness increased thirst increased urination polyphagia Weight loss

r/t insulin deficiency

the pt. will exhibit adequate nutritional intake as evidenced by stable weight, intake of adequate calorie levels, and adequate muscle strength to breath spontaneously

understandin Ascertain g of causative factors when known and necessary interventions and identified diabetic client. understanding of individual nutritional needs;

To determine what information to be provided to client/SO

understanding of causative factors when known and necessary interventions

Discuss eating To achieve habits and encourage diabetic diet as prescribed by the Doctor Document actual weight, do not estimate. health needs of the patient with the proper food diet for is/her disease Patient may be un aware of their actual weight or weight loss due to estimating

and identified diabetic client. Long Term: After 1-4 months of NI, the patient will have demonstrated weight gain toward goal

weight. Note total daily intake including patterns and time of eating . Consult dietician/physi cian for further assessment and recommenddation regarding food preferences and nutritional support To reveal changes that should be made in clients dietary intake For greater understanding and further assessment of specific foods.

Subjective: nangihina pa din ako na parang pagod na pagos ang katawan ko Objective:

A3: Fatigue related to decreased muscular strength

After 1-4 months of NI, the patient shall have demonstrated weight gain toward goal.

P3: At the end of the 8hour shift, The pt. will be able to participate in different activities like ambulating

Assess response to activity

-Response to an activity can be evaluated to achieve desired level of tolerance.

Short Term: Within the 8hour shift,The patient shall have been able to identify measures to conserve and increase body energy Long term: After 1-3

-Asses muscle -To determine strength of patient and functional level of activity. -Discuss with patient the need for activity -Education may provide motivation to increase activity level even though patient may feel too weak the level of activity

generalized weakness

increased respiratory rate of 25cpm

months, The patient shall have been free from signs of fatigue

presence of non-healing wound on both feet

body weakness

wt. loss

fatigue limited ROM inability to perform ADL -Alternate activity with periods of rest/ uninterrupted sleep. -Monitor pulse, respiration rate and blood pressure before/after activity -Perform activity slowly with frequent rest periods

initially -Prevents excessive fatigue

altered VS altered sensorium

-Indicates physiological levels of tolerance

-Tolerance develops by adjusting frequency, duration and intensity until

desired activity level is achieved. -Promote energy conservation techniques by discussing ways of conserving energy while bathing, transferring and so on. -Interventions should be directed at delaying the onset of fatigue and optimizing muscle efficiency. Symptoms of fatigue are alleviated with rest. Also, patient will be able to accomplish more with a

decreased expenditure of energy. -Provide adequate ventilation -Provide comfort and safety -Instruct patient to perform deep breathing exercises -For proper oxygenation -To be free from injury -Promotes relaxation

-Instruct client to increase Vitamins A, C and D and protein in her diet.

-For muscle strength and tissue repair

 -Instruct also patient to increase iron in diet -Administer oxygen as ordered.

-To prevent weakness and paleness -To provide proper ventilation