Cynthialyn Castro, 29 year old Female: with a Diagnosis of
Pre-eclampsia severe,to consider diabetic, to consider
Sub-involution Anemia Secondary. Assessment Diagnosis Planning
Intervention Rationale Evaluation Subjective Data: Di ko alam na
diabetic na pala ako. Ngayon lang nung na admit ako as manifested
by the mother. Objective Data: Alert, conscious and able to sit and
stand. Vital signs: T: 36.3' C RR: 24 bpm PR: 82 cpm BP: 120/80 mm
Hg Knowledge deficit related to lack of exposure to the disease
secondary to Diabetes Objective To participate in learning process.
Short term goal: The patient will be able to verbalize the
understanding of individual therapeutic interventions, medications
and its purposes. Longterm goal: The patient will be able to
verbalize her understanding regarding torich in iron Diabetic diet.
Independent Intervention: Assess Vital signs Explain to the client
the procedure and its purpose regarding to Capillary Blood glucose.
Monitor the capillary blood glucose of the patient. Instruct
patient to fasting or maintain NPO (nothing per orem) for 6 hours
prior to CBG (capillary bloodglucose measurement) Instruct patient
to avoid sugar-rich foods (e.g. chocolate) Instruct patient to eat
Iron rich foods (e.g. liver or animal organs, egg, fish, poultry,
leafy vegetables and dried fruits) for her anemia. Give the
importance of ambulation or exercise. Explain to the client facts,
causes and information regarding to her disease. Explain also the
purpose of the The patient is able to verbalize the understanding
of individual therapeutic interventions, medications and its
purposes. Long term goal: The patient will be able to verbalize her
understanding regarding to rich in iron Diabetic diet
To determine the current status of the patient. To reduce
anxiety of the patient
. To check the condition of her diabetes. To avoid inaccurate
reading of the result.
To prevent risk in hyperglycemia To prevent anemia and to help
in producing more red blood cells. To promote blood circulation. To
educate the client regardingto her status and acquired disease.
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treatment and therapeutic regimen given by her doctor. Provide
Oral care Instruct the Family to bathe the patient every other day.
Dependent Intervention: Give/administer medications as instructed
by the doctor. Collaborative Intervention:Refer patient to Med.
Tech for Laboratory Examination of her Hggt, TID For patient's
comfort To provide optimal skin care and comfort. To promote
wellness of thepatient and to stabilize her health. For further
evaluation and analysis of thepatient's disease.
