NURSING CARE PLAN

NURSING DIAGNOSIS: Risk for fluid volume deficit related to frequent urination.

Goal: Provision of fluid balance. Demonstrate adequate hydration as evidenced by stable vital

signs, palpable peripheral pulses, good skin turgor and capillary refill, individuality appropriate

urinary output.

INTERVENTIONS RATIONALE

1. Obtain history from patient related

to duration of intensity of

symptoms like excessive urination.

2. Weight daily and record data

gathered.

3. Monitor vital signs:

a. Body temperature

1. Assists in estimation of total

volume depletion.

2. Rapid losses or gains of 5%

more of total body weight indicate

moderate to severe fluid volume deficit or

excess.

3a. A decreased body temperature

b. Pulse rate

c. Respiratory rate

d. Blood Pressure

may result from hypovolemia. Although

fever, chills, diaphoresis are common

with infection process, fever with flushed,

dry skin may reflect dehydration.

3b. An increased pulse rate and a

weak, thread pulse may occur with fluid

volume deficit.

3c. Correction of hyperglycemia

will cause the rate and pattern to approach

normal. In contrast, increased work of

breathing, shallow, rapid respirations; and

presence of cyanosis may indicate

respiratory fatigue.

3d. Hypovolemia may be

manifested by hypotension and

tachycardia. Estimates the severity of

hypovolemia may be made when patient’s

systolic blood pressure drops more than

10mmhg from a Recumbent to a sitting or

standing position.

4. Maintain fluid intake of at least

2500 ml/day within cardiac

tolerance when oral intake is

resumed.

4. Adequate and increase in fluid intake

can maintain hydration or circulating

volume.

NURSING DIAGNOSIS: Risk for infection related to insufficient knowledge on proper wound

care.

Goal: Have knowledge on proper wound care. Identify interventions to prevent or reduce risk of

infection. Demonstrate techniques, lifestyle changes to prevent development of infection.

INTERVENTIONS RATIONALE

1. Observe for signs of infection and

inflammation, like fever, flushed

appearance, wound drainage.

2. Educate the patient on how to care

properly the wounds on step by

step process.

3. Change wound dressings if needed

using proper techniques of

changing and disposing

contaminated materials.

4. Encourage patient to eat foods rich

in vitamin c like citrus, oranges,

1. Proper assessment for signs of

infection can prevent any other

complication and can provide

essential care.

2. Prevention of infection is best

achieved through following the

guidelines of wound care obtained

during educating process.

3. Proper application and changing

of wound dressing can facilitate

the prevention of progress or

transfer of infection.

4. Fruits rich in vitamin c can boost

the immunity of an individual

pineapple etc. which helps him fight infection.

NURSING DIAGNOSIS: Imbalanced Nutrition: less than body requirements related to inability

to utilize nutrients.

GOAL: Maintain normal nutritional status. Demonstrate stabilized weight or gain toward

usual/desired range.

INTERVENTIONS RATIONALE

1. Weight daily or as indicated.

2. Identify food preferences,

including ethnic/cultural needs.

1. Assesses adequate of

nutritional intake

By absorption and utilization of nutrients.

2. If patient’s food preferences

can be incorporated into the

meal plan, cooperation with

dietary requirements may be

facilitated.

3. Discuss proper distribution of

meals that the client prefers but

may contribute in maintaining

normal body weight.

3. Proper intake and distribution

of meals can help an

individual to maintain, reduce,

or gain the ideal weight that he

should achieve.

XII.

A. CONCLUSION

In making this care study, I really appreciate how vital our organs are, that we should be

very careful in doing things, in every action we take, because it may result to damage of such

organ. Diabetes Mellitus is a very complex disease process if not treated appropriately. Patients

with such condition should know how to control his lifestyle, diet, and avoid factors that could

worsen the condition. Through this case study we learned many things that are necessary and

have relevance to our future career.

B. RECOMMENDATION

This study aims to recommend a continued teaching to enhance skills and abilities of

concerned people, and to develop a good quality loaded with knowledge. This is also to eradicate

complications patients with Diabetes Mellitus

 

XIII. IMPLICATION OF THE STUDY TO

A. NURSING EDUCATION

            The care study provides the academe of nursing education the opportunity to focus on

how to engage in care management of Diabetes Mellitus. And to renew the idea of dealing

patients easily, instead we must set much more effort in dealing with them because this is the

times when they need more support.

 

B. NURSING PRACTICE

The care study provides a wider venue for nursing students to develop and enrich their

skills and knowledge in rendering efficient and effective care. It sharpens our abilities in

performing nursing measures to be rendered to our respective clients. Thus, provides us

satisfactory exposure that can’t be paid by any means.  

C. NURSING RESEARCH

            The care study helps in further investigation and research to optimize nursing care and

expand the scope of nursing practice. Thus, continued investigation is further encouraged on the

ultimate predisposing factor of having Diabetes Mellitus.