informationfornurses

Here is a care plan that I have submitted in my student life of my nursing profession, you can go through this.

ATTENTION STUDENT NURSES: Don’t submit this copy to your tutor, as it is copy right protected. Just kidding guys …… rock the nursing life …

NURSING CARE PLAN OF MR.S. KUMAR WITH DIABETES MELLITUS

IDENTIFICATION DATA:-

Name of the patient; Mr. S. Kumar
Age ; 47
Sex; male
Marital status ; married
Occupation; driver
Religion; shop keeper

PERSONAL HISTORY:-

Nutritional pattern; mixed diet
Work pattern ; sedentary
Sleep pattern ; 4-5 hrs per day
Elimination pattern; urine -9-10 times per day
Feaces- 2 times per day
Habits ; smoking
FAMILY HISTORY; he has a wife and two children, and his father had diabetes and hypertension. There was no other specific family history
PAST MEDICAL/ SURGICAL HISTORY;-
He had a history of viral hepatitis and he had undergone a surgery of Appendicectomy, 3 years back. PRESENT MEDICAL/SURGICAL HISTORY;
Mr. S. Kumar was admitted at 4 pm with complaint of generalized malaise, numbness of hands and tooth ache.
LAB DATA;

Hb- 12.5 gm
Tc – 8000 / cu mm
Esr- 23 mm/ hr
Bu – 41 mg
Bs – 210 mg
S.K- 5 meq/l
MEDICATION;
C. Becadaxamine 1 od
T. Glycephage 500 mg 1 tid
T. Diclomol 1 tid
T. Levomac 500 od
T. Rantac 150 mg bd
VITAL SIGNS;-

Temperature- 99.2 F
Pulse – 86/minte
Respiration – 22/minute
BP- 110/ 70 mm of Hg

POSSIBLE NURSING DIAGNOSIS
1. altered nutrition more than body requirement related to excessive glucose intake
2. risk for injury related to complication of diabetes mellitus
3. body image disturbance related to long term illness
4. knowledge deficit related to management of prolonged illness and potential complication
5. sexual dysfunction related to impotence related to diabetes and Rx

Assessment Nursing diagnosis Nursing goal Planning Implementation Evaluation
Subjective data;

Patient says “ I am damn fatigued , will you give some medicines”

Objective data;

1. sunken eyes of the pt
2. most of the time confined to bed
3. dry mucous membrane
4. RBS;
210 mg
NURSING DIAGNOSIS:
Altered nutrition more than body requirement related to excessive glucose intake NURSING GOAL : Maintains normal nutritional pattern
PLANNING:
Asses the general condition of the patient
Asses the nutritional pattern of the pt
Provide comfortable bed
Check the vital signs every 4 hours
Monitor the urine and blood sugar level every 6 hrs
Give podiatric care
Provide psychological support
Give health education
Give medication as per physician order

IMPLEMENTATION:

Assessed the general condition of pt;
Pt was alert, oriented and fatigued.
Given foods that has little sugar content.
Bed rest was given
Checked the vitals 4hrly
Pulse; 86/minute
Temperature;99.2 F
Respiration-22/min
Urine sugar was checked showing orange color and RBS was 210 mg.
Foot care was given.
Emotional support was given by health care team and relatives.
Health education was given to patient and relatives about; role of diet, exercise, self checking the urine sugar, avoidance of stresses, bad effects of smoking, importance of taking foods along with medication etc

Medication was given as per physician’s order
EVALUATION:
Pt maintained normal nutritional pattern as evidenced by the intake of foods in relation to the metabolic requirements.

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