Free Nursing Diagnosis Care Plan Template

Nursing Diagnosis Care Plan

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Patient Information:

Patient Name: Naomi Ortiz
Age: 58
Gender: Female
Diagnosis: Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease
Date of Admission: November 10, 2050
Date of Birth: April 15, 1962

Assessment:

The patient, Naomi Ortiz, presents with long-standing Type 2 Diabetes, hypertension, and early-stage chronic kidney disease. The following are the key findings:

Blood Pressure: 150/90 mmHg (elevated)
Blood Glucose Levels: 160 mg/dL (above normal range)
Urine Output: Decreased (noted during the previous 24-hour assessment)
Physical Activity: Minimal due to fatigue
Diet: High sodium and carbohydrate intake
Patient Concerns: Expresses concern about weight gain and inability to manage his blood sugar levels.

Nursing Diagnosis:

Ineffective Health Management related to lack of knowledge regarding diabetes and hypertension management as evidenced by elevated blood glucose and blood pressure levels.
Risk for Unstable Blood Glucose Levels related to poor dietary habits and inadequate physical activity.
Impaired Kidney Function related to chronic kidney disease as evidenced by decreased urine output and laboratory results.

Planning and Goals:

Nursing Diagnosis	Goal	Interventions	Outcome
Ineffective Health Management	Patient will demonstrate understanding of diabetes and hypertension management by November 15, 2050.	1. Educate the patient on the importance of glucose monitoring, medication adherence, and lifestyle changes.	Patient is able to verbalize three key points about diabetes and hypertension management.
Risk for Unstable Blood Glucose Levels	Patient will maintain blood glucose levels between 80-120 mg/dL by November 20, 2050.	1. Develop a meal plan with the patient focusing on low-carb, low-sodium foods. 2. Introduce light physical activities (e.g., walking for 20 minutes daily).	Blood glucose levels are within target range.
Impaired Kidney Function	Patient will demonstrate understanding of fluid management and monitoring for edema by November 20, 2050.	1. Educate the patient on signs of fluid retention and proper fluid intake. 2. Monitor urine output and weight daily.	Patient is able to explain signs of fluid retention and tracks daily urine output.

Nursing Diagnosis

Goal

Interventions

Outcome

Ineffective Health Management

Patient will demonstrate understanding of diabetes and hypertension management by November 15, 2050.

1. Educate the patient on the importance of glucose monitoring, medication adherence, and lifestyle changes.

Patient is able to verbalize three key points about diabetes and hypertension management.

Risk for Unstable Blood Glucose Levels

Patient will maintain blood glucose levels between 80-120 mg/dL by November 20, 2050.

1. Develop a meal plan with the patient focusing on low-carb, low-sodium foods.

2. Introduce light physical activities (e.g., walking for 20 minutes daily).

Blood glucose levels are within target range.

Impaired Kidney Function

Patient will demonstrate understanding of fluid management and monitoring for edema by November 20, 2050.

1. Educate the patient on signs of fluid retention and proper fluid intake.

2. Monitor urine output and weight daily.

Patient is able to explain signs of fluid retention and tracks daily urine output.

Implementation:

Education: Provide tailored educational materials on diabetes and hypertension management, including information on diet, physical activity, and medication.
Medication: Continue prescribed medications (e.g., Metformin for diabetes, Lisinopril for hypertension) and ensure patient compliance.
Monitoring: Monitor blood glucose levels, blood pressure, urine output, and weight daily to track progress.
Diet: Coordinate with a dietitian to create a low-sodium, low-carb meal plan tailored to the patient’s preferences and cultural needs.
Physical Activity: Develop an activity plan with the patient’s agreement, starting with light exercises like walking and gradually increasing the duration and intensity.

Evaluation:

Blood Pressure: Continue to monitor blood pressure to ensure the target of <140/90 mmHg is achieved.
Blood Glucose: Check fasting blood glucose levels every morning and ensure levels remain within 80-120 mg/dL range.
Urine Output: Daily monitoring of urine output to ensure adequate kidney function and early detection of fluid retention.
Patient Feedback: Reassess the patient’s understanding of the disease management plan and adjust teaching methods as needed.

Follow-Up:

Date of Next Visit: November 30, 2050
Scheduled Follow-up with Specialist: Nephrologist for chronic kidney disease monitoring, December 5, 2050.

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