Free Nursing Process Care Plan Template

Nursing Process Care Plan

Patient Information

  • Patient Name: Salvador Green

  • Age: 67

  • Gender: Male

  • Admission Date: January 10, 2050

  • Diagnosis: Type 2 Diabetes Mellitus, Hypertension

  • Patient ID: 12345

Assessment

  • Chief Complaints:

    • Frequent urination

    • Increased thirst

    • Fatigue

  • Medical History:

    • Type 2 Diabetes Mellitus diagnosed 10 years ago

    • Hypertension diagnosed 5 years ago

  • Physical Assessment:

    • Blood Pressure: 150/90 mmHg

    • Blood Glucose: 215 mg/dL

    • Weight: 180 lbs

    • Heart Rate: 88 bpm

    • Respiratory Rate: 16 breaths/min

Nursing Diagnosis

  1. Ineffective Health Management related to difficulty in managing diabetes and hypertension as evidenced by fluctuating blood glucose levels and non-adherence to medication regimen.

  2. Risk for Unstable Blood Glucose related to lack of knowledge about proper diet and medication adherence.

Goals and Expected Outcomes

  1. Goal: Patient will demonstrate improved understanding of diabetes and hypertension management within 1 week.

    • Expected Outcome: Patient will verbalize understanding of proper medication use, diet modifications, and lifestyle changes by January 17, 2050.

  2. Goal: Patient will maintain blood glucose levels within the range of 100-140 mg/dL within 2 weeks.

    • Expected Outcome: Blood glucose readings will remain within the target range by January 24, 2050.

Nursing Interventions

Intervention

Rationale

Timeframe

Evaluation

Educate the patient on diabetes management, including diet and medication.

Increases patient knowledge and self-management skills for diabetes care.

January 12, 2050

Patient attended education session and demonstrated understanding.

Monitor blood glucose levels regularly, at least 3 times per day.

Ensures timely intervention for any blood glucose abnormalities.

Daily, ongoing

Blood glucose readings recorded; patient’s glucose levels within target range.

Collaborate with dietitian for personalized meal planning.

Ensures appropriate nutrition to manage blood sugar and hypertension.

January 14, 2050

Diet plan implemented, patient compliant with dietary recommendations.

Administer prescribed antihypertensive and antidiabetic medications.

Controls blood pressure and blood glucose levels, preventing complications.

As prescribed

Medication administered as per prescribed schedule.

Follow-up with a follow-up visit or telehealth check-in.

Ensures continuous assessment of patient's progress and needs.

January 24, 2050

Follow-up scheduled and completed with no major concerns.

Evaluation

  • Short-Term Goals:

    • Patient demonstrated understanding of medication and lifestyle changes by January 17, 2050.

    • Blood glucose levels within the target range on January 24, 2050.

  • Long-Term Goals:

    • Improve overall health management and reduce complications related to diabetes and hypertension.

  • Outcome:

    • January 24, 2050: Blood glucose levels remain stable at 130 mg/dL, and blood pressure is within the target range of 130/80 mmHg.

    • Patient adheres to prescribed treatment plan, including medications and diet, with no new complaints.

Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]

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