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:
Physical Assessment:
Nursing Diagnosis
Ineffective Health Management related to difficulty in managing diabetes and hypertension as evidenced by fluctuating blood glucose levels and non-adherence to medication regimen.
Risk for Unstable Blood Glucose related to lack of knowledge about proper diet and medication adherence.
Goals and Expected Outcomes
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.
Goal: Patient will maintain blood glucose levels within the range of 100-140 mg/dL within 2 weeks.
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:
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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