X. NURSING CARE PLAN 1.

ASESSMENT SCIENTIFIC EXPLANATION PLANNING Within one hour of proper nursing interventions, the patient will understand the consequences of being underweight. INTERVENTION/RATIONALE EVALUATION Weight the client properly: R: to know if the client is underweight for her age and height. Determine what time of the day when the client appetite is the greatest. Offer low sugar meal at that time. R: to meet the metabolic needs as the patient will not worsen her situation. Teach the client about the appropriate diet for her sick as low sugar diet. R: to have knowledge about what her diet and metabolic needs. Ask the family to prepare the client meals most of the time: clear unsightly supplies and excretion. R: a pleasant environment helps promote intake. Within one hour proper nursing intervention patient has been understand the consequences of being underweight.

S > Paunti- unting The client is having a nababawasan ang weight loss because of timbang ko. the reason that the patient has increased O > weight loss metabolism and ( BMI= 18.08 under decrease in catabolism. weight) > pale conjunctiva and mucous membrane > weakness > hyperactive bowel sounds >poor muscle tone NURSING DIAGNOSIS: Imbalance nutrition: less than body requirements related to inability to use glucose

 Ask the patient to continue her medications prescribed by her physician such as metformin. R: to treat her disease.

2. ASESSMENT S > Hindi ko alam kung kelan ako pupunta sa doctor ko pag may nararamdaman akong kakaiba. O > history of lack of health seeking behavior. > lack of financial resources > lack of health resources such as medications > lack of knowledge to signs and symptoms of diabetes mellitus NURISNG DIAGNOSIS: Ineffective health maintenance related to lack of financial SCIENTIFIC EXPLANATION Inabilities to identify, manage, or seek out of help to maintain health because of having not enough financial resources. PLANNING INTERVENTION/RATIONALE EVALUATION Within two hours the patient of proper nursing interventions the patient has been identified on how to meet goals for the health care maintenance.

Within two hours of Provides sufficient outside proper nursing support like written notices intervention, the calendars to assist with follow patient will identify through on the agreed actions. on how to meet goals R: cues play a significant role in for health stimulating completion of desire maintenance. health actions. Establish a written contract with the client to follow the agreed upon health care regimen. R: reinforcement of written agreements. Have the client and family to demonstrate at least twice of any procedures to be done at home. R: practicing procedures, exposes problems, enhances skill level and promote confidence in performing new behaviors. Provide aids to assist in compliance with the plan of care like preparing medications, schedules, and

resources.

put a weeks medications in daily containers. R: to organize in meeting the goals of the client. Ask the clint to continue the medication prescribed by the doctor R: to continuously managing and treat her disease.

3. ASESSMENT SCIENTIFIC EXPLANATION PLANNING INTERVENTION/RATIONALE EVALUATION Within one hour proper nursing interventions, the patient has been describe ways to assess and track patterns of fatigue.

S > Palagi akong Patient has an pagod. overwhelming, sustained sense O > weak in exhaustion and appearance decreased capacity for > pallor physical and mental > depressed looking work at usual level. >disinterest to surrounding >decrease performance of activities of daily living. NURISNG DIAGNOSIS: Activity intolerance related to weakness.

Within one hour of Provided good ventilation by proper nursing opening the windows and interventions patient turning on the fans will describe ways to R: to promote relaxation to assess and track patient. patterns of fatigue. Suggest restorative activities using nature such as sitting outside, bird watching and gardening. R: being outside and enjoying nature are restorative thus can help people recover their strength and think more clearly. Review me dictions for side effects. R: there are certain medications that cause fatigue. Help the client to do cognitive reframing shade informations about fatigue and how to live with it including need for positive self talk. R: client medication legitimizes fatigue and enhances the client

control through self care and positive self talk. Teach strategies for energy conservation such as sitting instead standing, and during showering, strong items at waist level. R: energy conservation strategies can decrease the amount of energy used. Teach the client to carry a product calendar, make list of required activities, and post reminders around the house. R: fatigue is associated with memory loss and sometimes difficulty of thinking.

4. ASESSMENT S > Mahirap tanggapin na nagkaroon ng ganitong kalagayan. May mga bagay na hindi ko nagagawa ngayon na nagagawa ko noon. O > recurrent feeling of sadness > anger > confused in appearance > depressed in appearance > frustrated looking > weak > irritable > pale looking NURSING DIAGNOSIS: SCIENTIFIC EXPLANATION Patient is having anxiety because of gradual decrease of the patient of activities of daily living. PLANNING Within one hour of proper nursing interventions, the patient will accept the fact and express the feelings of guilt, fear, anger or sadness. INTERVENTION/RATIONALE EVALUATION Spend time with the client and family. R: to win trust and rapport. Position the client to comfortable position. R: to promote comfortability. Encouraged the used of positive coping techniques. a. Taking actions like keeping busy, keeping personal interest, and doing something to gain a feeling of control over life R: making busy can help to forget the problem. b. Cognitive coping like encourage the client to write experiences. R: promote self- esteem c. Intrapersonal coping like talking to close friend R: to find anyone to open problems. d. Emotional coping like coping and praying a desired. Within one hour of proper nursing interventions, the patient has accepted the fact and was able express the feelings of guilt, fear, anger or sadness.

Anxiety related to less performance of some activities of daily living.

R: to express what she feels Expect the client to meet responsibilities and give positive reinforcement. R: to forget her problem and help the patient to move on.

5. ASESSMENT SCIENTIFIC EXPLANATION PLANNING Within one hour of proper nursing interventions, patient will have a good skin, tongue turgor and moist skin, mucous membrane. INTERVENTION/RATIONALE EVALUATION Increase fluid intake. R: to change the fluid that has been loss. Assist the patient for ambulation. R: to promote circulation of blood Teach the family about the complications of deficient fluid volume and when to call a physician. R: to have knowledge about the existing problem. a. Teach the family and client about apprise diet and fluid intake. R: to have knowledge on how to treat the existing problem. b. Teach the client and family on how to measure and record the intake and output accurately R: to determine if the client is having deficient fluid volume. Advise the client to continue Within one hour of proper nursing interventions, the patient has a good skin, tongue turgor and moist skin, mucous membrane.

S > Lagi akong The patient is having nauuhaw deficient fluid volume because a diabetic O > polyuria ( 5-6 client is having times a day) polyuria or increases > weakness urine output resulting > sudden weight loss to fluid volume ( BMI= 18.08 deficit. underweight) > decreases tongue turgor > decreased skin turgor > dry skin and mucous membrane NURSING DIAGNOSIS: Risk for deficient fluid deficit related to frequently urination.

medications prescribed by the physician. R: to treat her problem.