Priority Problem: 1. 2. 3.

Unstable blood glucose related to lack of adherence to diabetes management Imbalanced nutrition: more than body requirements Risk for falls related to abdominal girth

4. Noncompliance related to diet regimens 5. Sleep deprivation related to uncomfortable sleep environment

ASSESSMENT Subjective: Ano bumaba yung glucose ko? Kanina mataas ah. Objective: - CBG levels July 6, 2011 0500H 132 mg/dL 1100H 163 mg/dL

DIAGNOSIS Unstable blood glucose related to lack of adherence to diabetes management

RATIONALE If beta cells cant keep up for high demand of insulin, blood sugar does not get into cell that can be stored and used for energy. Increased levels of sugar build up in blood Source: Brunner and suddhart

PLANNING

INTERVENTION 1. Provide health teaching regarding the ordered diet, for foods the patient can or cannot eat.

RATIONALE 1. Proper diet decreases glucose levels/ insulin needs, prevents hyperglycemic episodes, can reduce serum cholesterol levels and promote satiation.

EVALUATION

After 8 hours of nursing intervention, the patients blood glucose will stabilize to 120 mg/ dL

After 8 hours of nursing intervention, the patients blood glucose stabilized to 120 mg/ dL

Collaborative 2.Monitor CBG as ordered 3. Administer antidiabetic medications

2. Monitoring CBG levels can determine progress of diet plan. 3. treats underlying metabolic dysfunction, reducing hyperglycemia and promote healing.

ASSESSMENT No subjective assessment

DIAGNOSIS Imbalanced nutrition: more than body requirements related to excessive intake in relation to metabolic needs as evidenced by obese type II (BMI of: 35.29kg).

RATIONALE Diet increases intake of food rich in fats and cholesterol Sedentary lifestyle Unused glucose turn into fat ( glucagon) Accumulation of fat

PLANNING After 3 days of nursing intervention, the client will be able to verbalize: - Understanding of proper intake of food in relation to diet regimen - Identify appropriate serving size per meal.

Objective: - Weight of 96kg - Abdominal girth of 38-44 inches

INTERVENTION Independent: 1. Assess presence of conditions associated with obesity 2. Review daily activity and exercise program.

RATIONALE

EVALUATION After 3 days of nursing intervention, the client was able to understand proper intake of food in relation to diet regimen. He can also identify appropriate serving size per meal.

1. To identify contributing
factors for weight gain. 2. Sedentary lifestyle is frequently associated with obesity and is primary focus of modification. 3. Provides comparative baseline and helps determine nutritional needs. 4. To meet fluid requirements and reduce possibility of early satiety resulting in feelings of hunger.

3. Record height(57),
weight(192kg), body build(mesomorph), gender(male), and age(72yrs. old). 4. Stress need for adequate fluid intake and taking fluids between meals rather than with meals. (1.5L/day) Collaborative: 5. Do exercise as tolerated. Limit to 1 hour per day as ordered by the doctor.

Source: Brunner and Suddharts

5. To create effective
nutritional program

ASSESSMENT Subjective: Kasi pag nakatayo ako hindi ko makita yung paa ko.

DIAGNOSIS Risk for falls related to body size greater than normal as increased abdominal girth size from 38 44 inches

RATIONALE Increase intake of food rich in fats and cholesterol Sedentary lifestyle

PLANNING After 1 hour of nursing intervention, the client will be able to: - Verbalize understanding of individual risk factors that contribute to possibility of falls. - Modify environment as indicated to enhance safety.

INTERVENTION Independent: 1. Assist client when moving from one place to another. 2. Use assistive devices when needed.

RATIONALE

EVALUATION After 1 hour of nursing intervention, the client : -Verbalized understanding of individual risk factors that contribute to possibility of falls. -Modified environment as indicated to enhance safety.

1. To prevent client from

Objective: a.Abdominal girth from 38-44 inches

Unused glucose turn into fat ( glucagon) Accumulation of fat Source: Brunner and Suddharts

ASSESSMENT Subjective: healthy naman ako ngayun, sinusunod ko ung diet regimen. Objective 1.unstable glucose levels 2. weight gain

DIAGNOSIS Noncompliance related to clients denial; issues of secondary gain as evidenced by clients failure to progress.

RATIONALE The patient is aware of diet regimen, but patient still has unstable glucose levels and weight gain, as a result of non compliance and denial of incorrect decisions and actions that affected his health

PLANNING After 8 hours of nursing intervention client will: 1.Verbalize accurate knowledge condition and understanding of regimen. 2.Make choices at level of readiness based on accurate information.

INTERVENTION 1. Determine reason for alteration of therapeutic regimen or instructions 2. develop a system for self monitoring 3. Encourage relative to provide a strong support system.

RATIONALE 1.To be able to correct misconceptions and provide alternative solutions encountered on the said therapeutic regimen. 2.To provide a sense of control and enable client to follow own progress and assist with making choices 3.To reinforce negotiated behaviors, encourage client to continue positive behaviors especially if client is beginning to see benefit.

EVALUATION After 8 hours of nursing intervention client : 1.Verbalized accurate knowledge condition and understanding of regimen. 2.Made choices at level of readiness based on accurate information. 3.Verbalized

3.Verbalize commitment to mutually agreed upon goals and treatment plan

commitment to mutually agreed upon goals and treatment plan

SSESMENT Subjective: nahihirapan nga ako makatulog ditto sa hospital, kasi di ako makatulog pag may ilaw. as verbalized by the client Objective: - Do not feel well rested (restlessness)

DIAGNOSIS Sleep Deprivation related to uncomfortable sleep environment as manifested by restlessness.

RATIONALE Uncomfortable hospital environment ( lights not conducive to hospital environment) Patients restlessness Sleep deprivation

PLANNING After 48 hours of nursing intervention the client will be able to: Identify appropriate interventions to promote sleep.

INTERVENTION Independent: 1. Note environmental factors affecting sleep. a. b. Turn off lights Position client in side lying or most comfortable position. 2. Determine clients usual sleep pattern and expectations.

RATIONALE

EVALUATION

1.To assess contributing factors to problem and provide interventions to correct it.

After 3 days of nursing intervention the client: Identified appropriate interventions to promote sleep. Reported improvement in sleep pattern.

2.To provide comparative baseline. 3.To identify appropriate options.

Report improvement in sleep pattern.

4. To document symptoms and identifying factors that are interfering with sleep. 5.These factors disrupt sleep patterns.

3.
Determine interventions client has tried in the past. 4. Instruct client and relative to keep a sleep wake log.

6.Enhances expenditure of 5. Encourage client to restrict caffeine and other stimulating substances from evening intake. 6. Promote adequate physical exercise activity during day. release of tension so that client feels ready for sleep. 7. Because they impair ability to sleep at night. 8.To reduce stimulation so client can relax.

7. Suggest abstaining from daytime naps. 8. Recommend quiet activities such as listening to soothing music in the evening.