A Sample Nursing Care Plan for a patient with Diabetes MellitusFull description
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Nursing Care Plan Assessment Subjective
Patient states that he has difficulty walking to the bathroom or the chair.
Objective: -Patient appears weak -Unable to perform some ADLs -Spends most of the time on bed
Diagnosis Activity intolerance related to general malaise secondary to MDR TB
Planning Short Term Goal: After 4 hours of giving effective nursing interventions, the patient will be able to cope with fatigue as evidenced by verbalized feelings of comfort and increase activity participation Long Term Goal: Within 2 days of giving nursing interventions, the patient will be able to demonstrate an increase in activity tolerance as evidenced by doing simple ADL’s
Intervention 1. Assess Assess pati patient ent’s ’s abilit ability y to perform tasks/ noting reports of weakness, fatigue and difficulty accomplishing task. 2. Reco Recomme mmend nded ed qui quiet et atmosphere; bed rest if indicated stress-need to monitor and limit visitors, phone calls and repeated unplanned interruptions 3. Elev Elevat ated ed hea head d of bed bed as tolerated. 4. Provid Provided/ ed/rec recomm ommend ended ed assistance with activities/ ambulation as necessary, allowing pt to do as much as possible
Rationale 1. Infl Influe uenc nce e of choice of interventions assistance 2. Enha Enhanc nce e res restt to lower body’s oxygen requirements, and reduces strain on the heart and lungs 3. Enha Enhanc nces es lun lung g expansion to maximize oxygenation for cellular uptake. 4. Alth Althou ough gh hel help p may be necessary, self esteem is enhanced when pt does things for self.
Evaluation After 4 hours of giving effective nursing interventions, the patient was able to cope with fatigue as evidenced by verbalization of feelings of comfort and participating in passive ROM
Within 2 days of giving nursing intervention, the patient was able to do simple ADLs