NURSING CARE PLAN

Patients Name: Diagnosis: Patient EG Cardiac Dysrhythmias Secondary to DM Type II NURSING ANALYSIS / ASSESSMENT PLANNING DIAGNOSIS INFERENCE
Ineffective breathing pattern related to decreased respiratory depth secondary to pain as manifested by the respiratory rate of 25 bpm. Spontaneous Depolarization Triggers extra beas Altered automacity Dysrhythmia Short-term: After 15 minutes of nursing intervention, the client will demonstrate understanding of the ways on how to improve breathing pattern. Long-term: After 1 hour of nursing intervention, the client will establish a normal, effective respiratory pattern.

Age: Religion:

51 y/o Gender: Dating Daan

Male

INTERVENTION / RATIONALE
Independent: Strictly monitor V/S. Auscultate chest R: To evaluate presence/character of breath sounds and secretions. Note rate and depth of breath sounds, type of breathing pattern. Monitor pulse oximetry. R: To verify maintenance/improvement of oxygen saturation. Review lab data such as the ABG. R: To determine degree of oxygenation. Elevate the head of bed. R: To promote maximum lung expansion. Encourage slower/deeper respirations and use of pursed-lip technique. R: To promote deep breathing. Encourage adequate rest periods. R: To limit fatigue. Assess for pain/discomfort. R: This may restrict respiratory effort. Assist the client in using relaxation techniques. R: To minimize anxiety. Keep calm attitude while dealing with the client. R: To minimize anxiety.

EVALUATION
Goals were met. After 15 minutes of nursing intervention, the client demonstrated understanding of the ways on how to improve breathing pattern. After 1 hour of nursing intervention, the client established a normal, effective respiratory pattern.

Subjective: Pag humihinga ako, parang ang bigat, hindi ako masyado makahinga ng maayos. Objective: V/S : T 36.8; PR 103; RR 25: BP 120/80 Use of accesory muscle in breathing (trapezius) Restlessness

Dependent: Administer oxygen at lowest concentration indicated and prescribed respiratory medications. R: For management of underlying respiratory condition. Collaborative: Maintain emergency equipments readily accessible. R: For easy access in case of emergency situation. Advise regular medical evaluation with primary care provider R: To determine effectiveness of current therapeutic regimen and to promote general well-being.

NURSING CARE PLAN Patients Name: Diagnosis: ASSESSMENT

Subjective: Hindi ko nasusunod yung tamang pag-inom ng gamut ko. Objective: V/S : T 36.8; PR 103; RR 25; BP 120/80 CBG: 161 mg/dL (12pm; 06/25/12) Dry skin Restlessness

Patient EG Cardiac Arrhythmias NURSING DIAGNOSIS

Unstable blood glucose level related to lack of medication adherence as manifested by CBG level of 161 mg/dL.

Age: Religion: ANALYSIS / INFERENCE

51 y/o Dating Daan PLANNING

Short-term: After 20 minutes of nursing intervention, the client will: Acknowledge factors that may lead to unstable glucose level. Verbalize understanding of body and energy needs. Verbalize understanding of importance of healthy lifestyle in stabilizing glucose level. Long-term: After 4 hours of nursing intervention, the client will maintain blood

Gender: INTERVENTION / RATIONALE

Male EVALUATION
Goals were met. After 20 minutes of nursing intervention, the client: Acknowledged the factors that may lead to unstable glucose level. Verbalized understanding of body and energy needs. Verbalized understanding of importance of healthy lifestyle in stabilizing glucose level. After 4 hours of nursing intervention, the client maintained blood glucose level in a satisfactory range.

Independent: Review clients dietary program and usual pattern; compare with recent intake. R: This identifies deficits and deviations from therapeutic plan, which may precipitate unstable glucose and uncontrolled hyperglyc emia. Weigh daily or as indicated. R: This assesses adequacy of nutritional intakeboth absorption and utilization. Identify food preferences, including ethnic and cultural needs. R: This increases clients cooperation. Observe for signs of hypoglycemia changes in LOC, cool & clammy skin, rapid

glucose level in a satisfactory range.

pulse, hunger, irritability, anxiety, headache, lightheadedness, and shakiness. R: Once CHO metabolism resumes, blood glucose level will fall, and as insulin is being adjusted, hypoglycemia may occur. Strictly monitor clients CBG levels. R: To check effectiveness of the above interventions. Review lab results such as the FBS. Dependent: Administer hypoglymic drugs as prescribed by the physician. Collaborative: Consult with dietician about specific dietary needs based on clients condition.