A Sample Nursing Care Plan for a patient with Diabetes MellitusFull description
KNOWLEDGE DEFICIT Date/ Cues Time 08 Subjective: /19 /10 “Wala “Wala ko kabalo kabalo asa asa gik gikan ning ning @ akong akong hepat hepatit itis is,, wala pud gani ko 3:00 kabalo unsa na.” pm “Katong “Katong nagsakit nagsakit ko sauna kay nagpa nagpado doct ctor or ko ato unia naa man to mga mga tamb tambal al,, tapos nagkasaki nagkasakitt napud pud ko mga pila ka bulan, mao to gbalik lang nako ug tuma tumarr tong tong mga mga tambal pero wala nako nagpacheck up ug usab.” As verbalized by the patient Objective: -
Lack of sourc urce of information
Need
C O G N I T I V E P E R C E P T U A L P A T T E R N
Nursing Objectives of Nursing In Intervention Evaluation Diagnosis Care Knowledge After 4 hours of Establish rapport. Goal Met! 1. deficit nursing ® to gain patient’s trust and have 08/19/10 regarding inte interv rvent ention ion my a good nurse-patient relationship @ condition, patient will ill be 7:00pm and able to know and 2. Evaluate Evaluate desire/read desire/readiness iness of treatment unde unders rsta tand nd the the patient to learn. After 4 hours of related to diseas disease e proces process s ® determine amount or level of my nursing abse absenc nce e of and treatment ent info inform rmat atio ion n to prov provide ide at any intervention my information regimen as given moment. patient was evidenced by: able able to know now 3. Prov Provid ide e an atmo atmosp sphe here re of and understand ® Defic Deficie ient nt a.) a.) Part Partic icip ipat ate e respec respect, t, openne openness, ss, trust, trust, and the disease knowledge is in learning collaboration. process and a state in process ® impo import rta ant when hen prov provid idin ing g treatment which b.) b.) verb verbal aliz izat atii educ educat atio ion n to pati patien ents ts with ith regimen as cognitive on of diff di ffer eren entt valu values es and and beli belief efs s evidenced by: information understan about health and illness. or ding about a.)patient psychomotor his 4. Assess motivat ivatio ion n and partic participa ipated ted in skills disease willi illing ngne nes ss of pat patient ient and and learning requir required ed for process caregivers to learn process health c.) c.) init initiat iatio ion n of of ® some some pati patien entt are are read ready y to recovery, lifestyle lear learn n as soon soon afte afterr they they are are b.) “Ah. Kabalo maintenance changes diagnosed; others cope better by nako asa na , or health and denying or delaying the need for makuha ang promotion participate instruction heap b ug are lacking. in unsaon treatment 5. Assess history of hepatitis b pagk pagkuh uha a ana ana regimen infection na sakit akit.” .” As ® to trace the source of infection verb verbal aliz ized ed by
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Asked questions regarding his condition Expresses confusion on the nature of the condition Denial of condition Purchase of over the counter drugs without consulting the physician
the patient 6. Be alert to signs of avoidance ® May need to allow client to suffer consequences of lack of knowledge before client is ready to accept information. 7. Discuss patient’s perception of need ® Relate information to patient’s personal desires/needs and values or beliefs. 8. State objectives clearly in learner’s term ® to meet learner’s need according to level of understanding 9. Participate in learning process ® to assess learning patient and correct the wrong belief of the patient 10. Teach patient about infection contol ® to avoid transmission of the present condition of the patient
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c.) “Dapat kung magsakit ko, magpa-check up diay ko sa doctor ug dili ko magpataka ug tumar sa mga tambal na wala gi-resita sa akong doctor.” As verbalized by the patient
