NCP (BODY WEAKNESS)

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Name of Patient: F.V. Age/Sex: 61/M Room & bed no.

: 319-1
Chief complain: BODY Physician: Diagnosis: DIAGNOSIS (IF DISCHARGED) CKD secondary
WEAKNESS to DM Nephropathy with Pulmonary Congestion and Anemia

Date & Cues Nursing Diagnosis Need Objective of Nursing Interventions Evaluation
Time Care
S O- Risk for unstable N Within the shift, Assist the patient in Goal partially
E lack of glucose level r/t U the patient will identifying eating met
P adherence to Deficient knowledge T be able to patterns that need to be September 23,
T diabetes of diabetes R maintain patent modified. 2017
E management management I airway, as ® This information
M – Inadequate T evidence by: provides the basis for Patient was
B blood glucose Rationale: I individualized dietary able to
E monitoring “Glucose” is what O 1. Patient instruction related to the achieve:
R practices our body utilizes N maintained a clinical condition that
– Fluctuating most. Other sugars A blood glucose contributes to fluctuation 1. Increase
23, physical activity we eat, like fructose L reading of less in blood glucose levels. engagement in
level from fruit or lactose - than 180 mg/dL activities
– Stress from milk, are M 2.No signs and Administer basal and 2. Increased
2 converted into E symptoms of prandial insulin. knowledge on
0 glucose in our T hyperglycemia ® Adherence to the the importance
1 bodies and use A 3. No signs and therapeutic regimen of maintaining
7 them for energy. B symptoms of promotes tissue the normal
Our bodies also O hypoglycemia perfusion. Keeping blood glucose
@ 7AM break down L 4. Increase glucose in the normal levels
starches, which are I engagement in range slows progression but unable to
sugars stuck C activities of microvascular achieve:
together, into 5. Increased disease. 1. Patient
glucose. Serum P knowledge on maintained a
glucose is A the importance Refer to a registered blood glucose
transported from the T of maintaining dietitian for individualized reading of less
intestines or liver to T the normal diet instruction. than 180
body cells via the E blood glucose ® Modifications in the mg/dL
bloodstream and is R levels patient’s food intake will
2.No signs and
made available for N contribute stabilization of
symptoms of
cell absorption via blood glucose levels. hyperglycemia
the hormone insulin, 3. No signs
produced by the Administer insulin and symptoms
body primarily in the medications as directed. of
pancreas. Insulin is ® Patients receiving TPN hypoglycemia
secreted by the beta may require insulin to
cells of the islets of maintain stable blood
Langerhans in the glucose in response to
pancreas in high dextrose
response to concentration in the
elevated level of solution.
blood glucose. This
pancreatic hormone Report BP of more than
facilitates the 160 mm Hg (systolic).
movement of Administer hypertensive
glucose across the as prescribed.
cell membranes to ® Control of BP prevents
be used for coronary artery disease,
metabolic activity. stroke, retinopathy, and
The alpha cells of nephropathy.
the islets of
Langerhans secrete Educate the patient
glucagon when about the importance of
blood glucose levels following a prescribed
are low. meal plan.
® A prescribed meal plan
Reference: will help the patient
D, Leader. (2017). 3 maintain stable blood
techniques to clear glucose levels.
out mucus in the
lungs Educate the patient
about the proper ways of
taking prescribed
medications.
® The patient with
diabetes needs to learn
about taking insulin or
oral hypoglycemic drugs
to lower blood glucose.

Refer the patient to an


exercise physiologist,
physical therapist, or
cardiac rehabilitation
nurse for specific
exercise instructions.
® Specific exercises can
be prescribed based on
any physical limitations
the patient may have.

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