This is what i have got from my assessment and info about my pt.
Pt is 76 year old married man who is a sheep farmer
Never smoked
Past health history:
Diagnosed with type 2 diabetes in 1996 (17 years).
March 2012: Cardio Vascular Risk Assessment (CVRA) = 27%
August 2012: Hba1c was high at 126mmol/mol - Normal range
Present health:
Blood test showed HBA1c 101mmol/mol (
He came in after the 3 days with his recordings BGL 4-4.5 in mornings than high prior to lunch 16-18. maintain lantus 10 u and glicazide BD and melformin TDS. Suggested to change diet- is not hhaving supper so advised to have 1 piece of toast before bed.
Advised to reduce breakfast reduce to 1 weetbix instead of 2 and 2 toast instead of 4,
Pt rang in a few days later saying his morning BGL readings had doped to 2.9 and 2.2. Advised to reduce lantus to 8u and glicazide to 1 tab nocte. advised re his carb intake for rest of the day post hypo.
I rang him the following day to check his BGL was 6
waiting to see diabetic nurse.
Can anyone help with how i write this up into a care plan
You're on the right track, but none of your three appear as nursing diagnoses in NANDA-I. See, just as a medical diagnosis of, say, anemia has a defined set of criteria, nursing diagnoses do too. And we can't make up a new name or call it anything but "anemia," and so are nursing diagnoses. Each has a set of defining characteristics which allow you to make the diagnosis. If at least one isn't present, that diagnosis is not supported. (I can't call you "anemic" just because you look pale -- I need a complete blood count for that.)
NANDA-I is an international resource. (The I is for "international.) You can go to Amazon.com and get your own copy for not very much money-- don't know what it would be in NZ money but it's less than US$30.
Im from New Zealand, in my final year, 1st time doing care plan.
1st nursing diagnosis i thought - Anxiety and lack of knowledge relating to insulin administration.
Deficient knowledge related to (meaning because he has...) absence or deficiency in cognitive information related to (diabetes, insulin, self care, what?) as evidenced by (how do you you know he doesn't know what he needs to know?)
2nd Unstable BGL related to irregular testing and knowledge regarding importance of stable BGL
Unstable BGL is not caused by irregular testing and knowledge, is it? That's what "related to" means. Look over the list and see what else might work.
3rd Knowledge deficit related to diet.
This might be a repeat of your first one. Is there anything in your assessment of this patient that leads you to believe he's ready to learn? Try looking at "readiness for enhanced self-health management," and say why you think he is.
Does this help you think about it in a different way?
I think a lot of people can get hung up on "related to" and the "as evidenced by" (also called "manifested by")
"Related to" is the cause (etiology) of the diagnosis. For instance: my acute back pain is related to (caused by) the improper use of body mechanics and muscle weakness.
"As evidenced by" or "Manifested by" is the objective and subjective signs and symptoms. For instance: my acute back pain is evidenced by rating my pain as a 6 on the 0-10 pain rating scale, grimacing, and/or comments such as "my back hurts so bad"...etc
I recommend you always include some psycho/social aspect in your care plan. For instance, Bob seems in denial about his condition and will need education on self-management as well as filling in knowledge gaps related to his condition. He assumes diet alone is responsible for his higher glucose reading and may not be compliant with meds in the future.
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
You're on the right track, but none of your three appear as nursing diagnoses in NANDA-I. See, just as a medical diagnosis of, say, anemia has a defined set of criteria, nursing diagnoses do too. And we can't make up a new name or call it anything but "anemia," and so are nursing diagnoses. Each has a set of defining characteristics which allow you to make the diagnosis. If at least one isn't present, that diagnosis is not supported. (I can't call you "anemic" just because you look pale -- I need a complete blood count for that.)
NANDA-I is an international resource. (The I is for "international.) You can go to Amazon.com and get your own copy for not very much money-- don't know what it would be in NZ money but it's less than US$30.