Writing a Care Plan

[gabtar823]

Mr. D, a 19 year old college student, has been brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times before arrival, and thirst. HE appears flushed and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid respirations, and there is a fruity odor to his breath. He has type 1 diabetes and may have skipped a few doses of insulin because of cramming for his finals.” He is alert and conversant but is having trouble focusing on your questions.

I am currently trying to write a nursing care plan to include subjective and objective data, 1 nursing diagnosis, NOC, and NIC.

I have the the nursing diagnosis as Risk for unstable blood glucose levels due to lack of adherence to diabetes management. I understand subjective and objective data, however, I get confused with the actual formation of a care plan. I kind of started writing it like this but I am not sure how to continue.

Diagnosis: Patient is at risk for unstable blood glucose levels due to lack of adherence to diabetes management.

Patient goals include

1. Patient will understand the importance of regularly monitoring blood glucose level.

2. Client will maintain a A1c less than 7%.

3. Patient will monitor blood glucose levels four times daily; before each meal and at bedtime.

4. Patient will exercise on a daily basis, including at least 20 minutes of exercise a day,

5. Patient will limit sugar intake and eat a well-balanced diet.

Any input would be greatly appreciated if I am on the correct track.

[Beginning15, BSN, RN]

Just a note: I have always had to include a time frame for my goals.... by discharge, by end of shift, or by a specific date/time. They are just hard, lol. Still trying to get used to them myself. Good luck!

[NurseGirl525, ASN, RN]

I think your is beyond risk for at this point. Plus using risk fors is actually not acceptable on my care plans. You have so much info and great dx to use on this. Is unstable blood glucose a nanda dx? Just wondering because I just finished my huge care plan and I did not see that in my nursing dx book. But I could have missed it.

To be honest, any time somebody uses a risk for, it's taking the easy way out. I'm sure the first thing the ED did is get labs which blood glucose would be one. Do you have that info? If you do, you can't use a risk for. Think about this, what else is going on with your patient right now?