Question

Develop 3 nursing care plans with 1 nursing diagnosis, 1 short term goal, 3 interventions and 3 rationales and evaluation for each rationale for a patient who is diagnosis with diabetes mellitus 252 mg/dL, COPD who also exhibits dry skin and erythema in lower extremities.

Answer 1

1.Diabetes Mellitus

Risk for unstable blood glucose

Short goals

• optimal control of blood glucose levels.

3

• Detrmine the clients factors that may contribute to unstable blood glucose levels s

rationale-Certain risk factors like family history of diabetes,history of poor glucose control,poor excercise habits and failure to recognize changes in glucose needs can result in blood glucose stability problems.

• Determine influence of clients cultural and religious factors affecting dietary practices,taking responsibility for own care and expectations of health care outcome.

Rationale-These factors may need to be addressed in creating clients health care plan.

• Ensure client is knowleadgable about using his own blood glucose monitoring device.

Rationale-The blood glucose monitoring device is a handy and accurate way of assessing blood glucose levels,Proper usage of this device is essential in detecting unstable blood glucose levels.

2 Ineffective airway clearance related to bronchoconstriction,increased mucus production,ineffective cough,bronchopulmonary infection and other complications,

Goal-Achievement of airway clearance.

Intervention

• Adequately hydrate the patient.Rationale-systemic hydration keeps secretions moist and easier to expectorate.
• Teach and encourage the use of diaphragmatic breathing and coughing techniques-Rationale-These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue.
• Assist in administering nebulizer Rationale-This ensures adequate delivery of medication to the airways.