NUR 200 care plan assignment 2 2 3 
Nursing Care Plan
Subjective data- visual blurriness,thirst,frequent urination,"always hungry"
Objective data- Black spot on 1st and 2nd toe of L foot, BP-190/88, T-98.7, Pulse-87, Respirations- 22
Nursing Diagnosis #1 -
Decreased cardiac output related to peripheral vascular resistance secondary to hypertension as evidenced by BP-190/88
Short term goal: After 6 hours, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits.
Long term goal: After 5 days the client will maintain adequate cardiac output and cardiac index.
Interventions:
1) Monitor BP every 1-2 hours.
2) Note prescence, quality of central and peripheral pulses.
3) Observe for confusion , restlessness, agitation, dizziness. Central nervous system disturbances may be noted with decreased cardiac output.
Rationale:
1) To establish baseline data.
2) Pulses are weak with reduced cardiac output.
3) Early signs of lung congestion may be associated with onset of heart failure.
Evalutation:
1) After 6 hours, blood pressure maintained within set parameters for the client. Goal was met.
2) After 5 days, the client had an adequate tissue perfusion to his body systems. Goal was met.
Nursing Diagnosis #2-
Fluid and Electrolyte imbalance related to diabetes as evidenced by glucose 457.
Short term goal: Clients blood glucose will be 80-150 within 24 hrs.
Long term goal: Client will demonstrate how to take her blood sugar and how to give herself injections by discharge.
Interventions:
1) Weigh patient daily.
2) Monitor serum glucose hourly as long as insulin infusion continues.
3) Instruct the client to prepare and administer insulin.
Rationale:
1) Changes in weight can provide information on fluid balance and adequacy of volume replacement.
2) Glucose levels need to be reduced gradually for fluid balance to occur. A steady decline is desirable.
3) Inaccurate technique can result in an elevated glucose level.
Evaluation:
1) Glucose level
Subjective data- visual blurriness,thirst,frequent urination,"always hungry"
Objective data- Black spot on 1st and 2nd toe of L foot, BP-190/88, T-98.7, Pulse-87, Respirations- 22
Nursing Diagnosis #1 -
Decreased cardiac output related to peripheral vascular resistance secondary to hypertension as evidenced by BP-190/88
Short term goal: After 6 hours, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits.
Long term goal: After 5 days the client will maintain adequate cardiac output and cardiac index.
Interventions:
1) Monitor BP every 1-2 hours.
2) Note prescence, quality of central and peripheral pulses.
3) Observe for confusion , restlessness, agitation, dizziness. Central nervous system disturbances may be noted with decreased cardiac output.
Rationale:
1) To establish baseline data.
2) Pulses are weak with reduced cardiac output.
3) Early signs of lung congestion may be associated with onset of heart failure.
Evalutation:
1) After 6 hours, blood pressure maintained within set parameters for the client. Goal was met.
2) After 5 days, the client had an adequate tissue perfusion to his body systems. Goal was met.
Nursing Diagnosis #2-
Fluid and Electrolyte imbalance related to diabetes as evidenced by glucose 457.
Short term goal: Clients blood glucose will be 80-150 within 24 hrs.
Long term goal: Client will demonstrate how to take her blood sugar and how to give herself injections by discharge.
Interventions:
1) Weigh patient daily.
2) Monitor serum glucose hourly as long as insulin infusion continues.
3) Instruct the client to prepare and administer insulin.
Rationale:
1) Changes in weight can provide information on fluid balance and adequacy of volume replacement.
2) Glucose levels need to be reduced gradually for fluid balance to occur. A steady decline is desirable.
3) Inaccurate technique can result in an elevated glucose level.
Evaluation:
1) Glucose level