NURSING CARE PLAN

Nursing Diagnosis: Orem's Self-Care Theory applied to hypertensive patients permits

guiding care towards self-care, as well as to organize and apply the nursing process in
several phases, such as interview and physical examination, nursing diagnosis and
evaluation.

The analysis of the universal requirements regarding development and health deviations
detected self-care deficits related to inadequate feeding, overweight, lack of control on
stress situations, lack of blood pressure control, ineffective pharmacological therapy
management, all of which are considered critical aspects to control hypertension and
prevent complications.

It was also verified that the supportive-education system was the main point for nurses'
actions, as these professionals seek to guide and prepare their clients for self-care.
Constant follow-up is necessary through return and routine consultations, so that this
aspect to be constantly checked and reinforced by the nurse at each meeting, considering
that incorporating lifestyle changes, which are critical to meet self-care demands, requires
dedication and motivation from the diseased patient.

In order to have a detailed assessment of how these clients are incorporating self-care into
their daily routine, of how they are incorporating the orientations received when they return
for a new consultation, and if they are really motivated to and aware of self-care, further
study is needed. What we can assure is that the application of Orem's Self-Care Theory
facilitated the organization of nursing attention delivery, as well as nurses' performance
towards these patients
Orem developed the Self-Care Deficit Theory of Nursing, which is composed of three
interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the
theory of nursing systems.

“The condition that validates the existence of a requirement for nursing in an adult is the
absence of the ability to maintain continuously that amount and quality of self-care which
is therapeutic in sustaining life and health, in recovering from disease or injury, or in
coping with their effects. With children, the condition is the inability of the parent (or
guardian) to maintain continuously for the child the amount and quality of care that is
therapeutic.” (Orem, 1991)

 Risk of Unstable Blood Glucose level Related to Insulin Deficiency or

excess/Inadequate blood glucose monitoring as evidence by abnormal blood glucose
reading

 Risk of injury related to Hyperglycemia/Peripheral sensory neuropathy/Immune

system deficit as evidence by delayed wound healing.
  Imbalance nutrition less than body requirement related to reduction of carbohydrate
metabolism due to insulin deficiency/inadequate intake due to nausea and vomiting
evidence by Hyperglycemia and weight loss

 Ineffective therapeutic regimen management related to insufficient knowledge as

evidence by continued hyperglycemia inaccurate statement regarding diabetes and
its management

ASSESSMENT NURSING GOAL INTERVENTION IMPLEMENTATION EVALUATIO

DIAGNOSIS N

Subjective Risk of Unstable To maintain Assess sign and Sign and symptoms
data- Blood Glucose Blood glucose symptoms of have been assessed for
level Related to level within hyperglycemia. hyperglycemia.
Patient Insulin Deficiency normal range
complaint that or and maintain Assess blood glucose Blood glucose level has
he feel hot and excess/Inadequate Hb A1c . level before and at been assessed before
Dry and some blood glucose bedtime. and at bedtime.
time feel cold Now patient
monitoring as
and clammy. evidence by Blood
abnormal blood Monitor patient’s Hb HbA1c Level has been glucose level
glucose reading A1C level. assessed of patient. is stable in
Assess sign and Patient has been some extent.
symptoms for assessed for sign and
Objective Hypoglycemia symptoms of
data- /Hyperglycemia and Hypoglycemia/Hypergly
treat with dextrose cemia.
I observed
25%/Insulin.
that patient’s
has Administer Medication has been
Fluctuating medication as order. administered to patient.
blood glucose
level ( Bipolar Teach the p Patient has been taught
attack of hypo about Home blood
patient about home glucose monitoring
or hyper
blood glucose
glycemia)
monitoring. .

ASSESSMENT NURSING GOAL INTERVENTION IMPLEMENTATION EVALUATIO

DIAGNOSIS N

Subjective Risk of injury To keep the Assess general General appearance has
data- related to patient free of appearance of the been assessed.
Hyperglycemia/Pe injury . foot& skin.
Patient ripheral sensory
complaint of neuropathy/Immu Assess the status of Status of patient’s Nails
Injury in feet has been assessed.
with delayed ne system deficit Nail.
wound as evidence by Skin integrity of Now risk for
healing delayed wound Assess the patient’s patient’s has been injury is
healing. skin integrity. assessed. reduced in
some extent.

Patient has been noted

Objective Note the presence of for presence of callus
data- callus formation or formation or corns.
corns
I observed Patient has been
that patient’s Assess the for assessed for edema and
has Foot evidence of edema infection.
lesion and and infection.
skin Patient has been
Instruct the patient instructed to inspect
breakdown
to inspect the feet feet daily for cuts,
daily for cuts, scratches and blisters.
scratches and
blisters.
Patient has been
Instruct the patient instructed for wear
to wear protective protective footwear and
footwear never use never used barefoot.
barefoot.

ASSESSMENT NURSING GOAL INTERVENTION IMPLEMENTATION EVALUATIO

DIAGNOSIS N

Subjective Imbalance To Improve Asses the patient’s Patient’s weight has

data- nutrition less than patient weight daily or as been assessed.
body requirement nutritional ordered.
Patient related to intake
complaint of reduction of Discuss eating habits Discussion has been
lack of done about eating
interest in carbohydrate and encourage for habits and patients have
food & metabolism due to diabetic diet as been encouraged for Now patient
weakness insulin prescribed by doctor. diabetic diet as Nutritional
with Fatigue deficiency/inadeq prescribed by doctor. level is
uate intake due to improved
nausea and in some
60% Carbohydrate,20% extent.
vomiting evidence
Protein and 20% Fat has
Objective by Hyperglycemia Provide diet of
been provided to
data- and weight loss approximately 60%
patient.
carbohydrate,20%
I observed protein,20% Fat in
that patient’s meals.
has recent Patient has been
weight loss. Instruct the patient in
instructed about to
Poor muscle the methods to
maintain hydration and
tone. maintains hydration
avoid hypoglycemia.
and avoid
hypoglycemia during
exercise.
Antiemetic and
Administer hypoglycemic
medication as medication has been
ordered such as administered.
antiemetic and
hypoglycemic.

Finger stick glucose

Perform finger stick testing has been
glucose testing and performed and insulin
administer insulin/ /oral hypoglycemic
oral hypoglycemic agent has been
agent. administered.

ASSESSMENT NURSING GOAL INTERVENTION IMPLEMENTATION EVALUATIO

DIAGNOSIS N

Subjective Ineffective To provide Assess the current Current level of

data- therapeutic adequate and level of knowledge knowledge related to
regimen appropriate disease process has
 management knowledge related to disease been assessed and
Patient related to regarding process and determined scope and
complaint of insufficient disease determine the scope extent of required
that he do not knowledge as process and and extent of require teaching.
know about Now patient
evidence by its teaching.
disease Know some
continued management.
process and Knowledge regarding points about
hyperglycemia
its Provide appropriate disease process & its disease
inaccurate
management knowledge regarding etiology and process and
statement
disease process, its management has been its
regarding diabetes
etiology & provided to patient. managemen
and its
management to t and level of
management
patient. knowledge
Objective
regarding
data- Initial sign and disease
Teach the patient symptoms of DM has condition is
I observed
about initial sign and been taught to patient. improved
that patient’s
symptoms of in some
has recent
Diabetes mellitus. extent.
weight loss. Information regarding
Poor muscle Provide information dietary pattern has
tone. regarding dietary been provided to
pattern needed in patient.
DM.
Patient has been taught
Teach about long about long term
term complication of complication of disease
disease process and process and awareness
increase awareness has been improved
of long term control about disease process.
of disease process.