Assessment two: Care Planning | Assessment

Assessment two: Care Planning
Care Plan template
Nursing Diagnostic statement 1
Acute pain related to the linear wound secondary to the uncontrolled blood glucose level.
Expected outcome1
Patient verbalizes that the pain management strategies are effective and his pain score is 2/10
Nursing interventions 1
The Assessment is the primary intervention. Assess the site, kind, commencement, duration,
feature and intensity of pain.
Rationale 1
Assessment reveals the actual need of the patient. The nurse needs to assess the pain with the
help of pain scale which enables the nurse to rule out the site, kind, duration, feature and
intensity of pain. The assessment helps the nurse to plan for the interventions that actually
benefit the patient (Mills, 2016).
Nursing interventions 2

Execute non-pharmacological nursing interventions like, deep breathing exercise, relaxation
therapy, music therapy and divisional therapy.
Rationale 2
Non-pharmacological interventions are scientifically proved to be effective (Tick, 2018).
Implementation of Non-pharmacological pain management increases the discharge of the
endorphins, which is found to be reducing the pain and has therapeutic action in pain
management (Liu, 2015).
Nursing intervention 3
Administer analgesics as per doctors advice
Rationale 3
Analgesics are also termed as painkillers which are scientifically proved to be having pain
relief action. The action of the analgesics is classified into many. It believed to be acting on
the central nervous system and also peripherally. The actions range from the reduction of
pain to the complete removal of pain (Smith, 2018).
Nursing intervention 4
Alleviate the environmental factors that are believed to be the contributory factor for pain like
loud noise, cold or hot environment and lighting.
Rationale 4

Environmental factors like pain like loud noise, cold or hot environment and lighting are
found to be increasing the perception of pain. A favorable environment is found to be helpful
in relaxation (Smith, 2018).
Nursing Diagnostic statement 2
Risk of increased glycemic level related to the altered secretion of insulin.
Expected outcome
Patient’s glycemic level is maintained in normal limits
Nursing interventions 1
Assess for the signs and symptoms of hypoglycemia and hyperglycemia and assess the blood
glucose level before the administration of insulin (Dumard, 2018).
Rationale 1
Assessment for signs and symptoms of hyperglycemia and hypoglycemia helps the nurse to
find the alteration in the glycemic level and act immediately which aids in preventing further
complications (Freeland, 2016).Checking glycemic level before administering the insulin
guides the nurse to determine the amount of insulin actually needed for the patient and also it
prevents accidental insulin overdose.
Nursing intervention 2

Check the glycemic level before meals and before administering insulin.
Rationale 2
Normal blood glucose level has to be between 140 to 180 mg/dl. Checking the glycemic
level before meals and before the insulin therapy prevents hypoglycemia (Dumard, 2018). It
also helps in making alterations in the food and also in insulin levels to prevent
complications.
Nursing intervention 3
Administer insulin as per the doctor’s order and as per the glycemic level at the time of
insulin therapy.
Rationale 3
Insulin therapy is the remedial intervention which helps to maintain normal glycemic level. It
promotes the tissue perfusion which helps in improved oxygen supply to the tissues and it
delays the complications related to the disease condition (Freeland, 2016). Maintaining the
normal glucose level helps in maintaining the health of the vital organs and slows the
evolution of micro vascular diseases (MacIntyre, 2018).
Nursing Intervention 4
Encourage the patient to take a diabetic diet and educate on importance of diabetic diet.
Rationale 4

It helps the patient to make alterations in the food intake based on the
glycemic level which helps in preventing hyperglycaemia (Lind,
2017).Educating the patient on the importance taking diabetic food improves
the patients understanding of the relation between food and glycemic level.
Nursing Diagnostic statement 3
Elevated body temperature related to the cellulitis in the left forearm secondary to the disease
condition.
Expected outcome
Patient’s temperature is normal and the related vital signs heart rate and respiration rate are
normal.
Nursing intervention 1
Continuously monitor the temperature and vital signs every two hourly.
Rationale 1
Patient with diabetes is prone to infection (Ji, 2016).Checking the temperature frequently
helps to identify the significant change in temperature. The assessment helps the nurse to plan
and implement the nursing intervention accordingly for the promotion of health and
prevention of complication.
Nursing intervention 2

Encourage the patient to take more fluids
Rationale 2
Increased fluid intake is a beneficial non-pharmacological therapy for hyperthermia.
Increased fluid intake hydrates the cells of the body (Nasir, 2017).Replacement of fluids that
lost through convection helps to stabilize the body temperature and normalize the vital signs.
Nursing intervention 3
Administer antipyretic medication every four hourly if the patient is febrile.
Rational 3
Antipyretics are the medication has a dual-action. It reduces pain and high temperature.
Antipyretic induces the hypothalamus a thermoregulatory unit of the body to reverse the
prostaglandin which is the major cause for increased temperature (Wasserman, 2018).Then
the body temperature is reduced. The antipyretic medication level in the blood maintains the
optimal range for four hours. so, The nurse can repeat the medication every four hours to
maintain the normal temperature (Panday,2019).
Nursing intervention 4
Apply non-pharmacological fever management strategies like a cold compress, ice cap, and
tepid sponging to maintain normal temperature.
Rationale 4

Cold compress is one of the non-pharmacological fever management technique helps in
regulating body temperature and blood circulation. Icecap is applied over the head which
reduces the temperature in the hypothalamus the thermoregulatory unit of the body. It helps
to maintain normal body temperature. Tepid sponging is the most effective Non-
pharmacological fever management technique in which the body temperature is maintained
manually. Tepid sponging reduces the body temperature by convection which is considered
to be one of thermoregulatory mechanism of the body.
Nursing Diagnostic statement 4
Lack of knowledge about the disease condition, related treatment, prevention of complication
and personal care needs.
Expected outcome
The patient says that he understood about the disease condition, treatment, and prevention of
complications.
Nursing intervention 1
Interact with the patient and assess the present knowledge, believes and attitude related to the
disease condition. Assess the patient’s level of understanding.
Rationale 1
Assessing the present knowledge about the disease condition, treatment and complications
help the nurse to plan patient education (Jung,2015).Assessing the attitudes and believes

about the disease condition helps the nurse find the myths and misunderstandings related to
the disease condition. Assessing the level of understanding helps the nurse to plan the patient
education and use of Audio-visual aids.
Nursing intervention 2
Educate the patient about the disease condition, the Pathophysiology of the disease condition,
treatment, importance of diabetic diet, and insulin therapy. Provide information on potential
complication and simple ways to prevent complications.
Rationale 2
Provision of information alleviates doubts, confusion, and misunderstanding. Patient
education encourages the patient to co-operate in the treatment and nursing care (Lind, 2017).
Nursing Intervention 3
Encourage the patient to ask questions and clear the doubts.
Rationale 3
Encouraging the patient to ask the question promotes the knowledge about the disease
condition and the related factors (Ung, 2016).Providing answers to his doubts build a
therapeutic relationship and trust between the nurse and patient.
Nursing intervention 4

Provide information on personal care needs after discharge and encourage the patient to
follow a diabetic diet, medication, exercise and follow up.
Rationale 4
Providing information on personal care needs after discharge builds confidence inpatient to
continue self-care strategies at home. It improves patient co-operation even after the
discharge (Mufunda, 2018). It helps the patient to be independent in meeting diabetic care
and prevents potential complications
Handover of Care - iSoBAR
Clinical Hand over for pain management
I I am an enrolled nurse wanted to present the
condition of the patient Mr. Shaun Jensen, 24
years male presented with pain in the left arm.
S He is presented with type 1 diabetes mellitus
with cellulitis on his left arm. He is
complaining of pain. Pain score is 7/10.
O A dermal piercing is visible within the wound.
The patient is holding his arm with facial
grimacing. Linear wound on his left forearm
which appears red with pus, and inflamed and

warm to touch
B Shaun was admitted with pain and he
describes that the pain is “throbbing”, His left
arm is so sore and worse when let it hang
down on the side. Pain score 7/10 on
admission.
A My assessment shows that the cause for pain
is cellulitis wound on his left forearm.
R I would like to request you to implement
nursing interventions of pain management
and pharmacological measures to reduce the
pain in the wound site.
Clinical Hand over for increased blood glucose level
I I am an enrolled nurse wanted to present the
condition of the patient Mr. Shaun Jensen, 24
years male with type 1 diabetes mellitus.
S He is presented with type 1 diabetes mellitus.
The glycemic level in the ambulance was

28.5mmol. Present glycemic level is 15mmol.
O Shaun was diagnosed with Diabetes Type I in
January 2019. He is on insulin therapy and
restricted diabetic therapy.
B He is presented with type 1 diabetic Mellitus
with the cellulitis.
A On assessment the cause for Type 1 diabetes is
unknown.
R I would like to request you to implement
nursing interventions that maintain a normal
glycemic level and prevent further
complications.
Clinical Hand over for hyperthermia
I I am an enrolled nurse wanted to present the
condition of the patient Mr. Shaun Jensen, 24
years male with hyperthermia.
S He is presented with elevated temperature
His temperature at the time of admission is

38.8C. Vital signs are also elevated. Heart
rate is 90 and the respiratory rate is 18b/mt.
O Shaun was presented with increased
temperature. Pharmacological measures are not
prescribed for him.
B Shaun was presented with increased
temperature with the infected wound on the left
arm
A The major cause for the fever and elevated
vital signs is the infected wound in the left
arm.
R I would like to request you to implement
nursing interventions that maintain normal
body temperature and promote health.
Clinical Hand over for knowledge deficit
I I am an enrolled nurse wanted to present the
condition of the patient Mr. Shaun Jensen, 24
years male with lack of knowledge on disease

condition.
S He is presented with type 1 diabetes and
cellulitis but he is not aware of the disease
condition and complications
O On admission, Shaun stated that he knows
less information about diabetes.
B Shaun presented with unstable blood glucose
level.
A A major cause for lack of knowledge is
unawareness and ignorance.
R I would like to request you to implement
nursing interventions to educate the patient
about the disease condition, management,
and prevention of complication.
Discharge plan
Patient: Mr.Shaun Jensen

DOB: 10/1/1995
Admitted:
20/08/2019
Discharged: 25/08/2019
LOS: 5 days
D/C Reason: Care complete
D/C Destination: Home with parents and sister
Specialty: Medical
Consultant:
Principle Diagnosis: Diabetes mellitus with cellulites poorly
controlled with most recent HbA1C
75mmol/mol
Other problems: Nil
Interventions/Procedures: Monitoring Blood glucose level wound care

and insulin therapy.
Blood ketone levels less than 0.6mmol/L.
Commenced on IV Cephazolin 1gm QID for
dermal piercing infection and given stat dose
of 8 units of actrapid subcut in emergency
department.
Past Medical Hx: Type 1 diabetes mellitus
Clinical Management: He is admitted in the medical ward
Reviewed by the medical ward nurse
Educated about the personal care needs
Educated on insulin therapy and encouraged
to continue at home
Diabetic diet plan provided
Educated about wound care at home
Educated on the signs and symptoms of
hyperglycemia and hypoglycemia.

Social Issues: He is single but maintains a good relationship
with parents, older sister, and grandparents.
Instructions to GP Please monitor the blood glucose level and
monitor the wound.
Information for Patient: Information was provided to Shaun.
Explained to him about the importance of
diabetic diet. Please check your blood sugar
before every meal. Please get a glucometer
which helps you to be independent in
monitoring the blood glucose level. Please has
do exercise regularly. Wound care and wound
dressing need to be done to prevent
complications. Please take insulin therapy
regularly. Please do follow up after a week.
Explained about the signs and symptoms of
hypoglycaemia and hyperglycaemia.
Review Details: Follow up appointment 1 week in the
outpatient clinic: Date: 1/09/19 1200hrs.
Copies of letter for: GP /Consultant/ medical record

Medications
DISCHARGE
MEDICATION
DOSAGE REASON
INSTRUCTIONS
Lantus 30units 8 pm s/c Before bed
Actrapid 8 units 7 am s/c before breakfast
Actrapid 10 units 12pm s/c before lunch
Actrapid 12 units 6 pm s/c before dinner
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