Comprehensive Nursing Care Plan: Type 2 Diabetes Mellitus

 Nursing Care Plan: Type 2 Diabetes Mellitus

Patient Information:

• Name: [Insert Patient Name]
• Age: [Insert Age]
• Gender: [Insert Gender]
• Date of Care Plan: [Insert Date]
• Medical Diagnosis: Type 2 Diabetes Mellitus (T2DM)

---

Assessment Data

Subjective Data:

• Reports of fatigue, increased thirst, and frequent urination.
• Expresses difficulty in managing blood glucose levels.
• Complains of occasional numbness in feet.

Objective Data:

• Blood glucose: [Insert Value] mg/dL (hyperglycaemia noted).
• Haemoglobin A1C: [Insert Value]% (elevated).
• Body mass index (BMI): [Insert Value] (overweight/obese).
• Presence of dry skin and delayed wound healing.
• Vital signs: [Insert Values].

---

Nursing Diagnoses

1. Imbalanced Nutrition: More than Body Requirements related to poor dietary habits as evidenced by elevated BMI and blood glucose levels.
2. Deficient Knowledge related to the disease process, management, and complications of diabetes as evidenced by the patient's statements of difficulty managing blood glucose.
3. Risk for Impaired Skin Integrity related to poor circulation and delayed wound healing.
4. Risk for Peripheral Neurovascular Dysfunction related to potential complications of diabetes.

---

Planning (Goals and Outcomes)

Short-term Goals:

• The patient will demonstrate proper blood glucose monitoring techniques within 48 hours.
• The patient will identify three dietary modifications to manage blood glucose levels by the end of the teaching session.

Long-term Goals:

• The patient’s blood glucose levels will remain within the target range (e.g., 4.4-7.2 mmol/L fasting) during the next three months.
• The patient will achieve a 5% reduction in body weight within six months.

---

Interventions

1. Imbalanced Nutrition: More than Body Requirements

Nursing Interventions:

• Collaborate with a dietitian to create a meal plan tailored to the patient’s preferences and needs.
• Educate the patient on the importance of portion control and carbohydrate counting.
• Encourage regular physical activity, such as walking for 30 minutes, five days a week.
• Monitor and record daily food intake and weight.

Rationale: Tailored dietary and exercise plans can improve glycaemic control and support weight management.

---

2. Deficient Knowledge

Nursing Interventions:

• Teach the patient about the pathophysiology of type 2 diabetes and its potential complications.
• Demonstrate the correct use of glucometers and insulin administration, if prescribed.
• Provide written materials and visual aids to reinforce teaching.
• Encourage the patient to ask questions and express concerns.

Rationale: Enhancing the patient’s knowledge can empower them to manage their condition effectively and prevent complications.

---

3. Risk for Impaired Skin Integrity

Nursing Interventions:

• Assess skin daily for signs of pressure ulcers, wounds, or infections.
• Encourage the patient to moisturise dry skin and avoid walking barefoot.
• Educate the patient on proper foot care, including daily inspection and avoiding tight-fitting shoes.
• Refer to a podiatrist if necessary.

Rationale: Preventing skin breakdown reduces the risk of infection and promotes overall skin health.

---

4. Risk for Peripheral Neurovascular Dysfunction

Nursing Interventions:

• Monitor for signs of neuropathy, such as numbness, tingling, or decreased sensation.
• Encourage regular follow-up appointments with a healthcare provider.
• Teach the patient about the importance of controlling blood glucose to prevent nerve damage.
• Advise the patient to avoid exposure to extreme temperatures.

Rationale: Early detection and management of neurovascular complications can improve outcomes and quality of life.

---

Evaluation

• The patient demonstrates accurate blood glucose monitoring and records values daily.
• The patient verbalises understanding of dietary modifications and implements changes in meals.
• No signs of skin breakdown or infection are observed during routine assessments.
• The patient maintains or improves sensory function as evidenced by self-reports and physical exams.

---

Signatures:

• Nurse: [Insert Name and Signature]
• Patient: [Insert Name and Signature]
• Date: [Insert Date]