CarePartners Nursing Care Plan Diabetes (Adult) Nursing Resources... · CarePartners Nursing Care Plan ... 8. Tingling or numbness sensation 9. Blood glucose tests consistently out

CarePartners Nursing Care Plan – Diabetes (Adult)

Diabetes March2015 Page 1 of 14

** If a CarePartners wound pathway, palliative care plan or oncology care plan is being used to guide the patient’s care, this Nursing Care Plan may not be required. **

Patient Name:

Date: Initials and Designation of Nurse Initiating Care Plan:

Initial Assessment Reason for referral, etiology of condition, co-morbidities, factors impacting self-management

Patient-Centred Goals SMART: Specific, Measureable, Attainable, Relevant and Time-related

Interventions/Teaching/Facilitating Self-Management/Discharge Planning Include nursing procedures/delegated acts that will be taught to UCPs

Type 1 Diabetes (5-10% of cases) Pancreas is no longer able to secrete insulin. Autoimmune process typically found in children and young adults. Treatment - insulin.

Contributing Medical History Family history Environmental factors (ie. foods, toxins) Autoimmune process Viruses and infections Dietary Factors (ie. Early exposure to cow’s milk and infant cereal)

Type 2 Diabetes (90-95% of cases) Pancreatic failure in producing adequate supply of insulin and/or body’s resistance to effects of insulin. Most typical of middle to older aged adults, sometimes children. Treatment - oral therapy or sometimes a combination of both oral therapy and insulin.

Contributing Medical History Family history Overweight or obesity Physical inactivity Ethnic background High blood pressure Gestational diabetes history Hyperlipidemia Polycystic ovary syndrome Pre-diabetes history (high Hg A1C) Cardiovascular disease Acanthosis Nigricans

Patient/caregiver will:

1. demonstrate adequate knowledge and skill for routine blood glucose monitoring within _____ visits. Adequate knowledge includes an understanding of monitoring capillary glucose levels at appropriate times / intervals for his/her disease specific requirements through the demonstration of skills, appropriate interpretation of findings & taking appropriate actions related to the findings.

2. demonstrate knowledge, skill, comfort & understanding to accurately measure & administer prescribed insulin within _____ visits. Insulin may be administered using an insulin pen, injection by syringe, insulin pump, etc.

3. make appropriate dietary choices with the guidance of available resources and a Dietician within ____ visits and ongoing. The patient will demonstrate that he/she has the necessary knowledge, comfort and understanding needed to make appropriate food choices which are in keeping with their diabetes regime and how to manage adjustments in terms of choices and glucose monitoring results

4. verbalize understanding of diabetes associated risks and complications, emergencies & prevention strategies within ____ visits.

5. will demonstrate ongoing appropriate use of self-management strategies by managing symptoms proactively and preventing exacerbations. Patient will use personal action plan and guideline for managing symptoms to set realistic goals.

Assessment: At each visit (document on flow sheet)

1. Assess vital signs and review BG results log with patient

2. Refer to “Patient/Caregiver Knowledge Assessment and Teaching Tool” on page 3; to assess knowledge and address any outstanding needs.

3. On admission and every 6 months, perform the ‘monofilament test’ to determine possible sensory loss thereby increasing the risk for diabetic foot ulcers (see P&P for Diabetic Foot Ulcers)

4. Assess patient for pain related to neuropathies and advocate for pain management using appropriate drugs for neuropathic pain such as Amitriptyline, Nortriptyline, Gabapentin, etc.

5. Assess and discuss potential for psychological concerns such a frustration, potential for non-compliance, depression, etc. and importance of seeking assistance in managing these concerns.

6. Assess patient’s plans for ongoing follow up with Diabetes Team, including; Physician, Certified Diabetes Educator, Nurse, Dietician, and/or Pharmacist.

7. Assess for opportunity to provide self-management education with specific focus on; self-care practices and behaviours, ability to learn self-management strategies (taking into account health literacy) and setting realistic goals. Refer to Goals for Managing Symptoms of Diabetes tool and the Personal Action Plan at the end of this care plan.

Interventions (also refer to patient/caregiver teaching) Report the following signs of worsening diabetes to the physician:

1. Frequent urination 2. Unusual thirst 3. Weight change (gain or loss) 4. Extreme fatigue or lack of energy

CarePartners Nursing Care Plan – Diabetes (Adult)

Diabetes March2015 Page 2 of 14

Patient Name:

Date: Initials and Designation of Nurse Initiating Care Plan:

Sign and symptoms of Diabetes on admission: BMI greater than 25 (adults) Frequent urination Increased thirst Fatigue Increased appetite Hyperlipidemia

6. confirm an established relationship with a Certified Diabetes Educator (CDE) and Medical Doctor (MD). Patient will ensure ongoing routine follow up in addition to consultation as needed.

7. have reviewed the CarePartners Diabetes self management tools and other Canadian Diabetes Association (CDA) resources. In addition, seeks clarification for information that is not well understood and express a confidence to manage their disease independently with aforementioned supports.

8. understand psychological issues related to chronic disease management within ___ visits and ongoing. Patient will express an understanding that there may be psychological needs related to having a chronic disease such as diabetes and therefore agree to access information and resources available to them, as needed.

5. Blurred vision 6. Frequent or recurring infections 7. Cuts or bruises that are slow to heal 8. Tingling or numbness sensation 9. Blood glucose tests consistently out of range 10. Non-adherence to medication 11. Reports of confusion, loss of consciousness, inability to

arouse from a sleep, seizure activity.

Note: If a goal or intervention is no longer part of the care plan, cross out with one line and initial. When adding a goal or intervention to the initial plan, record the date and your initials beside the new entry.

CarePartners Nursing Care Plan – Diabetes (Adult)

Diabetes March2015 Page 3 of 14

Patient/Caregiver Knowledge Assessment and Teaching Tool In 1

st Column - Indicate with (D) if controlled act and requires delegation

Patient Response (Comment on return demonstration & knowledge transfer)

Date/ initial Designation

Basic skills that must be achieved by all patients within first 2 visits (check when achieved)

Glycemic control – ensure patient; knows frequency of daily testing as determined by CDE and/or Physician. Recommendation is:

Type 1: 3 x daily pre and post meals Type 2 who use insulin and oral meds in combination: once daily at variable times Type 2 not on insulin: individualized plan according to treatment, level of control and risk

understands natural health products are not recommended for glycemic control due to insufficient evidence available to support their safety and efficacy.

understands S&S of hypoglycemia & hyperglycemia, risks, emergency measures for extreme blood sugar levels and its prevention – possible need for alternate strategies

able to recognize S&S of mild to severe hypoglycaemia or hyperglycaemia and recommendations for treatment (refer to Diabetes Symptom Monitoring Guideline in care plan).

reinforces with family to call 911 if patient becomes unable to swallow or unresponsive *for individuals at risk for severe hypoglycaemia – understands that caregiver may be taught to administer

glucagon by injection. understands that when hypoglycaemia episode is reversed, regular meal schedule should be resumed. If

>1hr then a carb/protein source snack should be consumed.

Use of glucometer - ensure patient/caregiver; has obtained / purchased a glucose meter suitable to their needs demonstrates proper use of the glucose meter, including running controls, changing strip codes, cleaning,

and seeking technical support from manufacturer, etc. shows ability to obtain blood sample for test, apply to meter strip, read meter and review memory of

glucose meter understands capillary glucose findings; their meaning, appropriate actions and adjustments, establishing

patient specific lows & highs as appropriate, identifying therapeutic range goals with actions necessary to achieve these goals

knows to report undesirable findings and appropriate follow-up with CDE or MD

Administration of Insulin - Ensure patient/caregiver: has ability to draw up insulin (single kind or combination of 2),dial up insulin dose using a pen, change

needle / cartridge, safely dispose of sharps, etc. demonstrates proper procedure for administration of insulin has adequate knowledge related to oral meds if applicable. If insulin dependent, assess knowledge in

relation to insulin ordered and ensure ability to secure dose and administer injection. *(for elderly population) has access to pre-mixed insulin and/or pre-filled insulin pens demonstrates ability to choose appropriate injection sites has knowledge related to rotation of sites, S&S of site problems & ways to manage site concerns

CarePartners Nursing Care Plan – Diabetes (Adult)

Diabetes March2015 Page 4 of 14

Patient/Caregiver Knowledge Assessment and Teaching Tool In 1

st Column - Indicate with (D) if controlled act and requires delegation

Patient Response (Comment on return demonstration & knowledge transfer)

Date/ initial Designation

understands to contact nurses via on call 24/7 if needed *if using an insulin pump - has ability in maintaining procedures and practices as per specific

pump/physician protocol including frequency of blood glucose monitoring, establishing and setting basal insulin rates and decisions related to patient activated doses and its administration. In addition specific protocols related to s/c site, tubing and cartridge changes, and pump maintenance

Nutrition - Ensure patient/caregiver: has knowledge and access to resources/support groups related to appropriate food choices with amounts

(refer to “Eating Well with Canada’s Food Guide”) understands importance of establishing a plan for ongoing nutritional counselling with a CDE and/or

Registered Dietician

Intermediate Skills and Knowledge that must be initiated for all patients within first 2 weeks (check when achieved)

Glycemic control – ensure patient; understands their individual glycemic targets - based on age, duration of diabetes, risk of severe

hypoglycemia, presence or absence of cardiovascular disease, and life expectancy. is aware of recommendations for frequency of A1C testing (best practice is every 3 months until goals are

met and maintained and then every 6 months once consistency is achieved) has knowledge of effects of insulin they are taking including aspects such as peak effect, dose adjustments

as ordered by physician has ability to manage diabetes in the event of illness, flu, inability to tolerate food and/or fluids. With type

1 diabetes, use of urine or blood ketone testing during periods of illness and elevated BG is recommended. a medic alert bracelet or necklace on their body with alert card in wallet

Use of glucometer - ensure patient/caregiver has; knowledge to access glucose history using glucose meter calibration requirements of glucose meter - calibrate annually or if concern about accuracy

Physical activity - ensure patient/caregiver understands that anyone with diabetes should: exercise for at least 150 min of moderate-vigorous intensity aerobic exercise each week spread over at

least 3 days (no more than 2 consecutive days without exercise) perform resistance exercise 2-3 times a week in addition to aerobic exercise consult with and exercise specialist and/or physician to establish and monitor exercise plan use a personal action plan to set specific activity goals; identify possible barriers; develop strategies to

overcome those barriers; and keep records of their physical activity.

Nutrition - Ensure patient/caregiver understands: benefits of maintaining an ideal body weight, relationship of waist measurement to risks (women <35”,

men <40”), benefits of even small weight losses, regular exercise and maintenance of normal lipid levels

CarePartners Nursing Care Plan – Diabetes (Adult)

Diabetes March2015 Page 5 of 14

Patient/Caregiver Knowledge Assessment and Teaching Tool In 1

st Column - Indicate with (D) if controlled act and requires delegation

Patient Response (Comment on return demonstration & knowledge transfer)

Date/ initial Designation

Self Management Nurse will: collaborate with patient to offer support and education that is timely, specific to the patient’s needs, and

tailored to enhance self-care practices and behaviours. discuss expectations and assess willingness to participate in self-care assess patient’s ability to use self-management strategies such as; problem solving, goal setting, self-

monitoring of health parameters. use patient-centred interventions (ask patient what is most important in managing diabetes) assess family’s ability to cope with stress or diabetes related complications support management of technology based home glucose monitoring systems ensure cultural considerations of patient and family consider level of health literacy of patient and/or caregivers Long term effects of diabetes - Reinforce with patient/caregiver; effects of long-term high blood glucose levels; A1C results and significance / relevance potential long-term effects of diabetes and associated risks related to;

obesity hyperlipidemia lack of exercise smoking alcohol and drugs

eyesight foot complications infections cardiovascular disease (ie. Hypertension)

Other complications such as heart & renal disease, neuropathy, etc. understand the importance of maintaining a relationship with CDE and MRP in the management of their

diabetes.

CarePartners Nursing Care Plan – Diabetes (Adult)

Diabetes March2015 Page 6 of 14

Advanced knowledge and skills for ongoing effective diabetes management

Preparation for successful diabetes self-management - Assess, encourage and assist patient/caregiver to: contact CDE with questions or changes ensuring their ability to manage diabetes most

effectively schedule regular follow-up with or return to CDE as needed. BPG recommends A1C

measured every 3 months, then every 6 months once stability is achieved. receive an annual influenza immunization to reduce the risk of complications associated

with influenza receive a pneumococcal immunization to reduce the risk of complications associated with

pneumonia discuss fears, anxieties and feelings of depression related to diagnosis seek support and appropriate referrals (ie. if no drug coverage for assistance with paying

for syringes, insulin, etc.) consider smoking cessation if appropriate discuss cultural and religious traditions affected by diagnosis of diabetes share spiritual issues or concerns: hopes, dreams, beliefs, fears ongoing review of resources provided by clinic or hospital related to insulin pump

procedures and protocols. awareness of specific protocols related to site changes, pump tubing and cartridge

changes, monitoring of glucose levels and appropriate insulin boluses as per findings knowledge related to specific basal dose and expected outcomes

Diabetes March2015 Page 7 of 14

Diabetes Symptom Monitoring Guideline Adapted from American Lung Association “My COPD Action Plan”

http://www.lung.org/lung-disease/copd/awareness/copd-action-plan-generic.pdf

How am I feeling? What does it mean? What should I do?

ALL

IS W

ELL Goal Weight: ________________________

Blood glucose is within normal range (A1C goal 7%) No increased urination No increased appetite Able to maintain/work towards a healthy weight No decrease in your ability to maintain your activity level

Your symptoms are under control

Continue taking your medications as instructed

Continue to follow the CDA Live Well Plan and you work toward your goals.

Keep all appointments with your Diabetes Healthcare Team

CA

UTI

ON

If you have any of the following signs and symptoms and are unrelieved by taking your medication:

Frequent urination Unusual thirst Weight change (gain or loss) Extreme fatigue or lack of energy Blurred vision Frequent or recurring infections Cuts or bruises that are slow to heal Tingling or numbness sensation Blood glucose tests are consistently out of range

Call your physician if you are going into the CAUTION zone

Your symptoms may indicate that you need an adjustment of your

medications or management plan.

Take medication as instructed Eat sugar snack or drink juice if signs of

hypoglycaemia. Retest in 15 min and repeat if necessary. (ie. BG <4.0 mmol/L)

Once improved resume eating schedule. Call a member of your diabetes team; doctor, Nurse Practitioner, or Visiting Nurse.

Name:_________________________________

Number:________________________________

MED

ICA

L A

TTEN

TIO

N If you (or someone with diabetes in your company) have any of the

following signs and symptoms that are unrelieved by ingesting sugar or are unable to swallow:

Confused or disoriented Loss of consciousness Unable to arouse from a sleep Having a seizure (uncontrolled jerking movements)

Call 911 immediately. You are in the RED zone.

This indicates that you need to be assessed by a physician right away

If taught, caregiver to administer glucagon by injection

Call your physician right away or proceed to the hospital.

Physician___________________________

Number____________________________

For more information on how to manage your disease, use to internet to access these resources:

Canadian Diabetes Association: www.diabetes.ca

CDA Healthy Living Tools: http://www.diabetes.ca/diabetes-and-you/healthy-living-resource

Diabetes March2015 Page 8 of 14

Goals for Managing Symptoms of Diabetes

Choose at least 1-2 strategies that you feel confident you can follow and work on them for a period of a week. Use your personal action plan to help guide you. Once you feel confident that you are managing these goals, select at least 1-2 more.

I will educate the people around me about;

the signs and symptoms of high and low blood glucose

what to do if I have those symptoms

when to call 911 I will always wear my medical alert.

Keep an updated list of all the medications I take and bring the list with me when I see my doctor.

Every week I will weigh myself, measure my abdomen and write it down. If I have gained weight, I will look at my diet journal and contact my dietician to review my eating choices. Recommended waist size: Women <35”, Men <40”

I will take all the medicines ordered by my doctor and remind myself by: ___ Keeping my medications in a pillbox or setting an alarm. ___ Writing out a list of what I need to take, how much and when I need to take it.

I will check my blood glucose levels every _____________ at __________________________ as directed by my diabetes team. If my levels are not within the range that was decided for me, I will contact my doctor.

I will meet with my RD regularly make an individualized plan for healthier eating choices each day.

I will plan my meals at regular intervals to help maintain my blood glucose levels.

Refer to “Eating Well with Canada’s Food Guide”

I will work on quitting smoking. I will be down to ___cigarettes a day by my next visit to the doctor.

I will limit alcoholic drinks to no more than _____drinks each week (as discussed with my doctor). When drinking alcohol I will check my blood glucose level and ensure that I am with a responsible adult who knows the signs of hypoglycemia.

I will exercise ____days a week for___ minutes ___ a day.

The exercise I choose to do is: _________________________________________

_________________________________________

Aerobic: 150 min per wk (best is 30min x 3 days) Resistance: 2 -3 times per wk (additional to aerobic exercise)

I will contact my Diabetes team whenever I have questions, need some help, or at least once every 3 months for regular follow up.

I check my feet every day for any changes or signs of injury and call my diabetes team if I see any changes.

I will use a relaxation strategy for ___ minutes, for ___days a week. The strategy I choose to do is: ________________________________

________________________________

Adapted from source Kosciusko Community Hospital, Warsaw, IN.: http://www.viha.ca/NR/rdonlyres/CA2D081F-E018-498F-8974-E6F2B67F72E1/0/GoalsforCongestiveHeartFailureSelfManagement.pdf

Diabetes March2015 Page 9 of 14

Me, My Health and My Diabetes Team Know your team. Stay Connected. Prepare for your Diabetes Care. Live Well.

My Team Family Doctor/Nurse Practitioner

Name Telephone/Fax Numbers Address/E-mail

Nurse

Dietitian

Pharmacy/Pharmacist

Social Worker/ Mental health specialist

Eye doctor (Optometrist/Ophthalmologist)

Diabetes doctor (Endocrinologist)

Kidney doctor (Nephrologist)

Heart doctor (Cardiologist)

Physical activity expert (Exercise physiologist, kinesiologist)

Naturopathic care provider

Other

guidelines.diabetes.ca diabetes.ca | 1-800-BANTING (226-8464)

Copyright © 2013 Canadian Diabetes

Association

Diabetes March2015 Page 10 of 14

Me, My Health and My Diabetes Team Know your team. Stay Connected. Prepare for your Diabetes Care. Live Well.

Date: Date: Date: Date:

My Target/Goal Result My Target/Goal Result My Target/Goal Result My Target/Goal Result

Lifestyle (Talk to your team every three months)

Nutrition and changes to my diet

Physical activity – Aerobic: 150 minutes per week – Resistance: 2 to 3 times per week

Weight / BMI / Waist Circumference

Am I thinking about becoming pregnant?

Glucose control (A1C lab test every three months. SMBG according to your unique needs)

A1C: Target less than or equal to 7% or

Self-Monitoring of Blood Glucose (SMBG). When do I check?

Kidney care (eGFR and ACR once per year)

Did I do a blood and urine test?

Foot care (Foot exam by your healthcare provider once per year)

I check my feet every day for any changes or signs of injury and call a healthcare provider if I see any changes.

Eye care (Go once per year)

Did I go to my eye doctor?

Blood pressure (BP)

Target less than 130/80

Cholesterol (Lab test every 1 – 3 years or after a change in your medicine)

LDL-C

Stress, mood, anxiety (Talk to a member of your team every three months)

Copyright © 2013 Canadian Diabetes Association

guidelines.diabetes.ca

diabetes.ca | 1-800-BANTING (226-8464)

Diabetes March2015

Care

What does it mean to me?

Weight A healthy weight can have many good effects on your health and well-being. A healthy weight can help you: • prevent or manage diabetes • improve your blood glucose levels, blood pressure and blood cholesterol (fats) • reduce the risk of complications such as heart disease and stroke • improve your energy and general well-being

BMI The Body Mass Index (BMI) is a general guideline to understand health risk. BMI is calculated using the numbers from a person’s height and weight. The BMI number result will tell you about your individual risk for serious health complications such as diabetes and heart disease. For most adults aged 18 to 64, a BMI of 25 or higher is overweight.

Waist Circumference

Waist circumference (WC) is an important way to tell if you are at high risk for certain health problems, because too much fat around the waist (apple shape) puts stress on the internal organs (heart, lungs, kidneys) and fat in this area is linked to health problems such heart disease and high blood pressure. WC goals are different for people depending on their ethnic background and gender. In general, a healthy WC for men is less than 40 inches (102 cm) and for women, it is less than 35 inches (88 cm).

A1C The A1C is a blood test and it is a measure of your blood glucose levels over a two to three month period of time. Your A1C will help you know whether your blood glucose has been at target, or not, over this period of time. The goal for most people with diabetes is to have an A1C of less than or equal to 7%, though you should talk to you doctor about the A1C target that is right for you. Studies show that any reduction in A1C will reduce your risk of heart disease, stroke, kidney disease, eye problems, nerve damage, and foot problems. Most people with diabetes should have this blood test done in a lab every three months. Self-Monitoring

of Blood Glucose (SMBG)

Checking your blood glucose (sugar) is called Self-monitoring of Blood Glucose (SMBG). The blood glucose number you see on your monitor tells if you have a high or low blood glucose level at that point in time. SMBG numbers show you how your eating, drinking, physical activity, stress and medication affect your blood glucose levels. The numbers will help you and your diabetes healthcare team make changes to your eating, drinking, physical activity and medications, if necessary, to help get the right blood glucose target for you. There is no “one-size-fits-all” pattern for checking blood glucose. When, and how often, to check your blood glucose, plus what your targets are, should be individualized to you and the medications you are taking. For most people, target levels when you check your blood glucose are:

- between 4 and 7mmol/L before meals - between 5 and 10mmol/L or 5 and 8mmol/L two hours after you start eating a meal

Your diabetes healthcare team will help you determine what your SMBG target is, when you should check your blood glucose, and what to do if the result of your blood glucose check is not at target.

Blood Pressure (BP) Blood pressure is a measure of the amount of pressure put on your blood vessels by your heart when it pumps, the top number, and, when it relaxes, the bottom number. The target for most people with diabetes is less than 130/80. Your healthcare provider should check your BP at every visit. You can also ask your healthcare provider if checking your blood pressure at home would be helpful for you.

Low-Density Lipoprotein (LDL) cholesterol

This lab test measures the amount of bad cholesterol (fat) in your blood and it can narrow your arteries causing heart disease and stroke. The target for most people with diabetes is less than or equal to 2.0 mmol/L. This cholesterol target can help reduce your risk of heart attack and stroke. Cholesterol should be measured with a fasting blood test in a lab every 1 to 3 years, and after a change in cholesterol treatment. Lowering your LDL-cholesterol through diet and medications can reduce your risk of heart disease and stroke.

Page 1

Diabetes March2015

Care

What does it mean to me?

Urine Protein (ACR Ratio) The ACR (albumin/creatinine ratio) is a urine test usually done once a year to see if your kidneys have any damage from your diabetes. The target

number for most people with diabetes is less than 2.0. This test for your kidneys is usually checked when you are first diagnosed with diabetes, and then once per year after that.

Kidney function – estimated Glomerular Filtration Rate (eGFR)

The eGFR is a test used to see how well the kidneys are working. This test is done in a lab. A result of less than less than 60 mL/minute may suggest that you have kidney disease. This test for your kidneys is usually checked upon when you are first diagnosed with diabetes, and then once per year after that. If you have kidney disease, you may need to have this test more often.

Foot Checkup Because diabetes affects your circulation, immunity, and nerve sensation, foot problems are very common in people with diabetes. Foot care problems can lead to serious complications such as sores or wounds that are hard to heal, or more the more serious situation of amputations. A foot exam by your healthcare provider checks for changes in your feet like shape, sensation, ulcers and infection. Foot exams by your healthcare provider are usually done once per year. You can prevent problems and keep your feet healthy by managing your diabetes, checking your feet every day for changes, caring for your feet, wearing properly fitted shoes and asking your healthcare provider for help if you experience any problems with your feet. Any change to your feet is important.

Eye Exam Over time, diabetes can cause changes in the back of the eye and can lead to blindness. People with diabetes are also at increased risk of eye diseases that can affect your sight called macular edema and cataracts. When you visit your eye doctor once per year, your doctor will put drops in your eyes and look into your eyes to check for signs of eye disease as a part of your full eye exam.

Nutrition Goals Healthy eating is important for the treatment of diabetes, and for your overall health. Follow Eating Well with Canada’s Food Guide.

Physical Activity Goals For people with diabetes, exercise can help with weight loss, strengthen bones, improve blood pressure control, lower rates of heart disease and

cancer, increase energy levels, improve the body’s sensitivity to insulin, and help manage blood glucose levels. A good goal would be 150 minutes per week of aerobic exercise such as brisk walking, running, swimming, dancing, hockey and skiing. Resistance exercises, such as weight training, are also recommended two to three times a week.

Copyright © 2013 Canadian Diabetes Association

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PAP v2 10Sept2014

Personal Action Plan

Today’s Date: _______________ Name: _______________________

1. Goals: Something you WANT to do:

2. Describe your plan:

How?

Where?

What?

When?

How often?

3. Barriers (what is standing in the way of meeting your goals?):

4. How can you overcome barriers?

5. Importance of achieving goal: 0 1 2 3 4 5 6 7 8

9 10

6. Confidence in achieving goal: 0 1 2 3 4 5 6 7 8

9 10

7. Follow-Up (Date that I will reassess my goal and progress?):

PAP v2 10Sept2014

SAMPLE Personal Action Plan

Today’s Date: Monday September 8th Name: Jane Doe

1. Goals: Something you WANT to do:

Begin exercising

2. Describe your action plan:

How? Walkihg

Where? Around the block

What? 2 times

When? After dinner

How often? 4 days a week

3. Barriers (what is standing in the way of meeting your goals?): 1. Have to clean up the supper dishes

2. Bad weather

4. How can you overcome barriers?

1. Ask kids and husband to help clean up dishes on those evenings.

2. Buy some rain gear

5. Importance of achieving goal: 0 1 2 3 4 5 6 7 8 9 10

6. Confidence in achieving goal: 0 1 2 3 4 5 6 7 8 9 10

7. Follow-Up (Date that I will reassess my goal and progress?):

Will report progress in one week (Sept 15th

) at next visit and re-evaluate plan.