VII. NURSING CARE PLAN
ASSESSMENT DATA(Subjective & Objective Cues)NURSING DIAGNOSIS(Problem and Etiology)GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATIONSubjective:
dugay kayo ga-ayo akong samad satiil
ncreased HGT level of 321mg/dL
itting edema on both lowerand upper extremities (4mm)
rolonged capillary refill of 4seconds.
allor in the punctured woundat the right foot
Ineffective tissue perfusion(Peripheral) related to increasedblood viscosity secondary tohyperglycemiaShort term goals:
After 8 hours of thoroughnursing intervention, theclient will be able to:a.)
Decrease bloodglucose level from321mg/dL withinnormal range of 80 110 mg/dLb.)
mprove the capillaryrefill from 4 secondsto 3 seconds.c.)
Reduce pittingedema from 4mm to2mmd.)
mprove skin color atthe wound site.
Long term goals:
ompletely eliminatepresence of pittingedema.b.)
Maintain normalblood glucose level of 80 110mg/dL
Assist client in frequent ambulation, whenpossibleR to enhance venous return2.)
Elevate the legs when sitting, avoidingsharp angulations of the hips or knees.R to promote proper venous return3.)
osition patient in a high back restR to increase gravitational blood flow.4.)
Apply patients bladder cold packsR To stimulate the urge to urinate.5.)
Let the patient hear the running water fromthe faucet.R To stimulate the urge to micturate.
Administer medications (insulin), s ordered.R helps in lowering down blood glucoselevel.4.)
Administer 2 ampules of amino acid (
).R to promote faster healing of thewound.
Refer to the dietician for his Diabetic diet.2.)
ncrease protein intake of the patient.R
rotein promotes faster healing of thewounds.Goals partially met.The patient wasable to reducepitiing edema from4mm to 2mm andimproved skin colorat the wund sitefrom pallor topinkish but failedto achieve normalblood glucose levelof 80 110mg/dLand failed toimprove capillaryrefill of 4seconds to3 seconds.