NCP DM TYPE II

ASSESSME
NT
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective
:“Hindi
gumagalin
g ang
sugat ko”
(My
wounds
are not
healing)
As
verbalized
by the
patient.
Objective:
•Flushed
appearanc
e.
•Wound
drainage.
•V/S
taken as
follows:
T:37.4
P:87 R:19
BP:
Risk for
infection
related to high
glucose levels,
decreased
leukocyte
function.
After 8 hours
of nursing
interventions,
the patient will
identify
interventions
to prevent or
reduce risk of
infection
Independent:
•Observe for
signs of
infection and
inflammation.
•Promote good
hand washing
by nurse and
patient.
•Maintain
aseptic
technique for
IV insertion
procedure,
administration
of medications,
and providing
maintenance
and site care.
Rotate IV sites
•Patient may be
admitted with
infection, which could
have precipitated the
ketoacidotic state, or
may develop a
nosocomial
•Reduces the risk of
cross-contamination
•High glucose in the
blood creates an
excellent medium for
bacterial growth.
•After 8 hours
of nursing
interventions,
the patient
was able to
identify
interventions
to prevent or
reduce risk of
infection.