You are on page 1of 14

NURSING CARE PLAN

Republic of the Philippines University of Eastern Philippines University Town, Northern Samar

College of Nursing

Nursing Care Plan


Name: Patient Y Sex: Male Assessment Date Admitted: Nursing Diagnoses November 16, 2012 Rationale Chief Complaint: Diabetic Foot, left Planning Intervention Case No.: 60-05-25_ Rationale Age: 48 Evaluation Address: Pambujan, Northern Samar Ward: Surgical Attending Physician: Dr. Unay _

S> Nadudunot na ak samad as verbalized.

Impaired skin integrity related to gangrenous wound secondary to diabetes mellitus type 2.

O>gangrenous wound on the left foot, 4th digit >foul smell noted

Altered epidermis and dermis: Infected areas heal slowly because the damaged vascular system cannot carry sufficient oxygen, white blood cells, nutrients and antibodies to the injured site. Source : MedicalSurgical Nursing 7th edition, pp. 1281

After series of nursing interventions, the patient will be able to : 1. Display progressive improvement in wound healing. 2. Maintain optimal nutrition/ physical wellbeing. 3. Participate in prevention measures & treatment programs.

keep the area clean/dry, carefully dress wounds to prevent infection, & stimulate circulation to surrounding areas. apply appropriate dressing & practice aseptic technique for cleaning/dressi ng.

to assist bodys natural process of repair & remove nonviable, contaminate d ,or infected tissue. For wound healing & to best meet needs of client & caregiver/ care setting.

Goal met. Patient responds to the intervention , he stated salamat kay genlilimpya han permi ak samad, nasisi-od gad ak sa iyo, pero sa yana na naadman ko na kun nanu an makakapalala saak kondisyon, pagmagkakwarta kami mabalyo kami san bulong na gen-resita san Doctor.

Encourage to provide optimum nutrition, including vitamins (A,C,D,E) & increased protein intake. Assist the client/ SO (s)

To provide a positive nitrogen balance to aid in skin/ tissue healing & to maintain general good health. Enhances commitment

in understanding & following medical regimen & developing program of preventive care & daily maintenance.

to plan, optimizing outcomes.

Republic of the Philippines University of Eastern Philippines University Town, Northern Samar

College of Nursing

Nursing Care Plan


Name: Patient Y Age: 48 Sex: Date Admitted: Male November 16, 2012 Chief Complaint: Diabetic Foot, left Ward: Surgical Case No.: 60-05-25_ Address: Pambujan, Northern Samar Attending Physician: Dr. Unay _

Assessment
S> Unta magkayaon na kami kwarta para ipabulong ko akon siki as verbalized.

Nursing diagnosis
Health Seeking Behavior related to expression of concern about current environmental conditions on health status.

Rationale

Planning

Intervention

Rationale

Evaluation

Active seeking of ways to alter personal health habits / the environment in order to move forward a higher level of health. Source: Nurses Pocket Guide, 11th edition

O> willingness to participate

During m 8 hours shift the patient will be able to : Express desire to change specific habit / lifestyle patterns to achieve / maintain optimal health. Participate in planning for a change. Seek community resources to assist with desired change

Identify behaviors such as : tobacco use, sedentary lifestyle.

Associated with health habits / por health practices & proliferation of chronic health problems. To provide information & encourage client to make healthy choices for future.

Discuss with client his particular risk-taking behavior like, smoking, drinking, lack of healthy food / exercise.

Refer to community

To address specific

Goal met. The patient stated kun makaguwa s man kami yana biskan dire ak maoperahan pa, kay wara pa man kami kwarta yana, maiiban nala ak saak pagsigarilyo, kay para man tai ne saak kaupayan, mag-iiban

resources ex. Smoking cessation groups if any, and alcoholic anonymous .

concerns.

nala liwat ak saak pagkaon, tapos magexercise gehapon, kay nagbabasketball man ak dati.

DRUG ANALYSIS

Republic of the Philippines University of Eastern Philippines University Town, Northern Samar

College of Nursing

Nursing Care Plan


Name: Patient Y Sex: Male Assessment Date Admitted: Nursing Diagnoses November 16, 2012 Rationale Chief Complaint: Diabetic Foot, left Planning Intervention Case No.: 60-05-25_ Rationale Age: 48 Evaluation Address: Pambujan, Northern Samar Ward: Surgical Attending Physician: Dr. Unay _

S> dri nahuhuwas ak samad. As verbalized by the patient. o>gangrenous wound on the left foot, 4th digit. Vital signs as follows: temp 37c BP- 130/90 RR- 23bpm PR-88 bpm

Risk for infection related to high glucose level, decreased leukocyte function secondary to diabetes mellitus type 2

Type 2 diabetes mellitus occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the bodys tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated. REFERENCE: MEDICAL SURGICAL NURSING 6TH EDITION, by Black.

After series of nursing intervention, the patient will be able to identify intervention to prevent/reduce risk of infection.

INDEPENDENT: observe for signs of infection and inflammation.

Patient may be admitted with infection, which could have precipitated t he ketoacidotic state, or may develop a nosocomial infection Reduces the risk of cross-contamination High glucose in the blood creates an excellent medium for bacterial growth.

Goal met; the patient was able to identify interventions and was able to understand the teachings imparted to prevent infection..

emphasize proper hygiene and hand washing. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance and site care. Rotate IV sites as indicated Provide conscientious skin care, gently massage bony areas. Keep the skin dry, linens dry and wrinkle free. Place in semi fowlers position. Encourage adequate dietary and fluid intake o f 3000 ml per day. Collaborative: Obtain specimen for culture and sensitivities as indicated.

Peripheral circulation maybe impaired, placing patient at increased risk for skin irritation or breakdown and infection Facilitates lung expansion and reduces risk of aspiration. Decrease susceptibility to infection identifies organisms so that most appropriate drug therapy can be instituted.

Republic of the Philippines University of Eastern Philippines University Town, Northern Samar

College of Nursing

Nursing Care Plan


Name: Patient Y Sex: Male Assessment Date Admitted: Nursing Diagnoses November 16, 2012 Rationale Chief Complaint: Diabetic Foot, left Planning Intervention Case No.: 60-05-25_ Rationale Age: 48 Evaluation Address: Pambujan, Northern Samar Ward: Surgical Attending Physician: Dr. Unay _

S>gin papaliwat ak nira kwarto kay mabaho na kunjo ak samad as verbalized by the patient.

Body Image Disturbance related to gangrenous wound on the 4th digit of the foot secondary to diabetes mellitus type 2

O> gangrenous wound on the left side of the foot, 4th digit. >foul smell noted

Since organism multiply locally and disseminate systemic through bloodstream and lymphatics results with diffusion of plasmatic infiltrate and endothelial proliferation cause to body image disturbance. REFERENCE: Medical Surgical Nursing 6th ed. by Black, Pathologic Basic of disease 5th ed. by Robbins.

After series of nursing intervention, the patient will be able to recognize and incorporate body image change into self-concept in accurate manner without negating self-esteem, and will be able to acknowledge self as an individual who has responsibility to self.

>acknowledge and accept expression of feelings of frustration, grief, hostility. Note withdrawn behavior and use of denial.

>Acceptance of this feeling as a normal response to what has occurred facilitates resolution. It is not helpful of possible to push patient ready to deal with situation. Denial maybe prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems. >Enhance trust and rapport between patient and nurse.

>Be realistic and positive during treatments in health teaching and setting goals within limitations. >Provide hope within parameters of individual situation, do not give false reassurance

>Promotes positive attitude and provides opportunity to set goals and plan for future based on reality >Words of encouragement can support development of positive coping behaviors. >maintain open lines of communication and provides on ongoing support for patient and family. >Promotes ventilation of feelings and allow for more helpful responses

>Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals. >Encourage family interaction with each other and with rehabilitation team. >Provide support group for So. Give information

about how so can be helpful to patient. COLLABORATIVE: >note for signs/indicators of severe of prolonged depression.

to patient.

>to evaluate need for counseling and/or medications.

Republic of the Philippines University of Eastern Philippines University Town, Northern Samar

College of Nursing

Nursing Care Plan


Name: Patient Y Sex: Male Assessment
S>sige la ak ihi-ihi, as verbalized by the patient.

Date Admitted: Nursing Diagnoses


Fluid volume deficit related to increase amount of excreted water secondary to increase blood glucose level.

November 16, 2012 Rationale

Chief Complaint: Diabetic Foot, left Planning Intervention

Case No.: 60-05-25_ Rationale

Age: 48 Evaluation

Address: Pambujan, Northern Samar

Ward: Surgical

Attending Physician: Dr. Unay _

o>weight loss of 200kl down to 85kl. >PR:23bpm >urine output: more than 10x a day when urinating >BP:130/90mmHg

Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increase amount of water, resulting in fluid volume deficit. REFERENCE: Medical Surgical Nursing, 6th edition by Black.

INDEPENDENT: After series of nursing >monitor vital signs; intervention the note for orthostatic BP patient will be able to changes. verbalize understanding of the causative factors and purpose of individual in therapeutic interventions and medications. >weight daily.

>hypovolemia may be manifested by hypotension and tachycardia. Estimate of severity of hypovolemia may be made when patients systolic BP drops more than 10nnHgfrom recumbent to sitting/standing position. >provides the best assessment of current fluid status and adequacy of fluid replacement. >maintains hydration, adequacy of circulating volume.

Goal partially met; the patient still voids more than 10x a day and was able to understand the teachings imparted.

>maintain fluid intake of at least 2500ml/day within cardiac tolerance.

COLLABORATIVE: >administer IV fluids or electrolytes

>increased metabolic demand and excessive diaphoresis associated with fever results in increased insensible

fluid losses. >monitor lab results. >restores fluid balance, reduces thirst and moisturizes mucous membrane. >given with caution to help correct acidosis in the presence of hypotension or shock.

>administer bicarbonate if pH is less than 7.0