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NCP DM TYPE II

ASSESSME DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


NT
Independent:
Subjective Risk for After 8 hours •Observe for •Patient may be •After 8 hours
: infection of nursing signs of admitted with of nursing
“Hindi related to high interventions, infection and infection, which could interventions,
gumagalin glucose levels, the patient will inflammation. have precipitated the the patient
g ang decreased identify ketoacidotic state, or was able to
sugat ko” leukocyte interventions may develop a identify
(My function. to prevent or nosocomial interventions
wounds reduce risk of to prevent or
are not infection reduce risk of
healing) infection.
As •Promote good
verbalized hand washing •Reduces the risk of
by the by nurse and cross-contamination
patient. patient.

Objective:
•Flushed •Maintain •High glucose in the
appearanc aseptic blood creates an
e. technique for excellent medium for
•Wound IV insertion bacterial growth.
drainage. procedure,
•V/S administration
taken as of medications,
follows: and providing
T:37.4 maintenance
P:87 R:19 and site care.
BP: Rotate IV sites
120/90 as indicated.

•Minimizes the risk


for infection.
•Provide
catheter or
perineal care.
Teach the
female patient
to clean from •Peripheral
front to back circulation may be
after impaired, placing
elimination. patient at increased
risk for skin irritation
• Provide or breakdown and
conscientious infection.
skin care,
gently • Facilitates lung
massage bony expansion and
areas. Keep reduces risk of
the skin dry, aspiration.
linens dry and •
wrinkle free. Decrease
susceptibility to
infection.
• Place in
semi –
fowler’s • Identifies
position. organisms so that
most appropriate
drug therapy can be
instituted.
•Encourage
adequate
dietary and
fluid intake of
3000 ml per
day.
Collaborative:

•Obtain
specimen for
culture and
sensitivities as
indicated.