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Medical Diagnosis

Subjective Data My foot has been giving me some problems

Objective Data: Blood glucose 230, Lower extremity diabetic wound, Oxygen 100%

Nursing Diagnosis: Skin impairment related to uncontrolled glucose as evidence by blood glucose
reading of 230.

Short term goal #1

The patient will identify 3 interventions to prevent or reduce risk of infection within 8 hours.

A. Educate patient on correct perineal care @ 0700 now.

Wipe front to back.
1. Wiping front to back reduces chance of transmitting fecal organisms to urinary meatus. Fund
B. Provide information on adequate diet @ 0900 today.
1.25-1.5g protein/kg
1000mg/day of vitamin C
30-35 ml/kg/day of fluid
2. TABLE 48-4 Role of Selected Nutrients in Wound Healing Fund pg1194
C. Promote handwashing before and after meals @ 0700 now.
3. Meticulous hand hygiene reduces bacterial counts on the hands. Fund pg452

Short term goal #2

Patient will not develop a new pressure ulcer within the next 36 hours.

D. Turn patient q2h beginning @ 0700 daily.

4. Repositioning reduces the duration and magnitude of pressure over vulnerable areas of the
body and contributes to comfort, hygiene, dignity, and functional ability. Fund pg1200
E. Keep bedsheets dry and wrinkle free at all times starting @ 0700 today.
5. Remove wrinkles or creases in clothing. Fund pg400
F. Use a draw sheet when lifting in bed @ 0700, 1200, 1500, 1900 daily.
6. Use a lift or transfer sheet to minimize friction and/or shear when repositioning, keeping bed
linens smooth and unwrinkled Fund pg1200

Short term goal #3

Patients blood glucose will lower to normal limits of 70-100 mg/dl within 48 hours

G. Administer Humalog SubQ @ 0730, 1200, 1700 daily.

Patients with type 1 DM require insulin therapy for blood glucose control. Med Surg pg 1310
H. Check Blood Glucose @ 0730,1200, 1700 daily.
I. Rationale Brook and page #
J. Intervention #3
K. Rationale Book and page #
L. Evaluation Short Term Goal #2
M. H. Evaluation Short Term Goal #3

Long term goal #1

Patients red area and exudate on her lower leg will be absent within 10 days.

I. Irrigate wound with saline solution twice per day per wound-care provider's order @ 0800 and
2000 daily.
Cleanse wound and surrounding area of wound debris and exudate. Fund pg1200
J. Apply dressing (i.e., gauze moistened with solution twice a day after irrigation) according to
wound-care provider's order @ 1000 daily.
Provides appropriate topical therapy to wound, placing wound in best environment for
healing. Fund pg1200
K. Evaluate patient's pain level and offer pain medication at 0800, 1200, 1600, 2000 daily.
Provides patient with pain reduction/relief, allowing for greater mobility and comfort.
Fund pg1200.

Long term goal #2

N. Intervention #1
O. Rationale Book and page #
P. Intervention #2
Q. Rationale Brook and page #
R. Intervention #3
S. Rationale Book and page #
T. Evaluation Long Term Goal #2

Long term goal #3

U. Intervention #1
V. Rationale Book and page #
W. Intervention #2
X. Rationale Brook and page #
Y. Intervention #3
Z. Rationale Book and page #
AA. Evaluation Long Term Goal #3