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ASSESSMENT Subjective: “Hindi gumagaling ang sugat ko” (My wounds are not healing) as verbalized by the patient. Objective: · Flushed appearance. · Wound drainage. · V/S taken as follows: T:37.4 P:87 R:19 BP: 120/90

• Risk for infection related to high glucose levels, decreased leukocyte function.

INFERENCE Type 2 diabetes mellitus occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the body's 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 complicatio ns if untreated.

• After 8

hours of nursing interventi ons, the patient will identify interventi ons to prevent or reduce risk of infection.

INTERVENTIO N Independent: · Observe for signs of infection and inflammation .


• Promote

good Hand washing by nurse and patient.
• Maintain

EVALUATI ON • Patient • After 8 may be hours of admitted nursing with interventio infection, n which s, the could have patient precipitated was the able to ketoacidotic identify state, or interventio may n develop a s to nosocomial prevent infection. or reduce risk of infection. • Reduces the risk of cross contaminati on
• High

aseptic technique for IV insertion procedure, administratio n of medications, and providing maintenance and site care. Rotate IV sites as indicated.
• Provide catheter or perineal

glucose in the blood creates an excellent medium for bacterial growth.

• Minimizes

the risk for infection.

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

.as indicated.