NURSING CARE PLAN

NAME OF PATIENT: Priya Sharma DATE OF ADMISSION: March 3, 2022 ROOM: 201 AGE: 60 SEX: Female CIVIL STATUS: Married
CHIEF OF COMPLAINT: Symptoms of increased thirst and hunger and frequent urination RELIGION: N/A ATTENDING PHYSICIAN: Dr. Sabido

CUES SCIENTIFIC BASIS GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

CRITERIA INTERVENTION
3/3/22 NDx: Infection Within 8 hours of ● Assess for necrotic ● Necrotic tissues 3/3/22
3 PM related to poor nursing intervention tissues around the around a diabetic 11PM
Subjective: peripheral circulation patient will be able to: client’s wound. person’s wound Goals Met
Patient verbalized, “I as evidenced by foot signify poor blood
rarely check my blood ulcer ● Ensures timely ● Assess and flow. Within 8 hours of nursing
sugar levels since I wound document skin ● To monitor infection intervention patient was
tend to forget them.” Scientific Basis: healing free condition around or progressing able to:
Infectious diseases from purulent the wound. necrosis.
Objective: are more frequent discharges ● Monitor blood ✔Ensured timely
● Bilateral and more serious in and necrosis glucose levels ● Unstable blood wound healing free
pitting patients with ● Demonstrate glucose levels from purulent
edema grade diabetes mellitus due techniques, contribute to delayed discharges and necrosis
1 (bilateral to the hyperglycemic lifestyle ● Clean and change wound healing. With NO presence of
lower environment that changes to wound dressings ● To prevent the other pus and other
extremities) favors immune prevent as indicated. infections that may discharges
● Wagner dysfunction. development be associated with
grade 3 High blood sugar of infection poor wound care and ✔Demonstrated
ulcer, left levels can damage ● Decrease ● Administer hygiene. understanding
foot your nerves and blood glucose medication as ● To manage techniques for wound
● RBC 2.14↓ blood vessels. That level prescribed: underlying care, adherence to diet
● WBC 14.0↑ lessens blood flow 1. Tramadol 50mg conditions and lifestyle changes
● Platelet 80 (especially to your IVTT Q8H as 1. For pain ("Salamat kaayo ma'am
● Neutrophils hands, feet, and needed karon nakasabot nako
85%↑ limbs), which makes 2. Metformin XR, na dapat musunod jud
● Lymphocytes it harder for sores 500mg 2 tablets 2. lowers your blood ko sa diet na gi advice
45%↑ and cuts to heal. It OD HS sugar levels by ni doc, ug karon kabalo
● Eosinophils makes you more improving the way nako na dapat jud nako
8%↑ likely to get an your body handles limpyuhan ug tarong
● Monocytes infection. 3. Glipizide, 5 mg 2 insulin. ang akong tiil na naay
12% ↑ (Doenges, tablets OD 3. lowers blood sugar samad para dili na mu
● ESR Moorhouse & Murr, by causing the grabe ang samad
 30mm/hr ↑ 2019) pancreas to produce nako", as verbalized by
insulin, and helping patient)
RBS: 310mg/dl the body use insulin
Wound GSCS: 4. Start Cefuroxime efficiently. ✔Blood glucose level
(+) Pseudomonas REFERENCE: 750mg IV Q8H 4. to treat infections decreased and is within
aeruginosa Doenges, M. E., caused by bacteria in normal range 180mg/dl
(+) Acinetobacter Moorhouse, M. F., & M ● Assist patient to the wound
baumanii A. C. (2019). Nurse’s po elevate legs ● Promote blood flow
guide: Diagnoses, ● Educate client to your feet.
VS: prioritized interventions about proper ● Proper wound care
BP: 150/100mmHg and rationales. wound care. prevents other
Temp: 37.5 C Philadelphia: F.A. Davis ● Educate patient wound infections.
RR: 25cpm about proper foot ● Diabetic foot care is
PR: 110bpm care. essential as diabetes
SPO2: 92% can be dangerous to
3/10 pain scale on your feet, to prevent
her left foot further damage to
the tissues of the
● Educate about the foot.
importance of ● Adherence to
following diabetic prescribed diabetic
treatment treatment ensures
consistently. good blood flow and
reduced risk for
delayed wound
● Review the client’s healing.
current diet and ● Proper diabetic diet
nutritional needs. balanced with
nutritional needs is
important in
maintaining normal
blood glucose levels.
Stabilized blood
glucose levels ensure
good blood flow,
especially around the
wound site.