NURSING CARE PLAN

DEFINING NURSING
SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE EVALUATION
CHARACTERISTICS DIAGNOSIS

SUBJECTIVE: Impaired tissue integrity After 8 hours of Independent: After 8 hours of

in diabetes is the result
“binhod akong tuo Impaired
of a complex
na tiil ug wala tissue
pathophysiology
nakoy ma feel na integrity r/t
involving vascular,
sakit” as verbalized neuro
immune, and biochemical
by the patient vascular
components (insulin).
complications
Hyperglycemia correlates
of DM causing
with stiffer blood vessels
decrease
which cause slower
blood flow to
circulation and
the
microvascular
peripheries
OBJECTIVE: dysfunction, causing
resulting in
reduced tissue
- swelling of right development
oxygenation. In addition,
foot of diabetic
peripheral neuropathy
foot ulcer
- dry skin can lead to numbness of
the area and reduced
ability to feel pain, which
can lead to chronicization
- Pitting test of the
of wounds that are not
wound >6secs
immediately noticed and
properly treated.
- ulcerative right
foot
Reference:
- V/S as follows:
Ullman, K. (2016,
BP: 140/80 mmHg February 5). Diabetes
and your skin.
Management. Retrieved
July 16, 2022, from
https://www.diabetesself
management.com/about-
diabetes/general-
diabetes-information/
diabetes-and-your-skin-
2/
nursing nursing
1. Assess characteristics of 1.  Pale tissue color is a sign of
interventions the interventions the
the wound, including color, decreased oxygenation. An odor
patient will be patient was able
size (length, width, depth), may result from the presence of
able to: to:
drainage, and odor. infection on the site; it may also
SHORT TERM: be coming from necrotic tissue. SHORT TERM:
1. Report any 2. A sterile technique reduces 1. Reported any
2. Keep a sterile dressing
altered sensation the risk of infection in impaired altered sensation
technique during wound
of the site of tissue integrity. This involves the of the site of
care.
tissue use of a sterile procedure field, tissue
impairment. sterile gloves, sterile supplies impairment.
and dressing, sterile instruments
2. Describes 2. Described
3. Encourage patient to
measures to 3. Putting legs on dependent measures to
elevate legs and avoid
protect and heal position will worsen leg edema. protect and heal
putting them on a
the tissue, the tissue,
dependent position for e
including proper long period of time. including proper
wound care. wound care.
Dependent:
1. Although intravenous LONG TERM:
1. Administer antibiotics as
antibiotics may be indicated,
LONG TERM: ordered. 1. Maintained
wound infections may be
normal tissue
1. Maintain managed well and more
integrity with
normal tissue efficiently with topical agents.
healing of the
integrity with 2. Assess the need for
2. To remove the ulcerated fot ulcers
healing of the wound debridement incase
of decayed foot & prepare and prevent worsening and
ulcers 2. Verbalized
the client for the surgical spreading of ulcers to the whole
wound decreases
2. Verbalize procedure as ordered. extremity.
in size and has
wound decreases
increased
in size and has Collaborative:
granulation tissue
increased 1. Physical therapists help
1. Refer the client to a
granulation tissue people with diabetes take part in
physical therapist as
safe, effective exercise
ordered. GOALS MET.
programs.