XI.

Nursing Care Plan

Nursing Goals and Nursing

Cues Analysis Rationale Evaluation
Diagnosis Objectives Interventions
Subjective: Impaired skin Clients with GOAL:
integrity related to Diabetes Mellitus •After 2-3 days
•Mrs. RO impaired blood are susceptible to of nursing
verbalized, “eh circulation infections of many intervention, the
hindi na ko halos secondary to types. Once client will be
nakakatulog sa Diabetes Mellitus infections occur, able to display
araw araw, gawa ng type 2 as they are difficult to signs of healing
madalas kong pag manifested by treat. Three factors with wound
ihi at sakit nitong open wound on that may contribute edges clean/pink
paa ko.” client’s left foot. to the development without any
of an infection are complication and
impaired able her to
• The client is
polymorphonuclear maintain
diabetic since she
leukocyte function, physical well-
was in her early
diabetic being.
thirties.
neuropathies, and
vascular OBJECTIVES:
• The client has
insufficiency. Poor •After 1-2 hours
poor compliance in
glycemic control of nursing Proper wound
medications due to
augments the intervention and care: •Cleans wound *Was the wound
financial problem.
importance of these continuous •Irrigate wound without harming of the client able
factors. Infected wound care, the with room delicate tissues. to be free from
•The client’s
areas heal slowly client will be temperature sterile any purulent
mother has
because the able to: procedure three drainage?
Diabetes Mellitus
damaged vascular times a day. Yes__No__Why?
which she believes
system cannot carry a. Be free
to be the reason
sufficient oxygen, of •assess wound
why she also has
white blood cells, purulent with each dressing •Provides
one.
nutrients, and drainage. change. Compare information about
antibodies to the the wound upon effectiveness of
• The client
injured site. admission and therapy, and
claimed the
Infections increase before discharge. identifies
presence of house the need for insulin additional needs.
pests in his house and enhance the •Apply wet to dry
such as possibility of sterile dressing.
cockroaches, rats, ketoacidosis. •Keeps wound
and mosquitoes. Diabetic foot clean/minimizes
infections are •Use paper tapes. cross
Objective: common. Their contamination.
•Glucose level: occurrence is
= 11.8 mmo/L directly related to •Adhesive tape
the three factors may be abrasive
• The client has an just listed, plus •Reposition client to fragile tissues.
open wound on her hyperglycemia. Up on regular
left foot with pus to 40% of diabetic schedule,
and also swelling clients with foot involving client in •To enhance
on her left leg. infections may reasons for and understanding and *Was the client
require amputation, decisions about cooperation of the able to participate
•Admitting and 5% to 10% will times and client. in those
diagnosis of DM die despite positions. preventive
type with amputation of the measures and
uncontrolled affected area. With •Teach client to treatment program
wound on the left proper education use appropriate that were being
foot. and early padding devices, taught?
intervention, foot when indicated. •To reduce Yes__No__Why?
infections are b. Participa pressure
usually eliminated te in •Encourage early on/enhance
in a timely manner. preventi ambulation/mobili circulation to
Effective foot care on zation. compromised
can be the initial measures tissues.
break in the chain and
of events that leads treatmen •Provide optimum •Promotes
to amputation. t nutrition, circulation and
program. including vitamins reduces risks
Source: Medical and increase associated with
Surgical Nursing protein intake. immobility.
Clinical
Management for •to provide a
Positive Outcomes positive nitrogen
Vol. 1 •Ascertain balance to aid in
th
8 edition by Joyce attitudes of skin/tissue healing
M. Black and Jane individual about and to maintain
Hokanson Hawks. condition. Note general good
misconceptions. health.

•Note presence of •Identifies areas to

compromised be addressed in
vision, hearing, or teaching plan and
speech. potential referral *Was the client
needs. able to verbalize
her feelings about
her self-esteem
and her ability to
•Skin is a manage the
particularly situation?
important avenue Yes__No__Why?
of communication
for this population
and, when
compromised,
may affect
responses.

c. Verbaliz
e
feelings
of
increase
d self-
esteem
and
ability to
manage
situation.