VII.

NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Problem and Etiology)
(Subjective & Objective Cues)

Subjective: Ineffective tissue perfusion Short term goals: Independent: Goals partially met.
(Renal) related to increased blood The patient was
“…. Dili man kayo ko ka-ihi..” concentration After 8 hours of thorough 1.) Monitor urine output on a regular able to verbalized
nursing intervention, the schedule. the urge to urinate
client will be able to: R – To come with a baseline data. and able to reduce
2.) Restrict client’s fluid intake pitting edema from
Objective:
R – To avoid severity of the problem. 4mm to 2mm but
 Increased serum creatinine 3.) Apply patient’s bladder cold packs failed to achieve a
a.) Verbalize the urge to
level (1.27) R – To stimulate the urge to urinate. normal blood
urinate
 Pitting Edema on both lower 4.) Let the patient hear the running water from glucose level within
b.) Decrease blood
and upper extremities (4mm) the faucet. the range of 80 –
glucose level from
 Decreased urine output R – To stimulate the urge to micturate. 110mg/dL
321mg/dL within
 Increased HGT level of 321 5.) Encourage patient to avoid foods that (111mg/dL)
normal range of 80 –
mg/dL triggers increase of blood glucose level.
110 mg/dL
 oliguria R – to maintain normal serum glucose level.
c.) Reduce pitting
edema from 4mm to Dependent:
2mm
1.) Administer medication (Furosemide), as
ordered
R – To stimulate urination.
Long term goals:
2.) Administer medications (insulin), as
a.) Completely eliminate ordered.
presence of pitting R – Helps in lowering down blood glucose
edema. level.
b.) Maintain normal
blood glucose level of
Collaborative:
80 – 110mg/dL
1.) Refer to the dietician for his Diabetic diet.

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
 VII. NURSING CARE PLAN
(Subjective & Objective Cues) (Problem and Etiology)

Subjective: Ineffective tissue perfusion Short term goals: Independent: Goals partially met.
(Peripheral) related to increased The patient was
“… dugay kayo ga-ayo akong samad sa blood viscosity secondary to After 8 hours of thorough 1.) Assist client in frequent ambulation, when able to reduce
tiil…” hyperglycemia nursing intervention, the possible pitiing edema from
client will be able to: R – to enhance venous return 4mm to 2mm and
2.) Elevate the legs when sitting, avoiding improved skin color
a.) Decrease blood sharp angulations of the hips or knees.
Objective: at the wund site
glucose level from R – to promote proper venous return from pallor to
321mg/dL within 3.) Position patient in a high back rest
 Increased HGT level of 321 pinkish but failed
normal range of 80 – R – to increase gravitational blood flow.
mg/dL to achieve normal
110 mg/dL 4.) Apply patient’s bladder cold packs
 Pitting edema on both lower blood glucose level
b.) Improve the capillary R – To stimulate the urge to urinate.
and upper extremities (4mm) of 80 – 110mg/dL
refill from 4 seconds 5.) Let the patient hear the running water from
 Prolonged capillary refill of 4 and failed to
to 3 seconds. the faucet.
seconds. improve capillary
c.) Reduce pitting R – To stimulate the urge to micturate.
 Pallor in the punctured wound refill of 4seconds to
edema from 4mm to
at the right foot 3 seconds.
2mm Dependent:
d.) Improve skin color at
the wound site. 3.) Administer medications (insulin), s ordered.
R – helps in lowering down blood glucose
Long term goals: level.
4.) Administer 2 ampules of amino acid (IV).
a.) Completely eliminate R – to promote faster healing of the
presence of pitting wound.
edema.
b.) Maintain normal Collaborative:
blood glucose level of
80 – 110mg/dL 1.) Refer to the dietician for his Diabetic diet.
2.) Increase protein intake of the patient.
R – Protein promotes faster healing of the
wounds.

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
 VII. NURSING CARE PLAN
(Subjective & Objective Cues) (Problem and Etiology)

Risk for infection related to tissue Short term goals: Independent: Goals met. The
destruction at the right foot patient was able to
punctured wound After 1hour of thorough 1.) Demonstrate proper hand washing. Demonstrate
nursing intervention, the R – It deters the spread of microorganisms. various techniques
client will be able to: 2.) Discuss the importance of not taking in order to avoid
antibiotics “leftover” drugs unless infection like
a.) Demonstrate various specifically instructed by healthcare proper hand
techniques in order provider. washing and
to avoid infection like R – Inappropriate use can lead to verbalize
proper hand development of drug-resistant comprehension on
washing. strains/secondary infections. the importance of
b.) Verbalize 3.) Advise patient to always wash his wound avoiding the spread
comprehension on with soap and water and apply “betadine”. of organisms.
the importance of R – it prevents from the exposure of
avoiding the spread microorganisms.
of organisms. 4.) Explain to the patient the importance of
avoiding the spread or accumulation of
Long term goals:
microorganisms.
a.) Achieve timely R – to give sufficient knowledge about
complete wound situation that patient might be risked for.
healing to the 5.) Tell patient never to touch the wound wuth
punctured site at the dirty bare hands.
right foot. R – Because it will initiate spread of
microorganisms.

Dependent:

1.) Administer medications (antibiotics), as

ordered.
R – To prevent from infection.

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
 VII. NURSING CARE PLAN
(Subjective & Objective Cues) (Problem and Etiology)

Subjective: Risk for falls related to visual Short term goals: Independent: Goals met. The
difficulties secondary to client was able to
“…. Dili naman ko kayo maka-klaro” hyperglycemia After 1 hour of thorough 1.) Assist client during ambulation Verbalize the
nursing intervention, the R – To avoid possible injuries. importance of
client will be able to: 2.) Provide side rails in the patient’s bed side preventing himself
R – To avoid the existence of falls. from falls to reduce
a.) Verbalize the 3.) Discuss with the patient the importance of injuries and
importance of using devices during ambulation like demonstrate
preventing himself wooden stuff. various techniques
from falls to reduce R – To assist him in his ambulation and to to avoid falls.
injuries. avoid possible falls.
b.) Demonstrate various 4.) Provide health teaching to client’s
techniques to avoid significant others that never leave the
falls. client alone especially in the comfort room.
R – To promote safety precautions.
5.) Instruct patient together with his significant
Long term goals: others to organize things appropriately.
R – To have a maximum space to avoid
a.) Maintain normal possible injuries.
blood glucose level of
80 – 110mg/dL Dependent:

1.) Administer medications (insulin), as

ordered.
R – Helps in lowering down blood glucose
level.