DIABETES MELLITUS CLIENT

“Nursing Care Plan”

ASSESMENT NURSING PLANNING NURSING INTERVENTIONS RATIONALE

DIAGNOSIS

Subjective: Risk for infection Goal:

related to broken  Assess for presence, existence of,  Represent a break in the body’s
 He got that during their skin, tissue After a complete nursing and history of risk factors such as normal first lines of defence.
outing/swimming on the last week destruction, invasive intervention the client will open wounds and abrasions
procedure and be able to demonstrate
of February as he verbalized,
chronic disease. understanding and  Monitor the following for signs of  Any suspicious drainage should
“Nabalatan ito nung nagswimming
behaviours about the infection: Redness, swelling, be cultured; antibiotic therapy is
kami tapos hinatak ko kasi balat lang disease and to prevent increased pain, or purulent determined by pathogens
naman yun ‘di ba parang iisipin mo developing the problem. drainage at incisions. identified at culture.
wala lang yun.”
 He also added that it got Objectives:
worst on April as he said, “Kasi  Monitor Assess nutritional status,  Patients with poor nutritional
After 20 minutes of nursing including weight, history of weight status may be anergic, or unable
nagsasapatos ako eh parang na-
intervention, the client will loss, and serum albumin. to muster a cellular immune
irritate siguro. Mga two weeks be able to have a response to pathogens and are
parang paltos na siya at hindi ko lang comfortable environment. therefore more susceptible to
pinansin. After two weeks ulet, infection.
lumaki siya parang kumakatas na.” After 20 minutes of nursing
 He also stated that he intervention the client will  Encourage intake of protein- and  This maintains optimal
be able to know the proper calorie-rich foods. nutritional status.
went to the hospital at St. Paul for a
diet she should have to
surgery and done x-ray to him and occurrence of infection.  Instruct the client not to smoke,  To maximize circulation of the
the doctor said that it is already
cross legs or wear restrictive feet.
gangrenous wound and luckily not After 20 minutes of nursing clothing.
reaching the bones. intervention the client will
 Then, the toe has been be able to know the proper  Teach the client daily care of feet  Use as preventive measures
scraped and the doctor told him that care and considerations that that includes washing with mild
he should do prior to her soap; drying thoroughly, especially
his toe can be amputated if it
condition. between the toes, moisturizing
becomes severe.
feet, except between the toes and
keeping toes nails trimmed.
Objective:

 The client has diabetes

mellitus for 11 years.

 PA findings (July 17, 2010) – The

client has a gangrenous wound
on his left toe (undergone a
surgery that requires slicing a
portion of his toe skin).

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired skin integrity GOAL: INDEPENDENT At the end of the 4 days
related to hypothermia, After 4 days of nursing  Discuss what is impaired  Encourage nursing intervention, the
presence of edema, intervention, the patient integrity accurately participation by client was able to:
 He also stated
injury, impaired will be able to display learner; permits
that he experienced circulation as improvement in wound reinforcement and a.display improvement in
manifested by reports of healing as evidenced by: repetition at learner’s wound healing as
pain in his lower
pain of affected area, -Intact Skin and level; permits evidenced by:
extremities due to the and disruption of skin minimized presence of introduction of - Intact Skin and minimized
surface. wound sensitive subjects. presence of wound
wound and his edema.
-Absence of itchiness, (Kozier) - Absence of itchiness,
Objective: redness redness

Objectives:
 PA findings
After 8 hours of  Establishes After 8 hours of nursing
(July 17, 2010) – Edema nursing intervention comparative baseline intervention, the patient
present specifically on the patient will be  Assessed skin. Noted providing opportunity was able to:
able to: color, turgor, and for timely a. Define Impaired skin
both feet of the client. sensation. Described intervention. Integrity accurately
Edema scale is 3+. wounds and observed (Doenges)
changes. b. Participate in
 PA findings  Define prevention measures
Impaired skin Integrity and treatment
(July 17, 2010) – The
accurately  Maintaining clean, dry program
client has a gangrenous skin provides a barrier
wound on his left toe  Demonstrated good to infection. Patting c. Demonstrate proper
 Participate in skin hygiene, e.g., skin dry instead of wound care c/o
(undergone a surgery prevention measures wash thoroughly and rubbing reduces risk watcher
that requires slicing a and treatment pat dry carefully. of dermal trauma to
portion of his toe skin). program fragile skin. (Brunner)
 PA findings
(July 17, 2010) –  Demonstrate proper  Skin friction caused
wound care c/o by stiff or rough
Temperature of the
watcher clothes leads to
client is 35.8 ◦C irritation of fragile
skin and increases risk
for infection. (Kozier)

 Instructed family to
maintain clean, dry  Improved nutrition
clothes preferably and hydration will
cotton fabric improved skin
condition. (Doenges)
 Assists them in
optimal healing with
less expensive
resources. (taylor)

 Emphasize
importance of
adequate nutrition and  Wound dressings
fluid intake. protect the wound and
the surrounding
tissues. (Doenges)

 To prevent dryness of
skin (Kozier

 To clean the wounded

area and prevents
 Provided and applied contamination.
wound dressings (Brunner)
carefully.
  Apply lotion on legs

COLLABORATIVE
 Assist with
debridement therapy
as indicated.

ASSESMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Hypothermia related to Goal:  Assess respiratory effort.  Rate and tidal volume Was the client able to
prolonged exposure to are reduced when obtain normal respiratory
cool environment as After a complete metabolic rate rate?
 Inside the manifested by body nursing intervention the decreases and Yes___ No___
hall, he stays in an air- temperature below client will be able to respiratory acidosis
conditioned room and normal range, demonstrate occurs. Why?
with ceiling fan for hypertension and cool understanding and  Auscultate lungs, noting
skin. behaviours about the adventitious sounds.  Pulmonary edema,
many hours.
disease and to prevent respiratory infection,
the problem from and pulmonary embolus
Objective: reoccurring. are possible
complications of
 PA findings Objectives: hypothermia.
(July 17, 2010) – The  Monitor BP, noting
skin is in cool After 1 hour of nursing hypotension.  Can occur due to
temperature. intervention, the client vasoconstriction and Did the client have a
 PA findings will be able : shunting of fluids as a normal range of BP?
 Define hypothermia. result of cold injury Yes___ No___
(July 17, 2010) –
 To have an effect on capillary
Temperature of the Why?
appropriate permeability.
client is 35.8 ◦C environment.
 To know the suitable  Measure urine output.  Renal failure can occur
PA findings (July 17, activities he should due to low flow state or
2010) – Blood pressure do to achieve normal following hypothermic
is 130/80 mmHg. body temperature. osmotic diuresis.
 NURSING
CUES ANALYSIS GOAL/OBJECTIVES RATIONALE EVALUATION
INTERVENTIONS
Subjective: Diabetes Mellitus Type 2 Goal:
 Prior on having occurs when the cells in After certain nursing
diabetes mellitus, he the body develops insulin intervention, the client
described himself as resistance and impaired will attain his ideal body
a fat person and eats production of the weight.
anything that he hormone. Because of
wants. inability of the muscles to Objectives:
 Now that he has increase glucose intake,
been diagnosed to despite the increased After 10 minutes of
have diabetes, there hunger and food intake of nursing intervention, the 1) Ascertain 1) To determine Was the patient able to
are many restrictions a diabetic client, the body patient will verbalize his understanding of informational needs of verbalize his
regarding his health will resort to the understanding about the individual nutritional client. understanding about the
especially in his diet. metabolism of the fats diet recommended for needs. diet recommended for
 He eats food and protein stores diabetic clients diabetic clients?
according to his diet. resulting into wasting and 2) Discuss about the 2) To meet the Yes___ No___
He does not eat therefore causing weight suggested diet for informational needs of
foods that can affect loss. After 10 minutes of diabetic clients. the client
his condition like nursing intervention, the
chicken, candies, patient verbalize and
softdrinks and other demonstrate selection of Was the patient able to
foods. foods or meals that will 1) Suggest consulting a 1) Dietitians have a verbalize and
help him gain weight dietitian for further greater understanding of demonstrate selection of
Objective: close or equal to an ideal assessment and the nutritional value of foods or meals that will
body weight. recommendations foods and may be helpful help him gain weight
 (3 DAY DIET regarding food in assessing specific close or equal to an ideal
RECALL) preferences and ethnic or cultural foods body weight?
nutritional support. 2) Will establish the skill Yes___ No___
  Weight=74 kg and habit of planning
Height =5.7 ½ ft. After 10 minutes of 2) Guide the patient in a meal.
BMI= 26kg/m² nursing intervention, the sample meal planning
client will mention appropriate for diabetes
behavior, lifestyle mellitus.
changes to regain and/or 1) Depending on the Was the client able to
maintain appropriate 1) Establish appropriate etiological factors of the mention behavior,
weight. short- and long-range problem, improvement in lifestyle changes to regain
goals. nutritional status may and/or maintain
take a long time. Without appropriate weight?
realistic short-term goals Yes___ No___
to provide tangible
rewards, patients may
lose interest in addressing
this problem.

2) Metabolism and
2) Encourage exercise. utilization of nutrients are
enhanced by activity.

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Disturbed visual After a complete nursing  Determine  To note whether  Are the painful
perception related to intervention the client response to response is stimuli
 Now that he
psychological stress as will be able to painful stimuli appropriate to determined?
has diabetes, he stated manifested by poor demonstrate stimulus, Yes?___No?___
concentration and understanding and immediate, or
that upon reading he
restlessness behaviours about the delayed.
should wear eyeglasses disease and to prevent
developing the problem.
for him to easily read the
 Were drug
texts.  To identify regimen
 Monitor drug medication with monitored?
 Then if he
regimen effects or drug Yes?___No?____
doesn’t use his interaction that
may
eyeglasses for prolonged
cause/exacerbat
use, his eyes got itchy e
sensory/percept
and teary. That is also
ual problems.
that reason why he
cannot drive their car.
He also stated that he
didn’t even have an eye
test related to diabetes.
Objective:
 The client has
diabetes mellitus for 11
years.
 The client is on
insulin treatment for his
condition.
 PA findings
(July 17, 2010) – 20/20
vision in the Snellen’s
Chart both eyes;
20/35 vision on his left
eye
20/25 vision on his right
eye
 Blood glucose
level= 155 mg/dl

ASSESMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTIONS
Subjective: Risk for fall related to Goal: Independent:
visual difficulty, foot  Review  To identify condition
 Now that he problem, decreased lower After a complete nursing medical/surgical/ commonly associated
has diabetes, he stated extremity strength, intervention the client social history with risk for fall for a
that upon reading he impaired balance, and will be able to Diabetic patient.
environmental conditions. demonstrate
should wear eyeglasses
understanding and  To identify the
for him to easily read the behaviours about the patient for signs
texts. disease and to prevent  Inspect for of the disease
 Then if he having infection and can presence of
doesn’t use his put at risk for injury/ fall. edema
eyeglasses for prolonged  Inspect for
Objectives: lesions
use, his eyes got itchy
according to
and teary. That is also After 1 hour of nursing location,
that reason why he intervention, the client distribution,
cannot drive their car. will be able : color,
 He also stated  Define and configuration,
that he didn’t even have understand size, shape,
an eye test related to Diabetes type or
accurately. structure
diabetes.  Exercise can
 To have a  Inspect tissues
 He also stated comfortable surrounding
improve
that he experienced pain circulation,
environment. nails especially in the
in his lower extremities  To prevent the
arms and legs.
due to the wound and his risk for
edema. injury/fall.
 To develop a  Encourage
healthy foot activity/exercise
care. within limits of
Objective:  To know the individual ability.
proper
 PA findings activities she
(July 17, 2010) – 20/20
should do prior  Medications should
to her be prescribed by the
vision in the Snellen’s condition. attending physician.
Chart both eyes;

20/35 vision on his left

eye
20/25 vision on his right Dependent:
eye  Administer drugs as  Reduced mental
ordered function and risk
 There is a stair for injuries and
in the barangay hall in falls.
which the client uses to
 To eliminate the
go to his office and to go pressure of
down for exit. infected area.
 PA findings
(July 17, 2010) – The client Interdependent:
has a gangrenous wound  Encourage/sup
port treatment
on his left toe
of underlying  To check for
(undergone a surgery
medical cause, areas of redness
that requires slicing a where or irritation
portion of his toe skin). appropriate especially on the
 PA findings  Encourage to bottom of the
(July 17, 2010) – Edema Take care of foot 
present specifically on feet. WOUND  Reduce the risk
CARE for infection and
both feet of the client.
normal wound
Edema scale is 3+.
recovery.
 PA findings
(July 17, 2010) –
 Failed
to complete the
flexion of his  Encourage to
left leg. inspect feet
 Failed daily
to complete the
extension of his
left leg.
 Failed
to complete the  Encourage to
always consult
hyperextension
that Doctor if
of his left leg. he notice any of
 Failed the symptoms
to complete the that he
abduction of his
left leg. experience.
 Failed
to complete the
adduction of his
left leg.
 Failed
to complete the
Circumduction
of his left leg.
 Failed
to complete the
internal
rotation of his
left leg.
 Failed
to complete the
external
rotation of his
left leg.
 Failed
to complete the
extension of his
left foot toes
downward.
 Failed
to complete the
flexion of his
left foot toes
upward
 Failed
to complete
inversion of his
left foot
 Not
able to flex the
left foot fingers.
 Not
able to extend
the left foot
left.