NURSING CARE PLAN

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS S

Subjective: Impaired skin Diabetes sometimes Short term:  Assess feet and  This will After appropriate
“may kakaibang integrity r/t open affects the nerves of  Clean and legs for skin prevent further nursing
pakiramdam sa mga wound secondary the feet, causing a disinfect the temperature, damage to intervention, the
paa ko” as verbalized to impaired loss of sensation. wound sensation, soft tissues in the patient will be able
by the patient circulation Therefore, when a  Promote timely tissue injuries, patient’s foot to
person with wound healing corns, calluses,  demonstrate
Objective: decreased sensory dryness, hammer how to take care
Signs: perception in the Long term: toe or bunion of open wound
-(+) DM Type II feet is wounded, the  educating the deformation,  discuss the
wound is left patient hair distribution, importance of
-Hard-to-heal skin unnoticed and may regarding the pulses, deep hygiene in
develop an importance of tendon reflexes. promoting skin
-Loss of sensory infection. monitoring of integrity
perception in feet open wound  Instruct patient  Educating the
and proper in foot care patient will help
Vital sign taken as wound care. guidelines promote
follows: cooperation
BP- 160/100 mmHg
HR- 88 bpm  Inspect incision  This will keep
RR-20 cpm regularly, noting the wound in
Temp - 36.3 C characteristics check and
SPO2- 97% and integrity. prevent
complications

 Teach patient  Clanliness helps

proper wound prevent infection
care and its spread.
 ASSESSMENT NURSING RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Subjective: Decreased Cardiac Decreased cardiac Short term goal: Independent: After 6 hrs of
The patient Output r/t output is an often- After 6 hrs of  Monitor BP  To establish nursing
verbalized of body malignant serious medical nursing every 1-2 hours baseline data. interventions, the
weakness and sudden hypertension as condition that interventions, the client had no
chest pain (described manifested by occurs when the client will have no  Observe skin  To determine if elevation in blood
chest pain as decreased stroke heart does not pump elevation in blood color, moisture, there is pressure above
squeezing, pressure, volume. enough blood to pressure above temperature and dehydration. normal limits and
heaviness, tightness meet the needs of normal limits and capillary refill will maintain blood
in his chest) the body. It can be will maintain blood time. pressure within
caused by multiple pressure within acceptable limits.
Objective: factors, some of acceptable limits.  Provide a calm  Quiet Goal was met.
-Vital sign taken as which include heart environment; atmosphere
follows: disease, congenital Long term goal: minimizing conducive to -After 5 days of
BP- 160/100 mmHg heart defects. After 5 days of noise; limiting rest alleviates nursing
HR- 88 bpm nursing visitors and stress which aids interventions, the
RR-20 cpm interventions, the length of stay. the heart in client maintained
Temp - 36.3 C client will maintain proper function. an adequate cardiac
SPO2- 97% an adequate cardiac output and cardiac
output and cardiac  Maintain activity index. Goal was
index. restrictions (bed  Activities that met.
rest) and assist requires too
patient with self- much work load
care activities. leads to heart
stress.
Depedent
 Administer
medications like  These
diuretics, alpha medications
and beta prescribed by
antagonists, the physician
calcium channel and dose and
blockers, and timing of
vasodilators. medications
should be
 followed.
Checking BP
prior to giving
of medications
is always a must
to prevent
hypotension.

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Infection r/t wet Diabetes sometimes Short Term:  IV antibiotics as  Antibiotics will After appropriate
“parang hindi gangrenous foot affects the nerves of - Clean and ordered by help eliminate nursing
gumagaling yung secondary to DM the feet, causing a disinfect the physician infection and intervention,
sugat ko sa paa.” As II loss of sensation. wound prevent its - The patient will
verbalized by the Therefore, when a - Prevent infection spread. have a clean and
patient person with from worsening disinfected the
decreased sensory  Assist in wound  This prevents wound
Signs: perception in the Long Term: debridement the spread of - The wound will
- Open wound @ R feet is wounded, the - Prevent future infection to be prevented
foot wound is left infections of the other organs of from worsening
unnoticed and may wound the body - The client will be
- (+) foul smell develop an able to prevent
infection.  Teach patient the  To help prevent future infections
- (+) purulent proper way to re-infection of of the wound
drainage on change the the wound
wound dressing
(using aseptic
- Cold, pale skin techniques)

Vital sign taken as  Emphasize the  Since the

follows: importance of patient’s DM
BP- 160/100 mmHg self-checking has lowered his
HR- 88 bpm sensory
RR-20 cpm perception, self-
Temp - 36.3 C checking will
SPO2- 97% prevent wound
from getting
infected

 Instruct the  This will

patient to cut prevent further
toenails wounds to the
regularly feet.
 ASSESSMENT NURSING RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Objective: Deficient Knowledge The focus of diabetes Before discharge,  Explain that regular Dosage may be After appropriate
related to education should be patient will insulins should be adjusted based on the nursing health
 With Uncontrolled Unfamiliarity with patient empowerment demonstrate injected 30 mins actual amount of food teaching,
Diabetes Mellitus information aeb to address changes in knowledge of before meals. Rapid- ingested because rapid- The patient
Type 2 Inadequate follow- health behavior and insulin injection, acting insulins may acting insulins can be demonstrated
 With poor through of self-care. Providing symptoms, and be injected before or given after a meal. knowledge of insulin
compliance to oral instructions complete information treatment of after eating. injection, symptoms,
 treatment and proper education hypoglycemia and and treatment of
 Poor nutrition and of patients with diet.  Teach patient to Systematic rotation of hypoglycemia and
diet habits diabetes can rotate insulin injection sites is diet.
 With a non- dramatically increase injection sites. recommended to
healing wound adherence to prevent lipodystrophy.
with purulent, foul treatment regimen.
smelling discharge  Explain the A 90-degree angle is
at left foot importance of the best insertion
inserting the needle angle. Injection that is
perpendicular to the too deep or too shallow
skin. may affect the rate of
absorption of the
insulin.

 Use various tools to In using variety of

complement teaching materials,
teaching and make sure that they
maintain flexibility match the patient’s
with regard to learning needs,
teaching method.  language, and reading
 Teach patient to level.
follow a diet that is A diet low in fat and
low in simple high in fiber helps to
sugars, low in fat, control cholesterol and
and high in fiber and triglycerides. sugars
whole grains. should be reduced, and
Carbohydrates, such as
cereals, rice, should be
increased.
 Teach patient and/or
significant others to Signs include
recognize the signs shakiness, sweating,
of hypoglycemia. nervousness,
weakness, hunger,
changes in LOC.
Hypoglycemia occurs
when the blood
glucose levels drop to
 Teach patient to less than 60 mg/dL.
treat hypoglycemia
with crackers, a
 snack, or glucagon Hypoglycemia should
injection. be treated with a
carbohydrate snack
Examples include: fruit
juice, soda, hard
candies, teaspoons of
sugar, or commercially
prepared glucose
tablets.
 Teach the patient on
the proper disposal
Insulin syringes,
of syringes and
lancets, pens, and
needles. 
needles should be
disposed according to
local regulations.
 Provide written
information about
Reinforces learning
diabetes
and convey the
management for the
maximum amount of
patient to refer to..
information.