NURSING CARE PLAN
ASSESSMENT
Subjective: “Hindi gumagaling ang sugat ko” (My
wounds are not healing) as
DIAGNOSIS
• Risk for infection related to high glucose levels, decreased leukocyte function.
INFERENCE
• Type 2 diabetes mellitus occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.
PLANNING
INTERVENTION
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RATIONALE
Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection. Reduces the risk of crosscontamination High glucose in the blood creates an excellent medium for bacterial growth.
EVALUATION
• After 8 hours of nursing intervention s, the patient was able to identify intervention s to prevent or reduce risk of infection.
verbalized by the patient. Objective: • • • Flushed appearance. Wound drainage. V/S taken as follows: T:37.4 P:87 R:19 BP: 120/90
Independent: After 8 hours • Observe for signs of nursing of infection and interventions, inflammation. the patient will identify interventions to prevent or reduce risk of infection. •
Promote good • handwashing by nurse and patient. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance and site care. Rotate IV sites as indicated. Provide catheter or perineal care. Teach the female patient to clean from front to back after elimination. Provide conscientious skin care, gently •
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Minimizes the risk for infection.
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Peripheral circulation may be impaired,
massage bony areas. Keep the skin dry, linens dry and wrinkle free.
placing patient at increased risk for skin irritation or breakdown and infection. •
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Place in semi – fowler’s position.
Facilitates lung expansion and reduces risk of aspiration.
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Encourage adequate dietary and fluid intake of 3000 ml per day.
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Decrease susceptibility to infection.
Collaborative: • Obtain specimen for culture and sensitivities as indicated.
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Identifies organisms so that most appropriate drug therapy can be instituted.