Disturbed Sensory Perception: tactile related to altered sensory transmission

as evidenced by decreased sensitivity to stimulation in hands (inability to grip

and feel objects)

Goal 1: Patient won’t experience injury by discharge 3/11/10

Intervention 1: Remove sharp objects from the patient’s environment.
Basic safety measures (3 pg500)
Intervention 2: Protect from burns by avoiding exposure to excessive heat or cold,
especially bath water. Basic safety measures to prevent accidental burns
(3 pg500)
Intervention 3: Inspect patient’s skin at least once a shift. To detect signs of skin
breakdown (2 pg317)
Evaluation:

Goal 2: Patient will describe 2 safety measures to avoid injury on 3/11/10

Intervention 1: Provide explanations of and plan care with client. Enhances commitment
to and continuation of plan…optimizing outcomes (1 pg60
Intervention 2: Teach patient to regularly check placement of hands and feet. To avoid
injury (2 pg 317)
Intervention 3: Teach patient safety measures, such as testing bath water with a
thermometer. To prevent injury (2 pg317)
Evaluation:

Goal 3: Patient will regain usual tactile sensation by 3/20/10

Intervention 1: Review home safety measures: using elbow to test water temperature
before putting hands in. To avoid injury (1 pg604)
Intervention 2: Stimulate sense of touch: give client objects to touch and grasp. Aids in
retraining sensory pathways to integrate reception and interpretation of
stimuli (1 pg 603)
Intervention 3: Collaborate with occupational therapist. to achieve maximal gains in
function (1 pg 602)
Evaluation:
Risk for unstable glucose related to activity level and physical health status

Goal 1: Patient will acknowledge factors that may lead to unstable glucose by 3/11/10.
Intervention 1: Nurse will determine patients individual factors as listed in risk factors
and go over them with client. To identify which factors can be modified
(1 pg 328)
Intervention 2: Nurse will help patient identify common situations that contribute to
client’s glucose instability on daily basis. Multiple factors can be in play
at any time (1 pg329)
Intervention 3: Nurse will help client in reviewing her diet, especially carbohydrates.
Glucose balance is determined by the amount of carbohydrates
consumed
(1 pg329)
Evaluation:

Goal 2: Patient will verbalize plan for modifying factors to prevent and minimize shifts in
glucose level by 3/11/10.
Intervention 1: Ascertain patient’s knowledge and understanding of diabetes and
treatment needs. To assess risk (1 pg 328)
Intervention 2: Help patient to identify individual perceptions and expectations of
treatment regimen. To assess contributing factors (1 pg328)
Intervention 3: Encourage patient to read labels and choose foods described as having a
low glycemic index, higher fiber, and low-fat content. These foods
produce a slower rise in blood glucose and more stable release of insulin
(1 pg329)
Evaluation:

Goal 3: Patient will maintain glucose in a satisfactory range for at least 1 month-4/11/10
Intervention 1: Determine patient’s awareness and ability to be responsible for dealing
with the situation. Age, developmental level, and current health status
affect client’s ability to provide for own safety. (1 pg328)
Intervention 2: Ascertain whether patient is adept at operating her in home glucose-
monitoring devise. All available machines will provide satisfactory
readings if properly used, maintained, and routinely calibrated.
(1 pg 329)
Intervention 3: Emphasize immediate and long-term consequence of actions and choices.
Close control of glucose levels over time has been shown to delay onset
and reduce severity of complications enhancing quality of life. (1 pg329)
Evaluation
Risk for infection related to surgical incision and diabetes mellitus type II

Goal 1: Patient’s incision site will remain free from signs and symptoms of infection on 3/11/10
Intervention 1: Observe skin and tissue surrounding abdominal incision. Redness,
warmth, swelling, pain, red streaks are signs of developing localized
infection that may have systemic implications if treatment is delayed
(1 pg402)
Intervention 2: Note onset of fever, chills, diaphoresis, altered LOC. Signs and
symptoms
of sepsis, requiring intensive medical treatment and evaluation for
source of infection and specific pathogen. (1 pg402)
Intervention 3: Administer Augmentin as ordered. Premature discontinuation of
treatment when client begins to feel well may result in return of infection
and potentiate drug-resistant strains (1 pg 404)
Evaluation:

Goal 2: Patient will identify interventions to prevent and reduce risk of infection on 3/11/10
Intervention 1: Show patient proper technique of hand washing and when it is necessary.
Most effective means for preventing microbial transmission (2 pg180)
Intervention 2: Teach cough and deep breathe exercises and recommend performing this
every 2 hours. Mobilizes static pulmonary secretions, thereby improving
gas exchange (3 pg55)
Intervention 3: Maintain adequate hydration and electrolyte balance. Prevent imbalances
that would predispose to infection. (1 pg 403)
Evaluation:

Goal 3: Patient will achieve timely wound healing by follow-up appointment on 3/18/10
Intervention 1: Review laboratory values (CBC) To identify presence of pathogens and
treatment options (1 pg 402)
Intervention 2: Teach client the importance of clean, well ventilated, quiet environment.
Promotes healing process (1 pg 402)
Intervention 3: Review individual nutritional needs, appropriate exercise program, and
need for rest. To enhance immune system function and healing. (1 pg404)
Evaluation: