NURSING CARE PLAN

Name of Patient: D.M.M Attending Physician: Dr. E

Age: 74 Ward/Bed Number: ICU Impression/Diagnosis: Sepsis 2 to diabetic foot left. CAP HR w/ hypertension DM2 w/ nepropathy Sepsis D (L) les 2x

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
Date & Time: Impaired skin integrity Type 2 diabetes mellitus After 8 hours of nursing INDEPENDENT: After rendering nursing
related to presence of occurs when pancreas interventions, the folks 1. Assess for necrotic 1. Necrotic tissues intervention the goal was
SUBJECTIVE: open wound secondary produces insufficient will be able to tissues around clients around a diabetic partially met the folks was
Nagkapilas tana sa to infected diabetic foot. amounts of the demonstrate techniques wound. persons wound signify able to demonstrate
kahig kag napabay hormone insulin and or to promote healing and poor blood flow. In techniques to promote
anas verbalized by the the bodys tissues minimize infection. severe cases, healing and minimize
patients son. become resistant to amputation may be infection.
normal or even high 2. Demonstrate hand needed.
OBJECTIVES: levels of insulin. This washing technique by Naman-an run namun
Presence of causes high blood nurse and patient. 2. Reduces the risk of kung paano atipanun ang
open wound at glucose(sugar) levels, cross-contamination. pilas ni papa, as
left foot. which can lead to a 3. Maintain aseptic verbalized by the patients
Wound is 6 cm number of technique for IV insertion son.
in diameter as complications if procedure, administration 3. High glucose in the
estimated. untreated. of medications, and blood creates an
Skin and tissue providing maintenance excellent medium for
color changes. Damage to mucous and site care. Rotate IV bacterial growth.
- Redness noted membrane act as a sites as indicated.
around wound physical barrier
area. preventing penetration 4. Provide conscientious
- Swelling against threats from skin care, by keeping skin
around affected external harm. Due to area clean and dry. 4. Peripheral circulation
area. physical trauma, people may be impaired placing
Decreased RBC are at risk for impaired patient at increased risk
(76) tissue integrity. Thus, for skin irritation or
Increased proper care must be 5. Clean and change breakdown and infection.
WBC(18,000) emphasizing to wound dressings as
Wound minimize further indicated. 5. To prevent
discharges complications. *instruct folks proper care development of
(pus) of wound including infections that may be
V/S taken as Reference: Nursing application of topical associated with poor
Diagnosis Manual by medication. wound care and hygiene.
follows:
Doenges, Moorhouse
T- 36.4C
and Geissler-Murr.
BP- 140/70 mmHg
PR- 59 bpm
RR- 26 cpm
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
DEPENDENT:
1. Administer antibiotics 1. Wound infections may
as prescribed. be managed well and
Metronidazole(Flagyl) more efficiently with
500mg, IV,Q6h topical agents although
6pm,10pm,2am,6am. intravenous antibiotics
 NURSING CARE PLAN
Name of Patient: D.M.M Attending Physician: Dr. E
Age: 74 Ward/Bed Number: ICU Impression/Diagnosis: Sepsis 2 to diabetic foot left. CAP HR w/ hypertension DM2 w/ nepropathy Sepsis D (L) les 2x

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
Date & Time: Ineffective Airway Definition: Inability to The patient will display INDEPENDENT: 08/11/17 2:00 pm
08/10/17 Clearance related to clear secretions or patent airway with clear
9:00 am excessive obstructions from the breath sounds, minimize 1. Assess rate and depth 1. Tachypnea, shallow Goal partially met. The
tracheobronchial respiratory tract to yellowish secretions, of respirations and chest respirations, and patient was able to
secretions. maintain a clear absence of dyspnea, movement. Monitor for asymmetric chest display a patent airway
SUBJECTIVE: airway. restlessness and V/S signs of respiratory failure; movement are frequently as evidenced by clear
Nabudlayan tana mag- within normal range by for example, cyanosis and present because of breath sounds, absence
ginhawa kay sa plemas 2:00 pm of August 11, severe tachypnea. discomfort of moving of dyspnea, restlessness
na, as verbalized by 2017. chest wall or fluid in lung. but still with productive
patients son. When pneumonia is cough and V/S within
severe, the client may normal range:
OBJECTIVES: require endotracheal
(+) Dyspnea intubation and T-36.5C
(+) Crackles Reference: Nursing mechanical ventilation to BP- 120/70 mmHg
(+) Yellowish Diagnosis Manual by keep airways clear. PR- 67 bpm
secretions/sputum Doenges, Moorhouse, RR- 20 cpm
(+) Restlessness and Geissler-Murr 2. Assist client to maintain 2. Elevation of the head
(+) Productive cough a comfortable position to of the bed facilitates
facilitate breathing by respiratory function using
elevating the head of bed, gravity; however, client in
V/S taken as follows: leaning on or over bed severe distress will seek
T- 36.4C table, or sitting on edge of the position that most
BP- 140/70 mmHg bed. eases breathing.
PR- 59 bpm Supporting arms and legs
RR- 26 cpm with table, pillows, and so
on helps reduce muscle
fatigue and can aid chest
expansion.
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
3. Increase fluid intake to
3,000 mL/day within
cardiac tolerance.
Provide warm or tepid
liquids. Recommend
intake of fluids between,
instead of during, meals.
4. Keep environmental
pollution from sources
such as dust, smoke, and
feather pillows to a
minimum according to
individual situation.
5. Observe for persistent,
hacking, or moist cough.
Assist with measures to
improve effectiveness of
cough effort.
DEPENDENT:
1. Administer
Bronchodilators, such as
anticholinergic agents:
Duavent Q8H 1 nebule.
2. Administer
Antimicrobials as
prescribed. Metronidazole
(Flagyl) 500 mg, IV Q6H.
6pm, 10 pm, 2am, 6am
3. Hydration helps
decrease the viscosity of
secretions, facilitating
expectoration. Using
warm liquids may
decrease bronchospasm.
Fluids during meals can
increase gastric
distention and pressure
on the diaphragm.
4. Precipitators of allergic
type of respiratory
reactions that can trigger
or exacerbate onset of
acute episode.
5. Cough can be
persistent but ineffective,
especially if client is
elderly, acutely ill, or
debilitated. Coughing is
most effective in an
upright or in a head-down
position after chest
percussion.
1. To relax smooth
respiratory musculature,
reduce airway edema
and mobilize secretions.
2. Various antimicrobials
may be indicated for
control of bacterial
exacerbations of COPD,
such as pneumonia.
.
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
3. Suction when indicated, 3. To clear airway when
using correct size catheter secretions are blocking
and suction timing airways, client is unable to
for adult. clear airway by coughing,
cough is ineffective.

COLLABORATIVE:
1. Refer patient to X-Ray 1. Establishes baseline
Department. for monitoring
progression or regression
of disease process and
complications.
 NURSING CARE PLAN
Name of Patient: D.M.M Attending Physician: Dr. E
Age: 74 Ward/Bed Number: ICU Impression/Diagnosis: Sepsis 2 to diabetic foot left. CAP HR w/ hypertension DM2 w/ nepropathy Sepsis D (L) les 2x

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
Date &Time: Deficient Fluid Volume Deficient Fluid Volume After 8 hours of nursing INDEPENDENT: 08/11/17 2:00 pm
08/10/17 related to Osmotic is the decreased intervention the patient 1. Monitor total fluid intake 1. Provides ongoing
9:00 am diuresis(from intravascular, interstitial will be able to meet fluid and output. estimate of volume After rendering nursing
hyperglycemia). and/or intracellular fluid. requirement to avoid replacement needs, intervention the goal was
SUBJECTIVE: This refers to progression of kidney function and partially met. The patient
Naga-dry ana nga skin dehydration, water loss dehydration (all that can effectiveness of therapy. was able to meet fluid
kag duro ana ihi, as alone without change in be taken to treat or requirement that avoids
verbalized by patients sodium. prevent fluid volume progression of
son. Osmotic Diuresis is the loss) as evidence by: 2. Monitor and document 2. Decrease in circulating dehydration (all that can
increase of urination Stable vital signs vital signs especially BP blood volume can cause be taken to treat or
OBJECTIVES: rate caused by the Improve skin turgor and PR. hypotension and prevent fluid volume loss)
Poor Skin turgor presence of certain Moist skin and soft tachycardia. as evidence by:
Dry skin and slightly substances in the small lips
cracked lips tubes of the kidneys. Appropriate urinary Moist skin and soft
Vital signs taken: output 3. Provide oral hygiene. 3. Decreases unpleasant lips
T- 36.4C References: Nursing tastes in the mouth and Improved skin turgor
BP- 140/70 mmHg Care Plans (Edition 4) allows the client to Stable vital signs
PR- 59 bpm By: Marilynn E. by 2pm of August 11, respond to the sensation T-36.5C
RR- 26 cpm Doenges, Mary Frances 2017. of thirst. BP- 120/70 mmHg
Blood Chemistry Moorhouse and Alice C. PR- 67 bpm
Creatinine Geissler 4. Advise to apply 4. To help moisten and RR- 20 cpm
(284 mmol/L) Lotion/moisturizer. soften skin. Appropriate urinary
Electrolytes NursesLabs.com output
(Soudium- 134 5. Assess skin turgor and 5. Signs of dehydration Intake - 870 ml
mmol/L oral mucous membranes are also detected through Output - 850ml
Potassium- 2.6 for signs of dehydration. skin. Skin of elderly Blood chemistry
mmol/L patients losses elasticity, Creatinine
Calcium- 1.10 hence skin turgor. (96 mmol/L)
mmol/L) Electrolytes:
HGT 6. Provide comfortable 6. Avoids overheating of (Soudium - 143
(372 mmol/L) environment. Cover patient, which could mmol/L
patient with light promote further fluid loss. Potassium - 4.7
blanket/sheets. mmol/L
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
DEPENDENT: Calcium - 1.25
1. Administer IVF as 1. Parenteral fluid mmol/L)
prescribed (PNSS 1L x replacement is indicated HGT (275 mmol/L)
100 cc/hr) to prevent or treat
hypovolemic
complications.

2. Administer medication 2.To meet appropriate

such as Furosemide urinary output.

COLLABORATIVE:
1. Monitor electrolytes, 1. Any abnormal values
blood chemistry, such as elevated BUN
Creatinine level and HGT. suggest fluid deficit.
 NURSING CARE PLAN
Name of Patient: D.M.M Attending Physician: Dr. E
 Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
Date &Time: Knowledge deficit The inability to identify, After rendering of INDEPENDENT: 08/11/17 2:00 pm
08/10/17 related to disease manages, or seeks out nursing intervention the 1. Assess ability to learn or 1. Cognitive impairments
9:00 am process, treatment and help to maintain health. patients folks will be perform desired health- need to be identified so After rendering nursing
individual care needs. Altered health able to demonstrate related care. an appropriate teaching intervention, the goal was
SUBJECTIVE: maintenance reflects a necessary health plan can be designed. partially met. The
Si papa ginapabay-an change in an maintenance activities patients folks were able
na ang ana kaugalingon individuals ability to and understanding of 2. Assess motivation and 2. Some clients are ready to demonstrate
kag pagusto lang kung perform the functions factors contributing to willingness of client. to learn soon after they necessary health
ano ang ana kaunon, necessary to maintain current situation. are diagnosed. maintenance activities
as verbalized by the health or wellness. That Develop plan to meet and understanding of
patients son. individual may already the patients needs as 3. Determine clients 3. Some persons may factors contributing to
manifest symptoms of evidence by: learning style especially if prefer written over visual current situation.
OBJECTIVES: existing or impending client had learned and materials, or they may Developed plan to meet
Ignorance physical ailment or Proper foot care retained new information prefer group versus the patients needs as
display behaviors that in the past. individual instruction. evidence by:
Wound at left foot are strongly or certainly Awareness Matching the learners Demonstrated
linked to disease. regarding self-care preferred style with the proper foot care
Poor hygiene of diabetic condition. educational method Awareness
References: Nursing facilitates success in regarding self-
Passive Care Plans (Edition 4) Proper hygiene mastery of knowledge. care of diabetic
By: Marilynn E. condition.
Disinterest in the Doenges, Mary Frances Active participation 4. Explore with the folks of 4. Identifies strengths Demonstrated
surroundings Moorhouse and Alice C. in the disease the patients status is may reveal problems proper hygiene
Geissler process. maintained ( nutrition, requiring immediate Active participation in the
exercise, sleep and rest) intervention. disease process.

by 2pm of August 11, 5. Instruct client/ family in 5. Promotes optimal

2017. disease process,
progression, what to
expect, and answer all
questions honestly.
learning environment
when client show
willingness to learn.
Family members may
assist with helping the
client to make informed
choices regarding the
treatment.

Render physical
comfort for the patient.
Age: 74 Ward/Bed Number: ICU Impression/Diagnosis: Sepsis 2 to diabetic foot left. CAP HR w/ hypertension DM2 w/ nepropathy Sepsis D (L) les 2x
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation

6. Render physical
comfort for the patient.
7. Grant a calm and
peaceful environment
without interruption.
8. Provide an atmosphere
of respect, openness,
trust, and collaboration.
9. Develop plan with the
patient or caregiver for the
care.
10. Promote and
demonstrate proper
hygiene.
Anxiety or large volumes
of instruction may impede
comprehension and limit
learning.
6. Based on Maslows
theory, basic
physiological needs must
be addressed before the
patient education.
Ensuring physical
comfort allows the patient
to concentrate on what is
being discussed or
demonstrated.
7. A calm environment
allows the patient to
concentrate and focus
more completely.
8. Conveying respect is
especially important when
providing education to
patients with different
values and beliefs about
health and illness.
9. Allows for
incorporating existing
strengths or limitations
and assistance in
adapting and organizing
care as necessary.
10. This decrease risk of
infection, promotes
maintenance and
integrity of skin and
teeth.
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Intervention Rationale Evaluation
11. Turn the patient every 11. To prevent bed
2hrs sores.

12. Provide safety and 12. To prevent further

comfort ( eg. Siderails) injury.

DEPENDENT:
1. Linagliptin rajenta 1. To ontrol
500 mg OD hyperglycemia

2. Monitor HGT 2. To assess the

concentration of glucose
in the blood.

3. Change foot dressing. 3. To decrease further

infection.