NURSING CARE PLAN - DM type 2.pdf - Nursing Crib

NURSING CARE PLANASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:“Hindi gumagalingang sugat ko” (Mywounds are nothealing) asverbalized by thepatient.Objective:• Flushedappearance.• Wounddrainage.• V/S taken asfollows:T:37.4P:87R:19BP: 120/90• Risk forinfectionrelated to highglucose levels,decreasedleukocytefunction.Type 2 diabetesmellitus occurswhen thepancreasproducesinsufficientamounts of thehormone insulinand/or the body'stissues becomeresistant to normalor even highlevels of insulin.This causes highblood glucose(sugar) levels,which can lead toa number ofcomplications ifuntreated.• After 8 hoursof nursinginterventions,the patientwill identifyinterventionsto prevent orreduce riskof infection.Independent:• Observe for signsof infection andinflammation.• Promote goodhandwashing bynurse and patient.• Maintain aseptictechnique for IVinsertionprocedure,administration ofmedications, andprovidingmaintenance andsite care. RotateIV sites asindicated.• Patient may beadmitted withinfection, whichcould haveprecipitated theketoacidoticstate, or maydevelop anosocomialinfection.• Reduces therisk of crosscontamination• High glucose inthe bloodcreates anexcellentmedium forbacterialgrowth.• After 8hours ofnursinginterventions, thepatient wasable toidentifyinterventions to preventor reducerisk ofinfection.• Provide catheteror perineal care.Teach the femalepatient to cleanfrom front to backafter elimination.• Provideconscientiousskin care, gently• Minimizes therisk forinfection.• Peripheralcirculation maybe impaired,

massage bonyareas. Keep theskin dry, linensdry and wrinklefree.placing patientat increasedrisk for skinirritation orbreakdown andinfection.• Place in semi –fowler’s position.• Facilitates lungexpansion andreduces risk ofaspiration.• Encourageadequate dietaryand fluid intake of3000 ml per day.Collaborative:• Obtain specimenfor culture andsensitivities asindicated.• Decreasesusceptibility toinfection.• Identifiesorganisms sothat mostappropriatedrug therapycan beinstituted.