NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Risk for • After 8 hours • Observe for signs • Patient may be • After 8
infection Type 2 diabetes of nursing of infection and admitted with hours of
“Hindi gumagaling related to high mellitus occurs interventions, inflammation. infection, which nursing
ang sugat ko” (My glucose levels, when the the patient could have intervention
wounds are not decreased pancreas will identify precipitated the s, the
healing) as leukocyte produces interventions ketoacidotic patient was
verbalized by the function. insufficient to prevent or state, or may able to
patient. amounts of the reduce risk develop a identify
hormone insulin of infection. nosocomial intervention
Objective: and/or the body's infection. s to prevent
tissues become or reduce
• Flushed resistant to normal • Promote good • Reduces the risk of
appearance. or even high handwashing by risk of cross- infection.
levels of insulin. nurse and patient. contamination
• Wound This causes high
drainage. blood glucose • Maintain aseptic • High glucose in
(sugar) levels, technique for IV the blood
• V/S taken as which can lead to insertion creates an
follows: a number of procedure, excellent
complications if administration of medium for
T:37.4 untreated. medications, and bacterial
P:87 providing growth.
R:19 maintenance and
BP: 120/90 site care. Rotate
IV sites as
indicated.

• Provide catheter • Minimizes the

or perineal care. risk for
Teach the female infection.
patient to clean
from front to back
after elimination.

• Provide • Peripheral
conscientious circulation may
skin care, gently be impaired,
 massage bony placing patient
areas. Keep the at increased
skin dry, linens risk for skin
dry and wrinkle irritation or
free. breakdown and
infection.

• Place in semi – • Facilitates lung

fowler’s position. expansion and
reduces risk of
aspiration.

• Encourage • Decrease
adequate dietary susceptibility to
and fluid intake of infection.
3000 ml per day.

Collaborative:
• Obtain specimen • Identifies
for culture and organisms so
sensitivities as that most
indicated. appropriate
drug therapy
can be
instituted.