VII.
NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES
(Problem and Etiology)
(Subjective & Objective Cues)
Subjective: Ineffective tissue perfusion Short term goals:
(Renal) related to increased blood
“…. Dili man kayo ko ka-ihi..” concentration After 8 hours of thorough
nursing intervention, the
client will be able to:
Objective:
 Increased serum creatinine
a.) Verbalize the urge to
level (1.27)
urinate
 Pitting Edema on both lower
b.) Decrease blood
and upper extremities (4mm)
glucose level from
 Decreased urine output
321mg/dL within
 Increased HGT level of 321
normal range of 80 –
mg/dL
110 mg/dL
 oliguria
c.) Reduce pitting
edema from 4mm to
2mm
Long term goals:
a.) Completely eliminate
presence of pitting
edema.
b.) Maintain normal
blood glucose level of
80 – 110mg/dL
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES
NURSING INTERVENTIONS AND RATIONALE EVALUATION
Independent: Goals partially met.
The patient was
1.) Monitor urine output on a regular able to verbalized
schedule. the urge to urinate
R – To come with a baseline data. and able to reduce
2.) Restrict client’s fluid intake pitting edema from
R – To avoid severity of the problem. 4mm to 2mm but
3.) Apply patient’s bladder cold packs failed to achieve a
R – To stimulate the urge to urinate. normal blood
4.) Let the patient hear the running water from glucose level within
the faucet. the range of 80 –
R – To stimulate the urge to micturate. 110mg/dL
5.) Encourage patient to avoid foods that (111mg/dL)
triggers increase of blood glucose level.
R – to maintain normal serum glucose level.
Dependent:
1.) Administer medication (Furosemide), as
ordered
R – To stimulate urination.
2.) Administer medications (insulin), as
ordered.
R – Helps in lowering down blood glucose
level.
Collaborative:
1.) Refer to the dietician for his Diabetic diet.
NURSING INTERVENTIONS AND RATIONALE EVALUATION

(Subjective & Objective Cues)
Subjective:
“… dugay kayo ga-ayo akong samad sa
tiil…”
Objective:
 Increased HGT level of 321
mg/dL
 Pitting edema on both lower
and upper extremities (4mm)
 Prolonged capillary refill of 4
seconds.
 Pallor in the punctured wound
at the right foot
ASSESSMENT DATA
VII. NURSING CARE PLAN
(Problem and Etiology)
Ineffective tissue perfusion
(Peripheral) related to increased
blood viscosity secondary to
hyperglycemia
NURSING DIAGNOSIS
Short term goals: Independent: Goals partially met.
The patient was
After 8 hours of thorough 1.) Assist client in frequent ambulation, when able to reduce
nursing intervention, the possible pitiing edema from
client will be able to: R – to enhance venous return 4mm to 2mm and
2.) Elevate the legs when sitting, avoiding improved skin color
a.) Decrease blood sharp angulations of the hips or knees.
at the wund site
glucose level from R – to promote proper venous return from pallor to
321mg/dL within 3.) Position patient in a high back rest
pinkish but failed
normal range of 80 – R – to increase gravitational blood flow.
to achieve normal
110 mg/dL 4.) Apply patient’s bladder cold packs
blood glucose level
b.) Improve the capillary R – To stimulate the urge to urinate.
of 80 – 110mg/dL
refill from 4 seconds 5.) Let the patient hear the running water from
and failed to
to 3 seconds. the faucet.
improve capillary
c.) Reduce pitting R – To stimulate the urge to micturate.
refill of 4seconds to
edema from 4mm to
3 seconds.
2mm Dependent:
d.) Improve skin color at
the wound site. 3.) Administer medications (insulin), s ordered.
R – helps in lowering down blood glucose
Long term goals: level.
4.) Administer 2 ampules of amino acid (IV).
a.) Completely eliminate R – to promote faster healing of the
presence of pitting wound.
edema.
b.) Maintain normal Collaborative:
blood glucose level of
80 – 110mg/dL 1.) Refer to the dietician for his Diabetic diet.
2.) Increase protein intake of the patient.
R – Protein promotes faster healing of the
wounds.
GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
 VII. NURSING CARE PLAN
(Subjective & Objective Cues) (Problem and Etiology)

Risk for infection related to tissue Short term goals: Independent: Goals met. The
destruction at the right foot patient was able to
punctured wound After 1hour of thorough 1.) Demonstrate proper hand washing. Demonstrate
nursing intervention, the R – It deters the spread of microorganisms. various techniques
client will be able to: 2.) Discuss the importance of not taking in order to avoid
antibiotics “leftover” drugs unless infection like
a.) Demonstrate various specifically instructed by healthcare proper hand
techniques in order provider. washing and
to avoid infection like R – Inappropriate use can lead to verbalize
proper hand development of drug-resistant comprehension on
washing. strains/secondary infections. the importance of
b.) Verbalize 3.) Advise patient to always wash his wound avoiding the spread
comprehension on with soap and water and apply “betadine”. of organisms.
the importance of R – it prevents from the exposure of
avoiding the spread microorganisms.
of organisms. 4.) Explain to the patient the importance of
avoiding the spread or accumulation of
Long term goals:
microorganisms.
a.) Achieve timely R – to give sufficient knowledge about
complete wound situation that patient might be risked for.
healing to the 5.) Tell patient never to touch the wound wuth
punctured site at the dirty bare hands.
right foot. R – Because it will initiate spread of
microorganisms.

Dependent:

1.) Administer medications (antibiotics), as

ordered.
R – To prevent from infection.

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION

(Subjective & Objective Cues)
Subjective:
“…. Dili naman ko kayo maka-klaro”
VII. NURSING CARE PLAN
(Problem and Etiology)
Risk for falls related to visual
difficulties secondary to
hyperglycemia
Short term goals: Independent:
After 1 hour of thorough
nursing intervention, the
client will be able to:
a.) Verbalize the
importance of
preventing himself
from falls to reduce
injuries.
b.) Demonstrate various
techniques to avoid
falls.
Long term goals:
a.) Maintain normal
blood glucose level of
80 – 110mg/dL Dependent:
Goals met. The
client was able to
1.) Assist client during ambulation Verbalize the
R – To avoid possible injuries. importance of
2.) Provide side rails in the patient’s bed side preventing himself
R – To avoid the existence of falls. from falls to reduce
3.) Discuss with the patient the importance of injuries and
using devices during ambulation like demonstrate
wooden stuff. various techniques
R – To assist him in his ambulation and to to avoid falls.
avoid possible falls.
4.) Provide health teaching to client’s
significant others that never leave the
client alone especially in the comfort room.
R – To promote safety precautions.
5.) Instruct patient together with his significant
others to organize things appropriately.
R – To have a maximum space to avoid
possible injuries.
1.) Administer medications (insulin), as
ordered.
R – Helps in lowering down blood glucose
level.