NURSING CARE PLAN

DEFINING NURSING
SCIENTIFIC ANALYSIS PLAN OF CARE NURSING INTERVENTIONS RATIONALE EVALUATION
CHARACTERISTICS DIAGNOSIS

SUBJECTIVE: Impaired tissue integrity After 8 hours of Independent: After 8 hours of

in diabetes is the result nursing nursing
“binhod akong tuo Impaired 1. Assess characteristics of 1.  Pale tissue color is a sign of
of a complex interventions the interventions the
na tiil ug wala tissue the wound, including color, decreased oxygenation. An odor
pathophysiology patient will be patient was able
nakoy ma feel na integrity r/t size (length, width, depth), may result from the presence of
involving vascular, able to: to:
sakit” as verbalized neuro drainage, and odor. infection on the site; it may also
immune, and biochemical
by the patient vascular SHORT TERM: be coming from necrotic tissue. SHORT TERM:
components (insulin).
complications
Hyperglycemia correlates 1. Report any 2. A sterile technique reduces 1. Reported any
of DM causing 2. Keep a sterile dressing
with stiffer blood vessels altered sensation the risk of infection in impaired altered sensation
decrease technique during wound
which cause slower of the site of tissue integrity. This involves the of the site of
blood flow to care.
circulation and tissue use of a sterile procedure field, tissue
the
microvascular impairment. sterile gloves, sterile supplies impairment.
peripheries
OBJECTIVE: dysfunction, causing and dressing, sterile instruments
resulting in 2. Describes 2. Described
reduced tissue 3. Encourage patient to
- swelling of right development measures to 3. Putting legs on dependent measures to
oxygenation. In addition, elevate legs and avoid
foot of diabetic protect and heal position will worsen leg edema. protect and heal
peripheral neuropathy putting them on a
foot ulcer the tissue, the tissue,
- dry skin can lead to numbness of dependent position for e
the area and reduced including proper long period of time. including proper
ability to feel pain, which wound care. wound care.
can lead to chronicization Dependent:
- Pitting test of the 1. Although intravenous LONG TERM:
of wounds that are not 1. Administer antibiotics as
wound >6secs antibiotics may be indicated,
immediately noticed and LONG TERM: ordered. 1. Maintained
properly treated. wound infections may be
- ulcerative right normal tissue
1. Maintain managed well and more
foot integrity with
Reference: normal tissue efficiently with topical agents.
healing of the
- V/S as follows: integrity with 2. Assess the need for
Ullman, K. (2016, 2. To remove the ulcerated fot ulcers
healing of the wound debridement incase
BP: 140/80 mmHg February 5). Diabetes of decayed foot & prepare and prevent worsening and
ulcers 2. Verbalized
and your skin. the client for the surgical spreading of ulcers to the whole
wound decreases
Management. Retrieved 2. Verbalize procedure as ordered. extremity.
in size and has
July 16, 2022, from wound decreases
increased
https://www.diabetesself in size and has Collaborative:
granulation tissue
management.com/about- increased 1. Physical therapists help
1. Refer the client to a
diabetes/general- granulation tissue people with diabetes take part in
physical therapist as
diabetes-information/ safe, effective exercise
ordered. GOALS MET.
diabetes-and-your-skin- programs.
2/