Anda di halaman 1dari 4

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology) Ineffective tissue perfusion (Renal) related to increased blood concentration

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Short term goals: After 8 hours of thorough nursing intervention, the client will be able to:

Independent: 1.)

Objective: Increased serum creatinine level (1.27) Pitting Edema on both lower and upper extremities (4mm) Decreased urine output Increased HGT level of 321 mg/dL oliguria

2.) a.) Verbalize the urge to urinate b.) Decrease blood glucose level from 321mg/dL within normal range of 80 110 mg/dL c.) Reduce pitting edema from 4mm to 2mm 3.) 4.)

5.)

Goals partially met. The patient was 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 Restrict clients fluid intake pitting edema from R To avoid severity of the problem. 4mm to 2mm but Apply patients bladder cold packs failed to achieve a R To stimulate the urge to urinate. normal blood 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 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.

Long term goals:

a.) Completely eliminate presence of pitting edema. b.) Maintain normal blood glucose level of Collaborative: 80 110mg/dL

1.) Refer to the dietician for his Diabetic diet. 2.)

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology) Ineffective tissue perfusion (Peripheral) related to increased blood viscosity secondary to hyperglycemia

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Short term goals: After 8 hours of thorough nursing intervention, the client will be able to: a.) Decrease blood glucose level from 321mg/dL within normal range of 80 110 mg/dL b.) Improve the capillary refill from 4 seconds to 3 seconds. c.) Reduce pitting edema from 4mm to 2mm d.) Improve skin color at the wound site. Long term goals:

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

Goals partially met. The patient was 1.) Assist client in frequent ambulation, when able to reduce possible pitiing edema from R to enhance venous return 4mm to 2mm and 2.) Elevate the legs when sitting, avoiding improved skin color sharp angulations of the hips or knees. at the wund site R to promote proper venous return from pallor to 3.) Position patient in a high back rest pinkish but failed R to increase gravitational blood flow. to achieve normal 4.) Apply patients bladder cold packs blood glucose level R To stimulate the urge to urinate. of 80 110mg/dL 5.) Let the patient hear the running water from and failed to the faucet. improve capillary R To stimulate the urge to micturate. refill of 4seconds to 3 seconds. Dependent: Independent: 3.) Administer medications (insulin), s ordered. R helps in lowering down blood glucose level. 4.) Administer 2 ampules of amino acid (IV). R to promote faster healing of the wound.

a.) Completely eliminate presence of pitting edema. b.) Maintain normal Collaborative: blood glucose level of 1.) Refer to the dietician for his Diabetic diet. 80 110mg/dL 2.) Increase protein intake of the patient. R Protein promotes faster healing of the wounds.

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology) Risk for infection related to tissue destruction at the right foot punctured wound

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Short term goals: After 1hour of thorough nursing intervention, the client will be able to: a.) Demonstrate various techniques in order to avoid infection like proper hand washing. b.) Verbalize comprehension on the importance of avoiding the spread of organisms. Long term goals: a.) Achieve timely complete wound healing to the punctured site at the right foot.

Independent: 1.) Demonstrate proper hand washing. R It deters the spread of microorganisms. 2.) Discuss the importance of not taking antibiotics leftover drugs unless specifically instructed by healthcare provider. R Inappropriate use can lead to development of drug-resistant strains/secondary infections. 3.) Advise patient to always wash his wound with soap and water and apply betadine. R it prevents from the exposure of microorganisms. 4.) Explain to the patient the importance of avoiding the spread or accumulation of microorganisms. R to give sufficient knowledge about situation that patient might be risked for. 5.) Tell patient never to touch the wound wuth dirty bare hands. R Because it will initiate spread of microorganisms. Dependent: 1.) Administer medications (antibiotics), as ordered. R To prevent from infection.

Goals met. The patient was able to Demonstrate various techniques in order to avoid infection like proper hand washing and verbalize comprehension on the importance of avoiding the spread of organisms.

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology) Risk for falls related to visual difficulties secondary to hyperglycemia

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Short term goals: 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.

Independent: 1.) 2.) 3.) Assist client during ambulation R To avoid possible injuries. Provide side rails in the patients bed side R To avoid the existence of falls. Discuss with the patient the importance of using devices during ambulation like wooden stuff. R To assist him in his ambulation and to avoid possible falls. Provide health teaching to clients significant others that never leave the client alone especially in the comfort room. R To promote safety precautions. Instruct patient together with his significant others to organize things appropriately. R To have a maximum space to avoid possible injuries.

Goals met. The client was able to Verbalize the importance of preventing himself from falls to reduce injuries and demonstrate various techniques to avoid falls.

4.)

5.) Long term goals:

a.) Maintain normal blood glucose level of Dependent: 80 110mg/dL

1.) Administer medications (insulin), as ordered. R Helps in lowering down blood glucose level.