NursingCrib.com Nursing Care Plan Diabetes Mellitus Type 2

NURSING CARE PLAN ASSESSMENT Subjective: “Hindi gumagaling ang sugat ko” (My wounds are not healing) as

verbalized by the patient. Objective: •

Flushed appearance.

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Wound drainage.

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V/S taken as follows: T:37.4 P:87 R:19 BP: 120/90

DIAGNOSIS •

Risk for infection related to high glucose levels, decreased leukocyte function.

INFERENCE

PLANNING •

Type 2 diabetes mellitus occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.

INTERVENTION

Independent: After 8 hours • Observe for signs of nursing of infection and interventions, inflammation. the patient will identify interventions to prevent or reduce risk of infection.

RATIONALE •

Patient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection.

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Promote good • handwashing by nurse and patient.

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Maintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance and site care. Rotate IV sites as indicated.

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High glucose in the blood creates an excellent medium for bacterial growth.

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Provide catheter or perineal care. Teach the female patient to clean from front to back after elimination.

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Minimizes the risk for infection.

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Provide conscientious skin care, gently

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Peripheral circulation may be impaired,

Reduces the risk of crosscontamination

EVALUATION •

After 8 hours of nursing intervention s, the patient was able to identify intervention s to prevent or reduce risk of infection.

placing patient at increased risk for skin irritation or breakdown and infection.

massage bony areas. Keep the skin dry, linens dry and wrinkle free.

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Place in semi – fowler’s position.

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Facilitates lung expansion and reduces risk of aspiration.

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Encourage adequate dietary and fluid intake of 3000 ml per day.

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Decrease susceptibility to infection.

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Identifies organisms so that most appropriate drug therapy can be instituted.

Collaborative: • Obtain specimen for culture and sensitivities as indicated.