Patient Name: Noy Age: 78 y/o Gender: Male Informant: Client

Assessment Nursing Inference Goal and Nursing Rationale Evaluation

Diagnosis Objective Intervention
Subjective: Risk for Chronic Short term Review individual To Short term
“Masakit at Infection illness goal: after 30 nutritional needs, underscore goal: after 30
may related *Diabetes minutes of appropriate overall minutes of
lumalabanas to Milletus nursing exercise program, wellness interventions,
na nana sa decrease type 2* intervention and need for rest and health the client’s
sugat” as leukocyte the client will plan. goal was fully
verbalized as Alteration be able to: -Instruct the met as
by the evidence in skin client/SO in evidence by:
patient by integrity -Identify techniques to
delayed interventions protect the -Identified
Objective: wound to prevent or integrity of the -To interventions
BP: 140/90 healing reduce risk of skin, care for prevent to prevent or
Temp.: 38 infection lesions, and infections reduce risk of
PR: 78bpm prevention of in the infection
Glucose -Verbalize spread of infection future
level: 180 understanding -Verbalized
mg/dL of individual -Note -Living in understanding
causative or socioeconomic poverty of individual
General risk factor status and delays causative or
appearance: availability and use treatment/ risk factor
clean- -To achieve of resources lack of
shaven, timely wound access to - Achieved
short-cut healing; be healthcare, timely wound
hair; hands free of and poor healing
rough and purulent general -Free of
dry; skin on drainage or -SO will Verbalize health purulent
feet dry, the ability to cope drainage or
cracked and Long term adequately with erythema
scaly, goal: After 5- existing situation, -be afebrile
Diabetic 8hrs of provide
Ulceration nursing support/monitoring Long term
on L foot intervention as indicated goal: After 5-
covering the client will 8hrs of
entire hallux be able to: interventions,
the client’s
- Assume goal was fully
responsibility met as
for own evidence by:
healthcare
needs within - Assumed
level of ability responsibility
for own
 healthcare
needs within
level of ability

Mr. Noy a client with type 2 Diabetes (noninsulin dependent) for 10 years, presented to his physician’s
office with a non-healing ulcer of 3 weeks’ duration on his left foot. Because of distance from medical
provider and lack of local community services, he is admitted to the hospital.