Cherubim Lei D.

Dela Cruz BSN-4

I. Nursing Care Plan

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Risk for infection r/t After 8hrs of nursing Observe for signs of After 8hrs of nursing
“Wala gaayo akong high glucose levels, intervention the patient infection and inflammation. intervention the patient
samad sa tiil. Dugay- decreased leukocyte will be able to identify was able to identify
dugay na pud baya ni.” function interventions to Promote good interventions to
-as verbalized by the prevent or reduce risk handwashing by nurse and prevent or reduce risk
patient of infection. patient. of infection.

Objectives: Maintain asepsis during

administration of
-Flushed Appearance medications and providing
wound site care.
-Wound Drainage
Provide meticulous skin
V/S: care: gently massage bony
areas, keep skin dry. Keep
Temp- 37.4 linens dry and wrinkle-
free.
P- 87
RR- 20
Provide antibiotic
BP- 120/90 medications as well as
maintenance medication
as prescribed by the
doctor.
 II. Drug Study

Name of Drugs Classification Dosage Indication Contraindication Adverse Reaction Nursing Intervention

Metformin Antidiabetics 500mg Adjunct to Contraindicated CNS: asthenia, Patient Teaching:

P.O, b.i.d diet to with allergy to headache, dizziness, Instruct patient about nature of
lowerblood metformin;CHF; chills, light- diabetes and importance of
glucose diabetes headedness following therapeutic regimen,
with type2 complicated by adhering to specific diet, losing
(non fever, severe CV: chest discomfort, weight, getting exercise,
 – infections, severe palpitations, hyper- following personal hygiene
insulin- trauma, major tension programs, and avoiding
dependent) surgery, ketosis, infection.
diabetes acidosis, coma(use EENT: ear pain,
mellitus in insulin); type1 rhinitis, seasonal Explain how and when to
patients (insulin- allergies, toothache, monitor glucose levels. Teach
dependent),serious tooth abscess, evidence of low and high
hepatic tonsillitis glucose levels. Explain
impairment, emergency measures.
serious renal GI: diarrhea, nausea,
impairment, vomiting, abdominal
uremia, thyroid or floating, flatulence,
endocrine anorexia, taste
impairment, disorder, abnormal
glycosuria, stools, constipation,
hyperglycemia dyspepsia
associated with
primary renal Metabolic: Lactic
disease. acidosis,
hypoglycemia
Contraindicated in
patients with acute Skin: Flushing,nail
 HF requiring disorder
pharmacologic
intervention and in
patients with
conditions
predisposing to
renal dysfunction,
CV collapse, MI
hypoxia, and
septicemia.

III. Sample Charting

FOCUS DATA ACTION RESPONSE

“Wala gaayo akong samad sa
tiil. Dugay-dugay na pud baya
ni.”
Risk for infection r/t high
glucose levels, decreased
leukocyte function
-Flushed Appearance Observe for signs of infection and After 8hrs of nursing
inflammation. intervention the patient was
-Wound Drainage able to identify interventions
Promote good handwashing by to prevent or reduce risk of
V/S: nurse and patient. infection.
Temp- 37.4 Maintain asepsis during
P- 87 administration of medications and
RR- 20 providing wound site care.
BP- 120/90
Provide meticulous skin care:
gently massage bony areas, keep
skin dry. Keep linens dry and
wrinkle-free.

Provide antibiotic medications as

well as maintenance medication
as prescribed by the doctor.