NURSING CARE PLAN
DEFINING NURSING
SCIENTIFIC ANALYSIS
CHARACTERISTICS DIAGNOSIS
SUBJECTIVE: Impaired tissue integrity
in diabetes is the result
“binhod akong tuo Impaired
of a complex
na tiil ug wala tissue
pathophysiology
nakoy ma feel na integrity r/t
involving vascular,
sakit” as verbalized neuro
immune, and biochemical
by the patient vascular
components (insulin).
complications
Hyperglycemia correlates
of DM causing
with stiffer blood vessels
decrease
which cause slower
blood flow to
circulation and
the
microvascular
peripheries
OBJECTIVE: dysfunction, causing
resulting in
reduced tissue
- swelling of right development
oxygenation. In addition,
foot of diabetic
peripheral neuropathy
foot ulcer
- Pitting test of the can lead to numbness of
the area and reduced
wound >6secs
ability to feel pain, which
- ulcerative right can lead to chronicization
foot of wounds that are not
immediately noticed and
- V/S as follows:
properly treated.
BP: 140/80 mmHg
Reference:
Ullman, K. (2016,
February 5). Diabetes
and your skin.
Management. Retrieved
July 16, 2022, from
https://www.diabetesself
management.com/about-
diabetes/general-
diabetes-information/
diabetes-and-your-skin-
2/
PLAN OF CARE NURSING INTERVENTIONS RATIONALE EVALUATION
After 8 hours of Independent: After 8 hours of
nursing nursing
1. Assess characteristics of 1.  Pale tissue color is a sign of
interventions the interventions the
the wound, including color, decreased oxygenation. An odor
patient will be patient was able
size (length, width, depth), may result from the presence of
able to: to:
drainage, and odor. infection on the site; it may also
SHORT TERM: be coming from necrotic tissue. SHORT TERM:
1. Report any 1. Reported any
2. Keep a sterile dressing
altered sensation altered sensation
technique during wound 2. A sterile technique reduces
of the site of of the site of
care. the risk of infection in impaired
tissue tissue
tissue integrity. This involves the
impairment. impairment.
use of a sterile procedure field,
2. Describes sterile gloves, sterile supplies 2. Described
measures to and dressing, sterile instruments measures to
protect and heal protect and heal
the tissue, the tissue,
Dependent:
including proper 1. Although intravenous including proper
wound care. 1. Administer antibiotics as antibiotics may be indicated, wound care.
ordered. wound infections may be
managed well and more
LONG TERM: efficiently with topical agents. LONG TERM:
2. Assess the need for
1. Maintain 2. To remove the ulcerated fot 1. Maintained
wound debridement incase
normal tissue and prevent worsening and normal tissue
of decayed foot & prepare
integrity with spreading of ulcers to the whole integrity with
the client for the surgical
healing of the extremity. healing of the
procedure as ordered.
ulcers ulcers
Collaborative:
2. Verbalize 2. Verbalized
1. Physical therapists help
wound decreases 1. Refer the client to a wound decreases
people with diabetes take part in
in size and has physical therapist as in size and has
safe, effective exercise
increased ordered. increased
programs.
granulation tissue granulation tissue
GOALS MET.