REY JEAN M.
GARCIA BSN 3-C
Name: Bacan, R.
Age: 37 years old
CUES
SUBJECTIVE:
Patient verbalized “Grabe
gid ang sakit sa akun pilas,
gadula-dula na du gina
tuslok ang sakit, kis-a di ko
katulog kay ga ngut-ngut
sa”
“Gamay lang ni akun pilas
hasta sa medyo nagdako
na sa, kabudlay kis-a
maglakat kay ang pilas ko
gasakit”
“Gapalang luya akun bilog
lawas. Budlay mag giho
kag du madulaan ko
pwersa pag piliton ko mag
giho”
OBJECTIVE:
Assessment:
Neurological:
-Patient is lethargic
-Displays difficulty of
elevating affected foot
PROBLEM LIST
Chief Complaint: Vomiting, Body Malaise
Diagnosis: Diabetes Mellitus Type 2 Poorly controlled; Hypertension
PROBLEM RANK PHYSIOLOGIC BEHAVIORAL
ACTUAL POTENTIAL ACTUAL POTENTIAL
Acute pain 1 Acute pain related to skin Risk of activity Disturbed sleeping Risk for sleep
tissue injury as evidence intolerance related to pattern related to pain deprivation related
by verbalization of patient pain as evidence by to discomfort
of intermittent sharp pain difficulty of sleeping
at patient’s right foot and caused by the pain
pain scale of 7 out of 10
Foot ulcer 2 Impaired skin integrity Risk of infection related Impaired walking Risk for impaired
related to poor glycemic to disruption of skin related to physical comfort related to
control as evidence by tissue and muscle deconditioning as inadequate control
presence of ulcerated integrity evidence by grimace over the situation
wound at right foot when using affected
foot to walk
Body weakness 3 Impaired physical Risk for fatigue related Powerlessness related Risk for adult fall
mobility related to to decrease muscle to pain as evidenced related to impaired
decrease muscle control strength by the verbatim of physical mobility
strength as evidence by patient
decrease range of motion
REY JEAN M. GARCIA BSN 3-C

-Pupils are equal, round and

reactive to light
-Facial grimace noted when
moving/elevating affected foot
-Pain scale of 7 out of 10

Cardiovascular:
-Radial Pulse palpable at right
arm with 90 bpm
-Capillary Refill is normal at <
3 seconds

Respiratory:
-Respirations are regular
-Lung sounds are clear

NURSING CARE PLAN

REY JEAN M. GARCIA BSN 3-C

Name: Bacan, R. Diagnosis: Diabetes Mellitus Type 2 Poorly controlled; Hypertension

Age: 37 years old Ward: Medical Ward 1
Chief Complaint: Vomiting, Body Malaise
General Objective: To maintain good hygiene and physical comfort

ASSESSMENT NURSING PATHOPHYSIOLOGY EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
SUBJECTIVE: Acute pain Predisposing factors: INDEPENDENT: After 24 hours of
Patient verbalized related to skin Diabetes Mellitus Within 24 hours of clinical duty, the
“Grabe gid ang sakit sa tissue injury as clinical duty, the 1. Assess for referred To help determine goal was partially
akun pilas, gadula-dula evidence by Skin tissue injury in patient will be able pain, as appropriate possibility of met.
na du gina tuslok ang verbalization of the foot to: underlying condition
sakit, kis-a di ko patient of As evidenced by:
katulog kay ga ngut- intermittent Release of pain and • Verbalize/Report 2. Assess for To aid in
ngut sa” sharp pain at inflammatory pain is relieved or potential types of understanding
patient’s right mediators controlled pain that may be reason for severity of 1. Pain scale is 5
foot and pain affecting client pain associated with out of 10
OBJECTIVE: scale of 7 out of Nociceptors send As evidenced by: client’s condition
Assessment: 10 signals to the brain 2. Patient
-Facial grimace noted 1. Pain scale will 3. Identify To fully understand demonstrate the
when moving/elevating Pain signals travel decrease from 7 out precipitating or patients pain use of relaxation
affected foot though the spinal cord of 10 to 3 out of 10 aggravating factors symptoms and comfort
-Pain scale of 7 out of and relieving factors activities or
10 Pain signals sent to 2. Demonstrate use techniques
-Ulcerated wound at the body, the to the of relaxation and 4. Perform pain To demonstrate
right foot with irregular affected part comfort activities or assessment each improvement or
border, (+) redness, (+) techniques time pain occurs. status or to identify
tenderness and warmth
Intermittent sharp Document any worsening of
pain, redness and changes underlying condition
warmth in the affected
are 5. Observe non- Observation may not
verbal ques and pain be congruent with
Acute pain behaviors verbal reports. It
adds additional data
and helps identify
the type of pain if
REY JEAN M. GARCIA BSN 3-C

patient cannot
verbalize

6. Instruct patient to For a more

report pain as soon successful alleviating
as it begins the pain

7.Provide comfort To alleviate the pain

measures such as
back rub, change of
position and use of
heat or cold
compress

8. Use relaxation To divert the

exercises such as attention of the
focused breathing, patient and alleviate
visualization and pain
guided imagery

9.Provide a quite For the patient to be

environment and comfortable and
calm activities ease the pain

10. Instruct the To evaluate coping

patient to verbalized abilities and to
feeling about pain, identify areas of
such as tolerating, additional concern
anxiety, and
pessimistic thoughts
11. Instruct patient to To assist client to
use transcutaneous explore methods for
electrical stimulation alleviation of pain
(TENS) unit, when
ordered
REY JEAN M. GARCIA BSN 3-C

DEPENDENT:

1. Administer
analgesics as To maintain
indicated acceptable level of
pain
2. Determine
medications, alcohol To maintain the
or other drugs efficacy of the
currently being used analgesic
and any medications
allergies that may
affect choice of
analgesics

COLABORATIVE:

1. Collaborate with
medical providers in To asses
pain assessment, precipitating
including neurological contributory factors
and physiological of pain
factors

2. Collaborate in
treatment of To assist client in
underlying condition alleviation of pain
or disease process
causing pain
Reference:
Nurse’s Pocket Guide, Sixteenth Edition. F.A. Davis
NURSING CARE PLAN

Name: Bacan, R. Diagnosis: Diabetes Mellitus Type 2 Poorly controlled; Hypertension

REY JEAN M. GARCIA BSN 3-C

Age: 37 years old Ward: Medical Ward 1

Chief Complaint: Vomiting, Body Malaise
General Objective: To maintain good hygiene and physical comfort

ASSESSMENT NURSING PATHOPHYSIOLOGY EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
SUBJECTIVE: Impaired skin Predisposing factors: INDEPENDENT: After 24 hours of
Patient verbalized integrity related Diabetes Mellitus Within 24 hours of clinical duty, the
“Gamay lang ni akun to poor glycemic clinical duty, the 1. Assess the Color of the skin and goal was partially
pilas hasta sa medyo control as patient will be able patient’s wound surrounding tissue met.
nagdako na sa, evidence by Lack of blood to: including the color, can indicate the
kabudlay kis-a presence of circulation in the distal odor and visibility of tissue’s vitality and As evidenced by:
maglakat kay ang pilas ulcerated wound areas of body such as • Display timely bone oxygenation
ko gasakit” at right foot feet healing of wound
without 2. Evaluate patient’s To determine the 1.
complication skin care practices contributing factors
OBJECTIVE: Poor skin hygiene and hygiene issues
Assessment: As evidenced by:
-Facial grimace noted 3. Assess blood To provide
when moving/elevating Walking barefoot 1. Patient will supply such as comparative
affected foot participate in capillary return time baseline and
-Capillary Refill is interventions and sensation of skin opportunity for timely
normal at < 3 seconds Sharp or fiction tears surfaces on affected intervention
-Ulcerated wound at the layer of the skin 2. Patient will show area
right foot with irregular understanding and
border, (+) redness, (+) demonstrate 4. Document results Systematic
tenderness and warmth interventions
Impaired skin integrety of routine skin inspection can
including proper inspection, describing identify improvement
skin care that observed changes or changes for timely
promote healing of intervention
wound
5. Determine
patient’s level of
discomfort To clarify
intervention needs
6. Maintain and and priorities
REY JEAN M. GARCIA BSN 3-C

instruct patient in
good skin hygiene To reduce risk of
dermal trauma,
improve circulation
7.Provide adequate and promote comfort
clothing or covers
To prevent
8. Keep bedclothes vasoconstriction
dry and wrinkle free;
use non irritating To maintain skin
linens integrity and avoid
complication to the
9. Encourage patient wound
early ambulation or
mobilization Promotes circulation
and reduces risks
associated with
10.Instruct patient to immobility
avoid or limit use of
plastic material. To minimize contact
Remove wet and with irritants and
wrinkled linens prevent moisture to
promptly. cause skin
breakdowns
11. Apply appropriate
dressing
For wound healing
and to best meet
12. Educate patient needs of client
regarding the
importance of health, To prevent further
skin intact, as well as complications and
measures in developing more
maintaining proper serious wounds
skin functioning
REY JEAN M. GARCIA BSN 3-C

DEPENDENT:

1. Apply topical
antibiotics and To eliminate bacteria
antiseptics as and promote fast
ordered healing of wound

COLABORATIVE:

1. Collaborate with
other healthcare To assist with the
providers plan of care for the
developing wound
2. Apply appropriate
barrier dressings or To protect the wound
wound coverings and and surrounding
skin protective agents tissues from
excoriating
secretions and
enhance healing
3. Collaborate with
the caregiver of the To promote wellness
patient to help and fast healing of
encourage in patient wound
in participating during
interventions
Reference:
Nurse’s Pocket Guide, Sixteenth Edition. F.A. Davis
NURSING CARE PLAN

Name: Bacan, R. Diagnosis: Diabetes Mellitus Type 2 Poorly controlled; Hypertension

Age: 37 years old Ward: Medical Ward 1
Chief Complaint: Vomiting, Body Malaise
REY JEAN M. GARCIA BSN 3-C

General Objective: To promote optimal activity; exercise, rest and sleep

ASSESSMENT NURSING PATHOPHYSIOLOGY EXPECTED NURSING RATIONALE EVALUATION

DIAGNOSIS OUTCOME INTERVENTION
SUBJECTIVE: Impaired Fatigue INDEPENDENT: After 24 hours of
Patient verbalized physical mobility Within 24 hours of clinical duty, the
“Gapalang luya akun related to Muscle weakness clinical duty, the 1. Asses patient’s To determine goal was partially
bilog lawas. Budlay decrease patient will be able developmental level, presence of met.
mag giho kag du muscle control to: motor skills, ease, characteristics of
madulaan ko pwersa strength as Performs simple and capability of client’s impairment As evidenced by:
pag piliton ko mag evidence by actions with much • Display movement, posture, and provide guide
giho” decrease range effort willingness to and gait. choice of
of motion participate in every intervention 1. Demonstrate
intervention and techniques and
OBJECTIVE: Difficulty of moving increase physical 2. Asses nutritional Deficiencies in behaviors that
movement status and patient’s nutrients and water, enables resumption
Assessment: report of energy level electrolytes, and of activities
-Patient is lethargic Impaired physical As evidenced by: minerals can
-Displays difficulty of mobility negatively affect 2. Patient displays
elevating affected foot 1. Patient displays energy and activity understanding of
understanding of tolerance situation, risk
situation, risk factors and
factors and 3. Assist or have To promote optimal therapeutic regimen
therapeutic regimen client reposition self level of function and safety
and safety on regular schedule measures.
measures. as dictated by
individual situation
2. Demonstrate
techniques and 4. Support affected To maintain position
behaviors that body parts or joints of function and
enables resumption using pillows, rolls, reduce risk of
of activities foot supports or gel pressure ulcers
pads
3. Patient will be To improve
able to exert force 5. Change patient’s circulation and
with no difficulty position frequently, reduced tightening of
REY JEAN M. GARCIA BSN 3-C

moving individual muscles and joints

parts of the body
such as arms and
legs
Reduces tissue
6. Provide pressure pressure and
reducing mattress, prevent dermal injury
such as pressure
relieving mattress,
such as air pressure
or water
Promotes well-being
7. Encourage patient and maximizes
to take adequate energy production
intake of fluids and
nutritious foods
To reduce fatigue
8. Schedule activities
with adequate rest
periods during the
day
To reduce fatigue
9. Provide client and exercises
ample time to muscle
preform mobility
related tasks
Enhances self-
10. Encourage concept and sense
participation in self- of independence
care; occupational,
diversional, or
recreational activities

11. Discuss to the To promote wellness

patient the
importance and
REY JEAN M. GARCIA BSN 3-C

purpose of regular
exercise

DEPENDENT:

1. Administered To permit maximal

medications prior to effort and
activity as needed for involvement in
pain relief activity

COLABORATIVE:

1. Collaborate with To create exercise

rehabilitation team and adaptive
such as physical program that is
therapist suitable and design
specifically for the
patient.

2. Collaborate with To develop individual

physical medicine exercise and mobility
specialist and program
occupational or
physical therapist in
providing rage-of-
motion exercises
Reference:
Nurse’s Pocket Guide, Sixteenth Edition. F.A. Davis

LABORATORY RESULTS

Name: Bacan, R. Chief Complaint: Vomiting, Body Malaise

Age: 37 years old Diagnosis: Diabetes Mellitus Type 2 Poorly controlled; Hypertension
REY JEAN M. GARCIA BSN 3-C

Patient B, R. had undergone laboratory test in clinical chemistry. In his recent Random Blood Sugar, the results showed that patient B had a 166 mg/dl
which is above the normal level of RBS that is only 70-130 mg/dl. This may indicate diabetes. The appropriate nursing consideration for this is to monitor vital signs
of patient, monitor patient’s blood sugar, encourage the patient to increase self-reliance and self-sufficiency, encourage to eat healthy food that is low fat and
calories, non-starchy vegetables such as green beans. Patient, B. also had a 2.41 mg/dl creatinine which is above the normal level of creatinine for male which is
only 0.7-1,3 mg/dl. This may indicate kidney problem such as kidney damage or failure. The appropriate nursing consideration for this are assess the patient
frequently for signs of skin breakdown, instruct the patient to reduce protein and salt intake, instruct to limit alcohol intake and encourage the patient to eat more
foods that is rich in fiber such as vegetables and whole grains.

Aside from high creatinine level, patient B. R. had also a low potassium levels which is only 2.8 mEq/L and the normal level is 3.5-5.3 mEq/L. This may
indicate hypokalemia. The nursing consideration for this are monitor for respiratory rate and depth, encourage deep breathing and coughing exercises, encourage
patient to frequent change position, monitor heart rate and rhythm, encourage to take high potassium diets such as orange, bananas, tomatoes, coffee, and red
meat and monitor the rate of IV potassium administration using a micro drop set. The calcium levels also of patient B. R. are low which is only 7.8 g/dl and the
normal level is 8.6-10.3 g/dl. This may indicate hypocalcemia. Nursing considerations are monitor blood calcium levels, check the albumin levels of patient, assess
patient’s calcium intake, monitor heart rate and rhythm, encourage the patient to eat foods high in calcium such as dark leafy greens, cheese, eggs, orange, and
sardine, instruct to avoid consuming phosphorus rich foods such as chocolates and nuts.

CBC were also done to patient B. R. It shows that he has RBC of 2.74 x 10¹²/L, Hemoglobin of 8.10 g/dl and Hematocrit of 0.24 which is all below their
normal levels. Low RBC, Hemoglobin and Hematocrit are all may indicate anemia. The nursing considerations would be monitor patient’s vital sign, instruct the
patient to consume foods that is rich in protein and iron such as liver, green leafy vegetables and egg yolk and encourage patient to exercise regularly. Aside from
that the WBC level of patient B is 12.12 x10⁹/L which is above normal level. This may indicate infection. The appropriate nursing consideration for this are instruct
the patient to add foods rich with vitamin C in her diet and encourage the patient to have an adequate rest.

DRUG STUDY

Name: Bacan, R.
Age: 37 years old
REY JEAN M. GARCIA BSN 3-C

Diagnosis: Diabetes Mellitus Type 2 Poorly controlled; Hypertension

Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
Action

Generic: Therapeutic Humulin 70/30 Diabetes Hypoglycemia, hypokalemia, Ensure uniform Instruct patients to
Insulin class: lowers blood Mellitus allergic reactions, peripheral dispersion of insulin always carefully
Regular glucose by edema, lipodystrophy, weight suspensions by rolling check that they are
Human Antidiabetics stimulating gain, immunogenicity, sudden the vial gently between administering the
peripheral glucose sweating, shaking, hunger, hands; avoid vigorous correct insulin
Brand: uptake by skeletal blurred vision, dizziness, tingling shaking.
Humulin muscle and fat, hands or feet Instruct the patient to
70/30 and by inhibiting Give maintenance avoid rubbing the site
hepatic glucose doses subcutaneously, of injection after
Dosage: production. rotating injection sites administering
20 units regularly to decrease
10 units incidence of Instruct the patient to
lipodystrophy maintain the injection
Route of site clean
Administration: Monitor urine or serum
SC glucose levels
frequently to determine
effectiveness of drug
Frequency: and dosage.
AC
Monitor insulin needs
Timing: during times of trauma
or severe stress;
dosage adjustments
may be needed.

Name of Drug Classification Mechanism of Indication Adverse Effects Nursing Consideration Patient Teaching
REY JEAN M. GARCIA BSN 3-C

Action

Generic:
Potassium Therapeutic Replaces To prevent CNS: paresthesia of limbs, Monitor continuous Teach patient signs
chloride class: potassium and hypokalemia listlessness, con fusion, ECG and electrolyte and symptoms of
maintains weakness or heaviness of limbs, levels during therapy. hyperkalemia, and tell
Dosage: Potassium potassium level flaccid paralysis. patient to notify
2 tablet supplements Patients at increased prescriber if they
CV: post infusion phlebitis, risk for GI lesions when occur.
Route of arrhythmias, heart block, cardiac taking oral potassium
Administration: arrest, include those with Warn patient not to
PO scleroderma, diabetes, use salt substitutes
ECG changes, hypotension. mitral valve re concurrently, except
Frequency: placement, with prescriber's
Q4H GI: nausea, vomiting, abdominal cardiomegaly, or permission.
pain, diarrhea, flatulence. esophageal strictures,
Timing: and older adults or Tell patient not to be
8am-12pm- Metabolic: hyperkalemia. patients who are concerned if wax
4pm-8pm- immobile. matrix appears in
12am-4am Respiratory: respiratory paralysis. stool because the
drug has already
Skin: injection-site reactions, been absorbed.
extravasation, febrile response.

DISCHARGE PLAN
REY JEAN M. GARCIA BSN 3-C

Problem Health Teaching Rationale

HYGIENE Reoccurrence of PROMOTIVE

Foot ulcer/wound
1. Teach patient the proper way of 1. Encourage washing feet daily with mild 1. Irritating soap could cause further
foot care soap. complications
2. Instruct to always maintain the feet clean 2. To avoid
2. Instruct to always maintain good
and dry.
skin hygiene.
3. It helps manage stress and improve
3. Encourage patient to have an adequate
body’s overall performance
3. Encourage to take daily bath to rest
avoid harboring microorganism.

PREVENTIVE
ACTIVITY 1. To monitor the condition of the feet.
1. Instruct patient to check feet every day
1. Instruct to do wash feet daily and for red spots, cuts, swelling or blisters
maintain it clean and dry 2. To avoid staying and entry of
2. Instruct patient to avoid walking with
microorganism in the feet that could
2. Encourage patient to do some barefoot. Always wear socks or slippers.
possible cause another wound
breathing exercises such as
focused breathing when pain is 3. Check that the lining of shoes or slippers
3. Dirt and small pebbles could cause
present are smooth and free from dirt and small
irritation and may cut the feet.
pebbles
3. Teach patient the importance of
having an adequate rest.

DIET CURATIVE
1. Instruct to include protein-rich 1. Apply prescribe moistening lotion the top 1. To keep the feet moisturized.
REY JEAN M. GARCIA BSN 3-C
food in the diet such as lean
meats, seafood and eggs
2. Instruct to add non-starchy
vegetables such as carrots,
tomatoes and cabbage
3. Drink more fluids such as water,
avoid drinking carbonated drinks,
alcoholic drinks and coffee.
REHABILITATIVE
INSTRUCTION
1. Instruct patient to replace soiled
dressing to the healing wound
2. Instruct patient to contact
physician, health care provider
and go to the nearest clinic or
hospital if sudden redness,
swelling, or bleeding of
cuts/wound is present
3.
Instruct patient to take prescribe
medicine for diabetes mellitus
and bottom of feet. Never apply between Applying between toes could
toes. harbor microorganism and cause
complications
2. Take regularly or as ordered the 2. For fast wound healing
prescribe medication
1. Instruct to come back for follow-up 1. To check on the condition of the
check-up 5-6 weeks after discharge. patient after discharge
2. Educate patient on the importance of 2. To speed up body recovery and
maintaining feet clean and dry, the reach the normal potassium level
importance of wearing protective shoes
or slippers and the possible to having
another foot ulcer if this will not be done.
3. Instruct the patient to visit the nearest 3. To get an assistance in proper
barangay health center/clinic for cleaning and changing of dressing
assistance in cleaning or changing
wound dressing.
4. If a blister or cut with redness, swelling or
bleeding is noted upon checking, instruct
the patient to visit the nearest
clinic/hospital.