Nursing care plan for type 2 diabetes
NM 222 Clinical Nursing I Name
Herzing University BSN Program Care Plan Assignment
Assessment | Nursing Diagnoses | Outcome / Goals | Plan | Rationale | Implementation | Evaluation |
Pt. stated she has Numbness or tingling of hands and feet. Pt. stated she has Blurred vision,Headaches, andNightmares.Objective:Pt. skin wasWarm and Dry, Sugar High.240 mg/dLV.S. T-99.8,R-20,P-97, BP- 110/68 O2- 92 |
NM 222 Clinical Nursing I Name: Bindu Komara
Herzing University BSN Program Care Plan Assignment
Assessment | Nursing Diagnoses | Outcome / Goals | Plan | Rationale | Implementation | Evaluation |
Subjective Data:Pt. stated that she has pain in her legs 8/10Pt. stated having stiffness in bilateral legsObjective Data:Tenderness and redness to bilateral legs joints.Joint area is warm to touchVS:BP-144/70,R-20,P-57, T-97.6,02-96% RA | Acute pain related to inflammation as evidence by pain of 8/10 tenderness, swelling and warmth.Impaired physical mobility related presence of joint pain.Potential for impaired skin integrity related to inflammation to bilateral legs as evidence by redness, tenderness, and warm. | Reduce inflammation result to reduction in pain to 2/10 or at a tolerable levelPt. will be able to have full ROM to bilateral lower extremities (BLE) without complaint of pain.Patient will have reduce inflammation to BLE to reduce risk of skin integrity | The nurse will Monitor signs and symptoms inflammation and pain throughout the shift.The nurse will perform Full ROM to BLE to prevent contraction.The nurse will Monitor signs and symptoms inflammation. | To assess level of inflammation and need for quick intervention. Prevent pain.Prevent immobility and contraction.Prevent impairment to skin integrity and reduce pain | 1. Administer acetaminophen 500mg every 4 to 6 hours for pain control.2. Apply cool compress as tolerable to reduce inflammation.3. Elevate BLE to reduce inflammation.4. ROM (10 to 15 repetition) to BLE every 4 hours to prevent contraction/immobilization.5. Assess circulation, sensation and motion to BLE to ensure adequate perfusion.6. Reposition BLE to prevent skin impairment. | Goal Not met: Pt. will have pain level of 8/10 to lower extremities with inflammation; tenderness to (BLLE).Pt. will be unable to do ROM (BLLE) at the end of the shift.Goal met: pt. pain 2/10 and verbalize adequate relieve of Inflammations reduced.Pt. has full ROM to BLE at the end of the shift. |