Jose R.

Reyes Memorial Medical Center

FEMALE - MEDICAL WARD
Michaela Katrina A. Trinidad
BSN III -2
Patient Name: F.G
Diagnosis: Sepsis secondary to Cellulitis DM Type II

November 24, 2014

NURSING CARE PLAN

ASSESSMENT
Subjective:
Patient
verbalized,
Namamaga ung
naputok kong
sugat sa likod ng
paa, mas lalo
siyang lumaki at
kumalat sa harap
kahit naka-admit
na ako
Kumikirot siya
paminsanminsan.
Objective:
c Redness on site
of injury
c Purulent pus on
site of injury
c Facial grimace
c Pain scale of 4

NURSING
DIAGNOSIS
Infection related to
impaired skin
integrity secondary
to ineffective
peripheral tissue
perfusion.

SCIENTIFIC
INFERENCE

PLANNING

INTERVENTION

EVALUATION

Patient will show

1. Maintain or teach asepsis Goal partially met, patient
Diabetics are susceptible
diminished signs of
F.G. showed and
for dressing changes, wound
to cellulitis than the
infection such as decreased
verbalized diminished
care and peripheral IV
general population
level of pain, absence of
Teaching aseptic technique will level of pain of 2 out of 10
because of impairment of
purulent secretion on site
help the patients level of
pain scale and showed
the immune system; they of injury and understanding understanding
of
infection understanding of proper
are especially prone to
of proper wound care
control.
Compliance
will
wound care procedure.
cellulitis in the feet,
procedure after 4 hours of
decrease patients susceptibility
because the disease causes
nursing intervention.
to pathogens that will help (Site of injury not assessed
impairment of blood
reduce the progression of due to aseptic measures)
circulation in the legs,
infection.
leading to diabetic
2. Provide comfort measures
foot/foot ulcers. Poor
such as maintaining proper
control of blood glucose
ventilation, e.g. fanning the
levels allows bacteria to
patient
and
opening
grow more rapidly in the
windows.
affected tissue, and
It will decrease discomfort and
facilitates rapid
reduce sympathetic stimulation
progression if the
thus decreasing the bodys flight
infection enters the
or fight response.
bloodstream.
3. Administer medications for
infection
control
as

out of 10
c History of DM
type 2

(see reference at
backpage)

Reference:
Initial Diagnosis:
Sepsis secondary
to cellulitis DM
Type 2

"Skin and soft tissue

infections.". Pediatric
clinics of North America
60 (5): 106382

prescribed by doctor such as

Piptazo 4.5 TIV every 8
hours until dosage has been
completed
This type of antibiotic has the
mechanism that inhibits bacteria
cell wall synthesis, interfering
with protein synthesis and nucleic
acid metabolism that will kill
pathogens that cause skin injury
infection.
4. Administer medications for
pain as needed and as
prescribed by doctor such
as Celecoxib 200mg/cap
twice a day.
This type of drug is an analgesic
and antipyretic, thus, taking these
will lessen the patients level of
pain and prevent fever from
developing.
5. Render health teaching to
reduce infection such as
> Keep regular general hygiene
most especially on the site of
injury.
To
prevent
harmful
microorganisms from invading
site of skin injury and prolonging
infection.
> Always have the surgical
dressing dry and intact, always
wear protective foot covering.

To maintain skin barrier and

wound healing.
> Avoid skin injury at lower
extremities.
Because having DM type 2
enables
ineffective
tissue
perfusion, blood has a trouble
circulating well on the injury,
thus peripheral areas are harder
for wound healing than the upper
extremities.
6. Keep patient safe.
Patient should always be
monitored for possibility of falls
and
unwanted
emergency
tendencies.