I.

Nursing Care Plan

Cues and
Clues
Objective

Presence
of
secretion
s in the
mouth
With
presence
of wet
cough
and
viscous
secretion
s
Unable to
cough
properly
BP 180/90
Capillary
refill less
than 2
Rapid
breathing
Restlessn
ess

Nursing
diagnosi
s
Ineffectiv
e airway
clearanc
e

Scientific
Rationale

Objective

Nursing
Interventions

Rationale

Evaluation

Medical
manageme
nt of the
clients with
coronary
artery
disease is
directed at
early
diagnosis
and
identificatio
n of the
client who
can benefit
from
thrombolyti
c
treatment.
Preserving
cerebral
oxygenatio
n,
preventing
complicatio
ns and
stroke

After 1-3
hours of
nursing
intervention,
the client will
maintain
patent airway

Position the patient

in high fowlers or
semi- fowlers
position if not
contraindicated

To promote good
lung expansion

Objective

As evidence
by:

After
nursing
interventio
ns, the
clients
airway
patency
will be
assessed
The
section
will be
readily
expectorat
ed

Monitor vital signs

Auscultate breath
sounds. Note
adventitious breath
sounds, eg.
Wheezes, crackles,
rhonchi.
Assess or monitor
respiratory rate.
Suction secretions
if present

Provide baseline for

patient care

Patients who are

immobile and
unconscious have
ineffective cough
reflexes thus
suctioning is
required to remove
secretions. Suction
time should be
minimized and
hyperoxygenation
performed to reduce
the potential for

Presence
of
secretions
in the
mouth
With
presence
of wet
cough and
viscous
secretions
Unable to
cough
properly
BP 180/90
Capillary
refill less
than 2
Rapid
breathing
Restlessne
ss

recurrence,
and
rehabilitati
ng the
client are
other
goals.
Emergency
care of the
client with
stroke
includes
maintainin
g a patient
airway.

The client
will be
positioned
comfortabl
y with
maximum
lung
expansion
Learn and
perform
coughing
exercise
properly

After 1-2 days

of nursing
interventions
patient must
be able to:

Expectorat
e
secretions
Able to
cough

hypoxia
Perform and teach
proper coughing
technique

Place patient in a
comfortable
position.
Advised patient to
take 2-3 deep
breaths through the
nose and exhale.
Hold the last break
for at least 3
second when you
inhale
Open the mouth
slightly, place the
hand on the
abdomen and while
gently pressing the
diaphragm. The
first cough should
have moved the
mucus to the
throat.

To promote airway
clearance and
reduce straining that
can increase ICP
Semi- fowler is
recommended

Take a break and

repeat as needed

Cues and
Clues
Objective

Body
weakness
Loss of
conscious
ness
Unable to
communi
-cate
Headache
with
seizures,
clonic
with
upward
rolling of
eyeballs
BP
180/90
shallow
and in
quantity
Capillary
refill less
than 2
Pale and
cool to
touch

Nursing
diagnosis
Ineffective
tissue
perfusion
A. Cerebral
B. Peripher
al
C. Respirat
ory

Scientific
Rationale
Atherroscler
osis affects
the intima of
the large
and
mediumseized
arteries.
These
changes
consist of
the
accumulatio
n of lipids
calcium,
blood
components,
carbohydrat
es, and
fibrous
tissue on the
intimal layer
of the artery.
These
accumulatio
ns are
referred to
as plaques.
The most

Objective
After 2-4
hours of
nursing
intervention
s patient
must be able
to:

Breath
effectivel
y
Determin
e the
factors
that
causes
ineffectiv
e
cerebral
tissue
perfusion
Promote
lung
expansio
n
Blood
pressure
will
decrease

Nursing
Interventions
A. Cerebral
tissue
perfusion
Monitor/documen
t neurological
status frequently
and compare
with baseline
- GCS
- Cranial
nerves
- Reflex
response
- Motor and
sensory
response

Rationale

Keep client flat

on back for
several hours,
per protocol.
Monitor vital
signs Note skin
color and
capillary refill

Fluctuations in
pressure may occur
because of cerebral
pressure/injury in
vasomotor area of
the
brain. Hypertension
may have been a
precipitating factor.
Hypotension may
occur because of
shock (circulatory

Evaluation
Objective

Assesses trends in
level of
consciousness (LOC)
and potential for
increased ICP and is
useful in
determining
location, extent, and
progression/resoluti
on of CNS damage.

Body
weakness
Loss of
conscious
ness
Unable to
communicate
Headache
with
seizures,
clonic with
upward
rolling of
eyeballs

BP 180/90

Capillary
refill less
than 2

shallow
and in
quantity

Pale and
cool to
touch
extremitie
s

extremiti
es

Fever

Restlessn
ess

Rapid
breathing

Nerve
compress
ion

common
direct result
is the
narrowing of
the lumen of
the arteries
and
obstruction
by
thrombosis
Gradual
narrowing of
the arterial
lumen
stimulates
the
developmen
t of
collateral
circulation.
Collateral
floe allows
continued
perfusion to
the tissues,
but it is
often
inadequate
to meet
increased
metabolic

from
180/90120/80
After 6-10
hours of
nursing
intervention
s, patient
must be able
to

Present
no signs
of
paleness
and cool
sensation
of the
extremiti
es
Must be
able to
communi
cate
effectivel
y,
decrease
slurring
of speech
weakness
must

Monitor I &O

Assess
extremitiesparticularly lower
extremities- for
redness, swelling,
and pain
Evaluate pupils,
noting size,
shape, equality,
and light
reactivity.

collapse). Increased
ICP may occur
because of tissue
edema or clot
formation.
bradycardia, can
occur because of the
brain damage.
Fluid balance
indicates circulatory
status and
replacement needs.
Excessive or
prolonged blood loss
requires evaluation
and ongoing
assessments to
continually
determine and
provide prompt and
appropriate
intervention
Redness, swelling,
and pain in the
extremities suggest
complications
associated with
immobility including
DVT

Fever

Restlessne
ss

Rapid
breathing

Nerve
compressi
on

demand.

lessened

Document
changes in vision
such as
-Reports of
blurred vision,
-alterations in
visual
-Field/depth
perception.

Administer IV
fluids

Pupil reactions are

regulated by the
oculomotor (III)
cranial nerve and
are useful in
determining
whether the
brainstem is intact.
Specific visual
alterations reflect
area of brain
involved, indicate
safety concerns, and
influence choice of
interventions.

Monitor CBC
(Hgb, hct)

B. Peripheral
tissue
perfusion

Fluid replacement
depends on the
degree of
hypovolemia and
duration of bleeding
or leakage of CSF

Inspect legs from

groin to foot for
skin color and
temperature

These laboratory
tests help establish
fluid status and the

changes as well
as edema

need for fluid and

blood replacement

Assess capillary
refill

Symptoms help
distinguish between
thrombophlebitis
and DVT. Redness,
heat, tenderness,
and localized edema
are characteristics
of superficial
involvement

Elevate legs
when in bed, as
needed

Perform ROM
exercises

C. Respiratory
Elevate the head

Mechanical

Diminished capillary
refill usually present
in DVT
Reduces tissue
swelling and rapidly
empties superficial
and tibial veins,
preventing over
distention and
thereby increasing
venous return
To maintain joint
mobility, regain

ventilator may be
used if
respiratory
distress is
present
Monitor
laboratory
studies as
indicated, such
as,
-prothrombin
time
(PT)/activated
partial
-thromboplastin
time (aPTT) time
CBC
ECG
CT scan
Blood chem.
Urinalysis

motor control;
prevent
contractures in the
paralyzed extremity.
And also to prevent
venous stasis

To promote better
lung expansion
To prevent
respiratory
distress/failure

Provides information
about drug
effectiveness/therap
eutic level.

Cues and
Clues
Objective:
Dx: acute
coronary
syndrome
, cardiac
arrhythmi
a, ASHD,
CAD,
inferior
wall ST
segment
elevation
MI not in
failure
class IV-D,
dyslipide
mia,
decrease
effective
circulatin
g volume
Change in
the rate,
rhythm,
and
electrical
conductio
n
Reduced

Nursing
diagnosis
Decrease
d cardiac
output
related
to
decrease
myocardi
al
contractil
ity

Scientific
Rationale
Decrease
cardiac
output
occurs
when there
is a
decrease in
the
contractilit
y of
myocardial
muscles
caused by
an
alteration
in the
blood
supply to
the
coronary
arteries

Objective
After less
than an hour
of nursing
intervention,
the patient
will:
Maintain
hemodyna
mic
stability as
evidenced
by BP and
cardiac
output
within
normal
range,
adequate
urinary
output,
decreased
frequency
and
absence of
ischemia.
Report
decreased
episodes
of

Nursing
Interventions
Auscultate BP.
Compare both arms
and obtain lying,
sitting, and
standing position
when able.

Evaluate quality
and equality of
pulses, as indicated
Auscultate heart
sounds.

Monitor heart rate

and rhythm.

Note response to
activity and
promote rest
appropriately.

Rationale

Evaluation

Hypotension may
occur related to
hypoperfusion of the
myocardium.
Hypertension may
also occur possibly
related to pain,
anxiety, or
catecholamine
release. Orthostatic
hypotension may be
associated with
complications of
infarct.

After less than

an hour of
nursing
intervention,
the patient
was able to:
Maintain
hemodyna
mic
stability as
evidenced
by BP and
cardiac
output
within
normal
range,
adequate
urinary
output,
decreased
frequency
and
absence of
ischemia.
Report
decreased
episodes of
dyspnea,

Decreased cardiac
output results in
diminished
weak/thready
pulses.
S4 sounds may be
associated with
myocardial
ischemia.
Heart rate and
rhythm respond to
medication, activity,

preload
Increased
SVR
Infarcted
cardiac
muscle

dyspnea,
angina
After a week
of nursing
intervention,
the patient
will:
Demonstr
ate an
increase in
activity
tolerance

and developing
complications.
Provide small/
easily digested
meals as indicated
Administer
supplemental
oxygen, as
indicated

Maintain IV/ HepLock access as

indicated

Review serial ECGs

and laboratory data
such as cardiac
enzymes, ABGs,
and electrolyte

Overexertion
increases oxygen
consumption/
demand and can
compromise
myocardial function.
Large meals may
increase myocardial
workload.

Increases amount of
oxygen available for
myocardial uptake,
reducing ischemia
and resultant
cellular irritation.
Patent line is
important for
administration of
emergency drugs in
presence of
persistent lethal
dysrhythmias or
chest pain

angina
After a week of
nursing
intervention,
the patient
was able to:
Demonstrate
an increase in
activity
tolerance

Administer
antidysrhythmic
drugs as indicated

Provides information
regarding
progression/
resolution of
infarction, status of
ventricular function,
electrolyte balance,
and effects of drug
therapies
To enhance
ventricular output,
increase survival
and slow
progression of MI

Cues and
Clues
Subjective:
Reports of
chest pain
which
lasted for
30
minutes
without
any
radiation
to other
body
parts
Graded
3/10
Objective:
Changes
in level of
conscious
ness
which
lasted for
an hour
Changes
in pulse
and BP

Nursing
Diagnosi
s
Acute
pain
related
to tissue
ischemia

Scientific
Rationale

Objectives

Nursing
Interventions

Rationale

Evaluation

The
decrease in
blood
supply to
the heart
decreases
the amount
of oxygen
and
nutrients
coming to
the cardiac
tissues.
Cells begin
to respire
anaerobical
ly and
lactic acid
is produced
which
causes
pain.

After less
than an hour
of nursing
intervention,
the patient
will:
Verbalize
relief of
chest pain
Display
reduced
tension,
relaxed
manner
and ease
of
movement
Regain
normalizat
ion of vital
signs
Demonstr
ate use of
relaxation
techniques

Obtain full
description of pain
from client
including location,
intensity, duration,
characteristics, and
radiation.

Pain is a subjective
experience and
must be described
by the client to
provide baseline for
comparison to aid in
the effectiveness of
therapy

After less than

an hour of
nursing
intervention,
the patient
was able to:
Verbalize
absence of
chest pain
Display
reduced
tension,
relaxed
manner
and ease of
movement
Heart rate
and rhythm
is sufficient
to sustain
adequate
cardiac
output/
tissue
perfusion
Demonstra
te use of

After a week

Monitor
characteristic of
pain, noting verbal
reports, non-verbal
cues

Instruct the client

to report pain
immediately.

Provide quiet
environment, calm
activities, and
comfort measures

To determine the
progress of the pain
and to provide
proper and
appropriate
interventions
Severe pain may
induce shock by
stimulating the SNS,
thereby creating
further damage and
interfering with the
diagnosis and relief
of pain
Decreases external
stimuli, which may

(180/90)

Facial
grimacing
Restlessn
ess
Moaning
Crying
Diaphores
is
Clutching
of chest
Rapid
breathing

of nursing
intervention,
the patient
will:
Present no
signs of
pain
Adhere to
the
therapeuti
c regimen
provided

Assist in relaxation
techniques such as
deep/slow
breathing
Check vital signs
before and after
administration of
narcotic
medications

Administer
supplemental
oxygen by means
of nasal cannula or
face mask, as
indicated

Administer
medication as
indicated:
Aspirin

aggravate anxiety
and cardiac strain,
limit coping abilities
and adjustment to
current situation
Provides a sense of
having some control
over the situation
Hypotension/
respiratory
depression can
occur as a result of
narcotic
administration.
Increases amount of
oxygen available for
myocardial uptake
and thereby may
relieve discomfort
associated with
tissue ischemia

Aspirin is the
mainline medication
to be given first to
all acute MI clients.

relaxation
techniques
After a week
of nursing
intervention,
the patient
was able to:
Present no
signs of
pain
Adhere to the
therapeutic
regimen
provided

Antianginals
(nitroglycerin
, ISDN, ISMN)

Betablockers

Analgesics

ASA posseses antiinflammatory,

analgesic, and
antiplatelet qualities
that assist in the
stabilization of
plaque while
decreasing clotting
potential.
Nitrates are useful
for pain control by
coronary
vasodilating effects,
which increases
coronary blood flow
and myocardial
perfusion. Peripheral
vasodilation effects
reduce the volume
of blood returning to
the heart, thereby
decreasing
myocardial workload
and demand
Second-line agents
for pain control
through effect of
blocking
sympathetic
stimulation
To relieve the pain

Cues and
Clues
1 Episode of
vomiting (5
cups)
Fatigue,
Generalized
Weakness
Hypotension
Pulse
weak/thread
Tachycardia
Diarrhea
UrineDecreased,
Concentrated
Color,
Oliguria
Report thirst,
anorexia,
nausea
vomiting
Weight loss
Mucous
Membranes
are dry

Nursing
Diagnosi
s
Risk for
Fluid &
Electroly
te
Imbalanc
e related
to
vomiting

Scientific
Rationale

Extracellular
fluid deficit
leads to
reduction in
both the
intracellular
and
extracellular
fluid
volumes
which
results to
dehydration.
Sodium
and
Potassium
as well, are
the most
common
electrolytes
affected by
vomiting.
Hypernatre
mia is the
water loss
relative to

Objectives

Nursing
Interventions

Rationale

Evaluation

After less
than an hour
of nursing
intervention,
the patient
will:
- have no
epiasodes of
vomiting and
nausea
-Remain safe
from injury
associated
with
electrolyte
imbalance

Monitor VS and
CVP. Observe for
presence of fever.

Presence of
tachycardia and
hypotension is a
cause of fluid
deficit. CVP
monitoring are
useful in det.
Degree of fluid
deficit and response
to replacement
therapy. Fever
increases
metabolism and
exacerbates fluid
loss.

After less than

an hour of
nursing
intervention,
the patient :
-Had no
occurrence of
vomiting and
nausea
-Remained
safe from
injury
associated
with
electrolyte
imbalance

After a week
of nursing
intervention,
the patient
will:
-Present no
signs and
symptoms of
Fluid &
Electrolyte
Imbalance

Monitor laboratory
studies

Administer IV
solutions as
indicated
Palpate peripheral
pulses; Capillary
refill, skin color/
temperature. Asses
mental status.
Measure fluid
losses from all
sources (gastric

Electrolyte/
metabolic
imablances may be
present.
Fluid replacement
therapy
Extracellular fluid
deficit can result in
inadequate organ
perfusion to all

After a week
of nursing
intervention,
the patient :
-Was able to
present no
signs and
symptoms of
Fluid &
Electrolyte

Skin dry with

poor turgor,
pale , moist,
clammy
Restlessness
Apathy
Confusion
Hypernatrem
ia
Hypokalemia

Na content
due to
inadequate
amount of
water in the
body.
Hypokalemi
a is an
indirect
result of the
kidney
compensatin
g for the
loss of acid.

-Adhere to
the
therapeutic
regimen
provided

losses, wound
drainage,
diaphoresis,
urinary output)
Weigh daily and
compare with 24hr fluid balance.
Mark edematous
areas.

Assess patients
ability to swallow

Ascertain patients
beverage
preferences.
Encourage foods
with high fluid
content
Provide skin and
mouth care. Bathe
every other day
with mild soap.
Apply lotion as
indicated.

areas

Fluid replacement
needs are based on
correction of current
deficits and ongoing
losses

Detect if there are

any fluid losses.
Third-space fluid
accumulation
cannot be used for
tissue perfusion.
Impaired gag
reflexes, anorexia,
changes in LOC are
factors that affect
patients ability to
replace fluids orally/
Relieves thirst and
discomfort of dry
mucous
membranes.
Augments
parenteral
replacement

Imbalance
-Was able to
adhere to the
therapeutic
regimen
provided

Monitor for reports

of sudden chest
pain, dyspnea,
cyanosis, increased
anxiety,
restlessness
Monitor for sudden
elevation of BP,
restlessness, moist
cough, dyspnea,
crackles, frothy
sputum

Cues and
Clues
Food intake
less than
recommende
d dietary
allowance
Lack of
interest in

Nursing
Diagnosis
Imbalance
d
nutrition:
less than
body
requireme
nts related
to

Scientific
Rationale
Neuropathy
of the
autonomic
nervous
system due
to elevated
blood
glucose

Objectives
After 4 hours
of health
teachings,
the patient:
Explains in
own words
rationale for

Nursing
Interventions
Assess nutritional
status:
a. Weight changes
b. Laboratory
values (serum
electrolyte,
BUN, creatinine,
protein,

Skin and mucous

membranes are dry,
w/ decreased
elasticity, because
of vasoconstriction
and reduced
intracellular water.
Hemo concentration
and increased
platelet aggregation
may result in
systemic emboli
formation
May be a result of
too rapid correction
of fluid deficit
compromising the
cardiopulmonary
system.
Rationale
Baseline data allow
for monitoring of
changes and
evaluating
effectiveness of
interventions.

Evaluation
After 8 hours,
the patient
consumed
100% of every
plate of the
recommended
diabetic meal.
The patient

food
Misconceptio
ns about
diabetic diet
Body weight
20% under
ideal
Diarrhea
Pale mucous
membranes
Vomiting of 5
cups
Unable to
take meals
after
vomiting
episodes

imbalance
of insulin,
food,
and
physical
activity,
vomiting,
dietary
restriction
s

levels
results to
dysfunction
s affecting
the
GI system,
further
resulting to
delayed
gastric
emptying,
which may
occur with
early
satiety,
bloating,
nausea,
and
vomiting.
In addition,
there may
be
unexplaine
d wide
swings in
blood
glucose
levels
related to
inconsisten
t

dietary
restrictions
and
relationship
to
urea and
creatinine
levels
After the 8
hour shift, the
patient:
Chooses
foods within
dietary
restrictions
that are
appealing
Consumes
high-calorie
foods within
dietary
restrictions
Takes
medications
on schedule
After 24

transferrin, blood
glucose,
and iron levels)
Assess patients
nutritional dietary
patterns:
a. Diet history
b. Food
preferences
c. Calorie counts
Provide patients
food preferences
within dietary
restrictions
Alter schedule of
medications so
that they
are not given
immediately
before meals
Provide written
lists of foods
allowed and
suggestions for
improving their
taste without use
of sodium or

Past and present

dietary patterns are
considered in
planning meals

Increased dietary
intake is
encouraged.

Ingestion of
medications just
before
meals may produce
anorexia and feeling
of fullness.

Lists provide a
positive approach to
dietary
restrictions and a
reference for
patient
and family to use

also took the

necessary
medications
and self
administered
insulin in the
last 24 hours.

absorption
of the
glucose
from
ingested
foods
secondary
to the
inconsisten
t gastric
emptying,
further
resulting to
intake of
nutrients
insufficient
to meet
metabolic
needs.

hours, the
patient:
Consults
written lists
of acceptable
foods

potassium.

when at home

Provide pleasant
surroundings at
meal-times

Unpleasant factors
that contribute to
patients anorexia
are eliminated

After 7 days,
the patient:
Reports
increased
appetite at
meals

Weigh patient
daily.

Allows monitoring of
fluid and nutritional
status

Demonstrates
normal skin
turgor
without
edema;
healing and
acceptable
plasma
albumin and
glucose levels
After 30 days,
the patient:
Exhibits no
rapid
increases or
decreases in

Ensure that insulin

orders are altered
as needed for
delays in eating.
Take insulin or oral
antidiabetic agents
as usual.

If vomiting,
diarrhea, or fever
persists, take
liquids like 12 cup
orange juice, 12
cup broth, 1 cup
Gatorade every 12
to 1 hour.

Diagnostic and
other procedures
may interfere.

Normal values of
blood glucose
should be
maintained as much
as possible.
This prevents
dehydration and
helps to provide
calories.

Extreme fluid loss

weight

Encourage
high-calorie,
low-protein,
low-sodium,
and lowpotassium
snacks
between
meals

Report nausea,
vomiting, and
diarrhea to the
physician.

Avoid delays in
meal timing.
Do not skip meals.
Increase food
intake before
exercise if blood
glucose level is
<100 mg/dL.
Carry a form of
fast-acting sugar
at all times.

may be dangerous
and should be
reported
immediately.
Maintains adequate
glucose and energy
in the body.
Hypoglycemia
should be avoided.

In cases of
hypoglycaemia, fast
acting sugar could
be taken.

Cues and
Clues
Presence of
seizures
described as
clonic with
upward
rolling of
eyeballs
Loss of
consciousnes
s lasting for
an hour
Presence of
bruises and
injury
Fatigue
Weakness
Exhaustion
Headache
Nausea
Pain
Memory loss
Confusion
Depression

Nursing
Diagnosis
Risk for
Injury
related to
uncontroll
ed seizure
activity

Scientific
Rationale
Seizures
are
disturbance
s in normal
brain
function
resulting
from
abnormal
electrical
discharges
in the
brain,
which can
cause loss
of
consciousn
ess,
uncontrolle
d body
movements
, changes
in
behaviors
and
sensation,
and
changes in
the

Objectives
After less
than an hour
of nursing
intervention,
the patient
will:
- No
occurrence of
seizure was
present
-No incidence
of injury
related to his
seizure
activity
After a week
of nursing
interventions,
the patient
will:
-Have no
incidence of
injury related
to his seizure
activity
-Demonstrate
behaviors,
lifestyle

Nursing
Interventions
Explore with the
patient the various
stimuli that may
precipitate seizure
activity. Minimize
stimuli that may
cause seizure
Discuss seizure
warning signs and
usual seizure
pattern
Keep padded side
rails up with bed in
lowest position
Evaluate need for
protective head
gear
Maintain strict bed
rest if prodromal
signs or aura is
experienced.

Rationale
Lack of sleep,
flashing lights,
increase brain
activity,
hypertension may
cause potential
seizure activity

Enables the patient

to protect self from
injury

Minimizes injury

Use of helmet may

provide added
protection
Patient may feel
restless to ambulate
during aual phase,
inadevertently
removing self from
safe environment
and easy

Evaluation

autonomic
system that
may cause
injury to
themselves

changes to
reduce risk
factors and
protect self
from injury.

Turn head to side

or suction airway
as indicated. Insert
plastic bite block
only if jaw are
relaxed
Cradle head, place
on soft area, or
assist to floor if out
of bed

Reorient patient
following seizure
activity

Administer
medications as
indicated

observation.
Maintain airway and
reduces risk of oral
trauma.

Gently guiding
extremities reduces
risk of physical
injury when patient
lacks voluntary
muscle control
Patient may be
confused,
disoriented after
seizure and need
help to regain
control and alleviate
anxiety

Cues and
Clues
decrease in
deep tendon
reflexes
vibratory
sensation
paresthesias
numb
sensation of
feet
decreased
sensations of
pain and
temperature

Nursing
Diagnosi
s
Risk for
impaired
skin
integrity
related
to
decrease
d
effective
circulatin
g blood
volume
in the
peripher
al organs
particula
rly the
feet

Scientific
Rationale

Objectives

Nursing
Interventions

Rationale

Evaluation

Prolonged
durations
of elevated
blood
glucose
levels lead
to
neuropathi
es of the
peripherals
further
leading to
alterations
in the
dermis and
epidermis.

After 8 hours
of the shift,
the patient:

Work with the

health care team
and relatives to
keep the patients
blood glucose level
within a normal
range.

Collaborating with
the different
departments and
family members
helps in attaining
the goal of
maintaining the
blood glucose of the
patient.

After hours,
patient was
able to
verbalize
understanding
of the health
teachings
regarding skin
care.
Patient was
able to do
measures such
as cleaning
the
peripherals
especially the
feet during the
night,
inspecting the
feet, and
covering it
with fitting
and
comfortable
socks.

Participates in
the
prevention
measures of
ulcers and
skin
impairment.
Verbalize
feelings of
increased self
esteem and
ability
manage
situation.
After 7 days,
the patient
will be able to
maintain
good skin
integrity.
After 30 days,

Inspect the bare

feet every day.

Use a mirror to
check the bottoms
of the feet or ask a
family member for
help.
Check for changes
in temperature of
the peripherals.
Protect the feet
from hot and cold
Wash the feet
every day in warm,
not hot, water.

Presence of cuts,
blisters, red spots,
and swelling could
be detected early.
The patient may
have trouble seeing
and inspecting the
feet.

Changes in
temperature may
indicate possible
infections or
necrosis.

patient will
not develop
skin lesions or
ulcers.

Dry the feet well.

Be sure to dry
between the toes.
Do not soak feet.
Rub a thin coat of
skin lotion over the
tops and bottoms
of the feet, but not
between toes.
Use a pumice stone
to smooth corns
and calluses.
Instruct to wear
shoes and socks at
all times and never
walk barefoot.
Instruct to wear
socks at night if the
feet get cold.

Put the feet up

when sitting.
Wiggle the toes and
move the ankles up
and down for

Feet hygiene
minimizes necrosis
and infection.

Keeps the skin soft

and smooth.

This helps to smooth

corns and calluses
gently.

Provides protection
to the feet.

Avoidance of
temperature
changes to the feet
helps maintain good
circulation.
These keep the
blood flowing to the
feet.

5 minutes, 2 or 3
times a day. Do not
cross your legs for
long periods of
time.
Report if a cut,
sore, blister, or
acbruise on the
foot does not begin
to heal after one
day.

The patient may not

feel the pain of an
injury.