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Objective Data: Blood glucose 230, Lower extremity diabetic wound, Oxygen 100%
Nursing Diagnosis: Skin impairment related to uncontrolled glucose as evidence by blood glucose
reading of 230.
The patient will identify 3 interventions to prevent or reduce risk of infection within 8 hours.
Patient will not develop a new pressure ulcer within the next 36 hours.
Patients blood glucose will lower to normal limits of 70-100 mg/dl within 48 hours
Patients red area and exudate on her lower leg will be absent within 10 days.
I. Irrigate wound with saline solution twice per day per wound-care provider's order @ 0800 and
2000 daily.
Cleanse wound and surrounding area of wound debris and exudate. Fund pg1200
J. Apply dressing (i.e., gauze moistened with solution twice a day after irrigation) according to
wound-care provider's order @ 1000 daily.
Provides appropriate topical therapy to wound, placing wound in best environment for
healing. Fund pg1200
K. Evaluate patient's pain level and offer pain medication at 0800, 1200, 1600, 2000 daily.
Provides patient with pain reduction/relief, allowing for greater mobility and comfort.
Fund pg1200.
N. Intervention #1
O. Rationale Book and page #
P. Intervention #2
Q. Rationale Brook and page #
R. Intervention #3
S. Rationale Book and page #
T. Evaluation Long Term Goal #2
U. Intervention #1
V. Rationale Book and page #
W. Intervention #2
X. Rationale Brook and page #
Y. Intervention #3
Z. Rationale Book and page #
AA. Evaluation Long Term Goal #3