Theory-based (Betty Neuman)

NURSING CARE PLAN

Name of Student:________Madaeah Zoei R. Dagondon___________

Client’s Initials:__________________C. C. O____________________ Stressor Classification: (Please check)
Age:_67 yo_Gender: _Male_Civil Status:_Married_Religion:_Roman Catholic_ ______ Physiological (body structure and functions)
Allergies: __________no known food and drug allergies___________ ______ Psychological (mental processes and emotion)
Diet:________________Low Salt, Low Fat Diet__________________ ______ Socio-cultural (relationships, social expectations)
Date of Admission:____________September 9, 2023_____________ ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression:_Non-healing Wound Right Foot secondary to DM Type 2; HPN Stage 2_ ______ Developmental (developmental processes over the lifespan)
NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME
Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
(Goal attainable within the shift) (with Rationale & Source)
Subjective: Short-term goal: PRIMARY INTERVENTIONS (focuses on
“Lata na kaayo akong tiil mam Ineffective Peripheral Tissue After 8 hours of nursing strengthening the flexible line of defense through preventing
ay kay grabe na siya ka baho” Perfusion related to decreased intervention, the patient will be stress and reducing risk factors)
as verbalized by the patient. peripheral blood flow as able to: Promotive:
evidenced by necrotic right foot ● understand the factors Assess the wound
that improve R: To note the extent of the affected tissue
Objective: circulation, including damage and circulation
● Pain score of 5 over 10 lifestyle modifications S: (Murr et al., 2012)
● Pallor of hands
● Dry, scaly skin
● Cyanotic left and right ● verbalize the Ascertain impact of condition on functioning and
feet Theoretical basis: importance of daily lifestyle
● Open wound on right Ineffective peripheral tissue wound dressing R: To know how the condition seriously impact
hallux of feet perfusion is defined by the ● verbalize quality of life
● Foul odor of right foot NANDA as the decrease in understanding of S:(Murr et al., 2012)
blood circulation to the condition, therapy
periphery that may compromise regimen, side effects of Note patient’s nutritional and fluid status
health. This poor blood medications, and when R: Dehydration reduces blood volume and
circulation to the peripheries to contact healthcare compromises peripheral circulation
results in an insufficient supply provider S:(Murr et al., 2012)
of blood volume to the distal
areas of the body. Therefore, Long-term goal: Preventive:
this can lead to hypoxia and After 16 hours of nursing Identify presence of high-risk factors or conditions
even cell death or necrosis. intervention, the patient will be R: To know the factors that places the patient at
Some of the clinical able to: greater risk
manifestations of necrosis are ● demonstrate behaviors S: (Murr et al., 2012)
pain, foul odor, open wound, and lifestyle changes
and cyanosis of the to improve circulation
surrounding tissues. (Wayne, ● demonstrate SECONDARY INTERVENTIONS (focuses on
2023) interventions, including strengthening the internal lines of resistance and protecting
proper skin care that the basic structure through appropriate treatment of
symptoms)
promotes the healing
Curative:
of diabetic foot ulcers
Administer medications such as antiplatelet
agents, thrombolytics, antibiotics
R: To improve tissue perfusion or organ function
S: (Murr et al., 2012)

Encourage patient to turn side-to-side q2h

R: To avoid thrombosis formation and ulcer
development
S: (Murr et al., 2012)

Recommend or provide foot and ankle exercises

when client unable to ambulate freely
R: To reduce venous pooling and increase venous
return
S: (Murr et al., 2012)

TERTIARY INTERVENTIONS (focuses on

maintaining wellness or protecting the client system
reconstitution through supporting existing strengths and
continuing to preserve energy)
Rehabilitative:
Discuss relevant risk factors (e.g., family history,
obesity, age, smoking, hypertension, diabetes,
clotting disorders)
R: To encourage patient to make informed
choices about remediating risk factors and
committing to lifestyle changes
S: (Murr et al., 2012)
 Emphasize need for regular exercise program
R: To enhance circulation and promote general
well-being
S: (Murr et al., 2012)

Educate SO to report signs and symptoms of pain

or discharges from the wound
R: To provide opportunity for timely evaluation and
intervention
S: (Murr et al., 2012)

References:
1. __Murr, A. C., Doenges, M. E., & Moorhouse, M. F. (2012). Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. F. A. Davis
Company._________
2. __Wayne, G. (2023). Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan. Nurseslabs. Retrieved from
https://nurseslabs.com/ineffective-tissue-perfusion/____
3. ___Wagner, M. (2023). Diabetic Foot Ulcer Nursing Diagnosis & Care Plan. NurseTogether. Retrieved September 27, 2023, from
https://www.nursetogether.com/diabetic-foot-ulcer-nursing-diagnosis-care-plan/____

Nursing Care Plan Product Assessment Rubric

 CRITERIA Competent Advance Beginner Novice
All subjective and/or objective cues identified are The subjective and/or objective cues identified include some The subjective and/or objective cues identified include
Assessment aligned, relevant and sufficient in the formulation of data that are misaligned, irrelevant but sufficient enough in several data that are misaligned, irrelevant making it
(3) the nursing diagnosis formulating the nursing diagnosis insufficient in the formulation of the nursing diagnosis
(3) (2) (1)
The nursing diagnosis is appropriate based on the cues The nursing diagnosis is appropriate based on the cues The nursing diagnosis is inappropriate based on the cues
and the priority complaints of the patient or of the presented but may not necessarily be the priority nursing presented and does not reflect the patient’s response to
Diagnosis (3) case scenario problem based on the patient’s health situation or of the the illness.
(3) case scenario (1)
(2)
All the concepts, models and theories (at least 3) are The concepts, models and theories include some The concepts, models and theories are irrelevant and do
Theoretical relevant and substantially supports the nursing information that are irrelevant to the patient’s case, not substantially support the nursing diagnosis in relation
Basis (2) diagnosis in relation to the patient’s case however, the data (less than 3) still adequately supports the to the patient’s case
(2) nursing diagnosis in relation to the patient’s case (1.5) (1)
Goal/s set is/are specific, measurable, attainable, Goal/s set missed 1-2 elements but the statements are Goal/s set missed 3 or more elements and the statements
Goals/Goal realistic and time-bounded. Includes both short-term aligned to the identified nursing problem. Goal setting are not aligned to the identified nursing problem.
Setting and long-term goals and are aligned to the identified considers both short term and long-term care. (2)
(4) nursing problem. (3)
(4)
All interventions are related and responsive to the Interventions include some data that are unrelated and Interventions include several data that are unrelated and
Interventions identified needs and sufficient to help attain the goal. unresponsive to the identified needs, however, the identified unresponsive to the identified needs which results in the
(5) (5) interventions are sufficient to help attain the goal. non-attainment of the set goal/s.
(4) (3)
The subjective/objective data are aligned, relevant and The subjective/objective data include information that are The subjective/objective data include information that are
Evaluation adequate to assess the attainment of the outcome misaligned, irrelevant but adequate enough to assess the misaligned, irrelevant and are inadequate to assess the
(2) criteria. attainment of the outcome criteria. attainment of the outcome criteria.
(2) (1.5) (1)
At least 3 updated (within 8 – 10 years), accurate and Less than 3 updated (within 8 – 10 years), accurate and References provided are not updated, inaccurate,
References
credible references are provided using APA Format credible references are provided using APA Format (0.5) unreliable or no references provided
(1)
(1) (0)
Total Score

________________________________________
Name and Signature of the Faculty