PATIENTS NAME: Mrs. P. T.

Chinese General Hospital College of Nursing NURSING CARE PLAN AGE: 52 y/o

DIAGNOSIS: Charcots foot

ASSESSMENT Subjective: Client verbalized nagkaron na ko ng bukol dati at ngayon nagkaron ulit ako sa same foot ko Objective: (+) lump on left toe WBC: 3.2

NURSING DIAGNOSIS Risk for infection related to decreased leukocyte function on delayed healing

INFERENCE Endothelial progenitor cells (EPCs), which derive from bone marrow, normally travel to sites of injury and are essential for the formation of blood vessels and wound healing. A low WBC count is often linked to problems with the bone marrow and the inability to make enough white blood cells. Increased oxygen levels enhanced the mobilization of EPCs and WBCs from the bone marrow to the peripheral blood circulation. The high oxygen levels increased the activation of the bone marrow enzyme eNOS, which stimulated nitric oxide production, helping to produce greater numbers of EPCs. A low WBC count can be serious because it increases your risk of developing a potentially lifethreatening infection or delayed wound healing. REFERENCES Encyclopedia of Surgery: A guide for Patients and Caregivers.

GOAL SHORT TERM EXPECTED OUTCOME: After 30 minutes of nursing intervention, the patient will verbalize understanding of and willingness to follow up prescribed regimen LONG TERM EXPECTED OUTCOME: After 3 days of being provided with appropriate nursing care, the client will demonstrate no signs and symptoms related to infection

INTERVENTION Independent: Monitor vital signs every 4hours Assess the location, characteristic, frequency quality, intensity and aggravating factors, s/s of sepsis: fever, chills, diaphoresis Teach patient of comfort measures Monitor clients visitors of any illnesses especially on the respiratory Stress proper hand hygiene by all caregivers between therapies and clients Dependent: Administer antibiotics as ordered by the physician Collaborative: Emphasize necessity of taking anti-viral or antibiotics Using leftover drugs unless specifically instructed by healthcare provider

RATIONALE Changes in vital signs often indicate acute pain and discomfort To rule out worsening of underlying condition/development of complications

EVALUATION SHORT TERM After 30 minutes hours of nursing intervention, goal was fully met. The clients mother verbalized understanding of and willingness to follow up prescribed regimen

To promote nonpharmacological pain management To limit exposures, thus reducing of cross contamination A first line defense against healthcare associated infections

LONG TERM After 3 days of being provided with appropriate nursing care, goal was fully met. The client demonstrated no sign and symptoms related to infection

To prevent bactericidal infections

Premature discontinuations of treatment when client begins to fell well may result in return of infection and potentiation of drug resistant strains