homework

Prioritized Nursing Diagnoses

Goal

Nursing Interventions

Risk for infection

To ensure the patient is free of infection

1. Assess the patient’s wound, noting the odor, tissue color, and the discharge. A foot ulcer with a bad odor is more likely to be infected. Infected tissue is usually gray-yellow. Also, a yellow or green discharge could be a sign of infection (Morrison, 2019).

2. Perform hand hygiene before touching the patient.

3. Ensure any items used are properly sterilized or disinfected before use.

Impaired skin integrity

To maintain skin integrity

1. Monitor skin integrity, noting skin’s color, texture, temperature, and integrity (Fraser, 2020).

2. Perform wound care according to guidelines and orders.

3. Keep the skin dry and clean.

Risk for unstable blood glucose level

To ensure the patient maintains a blood sugar level less than 140mg/dL

1. Assess the patient for signs of hyperglycemia. Hyperglycemia occurs when the body cannot use insulin properly or the body has insufficient insulin (Mayo Clinic, 2020).

2. Assess eating patterns. Failure to adhere to dietary guidelines can lead to fluctuations in blood glucose.

3. Assess drugs taken regularly. Some drugs can cause fluctuations in blood glucose.