Patient Evaluation

Assessment Nursing Diagnosis Outcomes Interventions Rationale of Outcomes

Objective Data: #1: Impaired tissue Patient will: 1. Monitor color, 1. Systematic 1. Surrounding skin
-Gangrene infected integrity r/t wound, 1. Report any altered temp, edema, inspection can remained intact and
left foot presence of infection. sensation or pain at moisture, and identify possible w/o inflammation.
-Open wound site of tissue appearance of problem areas early
-Wet to dry dressing impairment during surrounding skin; in infection.
-Pain upon January 23 and 24. note any
movement, characteristics of any
grimacing, shaking drainage.
-She immediately 2. Demonstrate 2. Monitor site of 2. Pain secondary to 2. Wound did not
requests Morphine understanding of plan impaired tissue dressing change can have signs of added
-She needs assistance to heal tissue and integrity at least once be managed by infection.
when ambulating- prevent injury by daily for signs of interventions aimed
even to sit up in bed 1/24. infection. Determine at reducing trauma
Subjective Data: whether patient is and other sources of
-Patient said the pain experiencing changes wound pain.
is worse when in sensation or pain.
ambulating & turning Pay attention to all
-She said she dreads high risk areas such
physical therapy as bony prominences,
-She said she wishes skin folds, and heels.
she did not have to be 3. Describe measures 3. Monitor status of 3. Individualize the 3. Educated patient
in this situation to protect and heal skin around the plan according to on technique of
Medical Diagnoses: the tissue, including wound. Monitor patient’s skin cleansing and putting
-Diabetes foot ulcer wound care by 1/24. patient’s skin care condition needs and on dressing. Had her
-Diabetes Mellitus practices, noting type preferences. Avoid watch while I did it
Type 2 of soap or other harsh cleaning so she could
-PVD cleansing agents agents, hot water, understand. She
-Infection used, temp of water, extreme friction or stated she would try
and frequency of force, and too to do it herself when
cleansing. frequent cleansing. she is discharged.
 Nursing Patient Evaluation of
Assessment Diagnosis Outcomes Interventions Rationale Outcomes
4. Experience a 4. Select a topical treatment that 4. Choose dressings that 4. Used wet to dry
wound that maintains a moist wound –healing provide moist environment, dressing, which was
decreases in size environment but also allows keep skin around wound changed twice a day.
and has increased absorption of exudate and filling dry and control exudate
granulation tissue. of dead space. and eliminate dead space.

5. Achieve 5. Assess patient’s nutritional 5. A good diet with 5. She was on a clear
functional pain goal status; refer to nutritional nutritional foods and fluid diet but still has
of zero by 1/24 per consultation. vitamins may help promote little appetite. Continued
patient’s wound healing. consultation with
verbalizations. nutritionist before
discharge would be
beneficial.