Professional Documents
Culture Documents
Subjective: Impaired skin integrity as After 1 week the Goal was met. The patient
Independent
Reports of itch, pain, and evidenced by presence of wound patient is to achieve achieved timely wound
Reinforce initial dressing/change as Protects wound from mechanical injury
numbness on 2nd left foot and on the patitents dorsal proximal timely wound healing and contamination. Prevents healing
on the 1st-3rd digits 3rd of her 4th finger secondary to indicated. Use strict aseptic techniques.
accumulation of fluids that may cause
thromboangitis obliterans excoriation.
Objective: INTERFERENCE:
Gently remove tape (in direction of hair
growth) and dressings when changing. Reduces risk of skin trauma and
Disruption of skin A vascular abnormality slow and disruption of wound.
surface/layers and tissues delays the normal supply and
demand of circulation making
Erytmathous to blackish lesion wounds difficult to heal. Tissues Inspect wound regularly, noting
on 2nd left foot and skin surfaces are not well characteristics and integrity. Note patients
nourished. at risk for delayed healing, e.g., presence Early recognition of delayed
of chronic obstructive pulmonary disease healing/developing complications may
Non healing wound on dorsal prevent a more serious situation.
portion of 3rd finger (COPD), anemia, obesity/malnutrition,
DM, hematoma formation, vomiting, Wounds may heal more slowly in
ETOH (alcohol) withdrawal; use of steroid patients with comorbidity, or the elderly
therapy; advanced age. in whom reduced cardiac output
decreases capillary blood flow.
Collaborative
Removes infectious exudate/necrotic
Irrigate wound; assist with debridement as tissue to promote healing.
needed.
Cues Nursing Diagnosis Planning Nursing Intervention Rationale evaluation
Subjective Independent:
(Peripheral) Ineffective tissue After 4 hrs Patient will have After 4 hrs of nursing
Have a close monitoring of vital To obtain the accurete conditoin of intervention the patient
Reports of numbness on upper perfusion related to occlusive promotion in tissue perfusion to signs patient as if it neededs intervention
and lower extremities vascular disorder secondary to vital organs, as evidenced by and assistance. Changesin Vitals Perfusion was promoted as
thromboiangitis obliternas strong peripheral pulses and signs are dterminant of aggreviation evidenced by strong peripheral
Objective: reduction of signs and or alleviation of the condition pulses and reduction of signs
slow healing of wound symptoms and symptoms
Edema on upper and lower Do passive range-of-motion (ROM) Exercise prevents venous stasis.
extremities exercises to unaffected extremity
INTERFERENCE: every 2 to 4 hours
Skin temperature is slightly cold
Due to occlusive vascular
Skin discoloration disorder involving small and Administer oxygen as needed. This saturates circulating
medium sized arteries, hemoglobin and increases the
effectiveness of blood that is
Dyspnea circulation is altered causing reaching the ischemic tissues.
bipedal edema, and digital
Weak Peripheral pulses ischemia. Discoloration and
presence of gangrene in the pt’s Position properly This promotes optimal lung
digits was seen. More ventilation and perfusion. The
patient will experience optimal lung
importantly, The Hemoglobin expansion in upright position.
concentration in blood was
decreased
(see lab results) Anticipate and institute This reduces the risk of thrombus.
anticoagulation as prescribed
Therapeutic:
Administer medications as
indicated (e.g, diuretics)
Cues Nursing Diagnosis Goal/ Plan Nursing Intervention Rationale Evaluation
Subjective Data:
Activity intolerance (level 4) After 24 hrs of nursing After 24 hrs of nursing intervention
the patient reduced the effects of
Patient’s report of weakness related to generalized weakness intervention the patient will be Assess patient's level of This aids in defining what
inactiviyt, promoted physical activity
secondary to thromboangitis able to reduce effects of mobility. patient is capable of, which is and learned to how to achieve
Objective data: obliternas inactivity, promote optimal necessary before setting realistic satisfactory lifestyle
physical activity, and achieve goals.
Sedentary lifestyle INTERFERENCE: satisfactory lifestyle
Dyspnea How Valsalva maneuver affetcs
Assess patient's cardiopulmonary
Because of altered circulation, heart rate when patient moves in
status before activity bed, which requires breath
Disturbed rest period/sleep the patient is experiencing
holding and bearing down, can
muscle weakness that hinders cause bradycardia and related
Generalized weakness her to her usual activities. Her reduced cardiac output.
confidence was also diminished.