Carthage College
Department of Nursing
Health Pattern: ____Health maintenance, activity, cognition___________ Concept: mobility, tissue integrity, communication, pain
Subjective & Objective
Assessment/Medical
Diagnoses
Patient recently had pain
and ulcer with right great toe
which an x-ray showed
osteomyelitis. The patient
underwent a partial right
great toe amputation. The
patient has had one other toe
amputated on the left foot
prior. Patient also has
diabetes.
Subjective:
Patient verbalizes he had an
ulcer on his right great toe
and fell because of it where
he then injured his hip.
Patient verbalizes pain in
right great toe as 4/10
Patient verbalizes.
Objective:
Patient’s right great toe is
wrapped in gauze and
coband after the amputation.
The patient’s vital signs are:
-Temperature: 99.2F
-Heart Rate: 80
-Blood pressure: 148/77
-Respirations: 18
Nursing Care Plan Template
Nursing Diagnoses Nursing Interventions (3- Scientific Rationale Expected Outcomes
(Prioritized) 4 per nursing diagnosis) (include references)
1. Impaired tissue  1a. Inspect and monitor 1a. Pain secondary to 1. The surgical
integrity related to the site of impaired tissue dressing changes can be wound will
surgical amputation integrity at least once managed by decrease in size
of food as daily for color changes, interventions aimed at without infection
evidenced by right redness, swelling, reducing trauma and by the end of the
great toe incision warmth, pain, or other other sources of wound hospital stay
signs of infection or per pain (Wounds 2. The patient will
2. Acute pain related facility/agency policy. International, 2009) report any
to partial Determine whether the 1b. Individualize the altered sensation
amputation as client is experiencing plan according to the or pain at site of
evidenced by changes in sensation or client's skin condition, tissue
patient verbalizes pain (Ackley & Ladwig, needs, and preferences. impairment
pain in amputation 2017, p. 882). Avoid harsh cleansing throughout the
site as 4/10 agents, hot water, hospital stay
1b.  Monitor the status of extreme friction or force, 3. The patient will
3. Impaired physical the skin around the or too-frequent cleansing demonstrate
mobility related to wound. Monitor the (Baranoski & Ayello, understanding of
loss of right great client's skin care 2012) plan to heal
toe and injured right practices, noting type of 1c. A clearly stated tissue and
hip as evidenced by soap or other cleansing treatment plan ensures prevent reinjury
patient verbalizes agents used, temperature consistency in care and by discharge
slight trouble of water, and frequency documentation
4. The patient will
balancing and pain of skin cleansing (Ackley (Baranoski & Ayello,
describe
when walking or & Ladwig, 2017, p. 882). 2012).
measures to
standing 1d. Documentation of
protect and heal
1c. Implement and these essential elements
the tissue,
4. Impaired verbal communicate a is paramount to
including wound
communication comprehensive treatment establishing a framework
care by the end
related to autism as plan for the topical for quality care (Ackley
of the hospital
-O2: 97
The patient’s labs are
normal with a slight
decrease in red blood cells,
sodium, and hematocrit.
White blood cells are
normal.
evidenced by treatment of the skin & Ladwig, 2017, p. 882). stay
patient is impairment site: keep
1. By discharge, the
hyperverbal and has site dry and covered 2a. Obtaining an
patient will,
difficulty (Ackley & Ladwig, 2017, individualized pain
Describe
maintaining p. 882). history helps identify
nonpharmacologi
appropriate potential factors that
cal methods that
conversation 1d. Develop a may influence the client's
can be used to
comprehensive plan of willingness to report
help achieve
care that includes a pain, as well as factors
comfort-function
thorough wound that may influence pain
goal
assessment, treatment intensity, the client's
2. The patient will
interventions, support response to pain,
describe how
surfaces, nutritional anxiety, and
unrelieved pain
products, adjunctive pharmacokinetics of
will be managed
therapies, and evaluation analgesics (Pasero
by the end of the
of the outcome of care 2009a; Pasero &
hospital stay
(Ackley & Ladwig, 2017, Portenoy, 2011).
3. Throughout the
p. 882). 2b. Although more
hospital stay, the
evidence is needed to
patient will
2a. Ask the client to conclude effectiveness,
Notify member
describe prior nonpharmacological
of the health care
experiences with pain, methods (which are low
team promptly
effectiveness of pain cost and low risk) can be
for pain intensity
management used to complement
level that is
interventions, responses pharmacological
consistently
to analgesic medications treatment of pain
greater than the
including occurrence of (Gelinas & Arbour,
comfort-function
side effects, and concerns 2009; Ignatavicius,
goal, or
about pain and its 2013).
occurrence of
treatment (e.g., fear
side effects
about addiction, worries, 2c. Cognitive-behavioral
1. By discharge, the
or anxiety) and (mind-body) strategies
patient will
informational needs can restore the client's
Verbalize feeling
(Ackley & Ladwig, 2017, sense of self-control,
of increased
p. 640). personal efficacy, and
strength and
active participation in
ability to move
2b. Support the client's his or her own care 2. By discharge, the
use of (Bruckenthal, 2010). patient will meet
nonpharmacological mutually defined
methods to supplement 3a. Prescribing a goals of
pharmacological regimen of regular increased
analgesic approaches to physical activity that ambulation and
help control pain, such as includes both aerobic exercise that
distraction, imagery, exercise and muscle include
music therapy, simple strengthening activities individual
massage, relaxation, and is beneficial to choice,
application of heat and minimizing impaired preference, and
cold (Ackley & Ladwig, mobility; use exercise enjoyment in the
2017, p. 640). diary or log to improve exercise
adherence to mobility prescription
2c. Assist client to enhancement 3. By the end of the
identify resources for recommendations. hospital stay,
coping with Develop mobility they patient will
psychological impact of enhancement programs Verbalize less
pain (Ackley & Ladwig, that are specific to fear of falling
2017, p. 640). gender and ethnicity and and pain with
are culturally physical activity
3a. Consult with physical appropriate (Yeom et al, 1. The patient will
therapist for further 2009). use some
evaluation, strength different
training, gait training, 3b. To prevent hospital- effective
and development of a acquired disability, communication
mobility plan (Ackley & organizational values techniques by
Ladwig, 2017, p. 589). should consider both the end of the
safety (e.g., fall hospital stay.
3b. Help the client prevention) and injury 2. By the end of
achieve mobility and protection in concert the hospital stay,
start walking as soon as with a philosophy that the patient will
possible if not enables older adults to Use alternative
contraindicated (Ackley be self-directed and methods of
& Ladwig, 2017, p. 589). independent (Boltz et al, communication
2013).  effectively
 3. By the end of
3c.  Screen for additional 3c. The nursing the shift, the
measures of physical assessment should patient will
function to assess include factors related to express desire
strength of muscle mobility problems (e.g., for social
groups, including ability to walk and interactions
unassisted leg stand, use move), with nursing
of a balance platform, goals and interventions
elbow flexion and knee developed to promote
extension strength, grip maximum mobility
strength, timed chair (Kneafsey, 2007).
stands, and the 6-minute
walk (Ackley & Ladwig, 4a. Ignoring clients was
2017, p. 589). found to be a negative
communication strategy
4a. Avoid ignoring the (O'Hagan et al, 2014).
client with verbal
impairment; be engaged 4b. Client-centered care
and provide meaningful involves respect,
responses to client communication, and
concerns (Ackley & comfort (Bechtold &
Ladwig, 2017, p. 231). Fredericks, 2014).

4b. Use presence: spend 4c. Effective

time with the client, communication entails
allow time for responses, involving clients, being
and make the call light sensitive to client needs,
readily available (Ackley and ensuring client
& Ladwig, 2017, p. 231). understanding (O'Hagan
et al, 2014).
4c. Use therapeutic
communication
techniques: speak in a
well-modulated voice,
use simple
communication, maintain
 eye contact at the client's
level, get the client's
attention before
speaking, and show
concern for the client. 
(Ackley & Ladwig,
2017, p. 231).
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