NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Objec ve Cues Impaired Skin Within 8 hours of nursing 1. Assess site of impaired 1. Redness, swelling, pain, A er 4 hours of nursing
● SOB Integrity related to interven ons, the pa ent skin integrity and its burning, and itching are interven ons, the pa ent
● Dry gangrene (2nd decreased blood to will be able to describe condi on. indica ons of inflamma on was able to describe
toe, lateral aspects area of gangrene due measures to protect and and the body’s immune measures to protect and
of big toe, 5th toe) to obstruc on of heal the ssue, including system response to localized heal the ssue, including
● absent pulse in blood vessels wound care. ssue trauma or impaired wound care.
dorsalis pedis and ssue integrity.
posterior bial 2. Assess changes in body 2. Fever is a systemic GOAL MET.
● Right foot temperature, manifesta on of
erythematous specifically increased inflamma on and may
● Diminished body temperature. indicate the presence of
sensa ons infec on.
● Blood glucose level 3. Note signs of itching 3. The pa ent who scratches
of 201 mg/dl and scratching. the skin in an a empt to
● BP - 180/105 mg/dl alleviate extreme itching
may open skin lesions and
increase the risk for
infec on.
4. Teach skin and wound 4. Early assessment and
assessment and ways to interven on help prevent
monitor for signs and the development of serious
symptoms of infec on, problems.
complica ons, and
healing.
5. Instruct pa ent, 5. Accurate informa on
significant others, and increases the pa ent’s ability
family in the proper to manage therapy
care of the wound
REFERENCE:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurses pocket guide: Diagnoses, priori zed interven ons, and ra onales. Philadelphia: F.A. Davis Company.
 including handwashing,
wound cleansing, and
dressing changes.
6. Administer an bio cs
as ordered.
7. Encourage a diet that
meets nutri onal
needs.
8. Encourage early
ambula on or
mobiliza on.
9. Provide informa on
about the importance
of health, intact skin, as
well as a measure to
maintain proper skin
func oning.
10. Tell the pa ent to avoid
rubbing and scratching.
REFERENCE:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurses pocket guide: Diagnoses, priori zed interven ons, and ra onales. Philadelphia: F.A. Davis Company.
independently and reduces
the risk for infec on.
6. Wound infec ons may be
managed well and more
efficiently with topical
agents, although intravenous
an bio cs may be indicated.
7. A high-protein, the
high-calorie diet may be
needed to promote healing.
8. Ambula on s mulates
circula on which can help
stop the development of
stroke-causing blood clots.
Walking improves blood flow
which aids in quicker wound
healing. (Oakbend Medical
Center, 2018)
9. Intact skin is the body's
first line of defense against
the invasion of
microorganisms, provides a
protec ve barrier from
numerous environmental
threats, and facilitates
reten on of moisture.
(Caring, 2002)
10. Rubbing and scratching
can cause further injury and
delay healing