Cues Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired skin After 3 days of  Use foot cradle on  To prevent pressure After 3 days of
Pt reported that his integrity r/t impaired nursing interventions, the bed. Use space on pressure- nursing interventions,
wound does not heal circulation AEB pt display timely boots on ulcerated sensitive points. pt displayed timely
fast lesions that heal healing of skin heels, elbow  Systemic healing of skin lesions
slowly lesions without protectors, and inspection can without complication.
Objective: complication. pressure-relief identify developing
 skin lesion (2cm) mattresses. problems and
 Perform routine promotes early
skin inspections, intervention.
assessing color,  to provide a
temperature, positive nitrogen
surface changes, balance to aid in
texture and skin and tissue
contours. healing and to
 Provide optimum maintain general
nutrition, including good health.
vitamins and  to protect the
protein. wound and/or
 Implement and surrounding tissues.
teach skin hygiene  Prompt wound
by showering daily treatment helps
with lukewarm prevent infection. If
water and using the wound appears
mild soap. infected, encourage
 Use and apply the patient to
appropriate barrier notify the primary
dressings, wound health care provider
coverings etc. immediately.
 Reinforce that all  Adherence to the
cuts and blisters therapeutic regimen
need to be cleaned promotes tissue
and treated with perfusion. Keeping
antiseptic glucose in the
preparation. normal range slows
 Administer basal the progression of
 and prandial microvascular
insulin. disease.
 Discuss the need  Smoking can cause
of smoking cessati vasoconstriction
on if applicable. that can impair
 Instruct patient to blood supply to the
avoid heating pads feet.
and always wear  Patients have
shoes when decreased sensation
walking. in the extremities
due to peripheral
neuropathy.