Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Actual Throughout 1. Maintain aseptic 1. To avoid Goal met:

hospitalization technique for
1.Infection introducing infections Throughout
4th Post pt. the patient will dressing.
related to the into a wound.  his hospital
with AKA identify
disease process 2. Monitor vital
interventions stay, the
secondary to as evidenced by signs. 2. To indicate whether
to reduce risk
pt. having slight the pt is worsening or patient was
infected of infection. 3. Administer
fever, and wound improving over time. able to
right BKA. medications as per
drainage,
drug chart. 3. To reduce fever, identify
swelling around
swelling, and control
the wound. intervention
BP.
Objective:
to reduced
Flushed
2. Unstable blood risk of
appearance. 1. Asses blood
glucose level as Throughout 1. To obtain accurate
infection.
Wound evidence by as his hospital glucose levels reading.
drainage, inadequate stay pt. will
before meals and at
glucose achieve and 2. To reduce the
Febrile and bedtime.
maintain Goal met:
skin warm to monitoring. development,
glucose Throughout
touch. 2. Encourage pt. the complications and
reading in his hospital
V/S taken as Potential satisfactory importance of blood progression. stay pt.
follows: range of less glucose control.
1. Risk for achieved
than 180mg/dl. 3. To maintain overall
T- 100.1F situational low and
3. Educate pt on blood glucose control
self esteem r/t maintained
P- 88 bpm
loss of body part/ maintaining and prevent glucose
R- 18 bpm
change functional consistency in food reading
hypoglycaemic
B/P- 170/70 abilities as satisfactoril
and intervals reaction.
evidenced by y range of
SPO2 -98%
negative feeling between meals. less than
1. To learn to admit
Glucose- about the body Pt. will new self/image faster. 180 mg/dl.
190 mg/dl amputation, recognize and
feeling and integrate 1.Assist amputee 2. Expressing his

helplessness. changes into cope with his altered feelings will allow Goal

self-concept in partially
body image. him to proceed with
a mannerly
the reality of life met: Pt. was
way without 2.Encourage pt. to
negative self- without a limb. able to
express his negative
esteem. recognize
feelings over loss 3. Sufficient support
and
body part. by family, friends or
integrate
relative can facilitate
3. Assess degree of into self
rehabilitation process.
support available to concept,
pt. however, he

did not have

sufficient

support for

rehabilitatio

n process.