ASSESSMENT DIAGNOSIS OUTCOMES INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Wound Short term goal: Independent: Independent: Short term goal:
 “Even I want infection After 40 minutes of 1. Inspect for any 1. May indicate local infection After 40 minutes of
to exercise, I related to intervention the patient odor or or tissue necrosis. intervention the patient
couldn’t, my pain as will be able to: drainage from will be able to:
legs hurt so evidenced by 1. Rate the pain the wound. 2. Minimizes bacteria 1. Rate the pain
badly when I the limited 5/10 with the use 2. Instruct the contamination. 5/10 with the
walk almost range of of a numeric pain patient to avoid use of a numeric
any distance.” motion. scale. touching the pain scale.
As verbalized 2. Demonstrate the site of the 2. Demonstrate the
by the proper steps in wound. proper steps in
patient. cleaning wound. 3. Clean the 3. To remove any bacteria that cleaning wound.
 Patient rate 3. Move and walk wound. can be caused of swelling. 3. Move and walk
the pain 8/10 better. 4. Teach the 4. To inform the patient how better.
with the used patient how to to properly take care of her
of a numeric Long term goal: clean the wound. Long term goal:
pain scale. After 2 to 3 weeks of wound After 2 to 3 weeks of
intervention, the patient properly. intervention, the patient
Objective Data: will be able to: 5. Monitor vital 5. Temperature elevation and will be able to:
 Presence of 1. Have totally signs. tachycardia may reflect 1. Have totally
+3 edema healed wound. developing sepsis. healed wound.
 Disturbed 2. Move without 2. Move without
facial any pain. Dependent: Dependent: any pain.
expressions 1. Administer 1. To lessen the pain that the
when moving. medication for patient feels.
 Temperature pain as ordered
– 36.7 by the doctor.
degrees in 2. Refer to have a 2. Detects abnormalities such
celsius. CT scan. as bone necrosis.
 Blood 3. Refer to a 3. To properly practice moving
pressure – physician to again without forcing the
110/60 have physical muscles.
therapy.
 ASSESSMENT DIAGNOSIS OUTCOMES INTERVENTIONS RATIONALE EVALUATION
Subjective Data: Impaired skin Short term goal: Independent: Independent: Short term goal:
“I also feel dizzy, every integrity After 40 minutes of 1. Monitor 1. Peripheral pulses 2+or less After 40 minutes of
time I moved.” as related to intervention the patient peripheral pulses, than 0-4+ scale signal poor intervention the
verbalized by the decreased will be able to: and compare circulation that could patient will be able to:
patient blood 1. Have normal them bilaterally. compromise skin integrity. 4. Have normal
circulation as capillary time 2. Inspect the 2. When the skin is not intact capillary time
Objective Data: evidenced by refill which is presence of anymore, the patient is at risk refill which is
 5 seconds delayed less than 2 erythema, and for infection which can lead less than 2
capillary refill capillary refill seconds. discoloration for to amputation. seconds.
time time 2. Have normal adequate 5. Have normal
 Pulse rate – 56 pulse rate and visualization.
pulse rate and
beats per normal blood 3. Perform a 3. This promotes better blood
normal blood
minute pressure. massage if there circulation.
pressure.
 Blood 3. Dizziness when is no
moving will be contraindication. 6. Dizziness
pressure –
lessened. 4. Increase fluid 4. This will help in aiding when moving
110/60
intake. insufficient blood circulation. will be
Long term goal: lessened.
After 2 days of Dependent: Dependent:
intervention the patient 1. Refer to the 1. As the patient has diabetes, Long term goal:
will be able to: physician. and she is at risk for infection, After 2 days of
1. Maintain the amputation may occur so intervention the
normal range of deeper observation is patient will be able to:
blood pressure needed. 3. Maintain the
and pulse rate. normal range
2. Dizziness when of blood
moving will be pressure and
totally pulse rate.
eliminated. 4. Dizziness
when moving
will be totally
eliminated.