NURSING CARE PLAN

Subjective cue: Ga-ngutngot akong samad, as verbalized. Objective cues: (+) skin lesion at left foot Disruptions of skin surface noted Invasions of body structures

NURSING DIAGNOSIS: Impaired Skin Integrity related to pooling of venous blood in the left foot GOALS AND OBJECTIVES: After 5 hours of nursing interventions the patient will be able to: Display time healing of skin lesions without complication Maintain optimal nutrition or physical well-being Verbalize feelings of increased self-esteem and ability to manage situation NURSING INTERVENTIONS: INDEPENDENT 1. Measure wound and observe for complications (e.g., infection) R: To monitor progress of wound healing. 2. Keep the area clean and dry, prevent infection, and stimulate circulation to surrounding areas. R: To assist bodys natural process of repair. 3. Limit or avoid plastic material (e.g., rubber sheet, plastic backed linen savers). Remove wet or wrinkled linens promptly. R: Moisture potentiates skin breakdown 4. Use appropriate padding devices (e.g., air/water mattress, sheepskin) R: To reduce pressure on/enhance circulation to compromised tissues. 5. Encourage early ambulation/mobilization. R: Promotes circulation and reduces risks associated with immobility. 6. Keep skin free from pressure. R: Promotes circulation and prevents ischemia/necrosis. COLLABORATIVE 7. Wash sites with mild soap, rinse and lubricate with cream. R: To maintain flexibility. 8. Consult with wound specialist as indicated R: To assist with developing plan of care for problematic or potentially serious wounds. EVALUATION: GOALS MET At the end of 5 hours of nursing interventions the patient was able to: Displayed time healing of skin lesions without complication. Maintained optimal nutrition or physical well-being. Verbalized feelings of increased self-esteem and ability to manage situations.

Subjective cue: Dali ra ko makra-man, as verbalized. Objective cues: Skin temperature changes noted Skin discoloration noted Altered sensations (+) edema at left foot Delayed healing

NURSING DIAGNOSIS Ineffective Tissue Perfusion: peripheral related to decreased venous circulation in the left foot GOALS AND OBJECTIVES: After 8 hours of nursing interventions the patient will be able to: Verbalize understanding of condition, therapy regimen, side effects of medications, and when to contact healthcare provider. Demonstrate behaviors/lifestyle changes to improve circulation (e.g., relaxation techniques, exercise/dietary program). Demonstrate increased perfusion as individually appropriate (e.g., skin warm/dry, peripheral pulses present/strong, vital signs within clients normal range, alert/oriented, balanced intake/output, absence of edema, free of pain/discomfort). NURSING INTERVENTIONS: INDEPENDENT 1.) Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities. R: Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis/edema. 2.) Elevate affected extremities, as appropriate. R: Promotes systemic circulation/venous return and may reduce edema or other deleterious effects of constriction of edematous tissues. 3.) Investigate reports of deep/throbbing ache, numbness. R: Indicators of decreased perfusion and increased pressure within enclosed space. 4.) Encourage active ROM exercises of unaffected body parts. R: Promotes local and systemic circulation. 5.) Investigate irregular pulses. R: Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of myocardial depressant factor, compromising cardiac output/tissue perfusion. COLLABORATION: 6.) Maintain fluid replacement per protocol. R: Maximizes circulating volume and tissue perfusion. 7.) Monitor electrolytes, especially sodium, potassium, and calcium. Administer replacement therapy as indicated. R: Losses/shifts of these electrolytes affect cellular membrane potential/excitability, thereby altering myocardial conductivity, potentiating risk of dysrhythmias, and reducing cardiac output and tissue perfusion.

EVALUATION: GOALS MET At the end of 8 hours of nursing interventions the patient was able to: Verbalized understanding of condition, therapy regimen, side effects of medications, and when to contact healthcare provider. Demonstrated behaviors or lifestyle changes to improve circulation. Demonstrated increased perfusion as individually appropriate skin warm and dry, peripheral pulses present, vital signs within clients normal range, alert and oriented, balanced intake/output, absence of edema, free of pain/discomfort).

Subjective cue: Hapdos akong samad, as verbalized. Objective cues: With pain scale of 6/10 Irritability Guarded behavior

NURSING DIAGNOSIS: Acute Pain related to destruction of skin GOALS AND OBJECTIVES: After 30 minutes of nursing care the patient will be able to: a.) Reports relief of pain from 6/10 to 2/10. b.) Display relaxed facial expressions/body posture NURSING INTERVENTIONS: INDEPENDENT 1.) Assess reports of pain, noting location/character and intensity (0-10 scale). R: Pain is nearly always present to some degree because of varying severity of tissue involvement/destruction. 2.) Provide basic comfort measures; e.g., massage of uninjured areas, frequent position changes. R: Promotes relaxation, reduces muscle tension and general fatigue. 3.) Encourage use of stress management techniques; e.g., progressive relaxation, deep breathing, guided imagery, and visualization. R: Refocuses attention, promotes relaxation, and enhances sense of control, which may reduce pharmacological dependency. 4.) Provide diversional activities appropriate for age/condition. R: Helps lessen concentration on pain experience and refocus attention. 5.) Promote uninterrupted sleep periods. R: Sleep deprivation can increase perception of pain/reduce coping abilities.

COLLABORATIVE 6.) Administer Celecoxib 4Omg OD R: for non-steroidal anti-inflammatory drugs 7.) Provide or instruct in use of patient-controlled analgesia. R: provides for timely drugs administration, preventing fluctuations in intensity of pain, often at lower total dosage than would be given by conventional methods. EVALUATION: GOALS PARTIALLY MET At the end of 30 minutes of nursing care the patient was able to: a.) Reported relief of pain from 6/10 to 3/10. b.) Displayed relaxed facial expressions or body posture