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NCP New Impaired Tissue Integrity RPH

The patient had a below knee amputation of the right knee due to diabetes-related gangrene that impaired tissue integrity. The goals were for the patient to understand wound healing and demonstrate lifestyle changes to promote healing. Objectives included timely wound healing without drainage or fever and keeping the wound area clean and dry. Interventions included emphasizing a healthy diet, wound dressing changes, keeping the area dry, and taking medications as ordered to promote faster healing.

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548 views3 pages

NCP New Impaired Tissue Integrity RPH

The patient had a below knee amputation of the right knee due to diabetes-related gangrene that impaired tissue integrity. The goals were for the patient to understand wound healing and demonstrate lifestyle changes to promote healing. Objectives included timely wound healing without drainage or fever and keeping the wound area clean and dry. Interventions included emphasizing a healthy diet, wound dressing changes, keeping the area dry, and taking medications as ordered to promote faster healing.

Uploaded by

angelo022690
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Cues Nursing Rationale Goals and Nursing Rationale Evaluatio

Diagnosis Objectives Interventions n


Impaired Because of Goal: Patient Goal met:
S>“My Right Tissue his will be able to
Knee was Integrity r/t Diabetes have a timely Patient
amputated last Below Knee Miletus he wound had a
day” the client Amputation had a healing timely
verbalized. gangrene wound
which was OBJECTIVES: healing
S> “I can only medically After the
sleep 2 hours corrected series of
at night by below nursing
because it’s knee interventions,
aching the amputation the
client which patient will be
verbalized. impairs the able to:
tissues.
O> T-36.5°C [Link] 1. Assess the 1. High level
understandin blood of blood
O> Weak in g of individual glucose of glucose
appearance causative the client hinders
factors wound
healing
O> Clean and
intact dressing
at the right 2. It will help
knee [Link] 2. Emphasize in the
e techniques, the maintena
lifestyle importanc nce of
changes to e of blood
promote safe healthy glucose
environment. diet. therefore
Expiration: July it
15 2010 promotes
wound
healing

3. Regula
3. Achieve r wound
timely wound dressing
healing; be promotes
free of 3. Maintain fast
purulent aseptic healing
drainage or technique and
erythema; be when drying of
afebrile. changing wounds.
dressing/c
aring
wound. 4. Wet
area can
be lodge
area of
bacteria

4. Keep area
around
wound 5. To
clean and achieve
dry. timely
wound
healing

5. Emphasize
d
necessity
of taking
medicatio
ns for
faster
wound
healing as
ordered.

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