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Nursing Care Plans: Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Patient x, a 55-year-old client, presented with numbness in the legs and radiating pain. On assessment, the client's lower extremities were cool to the touch, pulses were diminished, and capillary refill was over 3 seconds. There was also a darkened area on the left great toe. The nursing care plan addressed improving circulation through diet, exercise, foot care instructions, and monitoring the darkened area for signs of infection. Goals included warming of the lower extremities and a capillary refill of 3 seconds or less.

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Rheeanne Mae Amilasan
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2K views

Nursing Care Plans: Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Patient x, a 55-year-old client, presented with numbness in the legs and radiating pain. On assessment, the client's lower extremities were cool to the touch, pulses were diminished, and capillary refill was over 3 seconds. There was also a darkened area on the left great toe. The nursing care plan addressed improving circulation through diet, exercise, foot care instructions, and monitoring the darkened area for signs of infection. Goals included warming of the lower extremities and a capillary refill of 3 seconds or less.

Uploaded by

Rheeanne Mae Amilasan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Patient name: Patient x

Age: 55 NURSING CARE PLANS


ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective data: -Tissue perfusion, -Short term: Client will Independent: Short term goal met:
-Client complained of ineffective, evidenced discuss ways to improve Give instruction about food -Client demonstrated
numbness in legs with by (see assessment) circulation and prevent care: readiness to learn and
radiating pain. Risk for infection infection. -Wash feet in warm to cool -Poor foots promotes the growth verbalized understanding
related to darkened water (avoid hot water) of organisms. and willing ness to comply.
area on left great toe. -Dry feet thoroughly after - Poor foots promotes the growth
each wash. of organisms.
-Use lotion lavishly, dry feet - Poor foots promotes the growth
after application. of organisms.
Defining -Use gentle approach with -Ischemia in lower extremities
Objective data: Characteristics: Long term: feet. predisposes the diabetic client to Long term goal met:
-Lower extremities cool -Skin cool to touch -Lower extremities will be bruises and breaks in the skin that -Lower extremities,
to touch. -Blanching of skin warm to touch. may lead to gangrene. circulation improved.
-Pulses diminished. - -Capillary refill more -Client will report -Use only Emory boards to - Ischemia in lower extremities Capillary refill 2+.
Capillary refill (3 than 3 seconds capillary refill 3 seconds. care for nails. predisposes the diabetic client to
seconds). bruises and breaks in the skin that
-Darkened area on left -Discoloration of skin -Darkened area on left may lead to gangrene.
great toe. -Complaints of great toe will show no -Do not wear tight-fitting - Ischemia in lower extremities
numbness in sign of infection, redness, shoes. predisposes the diabetic client to
extremities warmth, pain, or bruises and breaks in the skin that
drainage. may lead to gangrene.
-Report all cuts and bruises to -Prompt reporting facilitates early
doctor immediately. treatment and should reduce
complications.
-Adhere to diet -Diet enhances balance between
insulin and carbohydrates,
improves anabolism and
circulation.
-Keep feet warm when -Facilitates circulation.
weather is cold.
Patient name: Patient x
Age: 55 NURSING CARE PLANS
-Carry out doctor’s and
dietician’s orders as
prescribed:
-Diet
-Antidiabetic medication
-Exercise regimen

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