Assessment
Subjective
”Mga 3 months na sugat sa
paa ko pero 10 days nung
naging subrang sakit na
sya” as stated by the
patient.
Objective
•Pain scale of 8/10
•Facial grimacing noted
during ambulation or
moving of feet.
•Unable to stand or walk
due to the gangrene foot.
•Non-pitting edema on
both feet
•Presence of wound on
both feet
•Discharges present on the
wound
•Dry skin noted
•With capillary refill of 2
seconds
•Reddish-blackish
discoloration of skin
•Febrile
•V/s Taken:
T-38.3 ̊C
BP-160/90
RR-16 CPM
PR-94 BPM
Diagnosis Planning
Acute pain related to Short Term Objective
gangrene of the foot due After 8 hours of
to Diabetic Mellitus nursing intervention the
patient will be able to
demonstrate non-
pharmacological methods
to prevent or decrease pain
Long Term Objective
After 72 hours of
nursing interventions the
patient will be able to
report a decrease in pain
on a 0-10 scale.
Interventions
•Monitored for pain at least
every 2 hours.Utilize
appropriate methods of
assessment like numeric
pain scales, behaviour
assessment.
• Instructed use of non-
pharmacologic methods to
address pain.
•Turned the patient at least
every 2 hours.
•Monitored vital signs at
least every 2 hours.
•Provided calm, quiet
environment.
•Monitored the sleep-rest
pattern. Promote rest
periods during day and at
least 8 hours sleep each
night
•Administered pain
medication as ordered.
Rationale Evaluation
•Pain is subjective in After 72 hours of nursing
nature, and only the intervention the patient
patient can fully describe it. demonstrated the non-
pharmacological methods
and divertional activities to
•Non-pharmacologic relieve pain. The patient
methods like deep also reported a decrease in
breathing,coughing pain from 8/10 to 6/10.
exercises, music therapy,
watching t.v can alleviate
the attention of the patient
to the pain felt.
•Helps stimulate circulation
and prevent pain from
malposition and enhances
comfort.
•For baseline measurement
and detects early changes
that might indicate pain.
•Promotes action and
effect of medication by
providing decreased
stimuli.
•Fatigue may contribute to
an increased pain
response, or pain can
contributed to interrupted
sleep.
•Medication like analgesics
relieve pain.
Assessment Diagnostic Planning Interventions Rationale Evaluation
Subjective Impaired tissue integrity Short Term Objective: •Monitored V/s •For basement reference After 72 hours of
“Namanas ung paa ko related to the presence of After 8 hours of •Assessed the skin for •Basic elements of a skin nursing interventions the
siguro last year pa tapos gangrene in the extremity nursing interventions the condition,color,lesions,textur assessment are assessment patient is now
mga 3 months nag sugat patient will be taught that e changes, temperature and of knowledgeable that his
na siya” as verbalized by his lower and upper moisture and intact skin. temperature,color,moisture lower and upper
the patient. extremities are at most and intact skin. To know extremities are at risk for
risk for skin breakdown.He also the condition of the skin breakdown. The
Objective will also be taught how to skin of the patient and note patient also demonstrated
•Presence of perform simple skin •Monitored condition of skin any changes or simple skin assessment.
wound/gangrene at both assessment. covering bony prominences. complications. The patient also can now
feet •Pressure ulcers usually perform foot and arm care.
•Non-pitting edema at Long Term Objective: occurs over bony
lower extremities After 72 hours of •Assessed blood supply and prominences, such as the
•Reddish-blackish skin nursing interventions the sensation of affected area. sacrum, coccyx and heels.
discoloration patient will be taught •To evaluate
•Wound discharges noted what to look for and how •Encouraged to eat foods actual/potential for
•Swollen both upper to inspect his own legs and and vitamins rich in A,C,D,E. impairment of circulation to
extremities arms.The patient will be affected extremities.
•Dry skin noted taught on how to perform •To provide a positive
•Capillary refill of 2 foot and arm care. •Performed foot care and nitrogen balance to aid in
seconds wound dressing skin/tissue healing and to
•V/s taken: maintain general good
T-38.3 ̊C health.
BP-160/90 •Teach the client skin •Foot care is important in
RR-16 CPM assessment and ways to patient with DM foot to
PR-94 BPM monitor for skin breakdown. prevent further
complications and good
hygiene.
•Early assessment and
intervention helps prevent
the development of serious
problems.