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 1.Verbalize 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 2.Demonstrat 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.