Name:
Nursing
Diagnosis
1)Acute pain
related to
extensive
frostbite on
back, legs,
arms & below
the knee
amputation
Evidence
-suffered
extensive frost
bite to hands,
back, legs
- underwent
bilateral below
the knee
amputation
-underwent
ileostomy
-self reports of
pain
particularly
before
dressing
changes &
debridement
-use of PRN
morphine
frequently
throughout the
day.
-reported to
have an
increase pulse
rate 118 &
increased
blood pressure
145/90
-patient
having some
slight problems
sleeping at
night due to
pain
Nursing 300/301 Nursing Care Plan – Nursing Diagnoses with Supporting Evidence
Name:
Name:
Name:
Nursing
Nursing
Nursing
Evidence
Evidence
Diagnosis
Diagnosis
Diagnosis
2) Ineffective
- 26 years old –
3)Impaired
-Non compliance
4)Decreased
coping
single
Tissue integrity
to the hospital food Mobility
related to
-Change in
related to
diet (proper
related to
Generalized
normal routine
extensive frost
nutrition needed
below the
anxiety, Panic -> out of own
bite on back,
for wound healing
knee
attacks and
environment
hands, and feet please see links)
amputation
self reports of
-Lost of
& below the
-Large open
and size of
feeling
independence knee
wound on back
the client
overwhelmed
-Financial
amputation &
due to frost bite &
(188 kg)
by the current strains
rhabdomyolysis rhabdomyolysis.
situation.
- Non
Wound
complaint to
debridement on
the hospital
legs, arms & back
food regime
-Large male 188kg
(wants junk
affects tissue
food)
healing
- non
--application of
interested in his
flagyl and normal
own care
saline for daily
- depressive
dressing changes
talk
-ileostomy on
- 4 amputees
abdomen.
(bilateral
below the
knee, 5 digits of
right hand, 1
digit on left
hand)
- isolation
- acute pain
managed with
Morphine
- needs help
with ADLs
-Refused
spiritual care
worker
Evidence
- Acute pain
- amputations (bilateral
below knee and Rt ( all
5 digits) & Lt (5th digit)
- bedridden
necrotic tissue
(buttocks & back)
- morbidly obese
- reported decreased
tissue perfusion
- isolated
- medications side
effects
Metoprolol (dizziness,
fatigue, decrease BP)
Piperacillin/tazobactam
(lethargy, nausea)
Morphine (sedation,
drowsiness, confusion)
-PT wants an aggressive
ROM due to bed
ridden.
- unavailability of the
beriatric lifting
equipment
- In crease of stuff for
care ( needs 6 people
to move in bed)
5) readiness
for enhanced
nutritional
requirements
related to
clients
willingness to
learn new
nutritional
regimen.
Client
receiving
nutritional
advice from
the local
dietician
Learning to
resist chips,
pop from
mother.
Trying to
develop a
meal plan with
dietician.
Low albumin
levels
* Number each Dx and place the diagnosis number beside each assessment parameter, intervention and evaluation criteria that corresponds to it