Date/ Time Cues Need Nursing Diagnoses Goals & Objectives Nursing Interventions

Subjective Heal Risk for infection After 4 hours of 1. Monitor Vital Signs
th related non nursing R: To have baseline data
Objective: Perc healing wound interventions, the
 Numbne eptio secondary to patient will be 2. Assess the skin for color,
ss on n Peripheral Artery able to identify texture, elasticity, and
feet Heal Disease the risk factors of moisture.
 Dry and th the infection as R: Proper skin assessment and
crack Man Rationale: evidenced by documentation facilitates
skin age When a sore or prevention of the breakdown of
 Altered men wound doesn't skin breakdown which is the
circulatio t have sufficient a. remain free body’s first line of defense
n Patt blood supply or from signs against pathogens.
 Hemoglo ern circulation, it and
bin 73 affects your symptoms of 3. Assess and monitor
 Creatinin body's ability to any infection nutritional status, weight,
e: heal the wound history of weight loss, and
1.0049 and can increase b. understandin serum albumin.
 Non the risk of g about R: Patients with poor nutritional
healing infection. That’s infection status may be unable to muster
wound why people with control a cellular immune response to
since poor circulation pathogens making them
Novemb due to peripheral c. demonstrates susceptible to infection
er 2018 arterial disease ability to
 DM (PAD) often perform 4. Encourage the patient to do
type2 need special hygienic handwashing. Dry hands with
care for healing measure, like a paper towel after washing.
 Hyperte
wounds. handwashing R: Handwashing is an effective
nsion
technique to prevent the spread
of infection.
Ref: Wexner 5. Encourage adequate rest
Medical Center R: It can reduce stress and boost
(2015) the immune system
Peripheral Artery
Disease Wound 6. Encourage intake of protein-
Healing; The rich and calorie-rich foods.
Ohio State R: Helps support the immune
University; system responsiveness.
Retrieve from
https://wexnerme 7. Encourage coughing and
dical.osu.edu/wo deep breathing exercises;
und- frequent position changes.
healing/peripher R: To avoid any other
al-artery-disease complications

8. Teach patient how to perform

procedures at home, like
draining the colostomy bag
R: Patient and caregivers need
to master these skills to make
sure that they can continue
preventing risk of infection even
if they are already discharged.

9. Assess and monitor

nutritional status, weight,
history of weight loss, and
serum albumin.
R: Patients with poor nutritional
status may be unable to muster
a cellular immune response to
pathogens making them
susceptible to infection.
10. Encourage fluid intake of
2,000 to 3,000 mL of water
per day, unless
contraindicated.
R: Fluids promote diluted urine
and frequent emptying of bladder
– reducing the stasis of urine, in
turn, reduces risk for bladder
infection

11. Administer Antibiotic

medication as ordered
R: Antibiotics work best when a
constant blood level is
maintained which is done when
medications are taken as
prescribed