Nursing Care Plan

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Nursing Care Plan Nursing Diagnosis| Patient Outcomes/Goals| Nursing Interventions| Rationale| Evaluation| 1. Risk for systemic infection r/t cellulitis AEB breakdown of tissue on the lower extremities 2. Chronic pain related to multiply system diseases, gout, cellulitis, as demonstrated by patient complaints of pain| 1. Pt will demonstrate progressive healing of tissue by discharge(Long-term) 2. Manage acute & chronic pain to pt. identifiable tolerable level of 4 on scale of 0 to 10 | 1. Elevate lower extremities 2. Change dressings as prescribed and PRN using “no touch” and sterile techniques 3. Position LE to prevent any pressure sores 1. Teach pt to utilize the numerical rating scale 0 (no pain) to 10 (worst pain) for self-reporting pain 2. Monitor per the pain management protocol and ascertain effectiveness 3. Uses of non-med and alternative methods of pain relief, such as visualization, guided imagery, relaxation exercises, biofeedback, listening to music | 1. Elevation of extremities will decrease edema (Swearingen p.54) 2. Standard infection control guidelines to prevent infection (Swearingen p.55) 1. Pain management is only effective when it is accurately assess (Swearingen p.39) 2. Responses are potential indicators of pain and assessment optimizes reassessment and treatment intervals (Swearingen p.40) 3. The pain may be chronic and continuous, pain relief should be augmented with nonpharmacologic methods, which do not have side effects| Partially Met: Site now lacks drainageMet: patient stated pain was below 4 for most of the day| Identify a complete list of nursing diagnoses:Risk for falls, activity intolerance, anxiety, disturbed body image, risk for unstable blood glucose, hopelessness|
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