Marzan,

Darren
11/29/15
Desired Outcomes

Impaired Tissue Integrity

1. The patients tissues will show active
progress of healing each day.

Interventions

1.
2.
3.
4.
5.
6.

Impaired Tissue Integrity

Assess characteristics of the wound
including color, size, drainage, and odor.
Cleanse with normal saline as appropriate.
Provide tissue care as needed.
Premedicate for pain for dressing changes
as needed
Instruct patient proper care of the wound
(hand washing, wound cleansing, dressing
changes).
Teach patient the signs and symptoms of
infection and to notify HCP or nurse
immediately.
Administer antibiotics as ordered

Desired Outcomes
Acute Pain
2. The patient will report satisfactory pain
control at a level less than 3 throughout and
by the end of the shift.

Interventions
7.
8.
9.
10.
11.
12.

Acute Pain
Assess pain characteristics (quality,
severity, location, onset, duration)
Evaluate the patients response and pain
management strategies.
Assess the patients expectations for pain
relief.
Respond immediately to reports of pain.
Give analgesics as ordered.
Offer nonpharmacological methods
(Imagery, relaxation exercises, and
breathing exercises).
Evaluate effectiveness of measures used.

Desired Outcomes
Deficient Knowledge
3. The patient will verbalize understanding of
desired content (Consistent Carbohydrate
Diet) by the end of the shift.

Interventions
Deficient Knowledge
13. Assess the motivation and willingness of
the patient to learn.
14. Identify the priority of learning needs
within the overall care plan.
15. Question the patient regarding previous
experience and health teaching
16. Determine the patients learning style.
17. Pace the instruction and keep sessions
short. Focus teaching sessions on a single
concept or idea.
18. Encourage questions. Provide positive,
constructive reinforcement of learning.

Marzan, Darren
11/29/15
Desired Outcomes
Activity Intolerance
4. The patient will verbalize and use energyconservation techniques and return to near
baseline level of function by discharge.

Interventions
Activity Intolerance
19. Assess patients level of physical activity
and mobility.
20. Assess nutritional status and monitor
pertinent labs (H&H).
21. Assess the need for ambulation aids.
22. Encourage adequate rest periods, especially
before meals, other ADLs, exercise
sessions, and ambulation.
23. Assist patients with planning activities for
times when they have the most activity.
24. Teach energy-conservation techniques such
as: organizing a work-rest-work schedule,
changing positions often, pushing rather
than pulling, placing frequently used items
within easy reach.

Desired Outcomes
Noncompliance
5. The patient will report compliance with
therapeutic plan of care by the end of the
shift.

Interventions
Noncompliance
25. Assess the factors that the patient thinks
interfere with compliance.
26. Assess the patients individual perceptions
of health problems and interest in
following the treatment plan.
27. Assess the patients beliefs about his
current illness and the importance of health
care.
28. Tailor the information in terms of what the
patient feels is the cause of his health
problem and his concerns about therapy.
29. Tailor the therapy to the patients lifestyle
and culture.
30. If negative side effects of prescribed
treatment are a problem, explain that many
side effects can be controlled r eliminated.

Desired Outcomes
Unstable Blood Glucose
6. The patient will maintain blood glucose
levels > 72, < 126 mg/dL by the end of the
shift.

Interventions
Unstable Blood Glucose
31. Assess for signs of hyperglycemia
(polydipsia, polyphagia, and polyuria, hot
and dry skin).
32. Assess for signs of hypoglycemia
(tachycardia, diaphoresis, tremors,
headache, and fatigue, and visual changes,
cool and clammy skin).

Marzan, Darren
11/29/15
33. Assess blood glucose levels prior to meals
and at bedtime.
34. Instruct the client about prescribed diet
plan (consistent carbohydrate diet).
35. Administer insulin medication as directed.
36. Instruct the patient appropriate actions to
take if experiencing hypoglycemia.

Desired Outcomes
Ineffective Peripheral Tissue Perfusion
7. The patient will maintain optimal
peripheral tissue perfusion as evidenced by
strong palpable peripheral pulses, adequate
capillary refill (less than 3 seconds) by
discharge.

Interventions
Impaired Tissue Integrity
37. Assess for signs of decreased tissue
perfusion.
38. Assess for possible causative factors of
reduced tissue perfusion.
39. Monitor BP for orthostatic changes (drop
of 20 mmHg systolic or 10mm Hg diastolic
BP with position changes.
40. Encourage adequate fluid intake.
41. Assist with position changes.
42. Administer medications as ordered to treat
underlying problem (antihypertensives to
reduce systemic vascular resistance and
optimize cardiac output and perfusion).

Desired Outcomes
Disturbed Body Image
8. The patient demonstrates enhanced body
image and self-esteem as evidenced by the
ability to look at, touch, talk about, and
care for altered body part by the end of the
shift.

Evaluation

Interventions
Disturbed Body Image
43. Assess the perception of change in the
structure or function of the body part.
44. Assess the perceived impact of change on
ADLs, social behavior, personal
relationships, and occupational activities.
45. Encourage verbalization of positive or
negative feelings about the altered body
part.
46. Help the patient identify ways of coping
that have been helpful in the past.
47. Assess the patients behavior regarding the
actual changed body part or function.
48. Acknowledge normalcy of emotional
response to the change in body structure or
function.

Marzan, Darren
11/29/15
Impaired tissue integrity - I was able to do the dressing change for my patient and assessed the wound for
progress of healing. The wound was still in the initial stages of healing so the outcome was partially met.
Acute pain - The patient reported minimal pain throughout the shift and rated it at a 2, the outcome was
met.
Deficient knowledge - I educated the patient about his prescribed diet plan of consistent carbohydrate
diet. He verbalized the importance of adhering to the diet and that he orders his meals according to the
diet. The outcome was met.
Activity intolerance - The patient was able to ambulate without aid or assistance. He was able to bear
weight onto his Lt heel, so his gait is slightly affected. The outcome was partially met.
Noncompliance - The patient reported that he will adhere to his treatments and diet. Further assessment is
needed so outcome is partially met.
Unstable blood glucose - The patients blood glucose was 115 in the morning, and 152 at lunchtime.
Insulin aspart was administered based on sliding scale. Outcome partially met.
Ineffective tissue perfusion - The patients peripheral pulses were palpable, with capillary refill less than 3
seconds, and CMS intact. Outcome partially met.
Disturbed body image - The patient was apathetic to his recent amputation. He was able to verbalize past
issues with the amputation of his other toes. Outcome partially met.
Discharge Plan/Patient Teaching
The patient prefers to learn through verbal instruction and demonstration. Barriers to learning include
cognitive (English is second language) and complexity of treatment. The topics to be address include diet,
medications, safety issues (foot injury prevention and care), when to seek medical attention, and
community resources available to the patient. The patient will be discharged to home with the supervision
and care by the cousin and other members of the family. The family also has a history of diabetes mellitus
so they are familiar with treatments. The patient is independent with ADLs and requires minimal
assistance. He does ambulate on his own, but his gait is slightly affected because he is able to weight bear
through the left heel of his foot. He will have a walker/cane available when he is discharged home.

Marzan, Darren
11/29/15

The chief medical

diagnosis (this is the
actual, not just the
admitting diagnosis, as
these are often different)
is listed.
All relevant priority
assessments related to
the chief medical
diagnosis are listed
All ACTUAL nursing
diagnosis are listed
All pertinent assessment
data, treatments,
medications, and
medical history related
to each of the nursing
diagnosis are listed in
the corresponding
nursing diagnosis box
Interrelatedness of the
patient problems is
made clear with
different colored lines.
All relevant
relationships are
reflected.
Presentation is wellorganized and creative.
Research is provided to
support work.
Accurate grammar,
punctuation, and
spelling.

NURS 360- Health & Illness III

Concept Map Care Plan Grading Rubric

Yes
No
Instructor comments