Texture and turgor monitor vitals encourage fluid intake monitor wbc and differential within normal limits feet for any signs further tissue damage

Goal:

Pt will remain free from further infection.

Pt will state symptoms of infection before initiating a health care-related
procedure

Frequent turning & repositioning Q2.

Frequent turning and
repositioning
prevents skin
breakdown and keeps the patient moving every
few hours.

Assessing vitals and labs
frequently will be more likely to catch an
infection in the early stages.

Pt will remain free
from further peripheral tissue damage.

Outcomes:

Check bilateral pulses.

Assess for pain in extremities.

Client is diabetic so meticulous
foot care is
important to
make sure there are no further
ulcers or skin
breakdown.

Keeping client mobile as
tolerated will help prevent
DVT.

Number 3:

Pt will report any altered sensation or pain at sites of tissue impairment
within 24 hours.

Pt will demonstrate
understanding of plan to heal tissue and prevent reinjury by discharge.

Assess feet for any signs of further tissue damage. Determine severity of wound on left foot and what wound care needs to take place for it to heal.

Inspect and monitor sites of impaired tissue integrity at least once a day.

Pt and family are
able to keep a record of integument
assessment for
follow-up doctor’s appointments to
monitor
improvement of
wounds.