Cues Nursing Diagnosis
Subjective: Impaired skin integrity as
Reports of itch, pain, and
numbness on 2nd left foot and
on the 1st-3rd digits
Objective:
Disruption of skin
surface/layers and tissues
Erytmathous to blackish lesion
on 2nd left foot
Non healing wound on dorsal
portion of 3rd finger
Goal/ Plan
After 1 week the
evidenced by presence of wound
on the patitents dorsal proximal
3rd of her 4th finger secondary to
thromboangitis obliterans
INTERFERENCE:
A vascular abnormality slow and
delays the normal supply and
demand of circulation making
wounds difficult to heal. Tissues
and skin surfaces are not well
nourished.
Nursing Intervention
Independent
patient is to achieve
Reinforce initial dressing/change as
timely wound healing
indicated. Use strict aseptic techniques.
Gently remove tape (in direction of hair
growth) and dressings when changing.
Inspect wound regularly, noting
characteristics and integrity. Note patients
at risk for delayed healing, e.g., presence
of chronic obstructive pulmonary disease
(COPD), anemia, obesity/malnutrition,
DM, hematoma formation, vomiting,
ETOH (alcohol) withdrawal; use of steroid
therapy; advanced age.
Maintain patency of drainage tubes; apply
collection bag over drains/incisions in
presence of copious or caustic drainage.
Caution patient not to touch wound.
Cleanse skin surface (if needed) with
diluted hydrogen peroxide solution, or
running water and mild soap after incision
is sealed.
Collaborative
Irrigate wound; assist with debridement as
needed.
Rationale Evaluation
Goal was met. The patient
achieved timely wound
Protects wound from mechanical injury
and contamination. Prevents healing
accumulation of fluids that may cause
excoriation.
Reduces risk of skin trauma and
disruption of wound.
Early recognition of delayed
healing/developing complications may
prevent a more serious situation.
Wounds may heal more slowly in
patients with comorbidity, or the elderly
in whom reduced cardiac output
decreases capillary blood flow.
Facilitates approximation of wound
edges; reduces risk of infection and
chemical injury to skin/tissues.
Prevents contamination of wound.
Reduces skin contaminants; aids in
removal of drainage/exudate.
Removes infectious exudate/necrotic
tissue to promote healing.
 Cues
Subjective
Reports of numbness on upper
and lower extremities
Objective:
slow healing of wound
Edema on upper and lower
extremities
Skin temperature is slightly cold
Skin discoloration
Dyspnea
Weak Peripheral pulses
Nursing Diagnosis
(Peripheral) Ineffective tissue
perfusion related to occlusive
vascular disorder secondary to
thromboiangitis obliternas
INTERFERENCE:
Due to occlusive vascular
disorder involving small and
medium sized arteries,
circulation is altered causing
bipedal edema, and digital
ischemia. Discoloration and
presence of gangrene in the pt’s
digits was seen. More
importantly, The Hemoglobin
concentration in blood was
decreased
(see lab results)
Planning
After 4 hrs Patient will have
promotion in tissue perfusion to
vital organs, as evidenced by
strong peripheral pulses and
reduction of signs and
symptoms
Nursing Intervention
Independent:
Have a close monitoring of vital
signs
Do passive range-of-motion (ROM)
exercises to unaffected extremity
every 2 to 4 hours
Administer oxygen as needed.
Position properly
Anticipate and institute
anticoagulation as prescribed
Therapeutic:
Assist with diagnostic testing as
indicated.
Anticipate need for possible
embolectomy, heparinization,
vasodilator therapy, thrombolytic
therapy, and fluid rescue.
Rationale evaluation
After 4 hrs of nursing
To obtain the accurete conditoin of intervention the patient
patient as if it neededs intervention
and assistance. Changesin Vitals Perfusion was promoted as
signs are dterminant of aggreviation evidenced by strong peripheral
or alleviation of the condition pulses and reduction of signs
and symptoms
Exercise prevents venous stasis.
This saturates circulating
hemoglobin and increases the
effectiveness of blood that is
reaching the ischemic tissues.
This promotes optimal lung
ventilation and perfusion. The
patient will experience optimal lung
expansion in upright position.
This reduces the risk of thrombus.
Doppler flow studies or angiograms
may be required for accurate
diagnosis.
These facilitate perfusion when
obstruction to blood flow exists or
when perfusion has dropped to such
a dangerous level that ischemic
damage would be inevitable without
treatment.
Cues Diagnosis Planning Intervention Rationale Evaluation
Subjective: Note presence, quality of
Report of difficulty in breathing Decreased cardiac outpout After an hour of nursing central and peripheral Bounding carotid, jugular, After an hour of nursing
related to occlusion of vessels intervention the patient will be pulses. radial, and femoral pulses may intervention the patient
Objective: secondary to thromboangitis able to display hemodynamic be observed/ palpated. Pulses in displayed normal hemodynamic
CARDIAC OUTPUT obliterans stability (e.g., BP, cardiac output, the legs/feet may be diminished, stability.
3.54 L/min renal perfusion, peripheral reflecting effects of
(normal value-4.0 L/min) pulses) vasoconstriction

Altered stroke volume INTERFERENCE:

( decreased venous return)
Comparison of pressures
The vessels that supply blood to Monitor vital signs provides a more complete
Vasoconstriction the heart muscle are occluded, ( especially BP and I & O)
picture of vascular
Dyspnea shutting off the blood supply to involvement/scope of problem.
a portion of the myocardium.
Edema The large portion of the heart Reduces physical stress and
muscle, cardiac output falls tension that affect blood
Clammy skin because the affected muscle no Maintain activity restrictions, pressure and the course of
longer contracts. Interrelated to e.g., bedrest/chair rest; hypertension.
schedule periods of
Skin color changes tissue perfusion uninterrupted rest; assist
patient with self-care Proper positioning promotes
restlessness activities as needed good hemodynamics(e.g., semi-
Ischemia fowlers)
Pulmonary HPN (elevation of edematous
Proper positioning extremities)

(low salt lowcalories lowfat diet;

frequent small feedings)
Provide diet restrictions

Aid in the remedies to achieve normal

rnage of cardiac output.

Administer medications as
indicated (e.g, diuretics)
 Cues Nursing Diagnosis
Subjective Data:
Activity intolerance (level 4)
Patient’s report of weakness related to generalized weakness
secondary to thromboangitis
Objective data: obliternas
Sedentary lifestyle INTERFERENCE:
Dyspnea
Because of altered circulation,
Disturbed rest period/sleep the patient is experiencing
muscle weakness that hinders
Generalized weakness her to her usual activities. Her
confidence was also diminished.
Goal/ Plan
After 24 hrs of nursing
intervention the patient will be
able to reduce effects of
inactivity, promote optimal
physical activity, and achieve
satisfactory lifestyle
Nursing Intervention
Assess patient's level of
mobility.
Assess patient's cardiopulmonary
status before activity
Progress activity gradually, as
with the following:
o Active range-of-motion (ROM)
exercises in bed, progressing to
sitting and standing
o Deep breathing exercises three
times daily
o Sitting up in chair 30 minutes
three times daily
o Walking in room 1 to 2
minutes three times daily
Rationale Evaluation
After 24 hrs of nursing intervention
the patient reduced the effects of
This aids in defining what
inactiviyt, promoted physical activity
patient is capable of, which is and learned to how to achieve
necessary before setting realistic satisfactory lifestyle
goals.
How Valsalva maneuver affetcs
heart rate when patient moves in
bed, which requires breath
holding and bearing down, can
cause bradycardia and related
reduced cardiac output.
This Prevents over exerting the
heart and promotes attainmet of
short-range goals
Assist with activities and
provide/ monitor client’s use of To protect patient from injury
assistive devices (e.g., crutches,
walker, wheel chair, or O2)

Provide information about the

effect of lifestyle and overall (e.g., Nutrition, adequate fluid
health factors on activity intake, Resting periods etc.)
tolerance

Provide/ monitor response to

supplemental oxygen and
medications and changes in
treatment regimen
As prescribed by the physician to
help improve the condition or to
determine a need for
modification in providing the
following.