Nurse's Pocket Guide

daily maintenance. Enhances commitment to plan, optimizing
outcomes.
• Review measures to avoid spread/reinfection of communicable
disease/conditions.
• Emphasize importance of proper fit of clothing/shoes, use of
specially lined shock-absorbing socks or pressure-reducing
insoles for shoes in presence of reduced sensation/
circulation.
• Identify safety factors for use of equipment/appliances (e.g.,
heating pad, ostomy appliances, padding straps of braces).
• Encourage client to verbalize feelings and discuss how/if condition
affects self-concept/self-esteem. (Refer to NDs disturbed
Body Image; situational low Self-Esteem.)
• Assist client to work through stages of grief and feelings associated
with individual condition.
• Lend psychological support and acceptance of client, using
touch, facial expressions, and tone of voice.
• Assist client to learn stress reduction and alternate therapy
techniques to control feelings of helplessness and deal with
situation.
• Refer to dietitian or certified diabetes educator, as appropriate,
to enhance healing, reduce risk of recurrence of diabetic
ulcers.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Characteristics of lesion(s)/condition, ulcer classification.
• Causative/contributing factors.
• Impact of condition.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs/referrals and who is responsible for actions
to be taken.
• Specific referrals made.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 623
impaired SKIN INTEGRITY