hi, kenson, and welcome to allnurses!
i need some help for my nursing care plan....nursing diagnosis is edema on both legs; goal is prevent tissue damage. i need 5 interventions and 5 rationales. please help.
i saw the above post on the care plans + finding nsg articles: 2 really good websites everyone should know about!
thread and am combining that information with what you posted on this thread that you started here.
- edema on both legs
- prevent tissue damage
- encourage the patient to exercise
- elevate both legs with pillow
- weigh patient daily on same scale at same time of day
- document patient's input and output- it could help the blood circulation - to prevent all the fluid go down to the legs
leg edema is a common sign that results when there is excess interstitial fluid that has accumulated in the legs. it can result from venous disorders, trauma, and some bone and cardiac disorders that upset the normal fluid balance. you didn't mention the underlying reason for this patient's leg edema which would be very helpful to know because edema on both legs
is not an official nanda (north american nursing diagnosis association) nursing diagnosis. i don't know if your school requires you to use nanda nursing diagnoses or if you are allowed to make up your own. if you are required to use nanda diagnoses, then edema on both legs
would be incorrect to use. this is why i mention needing to know the underlying reason for the edema since edema is a defining characteristic (symptom) for a couple of the nanda nursing diagnoses. the most likely being decreased cardiac output
or excess fluid volume.
so, if you are supposed to use nanda nursing diagnoses you need to correct your nursing diagnostic label here to conform to what the patient's underlying medical problem is.
as for your goals and interventions. . .what other symptoms of the edema exist? any pitting? are peripheral pulses able to be palpated or auscultated? are they equal? how do they measure up on a scale of arterial flow? was there warmth or tenderness to touch? were any cords detected upon palpation? was there any deep pain? upon dorsiflexion was there a positive homan's sign (calf pain)? was there any open skin areas or weeping? these questions should have all been addressed as part of your assessment of the patient which is the first step in doing your care plan (nursing process).
then, (those that we alone are responsible for) nursing goals are
- the patient will express feelings of increased comfort
- the patient will openly express feelings and concerns about the reason for the edema
- the patient will remain free from signs and symptoms of infection (cellulitis) and dvt
- the patient will avoid injury to the legs
- peripheral edema will be decreased (more of a long-term goal)
- leg circumference will diminish daily
- skin of the legs will remain intact
nursing interventions to accomplish these would include things like
- measure the circumference of each leg daily
- check the pedal pulses daily
- monitor and note the degree of edema and any pitting at least daily
- note what kind of activity or positioning makes the edema improve or get worse
- listen to the dopplers of the arterial pedal pulses at least daily and note any changes
- monitor and record intake and output
- monitor and record daily weight and note any changes
- monitor for signs and symptoms of dvt or cellulitis
- perform/provide/assist in the actual care of the patient
- give the prescribed drugs, usually diuretics, as ordered (a collaborative intervention)
- elevate the affected extremities
- apply support hose, if ordered by the physician and remove and reapply them q8h (a collaborative intervention)
- encourage leg exercises (rationale: helps pump blood from the legs back to the heart)
- avoid sitting for long periods of time with the legs in a dependent position
- encourage adequate intake/or enforce fluid and sodium restriction, if so ordered
- take safety precautions to avoid injury to the skin of the legs
- keep linens smooth and free of wrinkles
- apply lotion to skin
- keep skin free of moisture due to diaphoresis or weeping
- keep sharp objects away from legs
- encouraging verbalization of feelings and concerns
- teach the patient about the medications they are receiving for this condition and any possible side effects of them
- teach the patient about the interventions for edema and why they are being done
- teach the patient the importance of protecting their skin against injury when edema is present
- teach the patient the signs and symptoms of dvt (deep vein thrombosis)
- manage the care
- make sure labwork is being drawn and results reported to physician
- notify the physician of any change in the patient's status
- decreased pulses
- increase in leg circumference
- decreased output in relation to input
- development of a fever
- legs become red, warm and painful to touch
i'll leave you to look up the rationales in your textbook(s) for these as i've pretty much written this part of the care plan for you.