Nursing Diagnosis for Mr Jones

Nursing Diagnosis for Mr jones Goals Interventions Rationale Evaluation
Nursing diagnosis
Physical examination of the patient and
wound history assessment requiring wound
characterisation gave an idea that patient is
have arterial leg ulcer as it was in lower
position of the body.
First care given
As it was diagnosed with leg ulcer, nurse can
give compression therapy of four layer
bandage. Chamanga, Christie and McKeown
2015).
Second Care given:
To administer pharmacological intervention
to get relieve form the pain. (White-Chu and
Conner-Kerr 2015).
Third care given:
Nurse can give care to make him able to do
daily living activities by assisting him in taking
shower and meals (Zúñiga et al. 2015)
Referring patient to residential services that
will help the client to visit wound care
hospital.
Goal no 1: for first care
First nursing goal is to treat
his bleeding of lower leg
ulcer.
Lower leg ulcer could be
due to many factors like
diabetes and may take
time to heal, therefore the
patient other associated
disease or illness will get
control that will foster
wound healing (Preston et
al. 2017).
Goal no 2: for second care
given
The client wound will heal
faster, reduce infection and
the functionality need to
be improved. His pain will
be controlled soon (Parani
et al. 2016).
Goal no 3: for third care
given
To make the person
capable to perform his
daily living activities
without help of any other
person (Beerens et al.
Intervention no 1:
Assessing the patient
wound, the type of
bandage applied, nutrition
being taken, and
medications that has been
used (Welle, Buchbinder
and Johnston 2016).
Intervention no 2:
Assessment of factors that
might affect healing
assessment. Different
illness and conditions can
affect patient healing such
as cardio-vascular disease,
renal failure, diabetes,
gastrointestinal disease,
immunosuppression,
malignancy, suppression,
bacterial contamination,
treatment related factors,
and any medications that
will address healing
process (Fonseca et al.
2016).
Intervention no 3:
Nurse assessed the patient
to record ABI, if more than
0.8 is noted nurse
administer compression
Rationale no 1:
Wrong approach to
bandage and dressing
can lead to poor
healing. Wound
assessment can help in
staging or grading the
wound and assessment
of spread of
inflammation (Davis and
McLister 2016).
Rationale no 2:
Person who have leg
ulcer is often linked with
many associated disease
which need to be
assessed (Hellström et
al. 2016).
Rationale no 3:
In lower leg ulcer, to get
detail about the arterial
element is important to
be noted before giving
compression therapy
(Chamanga et al. 2016).
Rationale no 4:
Patient with leg ulcer
suffer huge bleeding
and pain (Minnit and
The nursing intervention
given to the patient is
for the period of four
months and the patient
progress of treatment
will be assessed every
15 days of visit. Nurse
would evaluate the
status of his pain and leg
ulcer by physically
examining the wound. If
there is any pain after
first 15 days, nurse can
provide alternative
medicine. Every 15th day
nurse will evaluate his
capability to do daily
living activities. All the
changes will be
recorded and
comparative analysis
would be done to
evaluate the health
status of patients.
The nurse checks the
mobility of his leg after
given all the relevant
intervention. If still
immobility is noticed in
the patient, nurse will
increase the frequency
of physical exercise.
Nurse also evaluate

Nursing Diagnosis for Mr jones Goals Interventions Rationale Evaluation
2016). therapy.
Intervention no 4:
Nurse provided
pharmacological
intervention by
administering analgesics.
Intervention no 5:
Nurse checked the skin of
patient for sign of nay
infection (White et al.
2016).
Intervention no 6:
Nurse provided education
and teaching regarding
way to manage his lower
leg ulcer and provide all
the relevant information
about the adverse effect
of it so that he can be self-
conscious to manage it.
Intervention no 7:
Refer the patient for
subacute care at home
and provide the service
number of nearby
community hospitals
facilitating wound care at
home (Kelechi, Johnson
and Yates 2015).
Kato 2016).
Rationale no 5:
In the condition of leg
ulcer there is the chance
that patient may
develop infection and
skin becomes dry
(Sunshein and
Samouilov 2017).
Rationale no 6:
Giving education and
teaching often help
patient to be competent
about the ways to
manage it and they
would be accustomed
with the treatments
given (Suikkala
Koskinen and Leino-Kilpi
2018).
Rationale no 7:
Patient with lower leg
ulcer is unable to
perform his daily living
activities (Sheahan et al.
2017).
about the sign of any
infection. If there is
infection, nurse can give
an alternative ointment
which will lessen the
infection. All such
recording will be
maintained by the nurse
to evaluate the progress
from the disease. After
completion of four
months, his wound will
get healed and he would
be able to perform his
daily living activities
(Zarch and Jemec 2015).

Nursing Diagnosis for Mr jones Goals Interventions Rationale Evaluation
Pre-visit checklist of Mr Jones:
1. Is the patient able to walk?
2. Is there any medical history related to leg trauma or deep vein thrombosis?
3. Is he having problem with mobility?
4. Any sign of skin allergy?
5. Does patient had dermatitis in future?
6. Anyone in the family ever had venous or arterial leg ulcer?
7. Is patient allergic to any kind of medicine?
8. Does patient need assistance in shower?
9. What are the medication he is currently taking?
10. Is he having pain? If yes where?
Identified community and other resource:
1. Professional driver to take him to hospital from his home.
2. Physiotherapist to make his leg ulcer treatment fast.
3. Domestic helper to assist him in his daily living activities (Garvey et al. 2015).
Identification of ways to access the community and other resource:
1. By contacting the concern person who can give assistance
2. By searching online through mean of advertisement
Assessment of nursing intervention given to Mr Jones:
Nurse would keep regular monitoring on healing process of leg ulcer by physical examination of wound. The wound is checked every week and nurse
checked the status of pain by giving slight pressure. There is the 90% chance that intervention given will treat his leg ulcer and he would be able do his daily living
activities
Documentation done on arrival nurse in case of Mr Jones:
The documents must involve client consent form, assessments carried out, intervention and follow up. The referral service and patient education facilitated.
1. Nurse introduced herself and asked about good name of patient

2. Nurse documented his current status of leg ulcer
3. Nurse documented about patient’s medical history
4. Nurse noted sign of allergy or infection in the skin
5. Nurse noted the vital signs
6. Nurse documented about current status of pain
7. Nurse asked about the current medicine he is taking
8. Nurse noted any allergy to current medicine he is having.
Specific documentation the need to be done after home visit to Mr Jones:
Nurse visit to Mr Jones gave many data about his status of leg ulcer. Nurse would document those changes that has happen in course of treatment. Nurse
document the status of his leg ulcer and all the assessment made for evaluating pain. Nurse notes all the changed medicine that is being given to Mr Jones.