Signs and Symptoms Signs: -(+) swelling of right foot with foul-smelling drainage from the ulceration -With heavily soaked dressing Symptoms: -patient verbalized “parang hindi gumagaling yung sugat ko sa paa.”
Nursing Diagnosis
Rationale
Objectives
Intervention
Rationale
Evaluation
Impaired skin integrity r/t open wound secondary to impaired circulation
Diabetes sometimes sometimes affects the nerves of the feet, causing a loss of sensation. Therefore, when a person with decreased sensory perception in the feet is wounded, the wound is left unnoticed and may develop an infection.
Short term: - Clean and disinfect the wound - Promote timely wound healing
1) Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, hammer toe or bunion deformation, hair distribution, pulses, deep tendon reflexes. 2) Instruct patient in foot care guidelines
1) This will prevent further damage to tissues in the patient’s foot
After appropriate nursing intervention, the patient will be able to -demonstrate how to take care of open wound -discuss the importance of hygiene in promoting skin integrity
Long term: -educating the patient regarding the importance of monitoring of open wound and proper wound care.
3) Inspect incision regularly, noting characteristic s and integrity. 4) Teach patient proper wound care
2) Educating the patient will help promote cooperation 3) This will keep the wound in check and prevent complications
4) Cleanliness helps prevent infection and its spread.
Signs: - Open wound @ R foot - (+) foul smell - (+) purulent drainage on wound - Cold, pale skin Symptoms: -
Infection r/t wet gangrenous foot secondary to DM II
Diabetes sometimes affects the nerves of the feet, causing a loss of sensation. Therefore, when a person with decreased sensory perception in the feet is wounded, the wound is left unnoticed and may develop an infection.
Short Term: - Clean and disinfect the wound - Prevent infection from worsening Long Term: - Prevent future infections of the wound
1) IV antibiotics as ordered by physician
2) Assist in wound debridement
3) Teach patient the proper way to change the dressing (using aseptic techniques) 4) Emphasize the importance of self-checking
5) Instruct the patient to cut toenails regularly 6) Use heel protectors, special
1) Antibiotics will help eliminate infection and prevent its spread. 2) This prevents the spread of infection to other organs of the body 3) To help prevent reinfection of the wound
4) Since the patient’s DM has lowered his sensory perception, self-checking will prevent wound from getting infected 5) This will prevent further wounds to the feet. 6) Protects feet from getting wounded
After appropriate nursing intervention, - The patient will have a clean and disinfected the wound - The wound will be prevented from worsening - The client will be able to prevent future infections of the wound
Signs: -(+) DM Type II -Hard-to-heal skin -Loss of sensory perception in feet -BP 130/90 Symptoms: -patient verbalized “may kakaibang pakiramdam sa mga paa ko”
Ineffective tissue perfusion, peripheral r/t decreased arterial flow as evidenced by pale and cool feet, and numbness and tingling of the feet
Diabetes mellitus Type II occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the body’s tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.
Short Term: -Promote tissue perfusion to the affected area -Increase perfusion until adequate -client will verbalize understanding of the relationship between diabetes and circulatory changes -demonstrate awareness of safety factors and foot care Long Term: -Keep tissue perfusion adequate -Maintain adequate level of hydration to maximize perfusion
mattresses, foot cradles for patients on bed rest. 1) Antidiabetics as ordered by physician
2) Elevate feet when up in a chair. Avoid putting the feet in a dependent position. 3) Assess for signs of dehydration. Monitor I&O and encourage oral fluids.
4) Reinforce safety precautions regarding use of heating pads, hot water bottles, and soaks
1) Taking care of the underlying disease will help alleviate the effects 2) Minimizes interruption of blood flow and reduces venous pooling.
3) Glycosuria may result in dehydration with consequent reduction of circulating volume. 4) Heat increases metabolic demands on compromised tissues. Vascular insufficiency alters pain sensation, increasing risk
After appropriate nursing intervention, -the patient will be able to promote tissue perfusion to the affected area -Patient’s perfusion will increase until adequate -client will verbalize understanding of the relationship between diabetes and circulatory changes -demonstrate awareness of safety factors and foot care
5) Instruct client to avoid constricting clothing, socks and ill-fitting shoes 6) Discuss complications of the disease that result from vascular changes
of injury. 5) Compromised circulation and decreased pain sensation promotes tissue breakdown 6) Promote patient knowledge and cooperation
