- Impaired tissue perfusion related to weakening / decreased blood flow to the area gangrene due to obstruction of blood vessels.
- Integrity of the tissue disorder related to gangrene in the extremities.
Nursing Intervention for Diabetes Mellitus
1. Impaired tissue perfusion related to weakening / decreased blood flow to the area gangrene due to obstruction of blood vessels.
Peripheral Circulation remain normal.
Result Criteria :
- Palpable peripheral pulse strong and regular
- The color of the skin around the wound was not pale / cyanotic
- The skin around the wound felt hot.
- Edema did not occur and injuries from getting worse.
- Sensory and motor improvement.
Nursing Intervention :
- Teach the patient to mobilize
Rational : the mobilization improves blood circulation.
- Teach about the factors which can increase blood flow :
Elevate feet slightly lower than the heart (the position of elevation at rest), avoid crossing legs, avoiding tight bandage, avoid the use of pillows, hamstrings and so forth.
Rational : to increase blood flow through so that does not happen edema.
- Teach about the modification of risk factors such as :
Avoid a diet high in cholesterol, relaxation techniques, smoking cessation, and drug use vasoconstriction.
Rational : high cholesterol can accelerate the occurrence of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.
- Collaborate with other health team in giving vasodilators, checking blood sugar regularly and oxygen therapy (HBO).
Rational : giving vasodilators will increase the dilation of blood vessels so that tissue perfusion can be improved, while checking blood sugar regularly to know the progress and state of the patient, to improve oxygenation HBO areas ulcer / gangrene.
2. Impaired Skin Integrity related to gangrene in the extremities.
Goal : The achievement of the wound healing process.
Result Criteria :
- Decreased edema around the wound.
- The presence of granulation tissue.
- The stench of injury is reduced.
- Assess the wound area and state as well as the healing process.
Rational : the right assessment of the wound and the healing process will assist in determining further action.
- Treat wounds with good and true: clean wound abseptik use solution that is not irritating, lift the rest of the bandages that stick to the wound and nekrotomi dead tissue.
Rational : treating wounds with aseptic technique, wound contamination and can maintain the solution will damage the granulation tissue irritating tyang arise, the remaining dressing to hamper the process of necrotic tissue granulation.
- Collaboration with physicians for the administration of insulin, pus culture examination, examination of blood sugar, giving anti-biotic.
Rational : the insulin will lower blood sugar, pus culture examination to determine the types of germs and antibiotics, are appropriate for the medication, checking blood sugar levels to determine the progression of the disease.
3. Impaired sense of comfort (pain) related to ischemic tissue.
No pain / reduced pain
Result Criteria :
- Patients say the pain verbally reduced / lost.
- Patients can perform the methods or actions to overcome or reduce pain.
- Expanding patient movement.
- No cold sweat, vital signs within normal limits. (Temperature: 36 to 37.5 0C, Nadi 60 - 80 x / min, Blood Pressure: 100-130 mmHg, Respiratory: 18 - 20 x / min).
- Assess the level, frequency, and reaction to pain experienced by patients.
Rational : to find out how severe pain experienced by patients.
- Explain to the patient about the causes of pain.
Rational : understanding the patient about the causes of pain that occurs will reduce the tension of patients and allows patients to be invited to cooperate in taking action.
- Create a peaceful environment.
Rational : excessive stimulation from the environment will aggravate the pain.
- Teach a distraction and relaxation techniques.
Rational : distraction and relaxation techniques can reduce pain felt by patients.
- Adjust the position of the patient as pleasant as possible according to patient preference.
Rational : a comfortable position to help provide opportunities for relaxation in the muscles optimally.
- Collaboration with the doctor for giving analgesics.
Rational : analgesic drugs may help reduce pain patients.
Source : http://nanda-nursing.blogspot.com/2011/01/nursing-diagnosis-and-nursing_16.html