Nursing Diagnosis and Interventions - Diabetes Mellitus with Gangrene
Impaired tissue perfusion related to the weakening / decreased blood flow to the area of gangrene due to obstruction of blood vessels.
Objective: to maintain peripheral circulation remain normal.
- Palpable peripheral pulse is strong and regular
- The color of the skin around the wound is pale / cyanotic
- The skin around the wound felt warm.
- Edema does not occur and injuries from getting worse.
- Sensory and motor function improved
1. Teach the patient to mobilize
Rational: the mobilization improves blood circulation.
2. Teach about the factors that can increase blood flow:
Elevate the legs slightly lower than the heart (elevation position at rest), avoid penyilangkan feet, avoid tight bandage, avoid using a pillow, behind the knees and so on.
Rational: to increase blood flow through so that does not happen edema.
3. Teach about the modification of risk factors such as:
Avoid high-cholesterol diet, relaxation techniques, stop smoking, and drug use vasoconstriction.
Rationale: High cholesterol can accelerate the occurrence of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.
4. Cooperation with other health team in the provision of vasodilators, regular blood sugar checks and oxygen therapy.
Rational: vasodilator administration will increase the dilation of blood vessels so that tissue perfusion can be improved, while the regular blood sugar checks can be up to date and state of the patient, to improve the oxygenation of the ulcer / gangrene.