- Impaired Physical Mobility related to Peripheral neuropathy, Reluctance to move and Amputation as evidenced by Limited range of motion, Use of prosthetic devices and Use of assistive devices
- Impaired Skin Integrity related to: Poor glycaemic control and Inadequate knowledge about protective skin integrity as evidenced by Abscess formation and Disrupted epidermis/dermis
- Ineffective Tissue Perfusion related to Interruption in blood flow and Insufficient knowledge of diabetes mellitus and its management as evidenced by Foot ulceration, Weak or absent peripheral pulses and Prolonged capillary refill time. Delayed wound healing
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Expression of pain and discomfort with movement Refusal to move Objective data: -Limited range of motion -Poor balance -Inability to turn in bed, transfer, or ambulate -Postural instability -Gait disturbances -Reliance on assistive devices | Impaired Physical Mobility related to Peripheral neuropathy, Reluctance to move and Amputation as evidenced by Limited range of motion, Use of prosthetic devices and Use of assistive devices | Patient will demonstrate interventions that promote increased mobility. Patient will effectively use assistive devices and perform activities independently. | 1. Encourage the patient to perform range of motion exercises. Exercise can help prevent muscle stiffness and improves blood circulation in the affected area. 2. Assist the patient in using assistive devices. Pressure offloading is essential in the management and healing of diabetic foot ulcers. Patients can use assistive devices like wheelchairs, crutches, cancer, and trapeze bars to reposition themselves. Use pillows and wedges to elevate extremities. 3. Encourage the patient and family members to participate in care. Motivation and assistance by family members may be necessary to assist the patient with movement and repositioning expectations. 4. Consult with a prosthetist. In the event that the patient requires amputation, they may be fitted with a prosthetic. A prosthetist is trained to work with those with disabilities and instruct on the wear and use of the prosthetic for optimal mobility. | Patient demonstrated interventions that promote increased mobility. Patient effectively used assistive devices and performed activities independently. |
| Subjective data: -Pain -Itching -Numbness to affected and surrounding skin Objective data: -Changes to skin color -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Skin Integrity related to: Poor glycaemic control and Inadequate knowledge about protective skin integrity as evidenced by Abscess formation and Disrupted epidermis/dermis | Patient will demonstrate interventions, including proper skin care that promotes the healing of diabetic foot ulcers. Patient will demonstrate timely wound healing without complications. | 1. Remind the patient to inspect the feet daily. Patients with neuropathy or peripheral vascular disease may not be able to feel when they have cut their skin. They must inspect their feet and lower legs daily for open areas. They can accomplish this by holding a mirror under their feet or having a family member assess them. 2. Advise the patient to avoid walking in bare feet. The patient should wear footwear at all times. The patient can wear slippers indoors. 3. Assist with debridement. Wounds with necrotic tissue or nonviable tissue must be removed to allow for treatment and healing. 4. Perform wound care. Perform wound care per the physician’s orders. Depending on the type and thickness of the wound, this can include hydrocolloid dressings, absorptive dressings, alginate dressings, hydrogels, silver nitrate, and wound vacs. 5. Encourage the patient on skin care. The patient should keep their skin moisturized, clean, and dry to prevent breakdown. | Patient demonstrated interventions, including proper skin care that promotes the healing of diabetic foot ulcers. Patient demonstrated timely wound healing without complications. |
| Subjective data: Chest Pain Dyspnea Sense of impending doom Objective data: -Capillary refill >3 seconds -Altered respiratory rate -Abnormal arterial blood gases -Unstable blood pressure -Tachycardia or bradycardia -Cyanosis | Ineffective Tissue Perfusion related to Interruption in blood flow and Insufficient knowledge of diabetes mellitus and its management as evidenced by Foot ulceration, Weak or absent peripheral pulses and Prolonged capillary refill time. Delayed wound healing | Patient will maintain optimal peripheral tissue perfusion as evidenced by the following: Strong, palpable pulses Warm and dry extremities Capillary Refill Time of <2 secs Observed healing of the wound Patient will not experience complications of ineffective perfusion, such as infection, gangrene, or amputation. | 1. Instruct on an optimal hemoglobin A1c. Educate the patient on maintaining a HbA1c of < 7% to ensure glycemic control and reduce the risk of vascular complications. 2. Perform bedside Duplex ultrasonography. If palpating a pulse is difficult, the nurse can use a portable Doppler device to assess for alterations in blood flow and detect venous insufficiency. 3. Assess ankle-brachial index. This test is recommended to screen for PAD in patients with diabetes over age 50. A result of < 0.9 indicates PAD. 4. Consider hyperbaric oxygen therapy. Wounds that fail to heal after 30 days may need hyperbaric oxygen therapy to speed the rate of healing and reduce complications. 5. Inform on lifestyle factors that can promote improved tissue perfusion. These measures decrease venous compression/stasis and arterial vasoconstriction: Avoiding crossed legs when sitting Exercising Maintaining a healthy weight Not smoking | Patient maintained optimal peripheral tissue perfusion as evidenced by the following: Strong, palpable pulses Warm and dry extremities Capillary Refill Time of <2 secs Observed healing of the wound Patient will not experience complications of ineffective perfusion, such as infection, gangrene, or amputation. |