- Impaired Tissue Integrity related to Obesity and Insufficient knowledge about maintaining tissue integrity as evidenced by delayed wound healing and Tissue damage
- Ineffective Peripheral Tissue Perfusion related to Impaired circulation as evidenced by absent or decreased peripheral pulses and delayed peripheral wound healing
- Unstable Blood Glucose related to Insufficient adherence to diabetes management and Inadequate blood glucose monitoring as evidenced by Frequent urination and Increased thirst
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Pain -Itching -Numbness to affected and surrounding skin Objective data: -Changes to skin color (erythema, bruising, blanching) -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Tissue Integrity related to Obesity and Insufficient knowledge about maintaining tissue integrity as evidenced by delayed wound healing and Tissue damage | Patient will report altered sensation or increased pain in the area of tissue impairment. Patient will verbalize an understanding of the treatment plan to heal the tissue injury and prevent infection. Patient will demonstrate a decrease in wound size and the presence of granulation tissue | 1. Inspect and monitor the site of impaired tissue integrity. Instruct the patient to inspect their feet and lower legs daily. They may utilize a mirror for difficult-to-see areas or ask a family member to assist. Color changes, swelling, redness, warmth, and other signs of infection must be reported. 2. Clean, dry, and moisturize the skin. Keeping the skin clean, dry, and moisturized helps improve the skin barrier, aids tissue repair, and maintains skin integrity. 3. Provide wound care as indicated. Proper wound care will help promote tissue integrity and healing. Wound healing may be difficult due to the diabetic disease process and may require outpatient wound care support or treatments such as hyperbaric oxygen therapy. 4. Encourage physical therapy and exercise. Physical therapists can advise on appropriate exercise regimens to maintain mobility and strength. Even low-intensity aerobic exercise has been shown to improve sensations in the feet and reduce pain. 5. Involve case management and home care. Wound healing may take weeks to months. Educate the patient and family on proper wound care, dressing changes, and follow-up appointments, and involve other disciplines as necessary. | Patient reported altered sensation or increased pain in the area of tissue impairment. Patient verbalized an understanding of the treatment plan to heal the tissue injury and prevent infection. Patient demonstrated a decrease in wound size and the presence of granulation tissue |
| Subjective data: -Chest Pain -Dyspnea Objective data: -Arrhythmias -Capillary refill >3 seconds -Altered respiratory rate -Use of accessory muscles to breathe Abnormal arterial blood gases -Unstable blood pressure -Cyanosis | Ineffective Peripheral Tissue Perfusion related to Impaired circulation as evidenced by absent or decreased peripheral pulses and delayed peripheral wound healing | Patient will exhibit adequate tissue perfusion as evidenced by palpable pulses and warm and dry skin. Patient will demonstrate interventions to improve tissue perfusion and prevent further complications of diabetic neuropathy. | 1. Educate the patient on proper blood glucose management. Explain the importance of tight glycemic control and how chronic hyperglycemia damages blood vessels leading to poor tissue oxygenation. Ensure the patient understands how to monitor their glucose levels and adhere to their antidiabetic medication regimen. 2. Encourage the patient to ambulate as tolerated. Ambulation can help promote blood flow and encourage adequate tissue perfusion throughout the body. If the patient’s mobility is limited, seated exercises are also beneficial. 3. Educate and assist the patient in proper foot and leg care. Instruct on inspecting the feet daily and consulting with a podiatrist for any concerns. Discuss obtaining specially fitted footwear or inserts as necessary. 4. Instruct the patient to avoid heat to poorly perfused tissues. Heat application on the extremities of patients with diabetic neuropathy can easily damage ischemic and poorly perfused tissues | Patient exhibited adequate tissue perfusion as evidenced by palpable pulses and warm and dry skin. Patient demonstrated interventions to improve tissue perfusion and prevent further complications of diabetic neuropathy. |
Subjective data: Verbalizes unable to manage the Blood glucose level Objective data: -Frequent urination -Increased thirst -Tingling sensation/numbness in feet -Headache -Dizziness | Unstable Blood Glucose related to Insufficient adherence to diabetes management and Inadequate blood glucose monitoring as evidenced by Frequent urination and Increased thirst | Patient will maintain glucose levels at or below 125 mg/dL. Patient will verbalize a plan for modifying their lifestyle to prevent variations in glucose levels. Patient will verbalize their medication regimen for controlling diabetes mellitus. | 1. Perform blood glucose testing. Patients with diabetes will have individualized goals for glucose control, but most glucose levels should be below <125 mg/dL. Consistently high glucose levels damage blood vessels and nerves. 2. Conduct meal planning with the patient and family. Diet is a crucial component of diabetes management. Complex carbohydrates are recommended as they help maintain glucose levels, lower cholesterol, and ensure satiety. Carbohydrate intake must be balanced and calculated according to the patient’s specific needs. Involving the family will promote a sense of involvement, especially if they prepare the patient’s meals. 3. Administer hypoglycemic medications. The core management of DM lies primarily in the appropriate pharmacologic therapies necessary for each patient. Physicians may prescribe the following antidiabetic medications: Sulfonylureas (glipizide, gliclazide, glimepiride): These medications inhibit the K-ATP channel, causing an influx of calcium and insulin release. Meglitinides (repaglinide and nateglinide): They work similarly to sulfonylureas by inducing insulin secretion from the pancreas. Biguanides (metformin): Metformin is the first-line agent for patients with type 2 DM. It acts by decreasing glucose production in the liver, decreasing intestinal absorption, and increasing insulin sensitivity. Thiazolidinediones (rosiglitazone, pioglitazone): These drugs increase insulin sensitivity and peripheral uptake of insulin. It also stimulates fatty acid oxidation, which leads to an increase in the number of insulin-sensitive adipocytes. Insulin: Injectable insulin helps with the uptake of glucose to be used for energy and for storage in the liver as glycogen. 4. Educate about the management of diabetes at home. Since some possible reasons why patients have unstable glucose control include poor adherence and inadequate glucose monitoring, nurses must firmly instill in them the importance of adherence. Subsequently, compliance could be facilitated by providing adequate knowledge to patients about their disease condition and management. | Patient maintained glucose levels at or below 125 mg/dL. Patient verbalized a plan for modifying their lifestyle to prevent variations in glucose levels. Patient verbalized their medication regimen for controlling diabetes mellitus. |