Signs and Nursing Diagnosis Rationale Objectives Intervention Rationale Evaluation

Symptoms
Signs: Impaired skin Diabetes Short term: 1) Assess feet 1) This will After appropriate
-(+) swelling of integrity r/t open sometimes affects - Clean and and legs for prevent nursing
right foot with wound secondary the nerves of the disinfect the skin further intervention, the
foul-smelling to impaired feet, causing a wound temperature, damage to patient will be
drainage from the circulation loss of sensation. - Promote timely sensation, soft tissues in the able to
ulceration Therefore, when a wound healing tissue injuries, patient’s foot -demonstrate how
person with corns, calluses, to take care of
-With heavily decreased sensory Long term: dryness, open wound
soaked dressing perception in the -educating the hammer toe or -discuss the
feet is wounded, patient regarding bunion importance of
Symptoms: the wound is left the importance of deformation, hygiene in
-patient unnoticed and monitoring of hair promoting skin
verbalized may develop an open wound and distribution, integrity
“parang hindi infection. proper wound pulses, deep
gumagaling yung care. tendon
sugat ko sa paa.” reflexes.
2) Instruct 2) Educating the
patient in foot patient will
care guidelines help promote
cooperation
3) Inspect 3) This will keep
incision the wound in
regularly, check and
noting prevent
characteristic complications
s and
integrity.

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