Impaired Tissue Integrity - NCP for Diabetic Foot Ulcers
NCP for Diabetic Foot Ulcers
Diabetes mellitus is a metabolic disorder in which is found the inability to oxidize carbohydrates, due to interference with the normal mechanism of insulin, causing hyperglycemia, glycosuria, polyuria, thirst, hunger, body lean, and weakness.
People with diabetes may experience some complications together or there is a problem that dominates, which include vascular disorders, retinopathy, diabetic nephropathy, diabetic neuropathy and diabetic foot ulcers.
Diabetic foot ulcers that are present in patients with diabetes mellitus due to diabetic angiopathy, diabetic neuropathy or trauma.
Diabetic gangrene gangrene due to microangiopathy also called hot because although necrosis, acral areas it looks red and feels warm by inflammation, and usually palpable distal arterial pulsation. Usually there is a diabetic ulcer on the sole of the foot.
Nursing Diagnosis : Impaired Tissue Integrity related to the presence of gangrene in the extremities.
Goal: The achievement of the wound healing process.
Expected outcomes:
1. Assess spacious and state of the wound and the healing process.
Rationale: proper assessment of the injury and the healing process will assist in determining the next action.
2. Treat the wound properly: Clean the wound aseptically using a solution that is not irritating, lift the rest of the bandage that sticks to the wound and necrotomy dead tissue.
Rational: Taking care of the wound with aseptic technique, can keep the wound contamination and irritating solution would damage arising tyang granulation tissue, necrotic tissue wrapping the rest can hinder the process of granulation.
3. Collaboration with physicians to insulin administration, culture examination pussy blood sugar checks provision of anti-biotic.
Rational: insulin will lower blood sugar levels, pus culture examination to determine the type of bacteria and antibiotics, are appropriate for treatment, examination of blood sugar levels to determine the progression of the disease.
Diabetes mellitus is a metabolic disorder in which is found the inability to oxidize carbohydrates, due to interference with the normal mechanism of insulin, causing hyperglycemia, glycosuria, polyuria, thirst, hunger, body lean, and weakness.
Diabetic foot ulcers that are present in patients with diabetes mellitus due to diabetic angiopathy, diabetic neuropathy or trauma.
Diabetic gangrene gangrene due to microangiopathy also called hot because although necrosis, acral areas it looks red and feels warm by inflammation, and usually palpable distal arterial pulsation. Usually there is a diabetic ulcer on the sole of the foot.
Nursing Diagnosis : Impaired Tissue Integrity related to the presence of gangrene in the extremities.
Goal: The achievement of the wound healing process.
Expected outcomes:
- Reduced edema around the wound.
- Pus in the tissue is reduced.
- The presence of granulation tissue.
- Reduced wound stench.
1. Assess spacious and state of the wound and the healing process.
Rationale: proper assessment of the injury and the healing process will assist in determining the next action.
2. Treat the wound properly: Clean the wound aseptically using a solution that is not irritating, lift the rest of the bandage that sticks to the wound and necrotomy dead tissue.
Rational: Taking care of the wound with aseptic technique, can keep the wound contamination and irritating solution would damage arising tyang granulation tissue, necrotic tissue wrapping the rest can hinder the process of granulation.
3. Collaboration with physicians to insulin administration, culture examination pussy blood sugar checks provision of anti-biotic.
Rational: insulin will lower blood sugar levels, pus culture examination to determine the type of bacteria and antibiotics, are appropriate for treatment, examination of blood sugar levels to determine the progression of the disease.
