Signs and Symptoms Signs: -(+) swelling of right foot with foul-smelling drainage from the ulceration -With

heavily soaked dressing Symptoms: -patient verbalized parang hindi gumagaling yung sugat ko sa paa.

Nursing Diagnosis Impaired skin integrity r/t open wound secondary to impaired circulation

Rationale Diabetes sometimes affects the nerves of the feet, causing a loss of sensation. Therefore, when a person with decreased sensory perception in the feet is wounded, the wound is left unnoticed and may develop an infection.

Objectives Short term: - Clean and disinfect the wound - Promote timely wound healing Long term: -educating the patient regarding the importance of monitoring of open wound and proper wound care.

Intervention 1) Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, hammer toe or bunion deformation, hair distribution, pulses, deep tendon reflexes. 2) Instruct patient in foot care guidelines 3) Inspect
incision regularly, noting characteristic s and integrity.

Rationale 1) This will prevent further damage to tissues in the patients foot

Evaluation After appropriate nursing intervention, the patient will be able to -demonstrate how to take care of open wound -discuss the importance of hygiene in promoting skin integrity

2) Educating the patient will help promote cooperation 3) This will keep the wound in check and prevent complications

4) Teach patient proper wound care

4) Cleanliness helps prevent infection and its spread.

Signs: - Open wound @ R foot - (+) foul smell - (+) purulent drainage on wound - Cold, pale skin Symptoms: -

Infection r/t wet gangrenous foot secondary to DM II

Diabetes Short Term: sometimes affects - Clean and the nerves of the disinfect the feet, causing a wound loss of sensation. - Prevent Therefore, when a infection from person with worsening decreased sensory perception in the Long Term: feet is wounded, - Prevent future the wound is left infections of unnoticed and the wound may develop an infection.

1) IV antibiotics as ordered by physician

2) Assist in wound debridement

3) Teach patient the proper way to change the dressing (using aseptic techniques) 4) Emphasize the importance of self-checking

1) Antibiotics will help eliminate infection and prevent its spread. 2) This prevents the spread of infection to other organs of the body 3) To help prevent reinfection of the wound

After appropriate nursing intervention, - The patient will have a clean and disinfected the wound - The wound will be prevented from worsening - The client will be able to prevent future infections of the wound

5) Instruct the patient to cut toenails regularly 6) Use heel protectors, special

4) Since the patients DM has lowered his sensory perception, self-checking will prevent wound from getting infected 5) This will prevent further wounds to the feet. 6) Protects feet from getting wounded

Signs: - (+) DM Type II - Hard-to-heal skin - Loss of sensory perception in feet - BP 130/90 Symptoms: -patient verbalized may kakaibang pakiramdam sa mga paa ko

Ineffective tissue perfusion, peripheral r/t decreased arterial flow as evidenced by pale and cool feet, and numbness and tingling of the feet

Diabetes mellitus Type II occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the bodys tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.

Short Term: -Promote tissue perfusion to the affected area -Increase perfusion until adequate -client will verbalize understanding of the relationship between diabetes and circulatory changes -demonstrate awareness of safety factors and foot care Long Term: -Keep tissue perfusion adequate -Maintain adequate level of hydration to maximize perfusion

mattresses, foot cradles for patients on bed rest. 1) Antidiabetics as ordered by physician

2) Elevate feet when up in a chair. Avoid putting the feet in a dependent position. 3) Assess for signs of dehydration. Monitor I&O and encourage oral fluids.

1) Taking care of the underlying disease will help alleviate the effects 2) Minimizes interruption of blood flow and reduces venous pooling.

4) Reinforce safety precautions regarding use of heating pads, hot water bottles, and soaks

3) Glycosuria may result in dehydration with consequent reduction of circulating volume. 4) Heat increases metabolic demands on compromised tissues. Vascular insufficiency alters pain sensation, increasing risk

After appropriate nursing intervention, -the patient will be able to promote tissue perfusion to the affected area -Patients perfusion will increase until adequate -client will verbalize understanding of the relationship between diabetes and circulatory changes -demonstrate awareness of safety factors and foot care

5) Instruct client to avoid constricting clothing, socks and ill-fitting shoes 6) Discuss complications of the disease that result from vascular changes

of injury. 5) Compromised circulation and decreased pain sensation promotes tissue breakdown 6) Promote patient knowledge and cooperation