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Nursing Diagnosis Rationale Interventions Rationale Evaluation

This document outlines the nursing diagnosis, rationale, interventions, and evaluation for a patient at risk of impaired skin integrity due to unstable blood glucose from diabetes. The patient has diabetes mellitus type 2 which can cause peripheral neuropathy and poor circulation, increasing the risk of skin breakdown. The nurse will assess the patient's skin integrity, blood glucose levels, and provide interventions like foot inspections, moisturizers, and proper footwear to maintain healthy skin and blood sugar control during hospitalization. The goal is for the patient to learn how to manage their diabetes and prevent skin issues through daily foot care and keeping blood glucose within target ranges.

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Jobie Casipong
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873 views2 pages

Nursing Diagnosis Rationale Interventions Rationale Evaluation

This document outlines the nursing diagnosis, rationale, interventions, and evaluation for a patient at risk of impaired skin integrity due to unstable blood glucose from diabetes. The patient has diabetes mellitus type 2 which can cause peripheral neuropathy and poor circulation, increasing the risk of skin breakdown. The nurse will assess the patient's skin integrity, blood glucose levels, and provide interventions like foot inspections, moisturizers, and proper footwear to maintain healthy skin and blood sugar control during hospitalization. The goal is for the patient to learn how to manage their diabetes and prevent skin issues through daily foot care and keeping blood glucose within target ranges.

Uploaded by

Jobie Casipong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE EVALUATION

Risk for Impaired Skin Integrity Diabetes mellitus (DM) is a  Assess integrity of the  These are assessments At the end of my 8 hours of
secondary to Unstable Blood chronic disease characterized by skin. Assess knee and for neuropathy. Skin on nursing intervention the patient
Glucose as evidenced by insufficient production of insulin deep tendon reflexes and lower extremity pressure will be able to:
decreased circulation and in the pancreas or when the body proprioception. points is at great risk for
sensation caused by peripheral cannot efficiently use the insulin it ulceration.  Maintain blood sugar
neuropathy and arterial produces. This leads to an  Use foot cradle on the  To prevent pressure on control with minimal side
obstruction and lack of increased concentration of bed. Use space boots on pressure-sensitive points. effects.
adherence to diabetes glucose in the bloodstream ulcerated heels, elbow  Have blood glucose
management. (hyperglycemia). It is protectors, and pressure- reading of less than 180
SUBJECTIVE CUE: characterized by disturbances in relief mattresses. mg/dL; fasting blood
carbohydrate, protein, and fat  Wash feet daily with mild  Decreased sensation glucose levels of less
metabolism. soap and warm water. increases the risk for than <140 mg/dL;
Sustained hyperglycemia has Check water temperature burns. hemoglobin A1C level
been shown to affect almost all before immersing feet in <7%.
tissues in the body and is the water.  The skin on legs and feet
OBJECTIVE CUE: associated with significant  Inspect feet daily for  These are signs that the remains intact while the
complications of multiple organ erythema or trauma. skin needs preventive patient is hospitalized.
systems, including the eyes, care.  Demonstrate proper foot
nerves, kidneys, and blood  Change socks or  To prevent infection from care.
vessels. stockings daily. moisture. White fabric
Type II is when the cells don’t Encourage the patient to enables easy visualization
respond to the insulin trying to wear white cotton socks. of blood or exudates.
get sugar into them, called insulin  Use gentle moisturizers  Moisturizers soften and
resistance. Thus the sugar stays on the feet. lubricate dry skin,
GOAL/PLAN: in the blood and the cells starve. preventing skin cracking.
 Blood sugar control with The cause for Type II diabetes is  Cut toenails straight  This action prevents
minimal side effects. caused by a storm of events across after softening ingrown toenails, which
 Patient has a blood culminating such as weight gain, toenails with a bath. could cause infection.
glucose reading of less lack of activity, genetics, and
 The patient should not  This is a high risk for
than 180 mg/dL; fasting stress levels.
walk barefoot. trauma and may result in
blood glucose levels of ulceration and infection.
less than <140 mg/dL;
hemoglobin A1C level
<7%.
 Patient’s skin on legs and
feet remains intact while
the patient is hospitalized.
 Patient will demonstrate
proper foot care.

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