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Impaired Skin DM

Impaired Skin DM

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Published by togbrowpot

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Published by: togbrowpot on Jul 07, 2009
Copyright:Attribution Non-commercial


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O> altered level of consciousness>generalizedweakness>numbness of thelower extremities>disruption of skinlayers at the left leg>edema on both upper and lower extremities>muscle weakness>diagnosed DM patientImpaired skinintegrity r/t largevessel destruction asevidenced byalteration in pressuredistribution,ulcerationAlterations in bloodflow/ blood viscosity,increased plateletaggregation, andaccelerated capillaryendothelial growth/large vesseldestruction/loss of foot sensation/completely unnoticedcuts or trauma to theskin/ blood glucoseconcentration mayslow or even reversethis pathological process/Slow wound healing processD.O.After 1 wk of nursinginterventions, the patient will be able todisplay improvementin wound healing asevidenced by:
Intact skin andMinimized presenceof wound.
Absence of itchiness,rednessS.T.O.After 8 hours of nursing interventionthe patient will beable to:
Participate in prevention measuresand treatment program
Demonstrate proper wound care c/owatcher INDEPENDENTAssessed skin. Notedcolor, turgor, andsensation. Describedwounds and observedchanges.Demonstrated goodskin hygiene, e.g.,wash thoroughly and pat dry carefully.Instructed family tomaintain clean, dryclothes preferablycotton fabricEmphasizeimportance of adequate nutrition andfluid intake.Demonstrate to familymembers how to makea guava decoction toapply in the wound asalternativedisinfectant.Establishescomparative baseline providing opportunityfor timelyintervention.(Doenges)Maintaining clean, dryskin provides a barrier to infection. Pattingskin dry instead of rubbing reduces risk of dermal trauma tofragile skin. (Brunner)Skin friction caused by stiff or roughclothes leads toirritation of fragileskin and increases risk for infection. (Kozier)Improved nutritionand hydration willimproved skincondition. (Doenges)Assists them inoptimal healing withless expensiveresources. (taylor)Long and rough nailsincreases risk of skinD.O.At the end of the 1week nursingintervention, the clientwas able to displayimprovement inwound healing asevidenced by:
Intact skin
Minimized presenceof wounds,
Absence of rednessor itchinessS.T.O.After 8 hours of nursing interventionthe patient will be ableto:
Participate in prevention measuresand treatment program
Demonstrate proper wound care c/owatcher 
Instruct the family toclip and file the nailsregularly.damage. (Kozier).Provided and appliedwound dressingscarefully.Apply lotion on legsCOLLABORATIVE Note laboratoryresults pertinent tocausative factors(Hb/Hct, bloodglucose, albumin)Assist withdebridement therapyas indicated.Wound dressings protect the wound andthe surroundingtissues. (Doenges)To prevent dryness of skin (Kozier)To assess causativefactors. (Kozier)To clean the woundedarea and preventscontamination.(Brunner)

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Shiloh Theriault added this note
Ditto ! I know it works; saw evidence of it in the face of a nurse who is 53 and looks about 35; she just smears it on every morning and it defies belief but your looking at the proof that it work like a miracle !
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