ASSESSMEN DIAGNOSIS GOAL PLANNING EVALUATIO

T N
1. Assess for  Risk for Injury  THE 1. Instruct NOW TYE
the presence RELATED TO PATIEN the patient in PATIENT IS
of T the hygiene WELL UPTO
contributing Hyperglycemia SHOUL principle: SOME
factors that  Hypoglycemia D BE wash the feet EXTENT.
increase the  Peripheral sensory FREE daily in warm
risk for neuropathy FROM water using
injury.  Autonomic INJURY mild soap;
To provide neuropathy . avoid soaking
baseline data  Immune system  To the feet. Dry
necessary in deficit reduce carefully and
developing the risk gently,
 Vascular insuffici
individualized of especially
ency
care. Injury infection between toes.
 Blurred vision
risk increases and Use
with the  Cataracts moisturizing
amputati
number of  Decreased tactile lotion at least
on
factors sensitivity once daily.
 To
identified. improve Avoid the
function area between
and the toes.
2. Assess the
quality Maceration
general
of life between the
appearance
 To toes
of the foot.
reduce predisposes
Foot lesions
health the patient to
and
care infection. The
associated
costs use of lotion
wound
replaces the
infections are
moisturizing
the most
effects lost by
common
autonomic
reason for
neuropathy.
hospitalizatio
The patient
n of the
should select a
patient with
lotion with a
DM. The
low alcohol
patient’s feet
content to
should be
prevent
meticulously
drying.
inspected at
every visit.
The patient 2. Instruct
may be the patient to
unaware of inspect the
injuries to the feet daily for
feet due to cuts,
decreased scratches,
sensation and blisters.
from A mirror may
peripheral be necessary
neuropathy. to assess the
Impaired bottom of the
vision from foot. Instruct
DM may to use both
decrease the visual
ability to inspection
inspect the and touch.
feet. All surfaces of
the foot need
to be
3. Assess the
examined,
status of the
including the
nails.
skin between
Fungal
toes. Touch
infections in
will identify
nails serve as
skin surface
a portal of
alterations that
entry for
are not evident
bacteria. The
by sight.
patient with
diabetes has
an increased 3. Teach the
risk for patient to
infection inspect the
because of shoes daily by
impaired feeling the
immunity. inside of the
Patients with shoe for
thickened or irregularities
deformed or sharp
nails should objects.
be referred for Reduces the
treatment. risk of injury
to the foot.
4. Assess the
patient’s skin 4. Instruct
integrity. the patient
Autonomic always to
neuropathy wear
leads to protective
decreased footwear;
perspiration, never go
causing barefoot.
excessive Keeping the
dryness and feet covered to
fissuring of prevent
the skin. Skin injuries to the
breakdown foot.
predisposes
the patient to
5. Instruct
infection.
the patient to
trim nails
5. Note the straight
presence of across and to
callus file sharp
formation or corners to
corns. match the
Pressure over contour of the
bony toe.
prominences It helps avoid
leads to callus injury to the
formation; toes when
may lead to self-care
the cannot be
development provided.
of skin
breakdown. 6. Instruct
the patient to
wear clean,
6. Assess for
well-fitting
evidence of
stockings
infection.
made from
Infection may
soft cotton,
be the
synthetic
initiating
blend, or
event for
wool.
eventual
Soft cotton or
amputation.
wool absorbs
Symptoms of
moisture from
pain and
perspiration
tenderness
and
may be absent
discourages an
because of
environment
neuropathy.
in which
Look for
fungus can
redness,
thrive.
drainage, and
swelling.
7. Perform
urine ketone
7. Monitor
testing, as
for signs of
indicated.
ketone
For patients
accumulation
with type 1
and DKA.
diabetes
Ketones are
presenting
by-products
with persistent
of fat
glycosuria and
breakdown
hyperglycaemi
and
a, urine ketone
accumulate in
testing should
the blood and
be initiated.
urine.
Ketones
detected in
urine mean
insulin is
deficient.
When this
process
continues, the
risk of DKA
increases. The
body then
starts to break
down stored
fat for energy.

8. Assess for
oedema.
Oedema is a
major
predisposing
factor to
ulceration.
Autonomic
neuropathy
results in the
loss of
vasomotor
reflexes and
swelling in
the foot.