Impaired Skin Integrity related to Diabetes Mellitus

Nursing Diagnosis for Diabetes Mellitus: Impaired Skin Integrity

Goal: After nursing Interventions, improved wound healing:

Expected outcomes:
  • Luka shrink in size and increase in granulation tissue.

Nursing Interventions:

Wound care
  1. Note the characteristics of the wound: determine the size and depth of the wound, and the classification of the influence ulcers
  2. Note the characteristics of the fluid that comes out secret
  3. Clean with a liquid anti-bacterial
  4. Rinse with 0.9% NaCl fluid
  5. Perform nekrotomi, if necessary
  6. Perform the appropriate tampon
  7. With sterile gauze dressing as needed
  8. Make dressing
  9. Maintain a sterile dressing technique when performing wound care
  10. Observe any changes in the packing
  11. Compare and note any changes in the wound
  12. Give position to avoid pressure
Rational:
Assessment of injuries, will be more realible done by the same caregiver in the same position and the same techniques.

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