Impaired Tissue Perfusion Related To The Weakening / Decreased Blood Flow To The Area of Gangrene Due To Obstruction of Blood Vessels

ASSESSMENT NURSING DIAGNOSIS PATIENT OUTCOME/ NURSING INTERVENTION RATIONALE
CLIENT GOAL
Impaired Tissue  Maintain  Teach the patient to mobilize  The mobilization improves blood circulation.
Perfusion related to peripheral
the weakening / circulation  Teach about the factors that can increase blood flow:  To increase blood flow through so that does not
decreased blood flow remain normal. Elevate the legs slightly lower than the heart (elevation happen edema.
to the area of position at rest), avoid tight bandage, avoid using a
gangrene due to pillow, behind the knees and so on.
obstruction of blood  High cholesterol can accelerate the occurrence of
vessels  Teach about the modification of risk factors such as: atherosclerosis, smoking can cause vasoconstriction
Avoid high-cholesterol diet, relaxation techniques, stop of blood vessels, relaxation to reduce the effects of
smoking, and drug use vasoconstriction. stress.
 vasodilator administration will increase the dilation

of blood vessels so that tissue perfusion can be
 Cooperation with other health team in the provision improved, while the regular blood sugar checks can
of vasodilators, regular blood sugar checks and be up to date and state of the patient, to improve
oxygen therapy (HBO). the oxygenation of the HBO ulcer / gangrene.
 Hand hygiene is the single most effective way to

prevent the transmission of diseases. Include the
Risk for Infection
 Identify  Teach and promote good hand hygiene. patient’s SO in teaching.
interventions to  Increased glucose in the blood creates an excellent
prevent/reduce medium for immune dysfunction and for pathogens
risk of to thrive.
infection.  Maintain asepsis during IV insertion, administration  Urinary tract infections are more prevalent in
 Demonstrate of medications, and providing wound or site care. individuals with diabetes. Diabetes is a predisposing
techniques, Rotate IV sites as indicated. factor for vaginitis. Poor perineal hygiene increases
lifestyle the risk of vaginitis and can spread through the
changes to urinary tract causing infection.
prevent  Provide catheter or perineal care. Teach female
development of patients to clean from front to back after
infection. elimination.
 An impairment or ineffective peripheral circulation

can place the patient at risk for increased skin
breakdown and the development of infection.
 Provide meticulous skincare by gently massaging

bony areas, keep skin dry. Keep linens dry and  Facilitates lung expansion; reduces the risk
wrinkle-free. of aspiration.
 Helps in the ventilation of all lung areas and
mobilizing secretions – stasis of secretions can
 Place in semi-Fowler’s position. increase the risk of infection.
 Encourage coughing or deep breathing if the patient

is alert and cooperative. Frequent repositioning is
also recommended.  To help minimize the spread of infection.
 Provide tissues and trash bags in a convenient

location for sputum and other secretions. Instruct  Reduces risk of oral/gum disease.
patient in the proper handling of secretions.
 Encourage and assist with oral hygiene.

 Increase fluid intake to approximately 3,000 mL per
 Encourage an increase in fluid intake unless day to increase urinary flow and prevent stasis of
contraindicated. Encourage intake of cranberry juice urine, increasing susceptibility to infection
per day as appropriate. (i.e., urinary tract infection). Regular intake of
cranberry juice can help inhibit the adhesion of
pathogens to the bladder wall and impair
colonization.
 Early treatment may help prevent sepsis as patients
with diabetes are more prone to serious infectious
diseases.
 Streptococcus pneumonia and influenza virus are
 Administer antibiotics as indicated. the most frequent respiratory infections associated
with persons with diabetes. They are six times more
likely to need hospitalizations during influenza
epidemics than non-diabetic patients. Anti-
pneumococcal and influenza vaccines are
 Recommend obtaining vaccines, as indicated. recommended

Impaired Tissue Perfusion Related To The Weakening / Decreased Blood Flow To The Area of Gangrene Due To Obstruction of Blood Vessels

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ASSESSMENT NURSING DIAGNOSIS PATIENT OUTCOME/ NURSING INTERVENTION RATIONALE

 vasodilator administration will increase the dilation

 Hand hygiene is the single most effective way to

 An impairment or ineffective peripheral circulation

 Provide meticulous skincare by gently massaging

 Encourage coughing or deep breathing if the patient

 Provide tissues and trash bags in a convenient

 Encourage and assist with oral hygiene.

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