interventions for infectious tissue perfusion...

Cilantrophobe · Oct 5, 2009

Infection control and fall prevention are two I found in my book

Daytonite, BSN, RN · Oct 5, 2009

disturbed sensory perception related to infectious tissue perfusion as evidenced by necrotic right toe

this requires understanding what the parts of the nursing diagnostic statement mean:

problem:
disturbed sensory perception (probably tactile) -
change in the amount or pattering of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli
etiology:
infectious tissue perfusion - the patient has an infected wound with poor circulation? is that what this means?
symptoms:
necrotic right toe (this does not make sense as a symptom of this diagnosis)

the usual symptoms for disturbed sensory perception are things like poor concentration, irritability, disorientation, changes in behavior, etc. these are things that affect the perception of what the patient

feels

since

this diagnosis is about sensation

. a necrotic right toe doesn't tell us anything about what the patient is

feeling

in this toe or foot, so it makes it very difficult to develop nursing interventions for this diagnosis. what you need to do is re-assess what the patient's sensations are in this foot and toe before going any further.

skygirl · Oct 5, 2009

Thanks to all replies. yes I agree that this is not the correct nursing dx but this is what my teacher wrote and wants me to use. The pt is diabetic and has wound on his toe that is infected and is going to be amputated. Thats as much as I know. Im very new, one month into the program so not sure of the correct terms yet. I think I will just use the fall risk and infection control since this dx doesnt really make sense. Pt is gone so this is just for learning purposes but It does worry me that me teacher doesnt know how to write a nursing diagnosis!

Daytonite, BSN, RN · Oct 6, 2009

complications of diabetes like this are common and you are going to see them all the time in patients. whether the nursing diagnosis is written correctly or not, you need to understand what is happening with this patient. see http://www.columbia-stmarys.com/content.asp?pageid=p00336 - diabetic foot problems and note the reference to the loss of sensation in the feet that can be the cause of sores and ulcers that go undetected. that is disturbed sensory perception. the infectious tissue perfusion is what your instructor is saying is the cause of the necrotic right toe. what does the patient feel in that right toe? probably nothing. maybe pain of some sort. this is a common situation that we encounter in patients with diabetes. i'll agree that this is not the way i would write this nursing diagnosis (i would write this as disturbed sensory perception r/t ineffective tissue perfusion aeb necrotic right toe and the word "infectious" may be a typo), but i understand the idea behind what your instructor is wanting you to do. before giving up on this i would clarify with the instructor how to proceed with this.

interventions include preparation for wound healing such as increasing intake of vitamin c and zinc, attention to body image or grief at loss of the toe. if there is indeed an infectious process going on then attention to maintaining normal blood sugar levels needs to be done for any kind of healing to occur. the patient needs to protect the toes from any further trauma (bumps or stubbing them) because he has no sensation there. bathing water needs to be tested carefully for temperature so it isn't too hot (the other toes needs protection from this same fate). and do not forget about any patient teaching with regard to pre-op or post-op care.

skygirl · Oct 6, 2009

Thank you! You were right. My teacher had hand written this and I couldnt read her writing. Infectious was meant to be ineffective. Things are making much more sense now. I appreciate your help. This is my very first nursing dx so thats why I didnt catch it. much appreciated!