Nursin intervention

[kaylawhite95]

hello,

My pt presents with a stroke (paralysis left side), rhabdomyolysis, diabetic ketoacidosis and necrotic wounds. past medical history of diabetes, hypertension. the pt needs full assistance with everything.

the patient is now going through the process of debridement with a negative pressure her wound on the shoulder is the negative pressure with irrigation and the one on the buttock is the normal one

I am doing a nursing diagnosis on delayed wound healing related to diabetes and immobility as evidence by a necrotic wound.

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[TD]Goal 1

Pt will experience no further skin damage or complication

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intervention

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[TD]Pt will be turned every 2 hours and avoid being placed on the left side for long periods of time

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[TD]Increase protein and vitamin intake in order to help with healing

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however, I am missing 2 more goals and do not know what to put.

I would really appreciate the help.

thank you,

a struggling nursing student

[KelRN215, BSN, RN]

You don't want her to experience any further skin damage, what do you want to happen with the existing wound?

What do you want to prevent with the existing wound?

[SaltineQueen]

How could her diabetes/DKA affect her wounds?

[kaylawhite95]

for the existing wound we want to help heal it and not get worse or bigger.

[kaylawhite95]

her uncontrolled diabetes prolongs wound healing

impairs the function of white blood cells, resulting in an inability to fight bacteria.

poor circulation. As circulation slows, red blood cells move more slowly. This makes it more difficult for the body to deliver nutrients to wounds

Nerve damage is another factor affecting wound healing. Uncontrolled blood glucose can damage the body's nerves

but what would a good goal be? as well as nursing intervetions?

[TheDudeWithTheBigDog, ADN, RN]

but what would a good goal be? as well as nursing intervetions?

Does this sound like a person that regularly visits her doctor for checkups, or takes her medications?

[KelRN215, BSN, RN]

for the existing wound we want to help heal it and not get worse or bigger.

Yes and also there's at least one other thing she's at risk for that you definitely want to prevent.

[Ladyscrubs]

Since pain is a normal part of the inflammatory process, you would be wise to assess the patient's level of pain. Diabetic or not, the extent and depth of the wound will have some affect on pain sensations. Plus instructors love to see it on a care plan.