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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
Assessment of injuries, will be more realible done by the same caregiver in the same position and the same techniques.