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Impaired Skin Integrity

Nursing Care Plan for Diabetes Mellitus

Impaired Skin Integrity related to pressure, altered metabolic state, circulatory impairment, and decreased sensation, as evidenced by draining wound L foot.

Wound Healing: Secondary Intention (NOC) Indicators:

Client Will
Be free of purulent drainage within 48 hours (6/30, 7 p.m.). Display signs of healing with wound edges clean and pink within 60 hours (7/1, 7 a.m.).

Nursing care plan intervention and rationale:
1. Irrigate wound with room-temperature sterile normal saline (NS) tid.
Rationale: Cleans wound without harming delicate tissues.

2. Assess wound with each dressing change. Obtain wound tracing on admission and at discharge.
Rationale: Provides information about effectiveness of therapy and identifies additional needs.

3. Apply wet to dry sterile dressing. Use paper tape.
Rationale: Keeps wound clean, minimizes cross-contamination. Adhesive tape may be abrasive to fragile tissues.

4. Follow wound precautions.
Rationale: Use of gloves and proper handling of contaminated dressings reduces likelihood of spread of infection.

5. Obtain sterile specimen of wound drainage on admission.
Rationale: Culture/sensitivity identifies pathogens and therapy of choice.

6. Administer dicloxacillin 500 mg PO q6h, starting at 10 p.m.
Rationale: Treatment of infection and prevention of complications. Food interferes with drug absorption, requiring scheduling around meals.

7. Observe for signs of hypersensitivity: pruritus, urticaria, rash.
Rationale: Although no prior history of penicillin reaction, it may occur at
any time.
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