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Nursing Dx: Ineffective peripheral tissue perfusion r/t increased blood glucose levels AEB fasting blood glucose

levels ranging from 134-235


mg/dl, HgA1C of 9.5 %, and a non-healing wound to the LLE
Long Term Goal: Pt will maintain and show improvement in peripheral tissue perfusion
Outcome
Intervention
Rationale
Evaluation
Pt
is
a
62
y.o.
male
who
presented
with
a
non-healing
wound
to
the
LLE
with
a
hx
of
1. Pt will have a BP
Independent:
Outcome met;
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal insufficiency,
>90/50 and <140/90; Assess VS Q4H
plan ongoing
hyperlipidemia, and uncontrolled type 2 DM with diabetic neuropathy. DM is a chronic
HR will be between
and prn
due to the pt
multisystem disease that affects the vasculature throughout the body. In type 2 DM, the pt
60-100 bpm, regular;
still being at an
is unable ot produce enough insulin or the body is unable to utilize the insulin that is
produced. The extra free glucose causes damage to the blood vessels which results in a
respiratory rate
increased risk
narrowing of the vasculature. This narrowing prevents the tissues from getting enough
between 12-20
for
blood. The pt also has a hx of hyperlipidemia. When the body has high levels of lipids
breaths per minute,
compromised
circulating, the process of atherosclerosis is sped up as lipids stick to the walls of the arteries.
easy; SPO2 between
vasculature
As more plague builds up, the arteries can narrow and stiffen. Eventually, enough plague
93-100%; temp
may build up to reduce blood flow through the arteries. Both of these conditions can lead to and infection
an increase in blood pressure, since the space in the vessels has been significantly
between 96.8decreased. HR may decrease since the pressure that the heart needs to pump against is so
100.4F when assess
great. Combined, these things can decrease the amount of blood that is reaching the
Q4H and prn
tissues, especially in the periphery. If the body senses that the tissues are not getting
enough blood, respirations may increase, as the respiratory system tries to compensate for
the lack of oxygen that the tissues are receiving. Monitoring the SPO2 allows us to see the
percent of oxygen that is circulating in the blood on the hemoglobin and allows us to
determine if the tissues have an adequate availability of oxygen. Since the pt has a nonhealing wound to the LLE that edges are not approximated, he is at an increased risk for
developing an infection, because the bodys primary defense has been compromised. Since
the pt already has compromised peripheral vasculature, a localized infection to the
extremity has an increased chance of becoming systemic since the compromised blood flow
decreases the amount of WBC that can reach the infection. When the pt was first admitted
on 3/10, it was thought that he had an infection that was becoming systemic. Since
receiving the abx, his WBC has trended to normal but the wound still places him at risk and
monitoring his temperature and watching the trend, can provide information about a
systemic infection.

2.

Pts bil LE will remain


pink and warm and
pt will maintain
movement and
sensation when
assessed Q4H and
prn

Independent:
Perform CMST
checks to bil LE
Q4H and prn

Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Due to the type 2 DM and the hyperlipidemia, the pt has
compromised peripheral circulation and tissue perfusion, as evidenced by the nonhealing wound to the LLE. It is important that the status of the circulation of the
extremities be monitored so that the wound can heal and so that the pt doesnt
experience any further complications from the impaired tissue perfusion. When a

Outcome met;
plan ongoing
because pt still
has
compromised
peripheral
circulation

3.

Pts dressing will


remain dry, clean,
and intact when
assessed Qshift and
prn

Independent:
Assess dressing
on LLE Qshift
and prn

4.

Pts skin will remain


warm, dry, clean,
and intact when
assessed Q4H and
prn

Independent:
Assess skin
throughout,
paying special
attention to
bony
prominences,
and bil LE Q4H
and prn

normal individual experienced decreased circulation to an extremity, they


experience paresthesia, or the pins and needles feeling. It results from the
peripheral nerves not receiving adequate blood. This particular pt has had
uncontrolled DM for 8 years, which has resulted in neuropathy. He now has
decreased sensation to his LE so he is not able to feel the paresthesia, and
therefore he is not able to recognize when peripheral tissue perfusion has become
compromised. Completing CMST checks frequently allows medical personal to
know that his extremities are receiving an adequate supply of blood and are being
perfused appropriately.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. The pt underwent surgery and debridement of the LLE for the nonhealing wound that resulted from the DM. The limb is now covered with gauze, a
posterior splint and wrapped in an ace bandage. Since orthopedics will be doing
the dressing changes, it is difficult to visualize the wound on every shift to track its
progress. The bandage, however, can be assessed. The wound is not draining at
this point so if there were to be any drainage that appeared on the dressing, it
would suggest that healing is not going as it should. Also, since the pt does have
diabetic neuropathy, he has decreased sensation in the limb, likely from impaired
tissue perfusion resulting from the DM. This means that he is unable to sense if the
dressing is too tight and is impairing circulation, so its important that the dressing
be assessed to make sure that it is not too tight.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Due to the DM and the hyperlipidemia the pts vasculature has been
damaged. This has resulted in impaired circulation and as a result, impaired tissue
perfusion. Since the pt has neuropathy, he has decreased sensation, particularly in
his periphery which means that he is unable to feel the paresthesia that usually
results when nerves are not receiving enough blood so he is unable to adjust his
body position to restore blood flow to the area. Impaired tissue perfusion results
in the tissues not receiving the oxygen and nutrients they need and the wastes are
not removed. With prolonged impaired tissue perfusion, the tissue can become
necrotic. Assessing the skin throughout for reddened areas and feeling the
temperature of the skin, gives a good indication of the tissue perfusion status of
that area. Also, since the pt is refusing to get out of bed and is not changing
position as much as he should, hes at an even higher risk for impaired perfusion.

Outcome met;
plan ongoing
because pt still
has the
dressing

Outcome met;
plan ongoing
because tissue
perfusion is
still a concern

5.

Pts hemoglobin will


be between and
hematocrit will be
between 13-18 g/dl
and hematocrit will
be between 39-49%
as assessed when
resulted

Independent:
Obtain a
hemoglobin and
hematocrit
when ordered

6.

Pts blood glucose


will be between 70140 mg/dl as
assessed when
resulted

Dependent:
Obtain a blood
glucose reading
before meals,
before bed, and
prn

7.

Pt will not display sxs


of hyperglycemia
AEB polyuria,
polydipsia,

Dependent:
Administer
Humalog 1-25
units SQ before
meals TID

Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. The pt required surgery to the LLE for debridement of the wound and
experienced blood loss with the surgery. Hemoglobin is a protein in RBCs that
carries oxygen from the lungs to the bodys tissues and returns carbon dioxide from
the tissues back to the lungs. It is necessary that the body have an adequate
amount of hemoglobin to aid with cellular metabolism. Hematocrit is the volume
percentage of RBCs in the blood and it becomes an important reference in regards
to the capability of being able to deliver adequate oxygen to the bodys tissues.
Because this pt already has compromised vasculature, as evidenced by the nonhealing wound, it is important that the blood that is circulating have an adequate
hemoglobin and hematocrit. Following surgery, the pts hemoglobin was 10 and
the hematocrit was 29.9. The H&H has been trending upwards towards normal
values but if it does not improve at an adequate rate, a blood transfusion may be
considered so that tissue perfusion does not become an issue.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. In a pt with type 2 DM, the body is either unable to produce enough
insulin to meet the demands or the body is unable to use the insulin that is
produced. This leads to increased serum glucose levels. When there is extra
circulating glucose, it damages your blood vessels, which causes them to harden
and narrow. The damage to the vasculature impairs circulation, especially in the
periphery, which can lead to tissue necrosis because the cells are not receiving the
nutrients and oxygen that they need to perform metabolism. Insulin is usually
prescribed to pts who are unable to manage their blood glucose levels with nonpharmacological means. This pt is on Humalog, which is a rapid-acting insulin and
the dosage is dependent on the blood glucose levels. By obtaining a blood glucose
reading, we are able to adequately dose the medication and aid the pts body in
the glucose metabolism, which will help prevent further damage to the blood
vessels and help to maintain the peripheral circulation that the pt currently has.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. In type 2 DM, the body is either unable to produce enough insulin to
meet the needs or the cell are unable to utilize the glucose. This leads to increased
levels of glucose circulating in the blood that the body cannot utilize and it leads to

Outcome not
met; plan
ongoing
because pts
H&H are still
below normal
values

Outcome not
met; plan
ongoing
because pts
blood glucose
continues to be
difficult to
maintain

Outcome met;
plan ongoing
due to pt
continuing to
have problems

polyphagia when
assessed

8.

Pt will not display sxs


of hyperglycemia
AEB polyuria,
polydipsia,
polyphagia when
assessed

Dependent:
Administer
Levemir 8 units
SQ nightly

9.

Pt will maintain
peripheral LE
circulation AEB
warm, dry, pink,
extremities when
assessed

Independent:
Teach pt how to
perform heel
pumps, leg
raises, and knee
flexion Q2H

damage of the vasculature. The development of DM in this pt was likely largely


related to the long term use of steroids that were necessary for controlling the
Sjogrens syndrome. The pt was on an oral antidiabetic medication while at home
but due to the physiological stress of the hospitalization and the surgery, the
bodys insulin need has increased and a rapid acting insulin is needed to help the
body control blood glucose levels. Humalog lowers blood glucose by stimulating
glucose uptake in skeletal muscle and fat, and by inhibiting hepatic glucose
production. It takes approximately 15 minutes for it to start working which is why
it is given just before meals. When a person eats, the demand of insulin increases
because there is food, specifically glucose, which needs to be broken down. So, it is
usually just following ingestion of food, that the bodys insulin need peaks. By
controlling the blood glucose levels, further damage will not be done to the
vasculature, and the pt will be able to adequately perfuse the peripheral tissue.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. A pt with type 2 DM is either unable to produce enough insulin to
meet the demands or the body is unable to utilize it effectively. When pts are
unable to control the DM with diet and exercise, insulin is needed to help the body
control the blood glucose levels, because increased blood glucose levels cause
damage to the vasculature. Levemir is a long acting insulin that lowers the blood
glucose by stimulating glucose uptake in skeletal muscle and fat, and by inhibiting
hepatic glucose production. It helps the cells to use the glucose that is in the blood
over time because Levemir works by releasing small amounts over a time that leads
to a relatively constant effect. Controlling the pts blood glucose will help to
prevent further damage to the vasculature that would compromise peripheral
tissue perfusion.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Due to the hyperlipidemia, the pt has increased levels of lipids in his
blood that can lead to atherosclerosis resulting in a narrowing of the blood vessels.
The DM has led to damage of his peripheral vasculature as evidence by the nonhealing wound to his foot. Because of these chronic conditions and because he is
not getting OOB, the pts periphery is not receiving the blood supply that it should
in order to undergo cell metabolism. Healing tissue requires blood to bring
nutrients and oxygen and remove wastes. If adequate blood is not reaching the
cells, wound healing is stalled. Also tissues cannot survive very long without

regulating
blood glucose
levels

Outcome met;
plan ongoing
due to pt
continuing to
have problems
regulating
blood glucose
levels

Outcome met;
plan ongoing
due to the pt
still having
compromised
peripheral
circulation and
decreased
mobility

10. Pt will be free of s/s


of a DVT AEB a
negative Homans
sign and no
unilateral calf
tenderness or
edema when
assessed

Dependent:
Administer
Heparin 5000
units SQ BID

11. Pt will have a total


cholesterol of 0-200,
triglyceride of 0-150,

Dependent:

adequate blood supply and become necrotic. Knowing that the pt already has
compromised vasculature, its important that the pt maintain the circulation that
he has to help heal the wound and to prevent further damage. Completing AROM
exercises helps to do this and it also helps the pt to maintain the muscle strength
he has and to prevent atrophy. Completing each exercise 10 times on each
extremity every 1-2 hours helps to increase blood flow to those muscles and helps
to promote tissue perfusion. Although the pt cannot complete heel pumps on the
LLE due to the dressing, the bulk of the dressing can actually act as a weight when
he completes the leg raises and knee flexion, which will benefit him since he will
need to maintain NWB status on the extremity for weeks which can lead to muscle
atrophy.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. The pt is also 8 wk s/p lumbar surgery. Due to the debridement of his
LLE, the pt is to maintain a NWB status of that extremity which is resulting in a
decrease in mobility. Because of all of these conditions, the pt is at an increased
risk for developing blood clots. Heparin is an anticoagulant that works by
potentiating the inhibitory effect of antithrombin on factor Xa and thrombin. Due
to the hyperlipidemia, the pt has significant levels of lipids flowing in his blood.
These can speed up the process of atherosclerosis and a clot can form that would
occlude the blood vessel, preventing blood from reaching peripheral tissue. The
DM leads to increased levels of glucose in the blood because either the body is
unable to produce enough insulin or the cells are unable to utilize it. This also leads
to a narrowing of the vasculature. Knowing that the pt already has compromised
blood flow to the periphery as evidenced by the non-healing wound, it is important
that the integrity of his vasculature be maintained. Also since the pt is refusing to
get out of bed as often as he should, blood can pool in the extremities because
venous return is highly dependent on muscle contractions. The stasis blood is a
prime location for blood to clot and the narrowed vessels makes it that much easier
for clot formation that could occlude the vasculature. Even though the pt has been
refusing the heparin due to a previous negative experience with it, its the nurses
job to continually offer the medication and provide teaching regarding it with each
interaction.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. In pts with hyperlipidemia, there is an increase in circulating lipids.

Outcome met;
plan ongoing;
pt is still at a
high risk for
developing a
DVT

Outcome met;
plan ongoing as
the pt is still at

LDL of 0-100, and


HDL> 60 and
peripheral perfusion
will be maintained
AEB warm, dry, pink,
extremities when
assessed
12. Pts blood glucose
will be between 70140 when assessed

Administer
Simvastatin 100
mg PO TID

The lipids cause damage to the vasculature, which speeds up the process of
atherosclerosis. Because the pt also has uncontrolled DM, it is important the
interventions be performed to help maintain the status of his vasculature so that
tissue perfusion can be maintained. Simvastatin inhibits HMG-CoA reductase,
which is an enzyme responsible for catalyzing an early stop in the synthesis of
cholesterol. It helps to decrease the lipids that a in the blood so that narrowing of
the vasculature does not occur. This helps to maintain tissue perfusion.

risk for
impaired
perfusion

Collaborative:
Maintain a
consistent carb
diet with all
meals and
snacks daily

Outcome not
met; plan
ongoing as pt
still has
difficulty
maintaining a
stable blood
glucose

13. Pts blood glucose


will be between 70140 when assessed

Collaborative:
Obtain a diet
consult on 3/21

14. Pts cap refill will be


<3 sec when
assessed Q shift

Independent:
Assess capillary
refill to all

Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Because the pt has DM, his body is either unable to produce an
adequate amount of insulin or the body is unable to utilize what is produced. This
leads to increased blood glucose levels which results in damage to the vasculature.
When an individual normally ingests food, especially carbohydrates, the serum
glucose levels peak and the pancreas must produce enough insulin to use the
glucose. Pts with DM are often placed on a consistent carb diet so that their blood
glucose levels do not rise and fall so dramatically. It allows blood glucose levels to
be better maintained and thus helps to prevent the high glucose levels that will
damage the vessels leading to impaired peripheral tissue perfusion.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Because of the DM the pt is not able to control his blood glucose
levels without some intervention. While insulin helps, non-pharmacological means,
such as diet can help control blood glucose levels. The pt has been unable to
control the DM in the past but perhaps that was due to a lack of understanding of
the disease process or a lack of motivation. Prior to the hospitalization, the pt had
purchased a pair of diabetic shoes which shows that the pt is trying to take some
steps to deal with the condition. Also he does regularly see a podiatrist, which is a
very important consult for diabetic pts. Because the pt does appear to be making
some changes to manage the condition, he may be open to learning about dietary
changes that can be made. The pt did state that hearing that his LLE may need to
be amputated did scare him so he might be more receptive to education regarding
management of the DM.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic

Outcome not
met; plan
ongoing as pt
still has
difficulty
maintaining a
stable blood
glucose

Outcome met;
plan ongoing
because pt is

extremities
Qshift

15. Pt will be OOB TID

Independent:
Teach the pt
importance
of getting OOB
Q4H

neuropathy. Due to the damage to the vasculature as a result of the uncontrolled


DM and the hyperlipidemia, the pt has impaired tissue perfusion which is
evidenced by the non-healing wound to the lower extremity. As a means to
measure arterial blood flow of the extremities, capillary refill can be evaluated.
With normal perfusion color should return within 2 seconds. A sluggish color
return would indicate decreased perfusion. This pts capillary refill was <3 secs as
assessed in his fingertips. His pedal capillary refill was difficult to attain but was not
impossible. A change from this pts baseline would indicate impaired peripheral
perfusion to his extremities.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Due to the pts chronic conditions his vasculature, especially in the
periphery is damaged which has led to a decrease in tissue perfusion, resulting in
the non-healing wound to the LLE. Due to the neuropathy that has resulted from
the vascular damage from the uncontrolled DM, the pt has decreased sensation in
his LE and therefore cannot feel when tissue perfusion is being compromised.
Prolonged impaired tissue perfusion can lead to necrosis of the tissue. Also due to
the recent surgery, the decrease in mobility, and the refusal of the Heparin, the pt
is at an increased risk for development of a DVT, which can lead to occlusion of the
blood vessel and result in impaired tissue perfusion. Because of all of this it is
important that the pt get out of bed a few times a day so that his peripheral tissue
perfusion is maintained. Activity helps to increase blood flow to the utilized
muscles which helps improve tissue perfusion. Also the pt will be able to maintain
his strength so that he can ready for discharge.

still at risk for


impaired
peripheral
tissue
perfusion

Outcome not
met; plan
ongoing
because pt
continues to
refuse to get
OOB