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This Concept Map has information related to: oct 31, 2007, Outcomes participate in treatment regime, nursing dx: disturbed sensory perception related to longer term DM as evidenced by retinopathy leading to blindness and neuropathy interventions: -assess skin integrity -evaluate sensory awareness and investigate for signs of decreased peripheral circulation -note degree of alteration -assess mental status -describe therapy treatment -promote safety pt will: -be in a safe environment -recognize sensory decefits -verbalize awareness of sensation -verbalize sensory needs -good skin integrity, no breakdown or un-noticed bleeding or bruising -free of injury, interentions: - assess area of infection -monitor for VS and signs nad symptoms of sepsis -note lab values -proper aseptic techniques and handwashing -encourage compliance to therapy pt will -free of infection -decreased in temp no fever -no septic shock -improve condition, Test & Diagnostics CMP: Na: 138 K: 5.3 Cl: 104 H3CO: 25 BUN: 42 Cr: 2 BUN and creatine is elevated due to renal insuffecieny leading to renal fairlure, regular insulin Nrusing Dx: Risk for infection risk factors include delay wound healing, neuropathy, decreased leukocytes interventions: -assess distal extremities especially the leg foot (r foot amputated) -assess sensation -assess skin integrity -assess wound site -clean wound site frequent -keep sterile to prevent infection, regular insulin lower blood glucose level tx of DM, Nursing interventions discuss oxygen therapy and teaching, aspirin ND, Nursing interventions elevate HOB, positioning, Admission Dx Nursing Dx: altered protection related to right leg cellulitis as evidenced by redness, fever, high temp, increase WBC interentions: - assess area of infection -monitor for VS and signs nad symptoms of sepsis -note lab values -proper aseptic techniques and handwashing -encourage compliance to therapy