Appendix

Assessment B2
Using
Functional
Health Patterns
Refer to Chapter 2 “Assessment,” p. 64: Care Plans Developed after using
Functional Health Patterns Assessment Model
Client’s name: Mrs. Mary Acosta
Age: 55
Are there differences between the Body Systems Model and the Functional
Health Pattern Model?
Document Includes: Student Activities 1–3, Pathoflow sheet, Scenario with
Client Assessment, and 4 Care Plans

Activity 1
Compare the Functional Health Pattern Model with the Body Systems Model.
Note the areas that lend themselves specifically to nursing assessment such as
Health Perception/Health Management Pattern. When using this model be sure
to address all the component parts.

Activity 2
Note the scenario for aid in proper identification of the client, the pathoflow
sheet for the likely pathophysiological sequencing of events of the disease
process, the complete assessment format, and the four prioritorized nursing care
plans.

23
 Client: Mrs. Mary Acosta

Age Heredity Virus exposure Idiopathic Lack of exercise Obesity Ethnicity

Tissue Resistance to Insulin

Hyperglycemia
Excessive hepatic
Increased blood Hyperinsulinemia glucose production
glucose that cannot
enter the body cells Beta cell exhaustion
B-Cell Solute
Body reacts to glucose Hypoinsulinemia Glycosuria
diuresis
this as starvation toxicity
Release of epinephrine
Polyphagia Increased glucose
in kidney acts as
Release of glucagon Diabetes mellitus type II osmotic diuretic

Release of glycogen Hyperglycemia Inhibition of water reabsorption

mobilization of fatty
acids Plasma Polyuria
Increased insulin
hyperosmolarity
Dehydration
Decreased blood sugar Osmoreceptors
Activation of the
Release of epinephrine hypothalamic
trist center
 Release of
adenocorticotrophic
Decrease immune function
hormone Polydipsia
Hyperglycemia
Infection Release of corticosteroids
Osmotic diuresis Inhibition of
Increase in
Macroanogiopathy Release of growth hormone peripheral
WBC
Fluid volume deficit glucose use
Athereosclerosis Liver
Free fatty acids
Decreased sodium and proteins
Cardiovascular Gluconeogenesis
disease MI
and glycogenolysis
Decreased Gluconeogenesis
potassium
Cerebrovascular
disease Microangiopathy
Decreased protein
PVD
Retinopathy Nephropathy
Electrolyte imbalance Neuropathy
Amputation Gangrene Microvascular
Dehydration Infection damage and Diffuse/nodular Loss of
Neovascularization occlusion of rentinal glomerulosclerosis sensation
capillaries
Easy Basement membrane
Hypovolemia Microaneurysm Parenthesis
hemorrhaging of kidney thickened
in capillary and leaky
Decreased walls
renal Bleeding in
Hypotension Renal failure
perfusion vitreous cavity Capillary fluid
leaks
Tissue Anoxia Macula
Oliguria
involvement
Retinal edema
Anuria Hemoconcentration
Blindness
Hard exudate
Hyperviscosity intraretinal Vision changes
Thrombosis
hemorrhage

FIGURE B2–1 Diabetes Mellitus Type II Pathoflow Sheet (relates to functional health pattern).
26 Appendix B2

Activity 3
Use the guidelines in Appendix A to determine if each of the four care plans
are individually sequenced and if the goals are met.

HEALTH HISTORY

Client Assessment According

to Functional Health Pattern
The scenario: Mrs. Mary Acosta is a 55-year-old female who was admitted to the
hospital with a medical diagnosis of diabetes Type-II and hyperglycemia (blood
sugar 400) and vomiting; states she was diagnosed with diabetes 5 years ago.
1. Client Profile
MA is a 55-year-old white female born in New York. She grew up in
Austin Texas where she lives with her husband of 30 years. Her major rea-
son for seeking health care is extreme weakness, nausea, and vomiting.
Source of history is the client who seems reliable.
2. Treatment/Medications
(a) Glucophage: 10 mg in morning at breakfast and 5 mg after dinner
(antidiabetic agent)
(b) Over the counter drugs: None
3. Past Illnesses/Hospitalizations
Diabetes mellitus type-II for 5 years
Peripheral vascular disease
4. Allergies
(a) Codeine, generalized rash
(b) Denies any food and environmental allergies
5. Developmental History
Developmental level: Integrity vs. despair
Describes self as one of eight children who never had enough to eat
hence she was sent to an uncle in Texas. This she regrets because she
was never allowed to return to visit her family until she was grown.
States “I smoked heavily (two packs a day) but stopped when I was diag-
nosed with diabetes.” MA has been married for 30 years and attends a
Baptist church with her husband periodically.
6. Health Perception/Health Management Pattern
• Client’s rating of health scale: (1–worst, 10–best)
5 years ago rated at 7.
 Appendix B2 27

Now rates health at 5; states “Not so good, too much vomiting”

5 years from now, hopes to rate at 7, “Hopefully healthier”
• Denies use of tobacco, drugs, or alcohol
• Understands that she has diabetes but “does not know how to care
for the disease”
• Expects “vomiting to stop, diabetes to be controlled and to be dis-
charged from hospital in two days”
• Noncompliance with diet and diabetic medication, forgets to take
Glucophage.
7. Nutritional/Metabolic
• Height: 5 3
• Weight: 190 lbs
• Ideal body weight: 125–130 lbs
• Usual eating pattern: “Good appetite eats three meals a day and
many snacks,” has not eaten today, “vomited all day”
• Oral temperature 98F
• Signs of dehydration—decreased skin turgor
• Does not wear dentures, last dental exam was “two years ago”
• Nails hard and smooth. No recent hair loss or change in texture. No
complaint of itching or nonhealing sores (has small discolored spot
on left great toe). No excessive dryness or moisture, rash, or other
lesions. Voices intolerance to heat, “I prefer the winter.”
8. Elimination Pattern
• Bowel habits: States “I have at least two bowel movements a day
(soft and brown) no mucus, blood, or tarry stool.” No rectal bleed-
ing, change in color or consistency of stool.
• Bladder habits: Has been “voiding very frequently for the past three
days” (frequency with nocturia)
9. Activity Exercise Pattern
• States she arises at 0630, does her chores around the house and eats
breakfast with her husband at 0700 and eats her own breakfast at
about 0900. Sometimes she either forgets to take the Glucophage or
her “supply is depleted.”
• Extreme weakness for the past three days; “has been in bed”
• Has no regular exercise regimen, “watches soap operas most of the day”
10. Sexuality Reproductive Pattern
• Obstetric History: gravida 5, para 5, Abortions 0
• Children living, five all adults, three reside in close proximity to
patient
28 Appendix B2

11. Sleep/Rest Pattern

• Goes to bed at 2200 and awaken at 0630. States she often has trou-
ble falling asleep because of discomfort in her legs. Sometimes she
does not feel rested when she awakens. No use of sleep aids. Sleeps
with one pillow, has no difficulty breathing at night.
12. Sensory/Perceptual Pattern
• Vision: wears glasses for reading but sometimes her “vision is blurred.”
Denies itching, excessive tearing, discharge, redness, or trauma to eyes.
• Hearing: Does not wear hearing aids. Does not ask for questions to
be repeated at normal hearing level.
• Smell: States she has no decrease in smell. Denies pain, allergies,
nosebleeds, or discharge.
• Touch: States her feet often feel numb.
• States she has been adding more salt to her diet because her “food
never tastes good.”
• Pain: admits pain in both legs, “sometimes the pain radiates down
my legs.”
13. Cognitive Pattern
• Speech clear without stutter. Word choice appropriate to education
and culture. Follows verbal cues.
• Examines ideas clearly and concisely. Recalls past events without
difficulty, orientated to time, place, and person.
14. Role/Relationship Pattern
• Married for 30 years. Lives with husband. Has five grown children,
three of whom live very close to her. They are very caring and visit
often. When she is well she sometimes babysits her grandchildren.
Has a total of ten. The two children that are away call very often.
She is the fourth of eight children.
15 Value Belief Pattern
• Religious orientation is Catholic but is now nonpracticing
16. Coping/Stress Tolerance Pattern
• States “the overweight” creates great stress. Facial muscles tense.

NURSING PHYSICAL ASSESSMENT

General Physical Survey

• Height: 5 3, weight: 190 lbs., ideal weight: 125–130 lbs.
• Temperature: oral—98.0F, pulse–100, respirations—26, blood
pressure—130/86 lying, client attentive and cooperative. Lying in
 Appendix B2 29

low Fowler’s position muscles on face tense, dressed appropriately

for the occasion (wearing hospital gown).
17. Assessment of Skin, Hair and Nails
• Skin: light brown color, consistent throughout body. Temperature
cool on hands, arms, legs, and feet. Skin smooth, slightly dry
(dehydration). Skin turgor poor (skin remains tented for several sec-
onds over clavicle), small discolored spot on left great toe. No
edema.
18. Assessment of Head and Neck
• Hair: Shoulder length, graying, straight, and full. No hair on back,
legs or face.
• Nails: Fingernails short, thick, and clear. No clubbing or Beaus lines.
Capillary refill reflects pallor (poor capillary refill) bilaterally.
• Blood profile: Hbg—9.0 (normal: 12–16 g/dl), HCT—29.0 (normal:
37–47 %), RBC—3.1 (normal: 4.2–4.8 million/cu)
19. Assessment of Eye
• Head symmetrically rounded, neck with full ROM, and nontender.
No scars, masses or pulsation. Trachea midline. Carotid pulse—2 
bilaterally without bruits, can raise eyebrows, puff cheeks, frown,
and smile (CN VII intact).
20. Assessment of Ear
• Equal size and shape bilaterally. No swelling, redness, or thickening.
Skin color consistent with color of skin on face. No lumps or
lesions. Pinna firm and nontender bilaterally. Mastoid process pal-
pation painless. Voice test positive (heard words as whispered bilat-
erally CN VIII). Weber—sound heard in both ears (negative),
Rinne’s test ACBC (Positive Rinne).
21. Assessment of Nose and Sinuses
• Nares patent. Nasal septum: midline without bleeding or perfora-
tion, no inflammation on skin lesions. Frontal and maxillary si-
nuses nontender bilaterally.
22. Assessment of Mouth and Pharynx
• Lips moist and pink. No lesions or ulcerations.
• Buccal mucosa pink and moist, no discoloration, increased pigmen-
tation, bleeding, or discoloration.
• Hard palate smooth without lesions and masses.
• Tongue midline when protruded, no fasciculation (CN XII) intact,
no masses or lesions.
23. Assessment of the Heart
• No visible pulsation, heaves, lifts, or vibrations.
30 Appendix B2

• S1, S2 sounds, heard no splitting sounds, murmurs, gallops, or

rubs. Point of maximum impulse at 5th intercostal space, left mid-
clavicular line (PMI 5th ICS at LMCL).
24. Assessment of Peripheral Vascular System
• Arms: equal in size and symmetry, cool and dry to touch bilaterally,
no edema or lesions.
• Radial pulse—100, and regular
• Amplitude of radial and brachial pulses 1 bilaterally.
• Epitrochlear nodes unpalpable.
• Capillary refill does not return immediately (3 seconds).
• Legs: equal in size and symmetry.
• Small discolored area on left great toe, skin cool to touch, dry, no edema.
• Pedal and posterior tibial pulses 1 bilaterally.
• Homan’s sign negative bilaterally.
• Toenails fairly soft. Capillary refill 3 seconds.
25. Assessment of Thorax and Lungs
• No visible pulsation or lesions present. No use of accessory muscles
of respiration, no nasal flaring, tenderness, or masses
• Respirations—24 per minute and regular. Neither cough nor adven-
titious sounds.
• Tactile fremitus equal bilaterally.
• Resonance throughout lung fields.
26. Assessment of Breast
• Breasts symmetrical in size. No masses, lesions, tenderness on pal-
pation bilaterally. No dimpling or inverted nipples.
27. Assessment of Abdomen
• Abdomen: No distention, symmetrical without masses or lesions.
• Umbilicus midline without swelling or discoloration.
• Bowel sounds present in all four quadrants (hyperactive). Vomiting
for one day. No tenderness on light and deep palpation.
28. Genitourinary Assessment External Assessment
• Pubic hairs sparse, labia flattened, vula atrophied.
29. Musculoskeletal Assessment
• Walks to bathroom, gait steady, upper extremities have full range of
motion, muscles strong.
• Lower extremities: cool to touch, complained of radiating pain,
pulses diminished.
• Discolored area on left great toe. Shrugs shoulders and moves head
to right and left against resistance without weakness (CN XI intact).
 Appendix B2 31

30. Neurological Assessment

• Neurological status: Orientated to time, place, person, and events.
• Facial expression correlates with state of health and topic being dis-
cussed (appears somewhat sad and anxious).
• Speech clear, coherent.
• Questions answered appropriately
• Long-term and short-term memory intact.
• Cooperative throughout interview, vocabulary correlates to educa-
tion level.
• Asked appropriate questions relevant to illness and answered all
questions posed.
• CN I-XII intact and integrated
32

CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 1

AGE: 55 Relates to Functional Health Pattern Assessment

Ordered &
Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation

Subjective data: Nutrition imbalanced, less Short term: Independent: Client Teaching: Short-term goal met:
Client states “I have than body requirements as Client will deny nausea. • Inform client that vomiting • Knowledge of cause and Care plan implemented
been vomiting for a evidenced by prolonged Client will demonstrate no and frequent voiding are due effect relationship and as written.
whole day.” vomiting for 24 hours, dry further vomiting. to diabetes out of control. disease prognosis creates Client compliant.
“I am very weak, I am skin and frequency of Client’s skin will be moist hope and encourages self- Vomiting subsided,
still nauseated, I am not micturition (fluid volume and warm. involvement in treatment output approximated
hungry, and I can’t stop deficit) Client will void less regimen. intake.
running to the frequently and smaller • Diabetics develop complica- • Knowledge of cause and
bathroom.” Defining characteristics: amounts (secretes tions by non-compliance effect relationship and Long-term goal met:
• Decreased oral intake at least 30cc of urine (diabetic keto acidosis). These disease prognosis creates Tolerating food and
Objective data: • Anorexia per hour). are temporary conditions and hope and encourages self- fluids.
Skin cool and dry • Nausea Skin fold will return to can be prevented. involvement in treatment Dehydrated state
Displays moderate to • Weakness original state in less than Give client tools to control regimen. improved.
high level of anxiety • Fatigue 3 seconds (over clavicle). nausea and vomiting: Will access blood profile
(anxious look) • Weight loss • Oral care after each episode. • Removes unpleasant taste. at later date.
No engagement in • Inadequate food intake Long term: • Cool damp cloth to forehead, • Provides comfort.
activities of daily living • Lack of interest in food Client will ingest neck, and wrist.
Vomited twice within • Change in blood profile appropriate amounts of • Relaxation techniques—deep • May decrease anorexia and
last 3 hours (clear and —RBC calories/nutrients. breathing and imagery. promote desire for more fluids.
watery) —HCT Client will display usual • Rest before meals. • Increases energy.
Blood sugar—400 mg/dl —HGB energy level. • Pleasant relaxed atmosphere • Prevents nausea.
on admission Weight will be stabilized. before meal times (no
Lost 8 lbs. in 3 days Blood profile will return to emesis basin, bedpans, or
Tongue somewhat dry normal range. wash basins in view during
and mildly coated —RBC meal time).
Skin fold returns to —HCT • Sit up for about two hours. • Prevents overdistention and
original state in > 3 —HGB • Provide small meals initially, regurgitation.
seconds (over clavicle) consistent with diabetic diet • Prevents irritation of the
HGB 9.0 g/dl (normal (food not too cold or hot). gastrointestinal mucosa. continues
12–16)
 CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 1 (continued)
AGE: 55 Relates to Functional Health Pattern Assessment

Ordered &
Selected Data Nursing Diagnosis Goals Interventions Rationale Evaluation

HCT—29% (normal • Instruct client to avoid • Enhances digestion (liquids

37–47) drinking while eating. must be absorbed before
RBC—3.1 million/cu digestion begins).
(normal 4.2–4.8)
• Maintain semi-Fowlers • Decreases chance of
position. regurgitation.
• As nausea subsides, provide • Provides additional
higher caloric/proteins in nutritients.
portions (consistent with
diabetic diet).
• Consider food idiosyncrasies/ • Food preferences and culture
culture and provide food often influences food
exchanges according to choices.
client’s food likes and dislikes.
• Include iron-rich foods • Foods rich in iron will
(consistent with diabetic diet) improve blood profile.
to control low RBC, HCT, HGB.
• Administer intravenous fluids • Prevents dehydration and
as ordered. maintains electrolyte balance.
• When nausea subsides, offer • Enhances hydration.
oral fluids (6–8 eight-ounce
glasses of water per day).
• Monitor blood glucose • Aids in carbohydrate
(Normal 90–120 mg/dl) levels metabolism.
at least every four hours
before meals and administer
anti-diabetic medication as
ordered according to blood
glucose levels.
Dependent:
• Administer antiemic • Relieves vomiting.
medication one half hour
before meals.

References: Doenges, M., Moorhouse, M., & Geissler-Murr, A. (2002). Nursing care plans: Guidelines for individualizing patient care. Philadelphia: F.A. Davis. Kozier, B., Erb, G., Berman, A., & Burke,
K. (2002). Fundamentals of nusing: Concepts, process, and practice. Upper saddle River, NJ: Prentice Hall health. Gulanic, M., Klopp, A., & Galanes, S. (Eds.) (1998). Nursing care plans: Nursing
diagnosis and nursing intervention. St. Louis, MO: Mosby.
34

CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 2

AGE: 55 Relates to Functional Health Pattern Assessment

Ordered & Nursing

Selected Data Diagnosis Goals Interventions Rationale Evaluation

Subjective data: Risk for injury Short term: Independent: Short-term goals met:
Client states “I feel related to Client will discuss • Assess orientation. • Determines cognitive ability. Client stated she felt
extremely weak.” weakness from importance of • Assess muscle strength, share • Determines amount of weaker than before
prolonged seeking help to findings with client. activity that can be and will seek help
Objective data: vomiting, probably ambulate on tolerated. getting up.
Lying in bed dehydration and 06/09/03. • Allow client to express own • Develop client’s awareness
Vomited twice in altered tissue feelings. of state of illness.
three hours perfusion. Long term: • Correlate client’s statement • Establish client’s
Requested help to Client will be injury with objective findings. knowledge about this Long-term goal met:
bathroom Defining free on 06/19/03. particular condition. Client sustained no
Marked weakness, characteristics: • Instruct client to use call bell • Promotes safety. injury.
tends to lie in one • Altered mobility to ask for assistance in all
position • Fatigue activities of daily living until
Feet cold to touch. • Weakness strength is regained.
Peripheral pulses • Altered peripheral • Keep environment safe: side • Promotes safety and
diminished in lower tissue perfusion rails up when client is in bed. generates confidence about
extremities care given during the
Darkened spot on left client’s dependency state.
great toe • Bed in lowest position. • Promotes safety and
prevents accidents (rolling
out of bed).
• Room well lighted and • Reduces trauma if client
uncluttered, including gets up without assistance.
bathroom, and use a nightlight. • Reduces incidence of
• Assist with ambulation. slipping, sliding, and falling. continues
 CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 2 (continued)
AGE: 55 Relates to Functional Health Pattern Assessment

Ordered & Nursing

Selected Data Diagnosis Goals Interventions Rationale Evaluation

• Answer call bell promptly. • Enhances security and

builds trust.
• Meet needs as soon as • Same as above.
identified.
• Provide nonskid slippers. • Promotes safety.
• Assess for orthostatic • Determines if client is able
hypotension. to tolerate ambulation.
• Assess vital signs before • Determines circulation
ambulation. status (oxygenation to
tissues).
• Assess peripheral pulses and • Same as above.
assess for Homans’ sign before
ambulation.
• Examine lower extremities for • Same as above.
bruits, color change, and pain.
• Allow private time while client • Provides privacy and time
is in bathroom. for concentration and
reflection.
• Stay in close proximity. • Promotes safety.
• Check client’s condition and • Same as above.
needs frequently while in
bathroom.
• Do not forget client in • Demonstrates caring.
bathroom.
• Reassess client after • Provides cues regarding
ambulation. further ambulation.
Dependent:
• Provide assistive device • Decreases chances of falls
(walker) when ambulating and provides stability.
35
36

CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 3

AGE: 55 Relates to Functional Health Pattern Assessment

Ordered & Nursing

Selected Data Diagnosis Goals Interventions Rationale Evaluation

Subjective data: Nutrition more Short term: Independent: • Teaching the benefits of Short-term goal met:
Client eats “three than body Client will identify • Teach client that: adherence will create Client verbalized
meals a day also requirement ways to effectively —Diabetes can be controlled. interest in learning. understanding of the
many snacks probably related to: control her diabetes. —People can lead a normal life information given,
throughout the day. I • Erratic eating Client will verbalize and lose weight when there stated she wished
sometimes forget to • Noncompliance knowledge about the is compliance with the she knew this long
take the Glucophage • Knowledge relationship between medical regimen. ago, “my health
and sometimes I do deficit about diabetes, diet, —To control diabetes one must would be better.”
not have the diabetes exercise and comply with ordered diet,
medication. I really medication. medications, exercise, and Long-term goal met:
don’t know how to Defining doctor’s visit. Daughter came to
deal with this characteristics: Long term: • Perform a 24-hour diet recall, • Concentration on food teaching session.
diabetes.” • Food intake Client will achieve a point out foods that are preferences and culture Assisted mother with
exceeds high level of allowed on ADA diet. identification will enhance meal planning and
Objective data: metabolic needs wellness: compliance insulin administra-
Client is obese • Weight more Client will contribute • Discern food idiosyncrasies • Same as above tion. Stated that both
(190 lbs.), approxi- than 20% of to her own and her • Identify food exchanges that • Same as above would work with the
mately optimum body family’s welfare. are being consumed currently whole family to
60 lbs. overweight. weight Client will make due to idiosyncrasies. improve their diet.
Blood sugar out of • Dysfunctional contributions to • Inform client to take all • Understanding the benefits
control (400mg/dl) at eating pattern society. medication (Glucophage). of medication should
present. Client will achieve enhance compliance.
Ordered 1800 ADA weight only 20% • Walking is the best form of • Comprehensive instruction
diet. above ideal body exercise. on the diabetic plan of
weight (130–160 lbs.). care provides client with a
regimen to follow and aids
in weight loss. continues
 CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 3 (continued)
AGE: 55 Relates to Functional Health Pattern Assessment

Ordered & Nursing

Selected Data Diagnosis Goals Interventions Rationale Evaluation

• She should walk at least three • Same as above

times a week and avoid fatigue.
• She should eat lavishly of fruits • Same as above
and vegetables.
• Decrease fat and red meat and • Same as above
shellfish.
• Should eat three times a day • Same as above
approximately at the same
time each day.
• Diabetic medication should be • Stimulates secretions of
taken at the same time each day insulin thus aids in
as ordered by doctor (AC meals). digestion.
Client is now being regulated
on insulin.
• Encourage client to involve her • Assistance from caregivers
daughter in her diabetic can help the client achieve
education. the desired outcome.
• Discuss equipment/ supplies/ • Same as above
teach insulin administration:
—Syringes and needles.
—Insulin type cleaning agent.
—Infection control.
—Demonstrate giving injection
using substitute (orange).
—Repeat until client is
comfortable with technique.
—Have client administer
several injections before
discharge. Tell client insulin
treatment may be temporary
therapy.
37
CLIENT: Mrs. Mary Acosta Priority Nursing Care Plan 4
AGE: 55 Relates to Functional Health Pattern Assessment

Ordered & Nursing

Selected Data Diagnosis Goals Interventions Rationale Evaluation

Subjective data: Tissue perfusion, Short term: Independent: Short-term goal met:
Client complained of ineffective, Client will discuss Give instructions about foot care: Client demonstrated
numbness in legs evidenced by (see ways to improve • Wash feet in warm to cool readiness to learn
with radiating pain. ordered and circulation and water (avoid hot water). • Poor foot care promotes and verbalized
selected data). prevent infection. • Dry feet thoroughly after the growth of organisms. understanding and
Objective data: Risk for infection each wash. • Same as above. willingness to
Lower extremities related to darkened Long term: • Use lotion lavishly, dry feet comply.
cool to touch. area on left great Client will report after application • Same as above.
Pulses diminished. toe. capillary refill >3 • Use gentle approach with feet. Long-term goal met:
Capillary refill seconds. • Ischemia in lower Lower extremities,
prolonged (>3 Defining Lower extremities extremities predisposes circulation improved.
seconds). characteristics: will be warm to the diabetic client to Capillary refill 2+.
Darkened area on left Skin cool to touch touch. bruises and breaks in the
great toe. Blanching of skin Darkened area on skin that may lead to
Capillary refill left great toe will • Use only emory boards to care gangrene.
more than 3 show no signs of for nails. • Same as above.
seconds infection, redness, • Do not wear tight-fitting shoes.
Complaints of warmth, pain, or • Report all cuts and bruises to • Same as above.
numbness in drainage. doctor immediately. • Prompt reporting
extremities facilitates early treatment
Discoloration of and should reduce
skin • Adhere to diet. complications.
• Diet enhances balance
between insulin and
carbohydrates, improves
• Keep feet warm when weather anabolism and circulation.
is cold. • Facilitates circulation.
Dependant:
• Carry out doctor’s and
dietician’s orders as prescribed: • Collaborative care
—Diet produces positive
—Antidiabetic medication. outcome.
—Exercise regimen.