Gangrene Nursing diagnosis and care plan - NurseStudy.Net (2023)

Gangrene is a condition involving the destruction of body tissue caused by a major bacterial infection or lack of blood supply. The fingers and toes, as well as the arms and legs, are often affected by gangrene.

It can also occur in muscles and internal organs, such as the gallbladder. Skin damaged by gangrene often takes on a greenish-black appearance. There are several types of gangrene, but there are three main types: dry, wet, and gas.

When the blood supply to the tissue is cut off, dry gangrene develops. The region darkens, shrinks and dries. Invasion of this tissue by bacteria produces wet gangrene. With that, the region swells, loses liquid and starts to smell bad.

Finally, gas gangrene occurs when bacteria that multiply in the tissue begin to form toxins and release gas. Gas gangrene spreads quickly and can cause death within 48 hours if left untreated.

signs and symptoms of gangrene

Gangrene has several symptoms depending on its etiology. Although the general symptoms of the disease can include the following:

• Red and swollen skin
• Severe pain or numbness
• Skin pale and cool to the touch.
• Change in skin color
• The presence of pus accompanied by an unpleasant odor.

causes of gangrene

Gangrene develops when an area of ​​the body does not receive enough blood flow. The body's tissues receive oxygen, nutrition, and antibodies from the blood. Tissue cells begin to die when they don't get enough blood. Tissues can start to break down and infections can spread.

• tissue infections. Gangrene can develop as a result of an untreated bacterial infection.
• An injury such as severe and deep wounds.. Open wounds that allow bacteria to enter the body can arise from gunshot wounds or crush injuries sustained in car accidents. Gangrene can develop if the bacteria infects tissues and is left untreated.
• surgical complications.Although rare, other necrotizing soft tissue infections often have a different point of entry due to trauma or problems at the surgical site after surgery.
• Medical conditions that affect blood circulation.atherosclerosis orperipheral artery diseasecan lead to reduced blood flow

gangrene risk factors

People who have specific underlying medical conditions that affect their blood vessels are more vulnerable to gangrene. These conditions include:

• Blood vessel disease.narrowed arteries likeatherosclerosiscause plaque buildup that disrupts the body's blood flow.
• Diabetes. Blood arteries can eventually be damaged by high blood sugar levels. Damage to blood vessels can cause some of the body's blood flow to slow or stop.
• Serious injury or surgery.The risk of gangrene increases with any condition that damages the skin and underlying tissue, including burns.
• Obesity.The pressure of extra weight on the arteries can decrease blood flow, increase the risk of infection, and make it harder for wounds to heal.
• Immunosuppression.The body's ability to fight infection can be affected by chemotherapy, radiation, and many diseases, including the human immunodeficiency virus (HIV).
• Complications of COVID-19.Several cases of people who developed dry gangrene on the fingers and toes as a result of COVID-19 related blood clotting problems (coagulopathy) have been reported.
• Reynaud syndrome.The blood arteries of the fingers and toes are affected by low temperatures. Blood flow is restricted when blood vessels constrict.
• Popliteal artery entrapment syndrome.The popliteal artery is compressed by the calf muscle of the body. During exercise, this restricts blood flow to the leg.
• Vasculitis.Blood flow is hampered by inflammation of the blood vessels.
• Peripheral artery disease.Insufficient blood may flow to the legs, feet, arms or hands due to plaque buildup in the extremities.

gangrene complications

The amount of dead tissue from gangrene can be significant and it can spread quickly over a large part of the body. Treating these areas can lead to:

• Amputation
• Large areas of scars
• reconstructive surgery
• organ failure
• Death

Gangrene Diagnosis

Test diagnosis for gangrene includes:

• Complete footage of the story.Leg discomfort will occur in patients with critical limb ischemia/chronic limb threatening ischemia (CLI/CLTI) who have progressed from exertional intermittent claudication to chronic rest pain.
• Physical exam.A thorough examination of the affected extremity should include detection of any neuropathy and probing the bone in cases of ulceration or tissue loss to determine the extent of tissue damage and the likelihood of developing osteomyelitis.
• Blood analysis.The purpose of laboratory evaluation for ischemic gangrene is to detect clinical risk factors such as renal failure,hyperlipidemiaand diabetes. Evaluations for concurrent infection are also appropriate, but without other symptoms of infection, such as localized erythema andedema, wound cultures are less helpful. Infection is often indicated by a high white blood cell count. To check for the presence of specific bacteria and other microbes, other blood tests may be done.
• Culture of fluids or tissues.A sample of the affected skin can be tested for bacteria. For indications of cell death, a tissue sample can be examined under a microscope.
• imaging exams. Organs, blood vessels and bones can be seen using X-rays, CT scans and MRIs. These tests can help determine the extent to which gangrene has spread within the body.
• Ankle-brachial index (ABI).The ankle-brachial index (ABI) test, which is non-invasive and considered abnormal if it is less than 1.0, is crucial for early detection of PAD in a patient with tissue loss. Severe ischemia is also associated with ankle pressure below 40-60 mmHg, and 70 mmHg is considered abnormal in cases of tissue loss.

treatment for gangrene

There are several gangrene treatment methods. Depending on the underlying reason and the stage of the disease, the doctor will decide which treatment or combination of methods to use. Some common treatments are:

• Surgery. This can be done to understand how much tissue is infected and to take a closer look at the inside of the body. There are different types of surgeries available depending on the nature and severity of the gangrene. Gangrene surgery involves debridement, vascular surgery, amputation and reconstructive surgery.
  • debridementThis type of surgery is done to remove diseased tissue and stop the disease from progressing.
  • Vascular surgery.Surgery may be performed to repair any broken or diseased blood vessels to restore blood flow to the affected area.
  • Amputation.A toe, finger, arm or leg that has developed gangrene may require surgical removal in serious situations (amputation). Amputees can be fitted with artificial limbs
  • Reconstructive surgery.Occasionally, surgery may be needed to restore damaged skin or to lessen the visibility of gangrene scars. A skin graft can be used during an operation. The surgeon uses healthy skin from another part of the body to cover the damaged area during a skin graft. A skin graft can only be done if the site has sufficient blood flow.
• medicines. Antibiotics are needed when gangrene is caused by a bacterial infection. The correct dosage will be recommended by the doctor to the patient. A bacterial infection is treated with oral or intravenous medications. Painkillers may be given to relieve discomfort.
• Restoration of blood flow. Damaged blood arteries can undergo surgery to improve blood flow. The options consist of bypass surgery and angioplasty.
  • Surgical revascularization. A surgeon gives the blood a new route to take to bypass the blockage.
  • Angioplasty. A surgeon inflates a small balloon inside the artery to widen it and allow blood to flow. A stent may also be inserted.
• Hyperbaric oxygen therapy.Increased oxygen transport by hyperbaric oxygen therapy. Bacteria residing in oxygen-deficient tissues grow more slowly in oxygen-rich blood. In addition, it accelerates the healing ofinfected wounds.
• skin graft surgery. Scarred or damaged skin is covered with healthy skin from another area of ​​the body after therapy.

gangrene prevention

There are several things that the patient can do to increase the blood flow in the body and stop the gangrene. In particular, if the patient has risk factors such as diabetes or peripheral artery disease, it is recommended to:

• Have a healthy diet. Eat foods that are low in saturated fat and cholesterol.
• Regularly assess the body.. This is to check if there is an untreated wound on the body that could cause gangrene. Regularly wash and moisturize dry patches. Maintain proper hygiene. Use mild soap and water to clean open wounds. Until healing, keep hands dry and clean.
• Check for freezing. Blood flow to the affected area is reduced by frostbite. Call a healthcare professional if the patient complains of pale, hard, cold, or numb skin after being in cold weather.
• Diet.Eat foods that are low in saturated fat and cholesterol.
• Exercise.Having to exercise regularly improves the body's blood circulation. The risk of diabetes increases with weight gain. In addition, weight overloads the arteries, reducing blood flow. Reduced blood flow delays wound healing and increases the risk of infection.
• Monitoring blood glucose levels.Keeping blood glucose levels under control is important as diabetes is one of the risk factors for gangrene. Be sure to regularly check the patient's hands and feet for cuts, sores, and signs of infection such as swelling, redness, or drainage.
• abandonmentto smoke. Avoid all types of tobacco products. Smoking for a long period of time damages blood vessels.

Nursing diagnosis for gangrene

Nursing Care Plan for Gangrene 1

ineffective tissue perfusion

Nursing diagnosis: Ineffective tissue perfusion related to gangrene secondary to chronic diabetic foot evidenced by blisters and lesions on the patient's toes

Desired results:

• The patient identifies necessary lifestyle changes.
• The patient engages in behaviors or actions to improve tissue perfusion.
• The patient verbalizes or demonstrates normal sensations and movements as appropriate.

Nursing interventions in gangrene

Evaluate indications for decreased tissue perfusion. Note the texture of the skin, hair, sores, or gangrenous areas on the legs, feet, hands, and arms.Skin perfusion may be impaired and pulses may be stopped as a result of systemic vasoconstriction caused bydecrease in cardiac output. Therefore, evaluation is necessary for continuous comparisons.

Make sure the fluid balance is optimal. Administer intravenous fluids as indicated.Adequate filling pressures are maintained with sufficient fluid intake, which also maximizes cardiac output needed for tissue perfusion.

Maintain cardiac output at optimal levels.This ensures that essential organs receive sufficient circulation.

Help change positions and encourage ROM activities.Careful repositioning of a patient from supine to sitting or standing helps to lessen circulatory compromise.it is poisonousand subsequent circulatory compromise are minimized by exercise.

Whenever necessary, administer oxygen therapy.This increases the amount of hemoglobin in the blood and increases the rate at which blood reaches ischemic tissues.

Promote smoking cessation.Smoking is also related to the release of catecholamines, which cause vasoconstriction and inefficient tissue perfusion.

Teach the patient to identify the symptoms and signs that the nurse should be aware of.Early detection allows for quick treatment.

All procedures and treatments must be described. Heanxietycaused by the unknown can be reduced through a clear understanding of anticipated events and experiences.

Gangrene 2 Nursing Care Plan

impaired tissue integrity

Nursing diagnosis:Impaired tissue integrity related to gangrene secondary toperipheral vascular diseaseas evidenced by blisters and lesions on the patient's fingers and toes

Desired results:

• The patient reports any pain at the site of the tissue tear.
• The patient describes measures to protect and heal the tissue, including proper wound care.
• The patient's wound shrinks in size and forms granulation tissue.

Nursing interventions in gangrene

Check the site for discoloration, redness, swelling, heat, discomfort or other indicators of infection at least once a day..Early detection of potential problems is possible with systematic inspection.

When caring for wounds, maintain a sterile dressing approach..In cases of impaired tissue integrity, a sterile method reduces the risk of infection. This requires the use of sterile equipment, gloves, supplies and dressings, as well as sterile tools.

Inform the patient to avoid scratching and rubbing. If necessary, provide gloves or trim your fingernails. Scratching and rubbing can aggravate an injury and delay healing.

Encourage the use of pressure relief tools such as foam pads and wedges. These steps help redistribute pressure, relieve pressure, and prevent pressure sores.

Inform the patient about proper hydration, nutrition and tissue conservation techniques. To avoid deterioration of tissue integrity, the patient must be properly informed about his situation.

Teach the patient, their partners, and their families how to properly care for the wound, including hand washing, cleaning the wound, changing dressings, and applying topical treatments. Accurate information reduces the risk of infection and improves the patient's ability to independently manage therapy.

Teach the patient, their partners, and their families how to properly care for the wound, including hand washing, cleaning the wound, changing dressings, and applying topical treatments. Accurate information reduces the risk of infection and improves the patient's ability to independently manage therapy.

Gangrene 3 Nursing Care Plan

risk of infection

Nursing diagnosis:Risk of infection related to possiblesepticemiasecondary to gangrene

Desired result:The patient will achieve timely healing; be free of purulent discharge, drainage, or erythema; and be feverish

Nursing interventions in gangrene

Teach the patient and family to wash their hands correctly with antibacterial soap before and after each health activity.Cross contamination is made less likely by hand washing and good hand hygiene. Infections are most often spread through close contact with healthcare workers who fail to wash their hands between interactions with clients.

When changing dressings, aspirating and caring for the site with an invasive line or urinary catheter, maintain sterile technique.Medical asepsis limits the spread of microorganisms and decreases the possibility of nosocomial infection. Transmission of infection is prevented by personal protective equipment or PPE and isolation.

Watch for chills, chills, and heavy sweating as you look at temperature patterns.In the presence of a generalized infection, chills often precede a rise in temperature.

Dressings and other items must be disposed of in a double bag and properly labeled.Proper disposal of contaminated materials reduces contamination and bacterial spread.

Separate visitors and supervise as needed.For any client that is infectious, body substance isolation should be used. Wound drainage may only require manual cleaning, wound isolation, and plaque isolation.

When treating open wounds or anticipating direct contact with secretions or excretions, wear gloves and aprons.This prevents contamination and transmission of infections.

Monitor laboratory tests including white blood cell counts with neutrophils and band counts.An initial increase in bands and leukocytes represents the body's effort to fight the infection, while a decrease shows decompensation.

Prepare for hyperbaric treatment as needed. To treat anaerobic infections, wounds can be exposed to high voltage ambient oxygen therapy.

Gangrene 4 Nursing Care Plan

impaired physical mobility

Nursing diagnosis:Impaired physical mobility related to gangrene of the foot secondary to diabetes mellitus, as evidenced by the inability to intentionally move within the physical environment.

Desired results:

● The patient performs physical activity independently or within the limits of the disease.

● Patient demonstrates the use of adaptive devices to increase mobility.

● The patient wearssecuritymeasures to minimize the potential for injury.

● Patient assesses pain and quality of management.

Nursing interventions in gangrene

Assess the security of the environment. Carpets, children's toys, and pets can act as obstructions, further restricting the ability to move safely.

Look for redness and tissue ischemia throughout the skin (especially the ears, shoulders, elbows, sacrum, hips, heels, ankles, and toes).pressure ulcersit can be prevented, detected and treated early through routine inspection of the skin, especially over bony prominences.

When allowed to get out of bed, help the patient with muscle exercises by bending the knees, jumping on one foot and touching the toes. The patient increases their sense of balance and strengthens the body components used for compensation.

Encourage and assist early ambulation when possible. Assistance with every initial change: walking, sitting in a chair and swinging your legs. The patient is kept as functionally active as possible by these movements. Early mobility builds confidence to regain independence and reduces the likelihood of wasting away.

Demonstrate use of any necessary mobility aids, such as trapeze, crutches, or walkers. These devices can increase activity levels and compensate for decreased function. The use of these tools aims to increase safety, improve mobility, prevent falls and save energy.

Make sure the patient has time to rest between activities. Take energy-saving measures into account. Rest times are crucial for energy conservation. The patient must become aware of and accept his limitations.

Gangrene 5 Nursing Care Plan

Amputation

Nursing diagnosis:low situational self-esteemrelated to loss of toes secondary to gangrene

Desired result:The patient will verbalize and demonstrate self-acceptance and healthy adaptation to the current situation.

Nursing interventions in gangrene

Assess the patient's personal strengths and recall effective coping skills he has used in the past.Building on the patient's existing skills can be beneficial in helping the patient cope with their current circumstances.

Assess the patient's level of support.The rehabilitation process can be facilitated by sufficient support from significant others and friends.

Stimulate expression of concerns, unfavorable emotions, and grief over loss of body parts.The patient can begin to deal with the facts and reality of life without a member expressing emotions.

Encourage participation in ADL. Create opportunities for the patient to view and care for the stump while highlighting any healing progress.Promotes a sense of self-esteem and independence. Looking at the stump and listening to supportive comments (given in a normal and practical way) can help the patient in this acceptance, even if he integrates the stump intobody imageit can take months or even years.

Encourage and arrange for another amputee to visit, preferably one who is successfully recovering.A partner with a similar experience can serve as a role model, validate comments, and inspire hope for rehabilitation and a normal future.

Provide the patient with a safe space to express issues related to sexuality.This encourages discussion of values ​​and beliefs related to the sensitive issue and exposes myths and misconceptions that can impede situational adjustment.

Nursing References

Ackley, B.J., Ladwig, G.B., Makic, M.B., Martinez-Kratz, M.R. e Zanotti, M. (2020).Nursing Diagnosis Manual: An Evidence-Based Guide to Care Planning. St. Louis, MO: Elsevier.

Gulanick, M. y Myers, J. L. (2022).Nursing care plans: diagnoses, interventions and results. St. Louis, MO: Elsevier.

Ignatavicius, D.D., Workman, M.L., Rebar, C.R. y Heimgartner, N.M. (2020).Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.

Silvestri, LA (2020).Saunders Comprehensive Review for the NCLEX-RN Exam. St. Louis, MO: Elsevier.

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