Your nursing interventions should focus on providing foot care, monitoring your patient's response to the prescribed drugs and promoting circulation after surgery.

Foot Care

The primary goal of nursing care in patients with diabetes and peripheral vascular disease is to help reduce the risk of foot and leg amputations. Therefore, protect the patient's legs and feet from even minor traumas, which can lead to infection, ulcers, and ultimately loss of function.

Thoroughly assess your patient's legs and feet for signs of impaired skin integrity, such as pressure areas or skin tears. If your patient has peripheral or autonomic neuropathy, she may have decreased sensations of touch, pain, or temperature, so examine her legs and feet routinely for signs of breakdown. Check her pedal pulses, foot temperature, capillary refill, and skin color. Also, assess her for changes in feeling, such as numbness or tingling.

Provide your patient with meticulous foot care. To prevent pressure on her legs and feet, make sure she changes position every 2 hours and performs range-of-motion exercises, if possible. Wash her feet with warm water and mild soap, and dry them well, particularly between the toes. Inspect her feet and apply moisturizing cream every day but not between her toes. Use protective padding, foot cradles, or an alternating-pressure mattress to reduce the risk of pressure injuries. To prevent constriction and impaired circulation, don't use elastic antiembolism stockings.

Although your patient's activity may be restricted, make sure she wears appropriate foot­wear, even for short distances. Shoes or slippers that don't fit properly can cause further injury and lengthen her hospital stay.

Monitor your patient for signs and symptoms of wound infection, including redness, swelling, or foul-smelling, purulent drainage. Obtain a culture of any open or draining lesion, and begin antibiotic therapy as prescribed. If your patient is taking antibiotics, make sure she drinks at least eight 8-ounce glasses of fluid every day, and assess her renal function daily. Dress an infected wound with a wet-to-dry dressing and change it several times a day to achieve mechanical debridement. (Remember that the dressing helps lift off dead surface skin, which promotes new tissue growth.) If the wound isn't infected, dress it with an occlusive dressing that retains moisture and enhances cell migration and healing.

Drug Response

If your patient is taking pentoxifylline, check for headaches, dizziness, nausea, or vomiting. Monitor her WBC count for signs of neutropenia. If she's taking ticlopidine, closely monitor her complete blood cell count and WBC differential for adverse effects, such as neutropenia. Also, evaluate her liver function tests for elevated alanine amino transferase and aspartate amino transferase levels, which indicate liver dysfunction.

Postoperative Circulation

If your patient has a bypass graft, your primary goal after surgery is to promote and maintain circulation through the new grafts. So monitor the neurovascular status of her feet and legs. Immediately report signs or symptoms of graft occlusion, such as severe pain, loss of pulses, cold hands or feet, or new complaints of numbness or tingling.

Position your patient so that her knees aren't flexed, which might impair her circulation and compromise the patency of the graft. Also, make sure she doesn't sit in one position for a long period. Elevate the affected leg to reduce edema. Instruct her not to cross her legs and to avoid keeping the affected leg in a dependent position for a prolonged period.

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