Gangrene is a serious condition characterized by the death of body tissue due to a lack of blood supply or bacterial infection. This nursing diagnosis focuses on identifying symptoms, preventing complications, and managing tissue death while promoting healing and preventing further tissue damage.
Causes (Related to)
Gangrene can develop due to various factors that affect blood supply and tissue health:
- Peripheral vascular disease
- Diabetes mellitus
- Severe trauma or injury
- Deep vein thrombosis
- Severe burns or frostbite
- Surgical complications
- Immune system disorders
- Risk factors include:
- Smoking
- Obesity
- Advanced age
- Raynaud’s disease
- Atherosclerosis
Signs and Symptoms (As evidenced by)
Gangrene presents with distinctive signs that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Severe pain in the affected area
- Numbness or tingling
- Loss of sensation
- Foul-smelling discharge
- Weakness in the affected limb
- Fever and general malaise
- Anxiety about condition
Objective: (Nurse assesses)
- Discolored skin (black, blue, or bronze)
- Cold skin temperature
- Absent pulses in the affected area
- Skin breakdown or necrosis
- Crepitus on palpation
- Edema
- Drainage or pus
- Line of demarcation between healthy and gangrenous tissue
Expected Outcomes
The following outcomes indicate successful management of gangrene:
- Prevention of further tissue death
- Improved circulation to the affected area
- Wound healing progression
- Infection control
- Pain management
- Maintenance of remaining tissue integrity
- Prevention of complications
- Patient understanding of preventive measures
Nursing Assessment
Circulatory Assessment
- Check peripheral pulses
- Monitor skin temperature
- Assess capillary refill
- Document skin color changes
- Evaluate tissue perfusion
Wound Assessment
- Measure wound dimensions
- Document wound characteristics
- Assess drainage
- Monitor for infection signs
- Track healing progress
Pain Evaluation
- Assess pain levels
- Document pain characteristics
- Monitor pain patterns
- Evaluate pain management effectiveness
- Note the impact on mobility
Systemic Assessment
- Monitor vital signs
- Check blood glucose levels
- Assess nutritional status
- Evaluate hydration
- Monitor for sepsis signs
Risk Factor Assessment
- Review medical history
- Evaluate lifestyle factors
- Assess compliance with treatment
- Document contributing conditions
- Monitor medication effects
Nursing Care Plans
Nursing Care Plan 1: Impaired Tissue Perfusion
Nursing Diagnosis Statement:
Impaired Tissue Perfusion related to compromised blood flow as evidenced by tissue necrosis, absent peripheral pulses, and cold extremities.
Related Factors:
- Vascular insufficiency
- Diabetes mellitus
- Atherosclerosis
- Thrombosis
Nursing Interventions and Rationales:
- Monitor peripheral pulses q4h
Rationale: Tracks circulation status and identifies changes - Position the affected area below the heart level
Rationale: Promotes blood flow through gravity - Maintain optimal room temperature
Rationale: Prevents vasoconstriction
Desired Outcomes:
- Improved tissue perfusion
- Stabilization of tissue damage
- Maintenance of peripheral pulses
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to the presence of necrotic tissue and compromised circulation as evidenced by tissue death and altered inflammatory response.
Related Factors:
- Presence of dead tissue
- Compromised circulation
- Altered immune response
- Poor nutrition
Nursing Interventions and Rationales:
- Perform sterile dressing changes
Rationale: Prevents bacterial contamination - Monitor wound characteristics
Rationale: Identifies early infection signs - Administer antibiotics as ordered
Rationale: Treats existing infection and prevents the spread
Desired Outcomes:
- Absence of infection signs
- Improved wound healing
- Prevention of sepsis
Nursing Care Plan 3: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to tissue death and inflammatory process as evidenced by verbal reports of pain and guarding behavior.
Related Factors:
- Tissue necrosis
- Inflammatory response
- Nerve involvement
- Wound presence
Nursing Interventions and Rationales:
- Assess pain regularly
Rationale: Ensures appropriate pain management - Administer analgesics as prescribed
Rationale: Provides pain relief - Implement non-pharmacological pain measures
Rationale: Enhances pain management effectiveness
Desired Outcomes:
- Improved pain control
- Enhanced comfort level
- Increased mobility
Nursing Care Plan 4: Anxiety
Nursing Diagnosis Statement:
Anxiety related to the threat to body image and potential loss of function as evidenced by expressed concerns and restlessness.
Related Factors:
- Threat to health status
- Fear of amputation
- Change in body image
- Uncertainty about outcome
Nursing Interventions and Rationales:
- Provide emotional support
Rationale: Reduces anxiety levels - Explain procedures and treatments
Rationale: Increases understanding and cooperation - Facilitate coping strategies
Rationale: Helps manage emotional response
Desired Outcomes:
- Decreased anxiety levels
- Improved coping mechanisms
- Enhanced understanding of the condition
Nursing Care Plan 5: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to pain and tissue damage as evidenced by decreased range of motion and activity intolerance.
Related Factors:
- Pain
- Tissue damage
- Fear of movement
- Prescribed restrictions
Nursing Interventions and Rationales:
- Assist with position changes
Rationale: Prevents pressure injuries - Implement a progressive mobility plan
Rationale: Maintains function and prevents complications - Provide assistive devices
Rationale: Supports safe mobility
Desired Outcomes:
- Improved mobility
- Prevention of complications
- Enhanced independence
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Huayllani MT, Cheema AS, McGuire MJ, Janis JE. Practical Review of the Current Management of Fournier’s Gangrene. Plast Reconstr Surg Glob Open. 2022 Mar 14;10(3):e4191. doi: 10.1097/GOX.0000000000004191. PMID: 35295879; PMCID: PMC8920302.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Lewis GD, Majeed M, Olang CA, Patel A, Gorantla VR, Davis N, Gluschitz S. Fournier’s Gangrene Diagnosis and Treatment: A Systematic Review. Cureus. 2021 Oct 21;13(10):e18948. doi: 10.7759/cureus.18948. PMID: 34815897; PMCID: PMC8605831.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Yang Z, Hu J, Qu Y, Sun F, Leng X, Li H, Zhan S. Interventions for treating gas gangrene. Cochrane Database Syst Rev. 2015 Dec 3;2015(12):CD010577. doi: 10.1002/14651858.CD010577.pub2. PMID: 26631369; PMCID: PMC8652263.
