COLLEGE OF NURSING

BSN PROGRAM

NURSING CARE STUDY

ON

DIABETIC FOOT AMPUTATION

Secondary to Diabetes Millitus 2

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 Section I
Health History

Patient Biographical information

Hospital No : MKHS00203

Gender: Female
Age: 40
Religion: Islam

Marital Status: Married

Occupation: Accountant
Admitting diagnosis: Infected Diabetic foot ulcer

Chief Complaints: Pain and swelling, unhealed wound on the right foot and dry
cracks on the heel

History of Present illness: Accidentally step on a broken glass last 3weeks ago, thus
obtain a small abrasion on the Rt. Foot.

Past Medical history:

Immunizations: None
Allergies: Seafoods
Disease conditions: uncontrolled DM2.

Medications: Metformin (Glucophage 500mg P.o; O.D)

Amlodipine 10mg P.o; O.D

Past Surgical history:

2 times Cesarean Section 3 years ago

Family history:
Family medical history: DM2, Hypertension
Genetic/Congenital diseases: Hypertension and Diabetes Milletus
Consanguineous marriages: None
Family Tree:

Personal history:
Hygienic habits
Smoking/ Substance abuse: None

Dietary pattern:
Dietary preferences: Diet as tolerated (No specific Limitations of food intake and
preference)
Frequency and amount of food intake: 2-3 times a day (regular meal) with snacks (2 times a
day) in between
Food Allergies: Some Seafoods (shells and crabs)

Functional history:
Rest and sleep patterns: 5-7 hours per day
Bowel and bladder habits: constipation in between, no regular bowel schedule, Urine
frequency is noted.

Menstrual and Obstetrical history [if applicable]:

Length of cycle: 28-30 days
Duration of cycle: 3-5 days
Pain and other associated symptoms: Dysmenorrhea in between
Number of children: 7
Type of childbirth/s: 5 NSVD, 2 CS
Abortion/Still birth: None
Any ante/intra/post natal complications: None
Method of contraception: Normal

Social history:
Support Systems: Family and friends

Communication with family friends and neighbors: has Good communication relationship

Participation in social activities: Yes (occasionally at work) and family gathering

 Section II
Physical Examination

Head-foot examination
General Appearance:
• Nourishment: ¤ Well-nourished ¤ Undernourished ¤ Over nourished

• Body built: ¤ Moderate build ¤ Thin ¤ Obese

• Signs of distress: ¤ Absent ¤ Present; Specify___________

• Posture: ¤ Normal ¤ Kyphosis ¤ Lordosis ¤ Scholiosis ¤ Others:__________

• Gait : ¤ Well Balanced ¤ Imbalanced ¤ Limping ¤ Others:___________

• Mobility status: ¤ Mobile ¤ Immobile ¤ Needs assistance

• Ability to meet ADLs: ¤ No limitation ¤ Partial limitation ¤ Complete limitation

Mental Status:
• Level of consciousness: ¤ Conscious ¤ Unconscious ¤ Semi-conscious

• Coherence: ¤ Coherent ¤ Incoherent

• Orientation: ¤ Oriented ¤ Not oriented

• Look: ¤ Anxious ¤ Dull ¤ Crying ¤Depressed ¤ Fear ¤ Others:______

Anthropometric Measurements:

• Height: 162

• Weight: 109

• BMI: 41.5
 • Head Circumference:

• Chest Circumference: 42inches

• Abdominal Girth:

Vital Signs:
• Temperature: 37.2 c

• Pulse: 112 Bpm

• Respiration: 21 Cpm

• Blood Pressure: 155/90 mmHg

• Oxygen Saturation [if applicable]: 99%

Integumentary System:
 Skin Condition:
 Colour: ¤ Normal ¤ Pale ¤ Jaundiced ¤ Cyanosed ¤ Flushing

 Texture: ¤Dry ¤ Flaky ¤ Wrinkled ¤ Oily ¤ Moist

 Temperature[on touch]: ¤ Normal ¤ Warm ¤ Cool ¤ Clammy

 Turgor: ¤Normal ¤ Decreased

 Lesions: ¤ Absent ¤ Present ; Specify_corn and calluses on the right foot

 Hair:
• Body Distribution: ¤Evenly distributed ¤ Hirsutism ¤ Scarcely distributed
• Texture: ¤ Soft ¤ Coarse ¤Dry ¤ Oily
• Fullness: ¤ Normal ¤ Scarce ¤ Dense
• Strength: ¤ Strong ¤ Fragile
• Infestation: ¤ Absent ¤ Present ; Specify_________
 Nails:
• Shape: ¤ Normal ¤ Spoon shaped ¤ Clubbing of nails ¤ Onycholysis ¤ Others: ___
• Color: ¤ Normal ¤ Pale ¤ Yellowish discoloration ¤ Cyanosed ¤ Others: _______
 • Capillary Refill: ¤ Normal ¤ Delayed
• Deformities: ¤ Absent ¤ Present ; Specify_dorsal and medial foot ulcer________

Head:
 Shape: ¤ Normocephaly ¤ Microcepahaly ¤ Macrocepahly ¤ Others: _______

 Symmetry: ¤ Symmetrical ¤ Asymmetrical; Specify_________

 Fontanels (in children): ¤ Closed ¤ Open ¤ Depressed ¤ Bulged ¤ Others________

 Condition of scalp: ¤ Clean ¤ Dandruff present ¤ Pediculosis ¤ Infection ¤

Others___

 Face: ¤ Pale ¤ Flushed ¤ Puffy ¤ Yellowish discoloration ¤

Others______

Eyes:
 Eyebrows: ¤ Normal ¤ Absent ¤ Others______

 Eyelashes: ¤ Normal ¤ Absent ¤ Others______

 Eyelids: ¤ Normal ¤ Puffy ¤ Ectropion ¤ Entropion ¤ Others______

 Eyeballs: ¤ Normal ¤ Sunken ¤ Protruded ¤ Others______

 Sclera and Conjunctiva: ¤ Normal ¤ Pale ¤ Yellowish ¤ Reddish ¤ Others______

 Cornea and iris: ¤ Normal ¤ Irregularities ¤ Abrasions ¤ Others______

 Pupils: ¤Normal ¤ Dilated ¤ Constricted ¤ Reactive to light ¤ Others______

 Lens: ¤ Transparent ¤ Opaque ¤ Others________

 Fundus: ¤ Normal ¤ Congested ¤ Presence of hemorrhage spots ¤ Others _____

 Eye muscles: ¤ Normal movements ¤ Strabismus ¤ Ptosis ¤ Nystagmus ¤ Others

_____

 Visual field: ¤Normal ¤ Central vision loss ¤ Peripheral vision loss ¤ Others_________

 Visual acuity: ¤ Normal ¤ Myopia ¤ Hypermetropia ¤ Others___________

Ears:
  Auricle: ¤ Symmetrical ¤ Asymmetrical ¤ Low set ears ¤ Others_______

 Ear canal: ¤ Normal ¤ Discharges present ¤ Cerumen present ¤ Others_______

 Tympanic Membrane: ¤ Normal ¤ Lesions ¤ Perforations ¤ Bulging ¤ Others_______

 Hearing: ¤ Normal acuity in both ears ¤ Decreased ¤ Others_______

Nose and Sinus:

 External nares: ¤ Symmetric ¤ Asymmetric ¤ Flaring ¤ Crusts ¤ Others_______

 Nostrils:  ¤ Normal ¤ Signs of infection ¤ Septal deviation ¤ Others_______

 Discharge: ¤ Absent ¤ Present; Specify_______

 Sense of Smell: ¤ Present ¤ Decreased ¤ Absent ¤ Others_______

 Sinus: ¤ Normal ¤ Tender ¤ Swollen ¤ Others_______

Mouth and Pharynx:

• Lips: ¤Normal ¤Dry ¤Cracked ¤Swollen ¤Angular stomatitis ¤Cyanosed

¤Others___

• Odour of mouth: ¤ Normal ¤ Foul smelling ¤ Others______

• Teeth: ¤ Normal and complete ¤ Dental caries ¤ Discoloration ¤

Others______

• Gums & mucus membrane: ¤ Normal ¤ Ulceration ¤ Bleeding ¤ Swelling ¤

Others_____

• Tongue: ¤ Normal ¤ Pale ¤ Dry/Coated ¤ Lesions ¤ Sords ¤ Furrows ¤

Others______

• Palate and uvula: ¤ Normal & in midline ¤ Cleft palate ¤ Decreased/Absent gag

reflex ¤ Others________
 • Throat and pharynx: ¤ Normal ¤ Redness ¤ Pus ¤ Enlarged tonsils ¤

Others______

Neck:
• Lymph nodes: ¤ Not palpable ¤ Palpable ¤ Tender ¤ Others_________

• Trachea: ¤ In midline ¤ Not in midline ¤ Others_________

• Thyroid gland: ¤Normal ¤ Enlarged ¤ Presence of nodules ¤ Others______

• Range of motion: ¤ Normal ¤ Limitation of motion; Specify ____________

Thorax:
 Shape of chest: ¤ Normal ¤ Pectus excavatum ¤ Pectus carinatum ¤ Barrel Chest

¤ Others______

 Chest wall: ¤ Normal & intact ¤ Tenderness ¤ Digression ¤ Masses ¤ Others______

 Chest expansion: ¤ Symmetrical ¤ Asymmetrical ¤ Laboured breathing ¤ Others____

 Breasts [if applicable]: ¤ Tender ¤ Enlarged axillary lymph nodes ¤ Others______

 Respiratory rate: 20 cpm

 Breath Sounds: ¤ Clear ¤ Rhonchi/Wheeze ¤ Rales/Crackles/ Crepitations ¤ Stridor

¤ Pleural rub ¤ Others______

 Chest Percussion: ¤ Resonance ¤ Hyper-resonance ¤ Dull ¤ Others______

 Tactile vocal fremitus: ¤ Absent ¤ Present

 Heart Sounds: ¤ Normal S1S2 ¤ Heart murmurs ¤ Arrhythmia ¤ Others______

 Heart Rate: 112 bpm

Abdomen:
 Abdominal contour: ¤ Normal/Flat ¤ Abdominal distension ¤ Scaphoid abdomen

¤ Asymmetric ¤ Others: symmetric, round and soft to touch_____

 Vascularity: ¤ Not Visible ¤ Visible; Specify ______

 Hernia/protrusions: ¤ Absent ¤ Present; Specify ________

 Rashes/Lesions/striae/scars: ¤ Absent ¤ Present; Specify ________

 Bowel sounds: Normal

 Fetal heart sounds and rate[if applicable]:

 Presence of gas/fluid: ¤ Absent ¤ Present; Specify ______________________

 Presence of masses: ¤ Absent ¤ Present; Specify ______________________

 Liver margin: ¤ Easily palpable ¤ Palpable ¤ Not palpable

 Spleen: ¤ Palpable ¤ Not palpable

 Tenderness: ¤ Absent ¤ Present; Specify ________

Extremities:
 Symmetry in size and length: ¤ Symmetrical ¤ Asymmetrical; Specify ________

 Clubbing of fingers/toes: ¤ Absent ¤ Present; Specify ________

 Tenderness / oedema: ¤ Absent ¤ Present; Specify ________

  Varicose veins: ¤ Absent ¤ Present; Specify ________

 Deformities: ¤ Absent ¤ Present; Specify ________

Back:
 Contour and curves: ¤ Normal contour & curves ¤ Abnormal; Specify ____________

 Symmetry: ¤ Symmetrical ¤ Asymmetrical; Specify _______________

 Range of motion and Posture: ¤ Normal ¤ Abnormal; Specify ____________

 Deformities: ¤ Absent ¤ Present; Specify ________

Genitals and Rectum:

 Patency of urinary meatus: ¤ Patent ¤ Not patent/Obstructed; Specify ________

 Descent of testes [in infants-male] ¤ Descended ¤ Undescended

 Vaginal discharges [in females] ¤ Absent ¤ Present; Specify ________

 Signs of STDs: ¤ Absent ¤ Present; Specify ________

 Hemorrhoids: ¤ Absent ¤ Present; Specify ________

 Enlarged prostate gland [in males]: ¤ Absent ¤ Present

 Pelvic masses: ¤ Absent ¤ Present; Specify ________

 System wise examination ( Only mention the examination details of

affected system)
 INVESTIGATIONS

Slno Date Investigation Patient’s Normal Remarks

value value
 DRUG FILE

Sl Trade name Pharmacological Dose/route/ Action Side Contra Nurses responsibility

no name frequency effects indications
1
Sl Trade name Pharmacological Dose/route/ Action Side Contra Nurses responsibility
no name frequency effects indications
 ( WRITE THE PATIENT’S DIAGNOSIS HERE)
INTRODUCTION

Diabetic foot infections are an important cause of morbidity in patients with

diabetes mellitus. The lifetime risk of a foot ulcer for patients with type 2 diabetes
may be as high as 34 percent. Most diabetic foot complications that result in
amputation begin with formation of skin ulcers.

Management of diabetic foot ulcers accounts for a large number of inpatient stays,
has a high rate of hospital readmission, and is associated with a 2.5-fold risk of
death compared with patients with diabetes without foot ulcers.  A potentially
preventable initiating event, most often minor trauma that causes cutaneous injury,
can often be identified.

Foot amputations, many of which are preventable with early recognition and
therapy, may be required in up to 20 percent of diabetic foot ulcers. These
observations illustrate the importance of frequent evaluation of the feet in patients
with diabetes to identify those at risk for foot ulceration. Systematic screening
examinations for neuropathic and vascular involvement of the lower extremities
and careful inspection of feet may substantially reduce morbidity from foot
problems.

DEFINITION

Diabetic foot describes the foot of a diabetic patient that has a potential risk of
pathologic consequences, including infection, ulceration, and destruction of deep
tissues associated with neurologic abnormalities, various degrees of peripheral
arterial disease, and metabolic complications of diabetes in the lower limb (from
the World Health Organization definition).

The term “diabetic foot wound” refers to a variety of conditions like cellulitis,
osteomyelitis or ulcers.
People with diabetic foot ulcers have a decreased quality of life and an 8% higher
incidence of needing a lower extremity amputation in the future. Amputation is a
major complication of diabetes.

ETIOLOGY AND RISK FACTORS

Diabetic foot ulcers are characterized by an inability to self-repair in a timely and

orderly manner, and occurs as a consequence of the interaction of several
contributory factors.

These contributory factors may be schematically divided into:

1. Intrinsic
 Neuropathy
 Peripheral vascular disease
 Diabetes severity
2. Extrinsic

 Wound infection
 Callus formation
 Excessive pressure to the site/ Trauma

There is a TRIAD OF FACTORS that contribute ultimately to ulceration, and

they are:

 Presence of peripheral neuropathy
  Foot deformities
 Acute (or chronic) repetitive trauma.

In the diabetic foot, peripheral sensory neuropathy is responsible for the pain

insensitivity, while autonomic sensory neuropathy causes impaired sweat gland
function, resulting in dry, atrophic skin. Motor neuropathy commonly causes
intrinsic muscle wasting with a characteristic foot with joint contractures and
prominent bones to the metatarsal plantar region with limited fat padding. All
together the three components determine loss of sensation, changes in foot
structure with consequent deformity, and skin changes.

The diabetic foot is therefore more vulnerable to injury with poor defenses. Of
note, it has been shown that loss of peripheral sensory and autonomic nerves along
with diminished neuropeptide production precedes clinical symptoms of
neuropathy.

 Internal or external traumas are generally the next key factor and are generally
related to the development of abnormally high foot pressures during walking.
Internal traumas typically result from repetitive stresses from high-pressure areas,
external traumas derive instead from the environment, such as an object in the
shoe.

Risk factors for a patient with diabetes to require an amputation include:

 High blood pressure, above 140/80 (mmHg)

 High blood sugar levels

 Smoking
 Nerve damage in the feet (peripheral neuropathy)
 Calluses or corns
 Foot deformities
 Poor blood circulation to the extremities (peripheral artery disease)
 A history of foot ulcers
 Vision impairment
 Kidney disease
 BOOK PICTURE PATIENT PICTURE

CLINICAL MANIFESTATIONS:

Patient is experiencing the following:

 Loss of sensation
 Swelling on the right foot
 Numbness
 Fever
 Presence of increased exudate and foul smell wound
 Deep ulcers of the foot.
 Gangrene
BOOK PICTURE PATIENT PICTURE
DIAGNOSTIC STUDIES

Visible detection:
 Classified by depth from 0 to 3, with 0 meaning no ulceration and 3 meaning
extensive ulceration or abscesses.
 Classified by ischemia from A to D, with A being not ischemic through D
being complete foot gangrene.

BOOK PICTURE PATIENT PICTURE

MANAGEMENT

a)MEDICAL /CONSEVATIVE( IF AVAILABLE)

>  Antibiotics are prescribed to treat polymicrobial infection.

 BOOK PICTURE PATIENT PICTURE

b)SURGICAL MANAGEMENT

> Vascular debribement or resection

> Amputation for untreated ulcers

BOOK PICTURE PATIENT PICTURE

 SURGERY NOTES:
c) NURSING MANAGEMENT

 Nursing care plan

LIST OF NURSING DIAGNOSES

1.

7.

8.

9.

10.
Assessment Nursing Goal & Plan of action Rationale Implementation Evaluation
data diagnosis Expected
outcomes
Assessment Nursing Goal & Plan of action Rationale Implementation Evaluation
data diagnosis Expected
outcomes
Assessment Nursing Goal & Plan of action Rationale Implementation Evaluation
diagnosis Expected
outcomes

  Dietary plan/Management

Advised the patient to eat healthy and nutritious food as prescribed by the
doctor/ dietician.

 Low carbohydrate and less sugar diet

 High protein, less fat diet
d) Progress Notes ( starting from the first day of care to the end with dates )
e) Health education plan/discharge advice
f) Conclusion

g) Reference