Type II

Type II

Type II Type II Type II Type II Type II Type II Type II Type II

For this reason, he was brought to Bacolod our Lady of Mercy Specialty Hospital in Bacolod City and was admitted where he was diagnosed of having Diabetic Right Foot Wagner III after a series of assessments made. Patient was Diabetes mellitus, often simply Patient B.T., a 49 year old male living recommended to undergo chronic referred to as Diabetes, is a Below the Knee in Himamaylan was constantly having Amputation to prevent the spread of metabolic disorder that causes Diabetes Mellitus type II for two necrosis to the(polydipsia), upper portion persistent thirst (polydipsia), of his body. years. Patient got accidentally excessive urination (polyuria), (polyuria), wounded on the sole of his right foot increased hunger (polyphagia), (polyphagia), and due to poor management the weight loss and a surplus of sugar in wound continued to will surelyuntil us students This case study progress help the blood and urine. Although necrosis of some tissues occurred. have to enhance care for at any age, it Diabetes can develop patients who is Also, the patient manifested weight application Diabetes Mellitus II women than more common amongthrough the lossof nursing skills, interventions and as stated by his wife. among men, with excessive knowledge. overweight as contributing factor in later life.

The most important hormones secreted by the pancreas are insulin and glucagon. Structure of role Pancreas metabolism of Both play a the in proper sugars and starches in the body. Insulin The pancreas is an elongated organ that promotes the movement of glucose and other nutrients out of the blood and into lies behind and below the stomach. This cells. When blood glucose rises, insulin, mixed gland contains both exocrine and released from the beta predominant endocrine tissues. The cells causes glucose to enter body cells to be used for exocrine part consists of grape-like energy. Also, it sometimesthat form sacs clusters of secretory cells stimulates conversionacini, whichto glycogen ducts known as of glucose connect to in the liver. Another pancreatic hormone, that eventually empty into the first glucagon, promotes the movement of portion of the intestine called glucose into the blood when glucose duodenum. The smaller part of the gland levels are below normal. It causes the consists of isolated islands of endocrine breakdown of stored liver glycogen to tissue known as islets of glucose, so that the sugar content of Langerhans which are blood leaving the liver dispersed

Pancreas

throughout the pancreas

Assessment Assessment
Date: July 15, 2010 Time: 7:00 am

Patient skin is of dark complexion R-21 is able and is cpm to move from side Patient dry on lower extremities and on palm of hands. Patient to side with assistance from has Able to perform active folks.non-healing wound with necrotic tissues Patient foot. range of motion. on right is unambulatory.

Vital Signs Musculoskeleta Integumentary l bpm P-117

Pathophysiology Pathophysiology
PredisposingFactor: Predisposing Factor
Male and Age above 40y.o

Precipitating Factor:
Poor lifestyle (lack of exercise and excessive eating food high in sugar)

Destruction of beta and alpha cells

Stimulates beta cells to secrete Insulin (Malfunction of Insulin)

Unable to Transport glucose (Insulin resistant) inside the cell to oxidize it for energy;Unable to Store glucose in the Liver as glycogen or fat.

Glucose is retained in the bloodstream (hyperglycemia)

Without insulin, excessive glucose spills in the urine because kidney tubule cells cannot reabsorb it fast enough

Polyuria

Polyuria

Dehydration

Diabetes Insipidus

Polydipsia (Increased thirst)

Cells breakdown proteins and fats to meet bodys energy reqts

Infection Polyphagia Non- Healing Wound

Weight loss

Drug Study

C  Metformin hydrochloride 5 00 mg/tab  Exact  mechanism is not understood: possibly increase peripheral utilization of glucose, decreases hepatic glucose production, and alters intestinal absorption of glucose Antidiabetic

H Adjunct to diet to lower blood glucose with type 2 diabetes mellitus

E


C discontinue this medication without consulting your health care provider Monitor blood for glucose and ketones as prescribed. Avoid using alcohol while taking this drug Report fever, sore throat, unusual bleeding


Assess if there is allergy to metformin;diabetes complicated by fever, severe infections, severe trauma, major surgery

 TID

Monitor urine or serum glucose levels frequently to determine effectiveness of drug and dosage

 

Monitor adverse effects: Endocrine: hypoglycemia, lactic acid acidosis

GI: anorexia ,nausea, vomiting, epigastric discomfort, heartburn diarrhea, flatulence

Hypersensitivty:allergi c skin reactions, eczema, pruritus,erythema.

Drug Study
C  Antiinflammatory, analgesic, and anti pyretic activities related to inhibition of enzyme cyclooxygenase( COX), which is required for the synthesis of prostaglandin and thromboxanes. Somewhat more selective for COX-2 sites (found in the brain, kidney, ovary, uterus, cartilage, bone, and at sites of inflammation) NSAID

H  Relief from signs and symptoms of osteoarthritis and rheumatoid arthritis.

 TID

C   Take drug with food if GI upset occur Take only prescribed dosage Report sore throat, fever, rash, itching, weight gain, swelling in anklesor fingers. Report changes in vision
 

 Meloxica m 15 mg

  

 

Assess the history of the allergies of the medication Administer drug with food or milk if GI upset occurs Establish safety measures if CNS disturbance occurs Monitor adverse effects: CNS: headache, dizziness, somnolence, insomnia, fatigue,,tiredness,ti nnitus, ophthalmologic effects Dermatologic: rash,pruritus, sweating, dry mucous membranes, stomatitis GU: Dysuria, renal impairment GI: nausea, despepsia, GI pain, diarrhea, vomiting

Drug Study
C  Clindamycin 300mg  Isotretinoin  noticeably reduces the production of sebum and shrinks the sebaceous glands. It stabilises keratinization and prevents comedones from forming. H Inhibits  protein synthesis in susceptible bacteria causing cell death. E BID
 C If you miss a dose of Clindamycin, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. You may experience these side effects: nausea and vomiting, superinfection in mouth Report severe watery diarrhea, abdominal pain, inflamed mouth       K Culture infection before therapy. Do not use for minor bacterial or viral infections Monitor Adverse effects: CV:hypotension, cardiac arrest. GI: severe colitis, nausea and vomiting anorexia Hematologic: Neutropenia, leucopenia, agranulocytosis Hypersensitivity: rashes,urticaria

Nursing Care Plan

Pathophysiology Nursing Diagnosis Elevated Blood A. Actual Abnormal Ineffective Sugar levels Cues Tissue perfusion related to Objective Data: viscosity of blood due to Increase Viscosity y Presence of increase blood of Blood necrotic tissues sugar levels AEB on Right foot. presence of y Foul smelling necrotic tissues, odor on Decrease blood poor capillary affected foot. flow refill on affected y Poor capillary extremity, and refill of 4foul smelling 5seconds on Necrotic Right foot wound. right foot. y Increased blood Definition: sugar levels of decrease in Ineffective tissue B. Risk Related oxygen resulting perfusion Factor: in the failure to

Assessment

Desired Outcome After 16 hours of nursing care, patient will be able to: y

Nursing Interventions

Justification

Evaluation After 16 hours of nursing care, patient was able to: Client is about to undergo Below the knee amputation which will prevent the spread of necrosis. Goal partially met. Demonstrate a positive behavior toward therapeutic regimen as evidenced by good compliance and allowing the surgery to be performed. Goal Met.

y Old Age C. Strengths and Wellness y y Availability of health services Compliance of the patient and her family to medication Good family support

nourish the tissues at the capillary level. Reference: Nurses Pocket Guide

Reference: Medical Surgical Nursing

Independent intervention: 1. Assess vital signs and skin turgor. Prevent the spread 2. Instruct patient to perform of decreased Range of motion. tissue perfusion to 3. Provide a safe other parts of the environment for the body. patient. Demonstrate a 4. Monitor and document positive Attitude Intake and Output towards 5. Monitor vital signs every therapeutic 1 to 2 hours or as the regimen. clients condition indicates 6. Assess skin and mucous membrane moisture, skin turgor, presence of thirst, and mental status. 7. Explain to the patient the necessity and benefits in undergoing Below the Knee Amputation Collaborative intervention: 1. Collaborate with Dietitian and physician to. Reference: Fundamentals of Nursing

1,Accurate assessment enables the nurse to develop appropriate plans for therapy regimen. 2,To promote proper blood circulation. 3.To prevent complications such as skin breakdown, loss of skin integrity. 4.Measuring intake and output allows the nurse to maximize perfusion. 5.Hypotension and an increased pulse rate are indicative of intravascular deficit. 6.Poor skin turgor, tissue dryness, and presence of thirst are indications of dehydration. 7.To increase knowledge of patient that BKA is necessary to prevent the spread of necrosis. 1.To identify foods and other therapeutic regimens indicated for patient to decrease viscosity of the blood. Reference: Nursing Care Plans, Medical Surgical Nursing

NURSING RATIONALE DIAGNOSIS A. Actual Abnormal Impaired Skin Increased blood Cues: Integrity related sugar levels - Non Healing wound to Impaired with Necrotic tissues Tissue per Decreased protein on Right foot. fusion AEB levels B. Risk Related Necrotic Right Factors Foot. y Inadequate Definition: Delay of Healing primary defenses Alterations in process (broken skin, the Dermis and traumatized Epidermis. Non-healing tissue) SOURCE: wound with y Old age NANDA 8th necrotic tissues on y Decreased level edition of body proteins right foot. C.Strengths/Wellness y Strong belief in Impaired Skin God Integrity. y Good Family Source: Medical support. Surgical Nursing y Good compliance to therapeutic by Black and regimens. Hawks

ASSESSMENT

Nursing Care Plan DESIRED

OUTCOME After 16 hours of nursing interventions, my client will be able to: y Identify interventions to reduce spread of infection to other parts of the body. y Verbalize understanding of individual causative /risk factors. y Have a positive Attitude towards therapeutic regimen.

NURSING INTERVENTIONS Independent: 1. Daily wound dressing of wound. 2. Stress proper hand hygiene by client and clients visitors. 3. Monitor patients temperature and perform tepid sponge bath if temperature is elevated. 4. Monitor any drainage coming out from the patients wound. 5. Emphasize necessity of taking antibiotics as directed. 6. Explain the procedures needed for further care. Collaborative: 7. Prepare patient preoperatively (Below the knee Amputation) as ordered. 8. Encourage consultation of Dietitian. Reference: Fundamentals of Nursing

JUSTIFICATION

EVALUATION After 16 hours of nursing interventions, my client was able to: Client was able to identify interventions to prevent/reduce the risk of infection like requesting for regular wound cleaning. Goal met Client was able to understand the different causative /risk factors like unhygienic practices. Goal me Demonstrate a positive behavior towards therapeuti regimen by cooperating with the procedures performed. Goal Met.

To reduce bacteria present in the wound and prevent it from having a foul smell. To prevent spread of infection from direct contact. To determine the patients response to infection and decrease temperature. To identify severity of the wound. Premature discontinuation of taking antibiotics may result to increase infection and potentiate drug-resistant strains. To elicit cooperation and alleviate anxiety. To help patient in get ready for the upcoming operation. To have a list of foods indicated to restore energy levels and prevent worsening of condition (Diabetic Diet). SOURCE: NANDA 8th edition

Nursing Care Plan

NURSING DIAGNOSIS Risk Related Factors Risk for injury related to y Inadequate altered physical primary defenses mobility due to (broken skin, necrosis of traumatized right foot. tissue) Definition: At y Immunosuppresi risk of injury as a result of on. environmental y Prolonged stay conditions in the hospital interacting with the individuals Strengths/Wellness adaptive and y Strong belief in defensive resources. God SOURCE: y Good NANDA 8th compliance to edition medications ASSESSMENT RATIONALE Non-healing wound and Necrosis of Right foot. Alterations in mobility Risk for injury Source: Medical Surgical Nursing by Black and Hawks
DESIRED OUTCOME After 16 hours of nursing interventions, my client will be able to: y

NURSING INTERVENTIONS

JUSTIFICATIO N To prevent falls. To prevent from getting injured. To promote safety for the patient during transportation. To evaluate degree or source of risk inherent in the individuals situation. To correct or reduce individual risk factors. To enhance selfesteem. To correct or reduce individual risk factors. . SOURCE: NANDA 8th edition

EVALUATION

Independent: Provide side rails to patient. Teach patient to move carefully. Identify Use wheelchair in interventions transporting patient from to prevent/reduce one area to another. risk of injury. Ascertain knowledge of safety needs or injury Verbalize prevention and understanding motivation to prevent of individual injury. causative /risk Provide information factors. regarding disease or Demonstrate condition that may result behaviors, in increase risk of injury. lifestyle Encourage participation changes to in self-help programs reduce risk such as assertiveness factors and training, positive selfprotect self image. from injury. Collaborative: Refer to physical or occupational therapist as appropriate. Reference: Fundamentals of Nursing

After 40 hours of nursing interventions, my client was able to: Client was able to identify interventions to prevent/reduce the risk of infection like providing a safe environment. Goal met. Goal met. Client was able to determine the different causative /risk factors like falls. Goal Met. . Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury like identifying the benefits of undergoing procedures required for health maintenance. Goal Met.

Health Teaching
MEDICATION -Compliance to medications to promote optimal healing. EXERCISE Passive and active range of motion helps promote circulation and improve tissue perfusion and use body glucose for energy oxidation. TREATMENT -Compliance to treatment to promote optimal healing: Below the Knee Amputation to prevent the spread of necrosis going to the upper extremity. Antibiotics that inhibits the growth of bacteria which causes infection. Enough rest and sleep to provide the bodys needed energy. Regular cleansing of wound to prevent further infection. Laboratories ordered to detect abnormalities. Oral hypoglycemic agents and daily exercise. HYGIENE Daily brushing of teeth decreases number of microorganisms present in the mouth and prevent it from getting swallowed. Bed bath if not contraindicated. Tepid sponge bath to promote comfort and decrease body temperature if patient is febrile. Wound cleansing as ordered by the physician to prevent infection affected site. OUTPATIENT Good compliance to medication as prescribed by the doctor ( not to miss or double the dose) Daily wound dressing to promote wound recovery. Follow the diet as advised to help the body restore energy levels and prevent worsening of condition. Provide enough rest periods and sleep. Regular health check up the doctor to monitor patients recovery. Notify physician for any untoward symptoms of medications taken. Daily exercise to promote proper blood circulation and oxidize bodys excess glucose. DIET Diabetic Diet- foods low in sugar to prevent further worsening of the condition.