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A Case Study about


Patio, Patrick Jazzen P. Paz, Rizza Marie P. Poquita, Sienna Rose C. Ricafranca, Reylin Shalimar M. Sakaluran, Nurmina B Salazar, Kimberly P. Samatra, Troy A. Umayam, Cherry Ann D. Velarde, Arnel T.

Adviser: Ms. Susan C. Espadon, R.N MAN Clinical Instructor

Acknowledgement Abstract I. II. INTRODUCTION OBJECTIVES 1. General 2. Specific III. IV. SCOPE AND LIMITATIONS PATIENTS HEALTH INFORMATION 1. Patients Personal Profile a. Name b. Sex c. Age d. Height and weight e. Marital/Family Status f. Children g. Residential Address h. Admitting Diagnosis i. Final Diagnosis 2. Chief Complaint or Presenting Complaint 3. History of Present Illness 3.1 Location and radiation of complaint 3.2 Severity of complaint 3.3 Timing or onset 3.4 Situation of onset 3.5 Duration of complaints 3.6 Previous similar complaints 3.7 Exacerbating and relieving factors 3.8 Associated symptoms patients 3.9 Explanation of complaint 4. Past Medical History 5. Family History / 6. Drug History 7. Genogram 8. Lifestyle History / Gordons Functional Pattern


VI. VII. VIII. IX. X. XI. XII. PHYSICAL ASSESSMENT VITAL SIGNS ANATOMY AND PHYSIOLOGY SIGNS AND SYMPTOMATOLOGY PATHOPHYSIOLOGY COLLABORATIVE / MEDICAL MANAGEMENT 1. Symptomatic Approach 2. Laboratories / Diagnostic Proceeds 3. Drug Study 4. IV Therapy 5. Diet Therapy 6. Surgical Intervention/s XIII. NURSING MANAGEMENT a. NCP b. Algorithm of Care XIV. XV. GLOSSARY BIBLIOGRAPHY 1. Communication Letter 2. GCP Consultation Sheet 3. GCP Monitoring Sheet 4. Researchers Profile


The members of this case study would like to extend their warmest gratitude to all the people who made the success of this case presentation a reality. First and foremost, to the Almighty Father, for His unceasing love and blessings, for giving us enough power and fortitude to face all the hardships in the making of this work. To Him, be all glory and praise! Dean, Ms. Iris C. Castillon RN, RM, MAN, MaEd, for her vital encouragement and support. GCP adviser, Ms. Susan C. Espadon, RN MAN, thank you very much for being there at all times and pushing us so hard beyond our limits, for her invaluable time, knowledge and effort rendered to us. Most of all, for giving us the inspiration to finish this seemingly impossible task. Mr. Paul Obispo, RN MAN, III-2 class adviser, thank you for sharing your books to us, and for encouraging us to be eager with our studies and for being supportive at all times. Clinical Instructors, thank you for extending your patience and imparting the knowledge that we need. Ms. Menchie P. Palmejar RN MAN, GCP Chairman, thank you for the inspiration you extended, we will never forget you for the constant reminders and much needed motivation. To all the nurses and staff of Pasay City General Hospital, especially in the Surgical Ward for giving us the opportunity to complete this endeavor. To our dear parents, for their never ending support and understanding; for always being there to guide us and care for us.


The patient who marked a part of our hearts, for challenging us to do more to maintain his normal condition.

To the group, we would like to recognize each other for our own radical efforts in order to complete this case study, for sticking together through thick and thin and for simply being there. Lastly, to each and every one who helped us realize the importance of this case presentation, may it be direct or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is ours to share.


This is a case of patient N.L. 42 years old Male, Single, residing at Taft Avenue, Pasay City. The patient was admitted at Pasay City General Hospital last January 18, 2013 at 9:25 pm with a chief complaint of 1 week fever with unrecalled Body Temp and (+) pus on wound at left foot. Initial vital signs were taken Temp 38.2 C, PR 90 bpm, RR 20 cpm, BP 120/70. Initial medical diagnosis was diabetes Hematology, FBS mellitus left

foot. The patient was

subjected for Urinalysis,


and Anterior Posterior Radiologic Exam on Left Foot. Some complications that were displayed by the patient were infection, imbalance nutrition more than body requirements, management includes; daily wound care, continuous monitoring of the patients blood sugar and condition through laboratory test results and assessment of symptoms as demonstrated by the patient. In his 1 week of confinement in the hospital, the patients condition has improved.

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Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin.

The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary if treatment with diet and oral medication is not working.

The causes of diabetes mellitus are unclear; however, there seem to be both hereditary (genetic factors passed on in families) and environmental factors involved. Research has shown that some people who develop diabetes have common genetic markers. In Type I diabetes, the immune system, the bodys defense system against infection, is believed to be triggered by a virus or another microorganism that destroys


cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a role.

In Type II diabetes, the pancreas may produce enough insulin, however, cells have become resistant to the insulin produced and it may not work as effectively. Symptoms of Type II diabetes can begin so gradually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other symptoms may include sudden weight loss, slow wound, urinary tract infections, gum disease, or blurred vision. It is not unusual for Type II diabetes to be detected while a patient is seeing a doctor about another health concern that is actually being caused by the yet undiagnosed diabetes. Individuals who are at high risk of developing Type II diabetes mellitus include people who: are obese (more than 20% above their ideal body weight) have a relative with diabetes mellitus belong to a high-risk ethnic population (African-American, Native American, Hispanic, or Native Hawaiian)

have been diagnosed with gestational diabetes or have delivered a baby weighing more than 9 lbs (4 kg)

have high blood pressure (140/90 mmHg or above) have a high density lipoprotein cholesterol level less than or equal to 35 mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL

have had impaired glucose tolerance or impaired fasting glucose on previous testing.


Diabetes mellitus is a common chronic disease requiring lifelong behavioral and lifestyle changes. It is best managed with a team approach to empower the client to successfully manage the disease. As part of the team the, the nurse plans, organizes, and coordinates care among the various health disciplines involved; provides care and education and promotes the clients health and well being. Diabetes is a major public health worldwide. Its complications cause many devastating health problems.

The major goal in treating diabetes is to minimize any elevation of blood sugar (glucose) without causing abnormally low levels of blood sugar. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is treated first with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, treatment with insulin is considered.

Adherence to a diabetic diet is an important aspect of controlling elevated blood sugar in patients with diabetes. The American Diabetes Association (ADA) has provided guidelines for a diabetic diet. The ADA diet is a balanced, nutritious diet that is low in fat, cholesterol, and simple sugars. The total daily calories are evenly divided into three meals. In the past two years, the ADA has lifted the absolute ban on simple sugars. Small amounts of simple sugars are allowed when consumed with a complex meal. Weight reduction and exercise are important treatments for diabetes. Weight reduction and exercise increase the body's sensitivity to insulin, thus helping to control blood sugar elevations.


According to the world health organization the 10 top death causes in the world diabetes mellitus rank 9th disease of death in the middle income and 8th on the the high income countries and rank 9th around the world updated last June of 2011. Fact sheet N310 Updated June 2011 The 10 leading causes of death by broad income group (2008) Low-income countries Lower respiratory infections Diarrhoeal diseases HIV/AIDS Ischaemic heart disease Malaria Stroke and other cerebrovascular disease Tuberculosis Prematurity and low birth weight Birth asphyxia and birth trauma Neonatal infections Middle-income countries Ischaemic heart disease Stroke and other cerebrovascular disease Chronic obstructive pulmonary disease Lower respiratory infections Diarrhoeal diseases HIV/AIDS Road traffic accidents Tuberculosis Diabetes mellitus Deaths in millions 1.05 0.76 0.72 0.57 0.48 0.45 0.40 0.30 0.27 0.24 Deaths in millions 5.27 4.91 2.79 2.07 1.68 1.03 0.94 0.93 0.87 % of deaths 11.3% 8.2% 7.8% 6.1% 5.2% 4.9% 4.3% 3.2% 2.9% 2.6% % of deaths 13.7% 12.8% 7.2% 5.4% 4.4% 2.7% 2.4% 2.4% 2.3%


Middle-income countries Hypertensive heart disease

Deaths in millions 0.83

% of deaths 2.2%

High-income countries Ischaemic heart disease Stroke and other cerebrovascular disease Trachea, bronchus, lung cancers Alzheimer and other dementias Lower respiratory infections Chronic obstructive pulmonary disease Colon and rectum cancers Diabetes mellitus Hypertensive heart disease Breast cancer World Ischaemic heart disease Stroke and other cerebrovascular disease Lower respiratory infections Chronic obstructive pulmonary disease Diarrhoeal diseases HIV/AIDS Trachea, bronchus, lung cancers Tuberculosis Diabetes mellitus Road traffic accidents

Deaths in millions 1.42 0.79 0.54 0.37 0.35 0.32 0.30 0.24 0.21 0.17 Deaths in millions 7.25 6.15 3.46 3.28 2.46 1.78 1.39 1.34 1.26 1.21

% of deaths 15.6% 8.7% 5.9% 4.1% 3.8% 3.5% 3.3% 2.6% 2.3% 1.9% % of deaths 12.8% 10.8% 6.1% 5.8% 4.3% 3.1% 2.4% 2.4% 2.2% 2.1%



We, the student nurses chose diabetes mellitus wagner left foot 4rth digit for our Grand Case Presentation because it is a very interesting topic. In line with influenza, bronchitis, diarrhea, and hypertension, diabetes is one of the common problems in the country. In 2011, it ranked as 8 th leading causes of mortality in the world as stated by the world health organization. The objectives of this case study are the following: 1. Gain knowledge and deeper understanding of the disease process itself. 2. Provide the best nursing care for the client, and impart health teachings regarding the clients condition to maintain an optimum level of functioning.

Specific objectives

Cognitive Formulate an appropriate nursing care plan for the clients current condition. Relate the present state of the client with her personal and pertinent family history Analyze and interpret vital signs and laboratory procedures to determine the underlying cause of the clients condition. Identify treatment modalities and its importance like drugs, diet and exercise.

Psychomotor Give nursing care to our client; importance of proper hygiene, proper diet, and proper wound care. Gather a comprehensive assessment of the client. Monitor and analyze laboratory values along with signs and symptom


Apply and demonstrate what we have learned that may improve and help the client to do her daily routines with her condition.

Affective Gain camaraderie to our fellow students while learning. Exchange knowledge to fellow students in providing care through discussions. Develop our sense of unselfish love and empathy in rendering our nursing care to our patient so that we may be able to serve our future clients with higher level of holistic understanding as well as individualized care. Gain cooperation with fellow students for mutual benefit to achieve a shared goal. Respect our differences so that we may be able to make this case presentation possible.

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The scope of this study includes the collection of information specifically the patients health condition. The study also includes the assessment of the physiological and psychological status, adequacy of support systems and care given by the family as well as health care providers and medical records. The patients actual problems for 7 days including the initial assessment and its appropriate nursing intervention applied within his stay at Pasay City General Hospital. And for the limitations of this case study includes that we are not able to handle the patient from the time he came in the emergency room and to his admission January 18, 2013 and to his operation. We only have the chance to handle him on the 5th day of his hospital confinement which was last January 23-24 2013. Daily monitoring was done until he was discharge last January 31 at the surgical isolation ward. The patient was admitted again after a week February 7 during his opd follow up to have further observation. The data we gathered is from the patient and to his live in partner.



Patients Personal Profile

Name: Sex: Age: Height: Weight: Marital Status: Children: Occupation: Residential Address: Admitting Diagnosis: Final Diagnosis: Surgical Intervention:

N.L. Male 42 years old 54 80 lbs Single 0 Driver Taft Avenue, Pasay City DM Left foot DM Left foot (DM foot Left) E Disarticulation 4th digit left foot

Chief Complaint or Presenting Complaint

2 weeks remittent fever


History of Present Illness 1 month PTA client had symmetrical swelling on his left and right foot up to his knee. Client ignores it, no medication taken, no consultation was made. 3 weeks PTA, swelling was still present, according to the patient sloughing of skin between the third, fourth and fifth digit of his Left foot occurs, he describe it similar to an athletes foot and foul odor was noted. He used to put cotton in between the third, fourth and fifth digit of his Left foot, when he remove the cotton, client noticed the presence of pus so he cleaned it with Betadine and took antibiotic Amoxicillin 500 mg for 7 days 2x a day. (Self medication) still no consultation was done. 2 weeks PTA patient N.L. experienced fever unrecalled body temp. Medication Paracetamol 500 tablet was taken whenever patient feels he has fever, still no consultation was made. One day PTA patient sought consultation at Zapote Community Hospital because of 2 weeks fever He was given medication Metformin 500 mg O.D., Tempra Tablet 500 mg and Clindamycin 300 mg 1 cap TID for his wound and was advice to come back after a week. Two hours PTA he sought consult at PCGH E.R. due to 2 weeks continuous fever accompanied by dizziness and was subsequently admitted.


Past Medical History

According to our patient, Patient N.L. had fever, cough and colds during his childhood and adult days. He doesnt experience any accident / injury / hospitalization nor undergone any operation.

Social history

Patient is the fourth child among his 6 siblings, a College undergraduate of Patts Aeronautics. He is single but is living with his live in partner for 7 years and they have no children. The Ppatient is a Driver of a van with a route of Paliparan to Molino.

Personal History

He had no history of allergy to any food or dust. He started smoking when he was 16 years old, consumes about 1-3 sticks per day and stop on his 21 years of age. The patient also stated that he drinks alcohol occasionally and consumes 500 ml of brandy. Patient N.L. is single but is living with his live in partner for 7 years and has no children. Patient NL is a Driver of a van with a route of Paliparan to Molino. They have a monthly income of 8000 per month. Due to insufficient financial problem, his eldest brother who is working abroad helps him in his hospital needs. The patient includes meat as part of his diet, he loves to eat hamburger and tapsilog. He drinks 8 glasses of water a day and can consume 1 liter of soft drink a meal and prefers to drink energy drink whenever he is on work. He goes to work every 5:00 pm 3:00 am. He usually sleeps whenever he is at home. He stated that he has no active exercise. According to


patient NL, he is a legitimate resident of Taft Avenue, Pasay City. Their community is set in an urban environment. He lives in a two storey house, rented by him and his live in partner, their house is situated in a neighborhood with peace and order maintained by the Homeowners. The house is made of concrete. It is well ventilated provided with two windows and the main door. It also comes with a bathroom. They get water from the NAWASA as their water supply. Taking van and scooter is their means of transportation and cellular phones are their means of communication.

Family History The Patients family on his mother side has (-) history of asthma, (+) Hypertension, (+) Diabetes Mellitus, (-) Thyroid Disorders, (-) Heredofamilial diseases and has (-) history of asthma, and fathers side has (+) Hypertension, (-) Diabetes Mellitus, (-) Thyroid Disorders, (-) Heredofamilial diseases.

Drug History

No previous drugs taken


Family Genogram

(1925 1992) Car Accident (+) Hypertension (+) Diabetes

(1928 2000) Cervical Spondylosis (+) Hypertension

(+) Diabetes (+) Hypertension Male Patient Death Unmarried Married Female

(+) Hypertension)

(+) Diabetes



Lifestyle History / Gordons Functional Health Pattern

Gordons Functional Health Pattern Activity-Exercise Pattern 1 month before hospitalization patient can Ater operation patient can stand but with the help of his Before Hospitalization During Hospitalization

still go to his work as a driver live in partner. but has hindrances on walking because of his bilateral edema below his knee up to his foot Health Perception-Health He is able to groom his self Management Pattern independently, he doesnt requires assistance in bathing and dressing. He is able to groom his self independently. He doesnt requires assistance in bathing and dressing but requires assistance in cleaning his wound. Client regularly follows physician order of taking his medication alone. His live in partner is very supportive in taking care of his needs.

Lifestyle History /Gordons Functional Health Pattern14 | P a g e

Elimination Pattern

The patient can go to the bathroom and defecates every day usually in the

The patient can go to the bathroom and defecates every day usually in the morning. The patient is now aware of his disease and now monitors what he eats. He now prefers to eat fruits.The patient still can consume 8 glasses of

Nutritional-Metabolic Pattern

morning. The patient can eat independently and loves to eat. The patient includes meat and rice as part of his daily diet, he loves to eat

hamburger and tapsilog. He water a day and stops drinks 8 glasses of water a drinking softdrinks and

day and can consume 1 liter energy drinks of softdrink a meal and prefers to drink energy drink Sleep-Rest Pattern whenever he is on work. He goes to work every 5:00 pm 3:00 am. He usually sleeps whenever he is at The patient can sleep at around 10 pm and wakes up early at 5 am. He takes 1 2

home. He sleeps around 4:00 hours of nap in the afternoon. am 12:00 pm and the 2:00 He usually wakes up for pm- 4:00 pm. Cognitive-Perceptual Pattern medication and when taking

his vital signs. He is able to express his self He is able to express his self verbally and is willing to share what he feels and his verbally and is willing to share what he feels and his ideas. Patient can now cope with his

Coping-Stress Pattern

ideas. The patient makes himself

Lifestyle History /Gordons Functional Health Pattern15 | P a g e

busy in his work and he loves condition because of the to watch television or Value-Belief Pattern listening to the radio. Patient has not manifested conflict between treatment and his personal belief. support of his partner and his siblings. The patient and his family are willing to cooperate to the health care provider by

Patient and his family believe providing necessities and in medical treatment. The patient is just a normal assuring that the patient has undergone the requested

Roman Catholic Person that laboratory examination. Still knows God and just going to patient has not manifested church occasionally: Birthdays, Christmas and conflict between treatment given and he also can no

New Year with his family. He longer go to church to attend also believed in superstitious mass but can just offer a beliefs. His family believes in prayer. GOD and his son Jesus Christ and knows the Self-Perception-selfConcept Pattern importance in his well being. The patient describe as an industrious person. he used The patient is now aware of his disease/condition and is

to socialized with his friends now open to maintain his by drinking brandy occasionally. His live I partner and relatives is always there to give support. blood sugar level within normal limit and is now ready to have a healthy lifestyle.

Lifestyle History /Gordons Functional Health Pattern16 | P a g e

Sexual-Reproductive Pattern

The patient had no children. The patient had no children.

Role-Relationship Pattern The patient is known as a

Patient's family is with him

snob, strict and good person during his confinement. They but knows how to get along are supportive in giving the

with different types of people. necessary needs and wishing the patient to be well and to recover soon.

Lifestyle History /Gordons Functional Health Pattern17 | P a g e


Erik Eriksons Developmental Stage Adapted and expanded to Freuds theory of development to include the life span, believing that people continue to develop throughout life. Erickson envisions life as a sequence of levels of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial, or unsuccessful, Erickson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve the next task. These developmental tasks can be viewed as a series of crises and successful resolution of these crises is supportive to the persons ego. Failure to resolve the crises is damaging to the ego. Stage Competence: Industry vs. Inferiority (Latency, 5-12 years) Children start recognizing their special talents and continue to discover interests as their education improves. They may begin to choose to do more activities to pursue that interest, such as joining a sport if they know they have athletic ability, or joining the band if they are good at music. If not allowed to discover own talents in their own time, they will develop a sense of lack of motivation, low selfesteem, and lethargy. They may become couch potatoes" if they are not allowed to develop interests. At this stage the client had been encourage making and doing things and had been praised for his accomplishments. At this stage also the client starts his studies at Elementary and High School at Misamis, Mindanao. The client began to demonstrate industry by being diligent, persevering at tasks until finished and putting work before pleasure. At the age of 7 the client start to plays Filipino games like Patentero, Luksong baka and Tumbang preso with his friends. And in this stage he starts to learn different house hold chores.

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Fidelity: Identity vs. Role Confusion (Adolescence, 13-19 years)

Superego identity is the accrued confidence that the outer sameness and continuity prepared in the future are matched by the sameness and continuity of one's meaning for oneself, as evidenced in the promise of a career. The ability to settle on a school or occupational identity is pleasant. In later stages of Adolescence, the child develops a sense of sexual identity. As they make the transition from childhood to adulthood, adolescents ponder the roles they will play in the adult world. Initially, they are apt to experience some role confusion mixed ideas and feelings about the specific ways in which they will fit into society and may experiment with a variety of behaviors and activities (e.g. tinkering with cars, baby-sitting for neighbors, affiliating with certain political or religious groups. Identity Crisis. This turning point in human development seems to be the reconciliation between 'the person one has come to be' and 'the person society expects one to become'. This emerging sense of self will be established by 'forging' past experiences with anticipations of the future. In relation to the eight life stages as a whole, the fifth stage corresponds to the crossroads. Once people have established their identities, they are ready to make long-term commitments to others. They become capable of

In this stage of his life the patient starts to be independent and at this time the client is studying at PATTS College of Aeronautics. In this stage the client also start experiencing great body changes accompanying puberty, the ability of the mind to search ones own intensions and the intentions of the others, the suddenly sharpened awareness of the role society has offered for later life. At this stage the client enjoys his teenage life. At the age of 15 the client had his girlfriend at the same age. He had explore his life same like what a teenagers did. He drinks occasionally with his friends, go some party and all the alike.

Love: Intimacy vs. Isolation (Young adulthood, 2024, or 20-35

In this stage the client had his live in partner but they dont have child since they have been together. They decided to be



forming intimate, reciprocal relationships (e.g. through close friendships or marriage) and willingly make the sacrifices and compromises that such relationships require. If people cannot form these intimate relationships perhaps because of their own needs a sense of isolation may result. Generativity is the concern of guiding the next generation. Socially-valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. The adult stage of generativity has broad application to family, relationships, work, and society. Generativity, then is primarily the concern in establishing and guiding the next generation...the concept is meant to include. productivity and creativity

independent so that they prefer to rent a house. The client had his job as a driver of Public VAN (Paliparan-Molino) while his housewife is a plain housewife.

Care: Generativity vs. Stagnation (Middle adulthood, or 35-64 years)

By this time they cant provide all their hospital needs and asks help to the patients elder brother. They spent more time taking care of his condition thats why they are more intact to each other. At the age of 42 the client still works as a driver but since he is hospitalized he cant go to work.


Affected Part Wound Assessment - Diabetes Mellitus ( Left Foot) Part Assessed Neuropathic pain Assessment Findings Burning, stinging, shooting and stabbing (nonstimulus dependent) Local pain Deep infection or Charcot joint Deep infection Theres a new areas of breakdown Probes to bone (increased risk in the presence of osteomyelitis) Size Length, width, depth and location, preferably with clinical photograph Length: 12 cm Width: 5 cm Location: left foot Wound Bed Appearance Black (necrosis) Yellow, red, pink Undermined Source: Pocket Guide improved Patient Outcomes For Diabetic Foot Black (necrosis) due to the disruption of cells. It implicates that theres a deep infection occurs. Actual Findings Stinging May take place at the central level after peripheral nerve damage. Implication

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Infection Signs Odor Be aware that some signs (fever, pain, increased white blood count/ ESR) may be absent. Evaluate the ulcer for signs of infection, inflammation and Edema Exudate Copious, moderate, mild, none Wound edge Callus and scale, maceration, erythema, edema (+) callus and scale (+) maceration (+) erythema (+) edema Copious Consistent with more severe infections, and is commonly referred to as pus. a sign that the newly formed epithelial cells have migrated down and around the wound edge because they could not connect to moist, healthy, granulation tissue in the wound bed. (+) foul odor (+) edema (+) redness Infected wounds replicating organisms exist and tissue is injured and lead to poor healing.


Physical Examination and Health Assessment (NANDA ASSESSMENT TOOL) Pathologic Assessment Date Performed: January 26, 2013 Circulation

Part Assessed

Normal Color




Color depends on race, can be whitish, pink, brown shade to black


This is due to decrease blood circulation

B. Mucous Membrane C. Lips

Mucous is pinkish and moist Pink, moist and smooth


This is due to decrease blood circulation


This is due to decrease blood circulation

D. Nail bed

Nail bed is pinkish


This is due to decrease blood circulation

E. Conjunctiva

Conjunctiva is pink, clear, moist and has small blood vessels

Pale conjunctiva

This is due to decrease blood circulation

F. Sclera

Color is white few visible small vessels

Color is white few visible small vessels


Blood Pressure A. Lying N: 90/60-130/90mmhg R: 120/80 L: 130/90 Blood pressure is within normal


Pulses Pulse quality A. Carotid: B. Temporal +1= weak, thread pulse, C. Jugular D. Radial E. Popliteal F. Post-tibial G. Dorsalis pedis difficult to palpate, obliterate with pressure +2= diminished pulse, cannot be obliterate +3= easy to palpate, full pulse:cannot be obliterate +4= strong, bounding pulse: maybe abnormal Heart Sound A.Rate B. Rhythm C. Murmur 60-100 bpm Regular No murmur 80 Regular No murmur Normal Normal Normal +3 +3 +3 +3 +1 0= pulse not palpable or absent +3 +3 Pulses are within normal except the pulse in dorsalis pedis, it is weak, thready pulse, difficulty to palpate obliterated with pressure.

Jugular Vein A. Jugular vein distention Breath sound Breath sounds Bronchial or tubular (trachea part) No presence of breath sound on the lungs Bronchovesicular (1st and 2nd interspaces anteriorly and scapula posteriorly) Normal None None Normal


Vesicular (lung periphery) Extremities A. Temperrature B. Capillary Refill Warm to touch Blanch test results to nail that returns to its color instantly upon release <1-3 seconds C. Nail Abnormalities Angle between the nail and nail base is 160 degrees Warm to touch Nail color returns upon release within 4 seconds Angle between the nail and nail base is 160 degrees Normal Normal Poor circulation in the blood


VARIATIONS IN NORMAL VITAL SIGNS AGE TEMPERATURE (Celsius and Fahrenheit) 36.8(98.2) (axilliary) 36.8(98.2) (axilliary) 37(98.6) 37(98.6) 37(98.6) 37(98.6) 37(98.6) PULSE (Average and Ranges) 130(80-180) 120(80- 140) 100(75-120) 70(50-90) 75(50-90) 80(60-100) 70(60-100) RESPIRATION (Average and Ranges) 35(30-80) 30(20-40) 20(15-25) 19(15-25) 18(15-20) 16(12-20) 16(15-20) BLOOD PRESSURE (mmHg) 73/55 90/55 95/57 102/62 120/80 120/80 Possible increased diastolic

Newborns 1 year 5-8 years 10 years Teen Adult Older Adult (>70 years)


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On Jan 18 client was brought to PCGGH with a chief complaint of fever (remittent) that last for 2 weeks with a Temperature of 38.5. The temperature comes down but not reaching the normal 37.8 38. 5. Implications: Lifted from patients cart an indication of infection due to presence of wound on his Left foot Intervention: Paracetamol 500 mg. tab for fever was given as ordered. January 19, 2013 (Lifted from patients chart) at temp ranges from 38.2 38. Still febrile Intervention: TSB given by the relative Jan 20, 2013 clients temp is within normal VITAL SIGNS 27 | P a g e

Jan 23 (duty days we handled the client P op disarticulation of the 4th digit of left foot. Clients temp ranges from 36.1 to 36.7. Despite of the patient post op procedure clients temp is within normal

VITAL SIGNS 28 | P a g e


All cardiac and pulse rate were within normal limit

VITAL SIGNS 29 | P a g e


All respiratory rate were within normal

VITAL SIGNS 30 | P a g e


Increse Bp is due to viscosity of blond because of infection that the pstientcant give.

VITAL SIGNS 31 | P a g e


a. Normal

Pancreas is an organ situated in the upper part of ones abdomen. It is about 6 inches or 15 cms long and has a flattened bulbous head that is surrounded by part of the intestine called duodenum, a narrow body that lies behind the stomach and a tapered tail that rests on the front of the left kidney. Pancreas is one of the organs in the body that has both exocrine and endocrine functions. Exocrine Pancreas Secretion of water and electrolytes originates in the centroacinar and intercalated duct cells Pancreatic enzymes originate in the acinar cells Final product is a colorless, odorless, and is osmotic alkaline fluid that contains digestive enzymes (amylase, lipase, and proteases) 500 to 800 ml pancreatic fluid secreted per day Alkaline pH results from secreted bicarbonate which serves to neutralize gastric acid and regulate the pH of the intestine Enzymes digest carbohydrates, proteins, and fat



Amylase o o o only digestive enzyme secreted by the pancreas in an active form functions optimally at a pH of 7 hydrolyzes starch and glycogen to glucose, maltose, maltotriose, and dextrins

Lipase o o function optimally at a pH of 7 to 9 emulsify and hydrolyze fat in the presence of bile salts

Proteases o o o o essential for protein digestion secreted as proenzymes and require activation for proteolytic activity duodenal enzyme, enterokinase, converts trypsinogen to trypsin Trypsin, in turn, activates chymotrypsin, elastase, carboxypeptidase, and phospholipase

Within the pancreas, enzyme activation is prevented by an antiproteolytic enzyme secreted by the acinar cells.

Endocrine Pancreas Accounts for only 2% of the pancreatic mass Nests of cells - islets of Langerhans It secretes two important hormones namely - Insulin and Glucagon which are essential for regulation of glucose in the blood. Four major cell types


Alpha (A) cells secrete glucagon Beta (B) cells secrete insulin Delta (D) cells secrete somatostatin F cells secrete pancreatic polypeptide

Insulin o o Synthesized in the B cells of the islets of Langerhans 80% of the islet cell mass must be surgically removed before diabetes becomes clinically apparent o Proinsulin, is transported from the endoplasmic reticulum to the Golgi complex where it is packaged into granules and cleaved into insulin and a residual connecting peptide, or C peptide. o Major stimulants: Glucose, amino acids, glucagon, GIP, CCK, sulfonylurea

compounds, -Sympathetic fibers o Major inhibitors: somatostatin, amylin, pancreastatin, -sympathetic fibers

Glucagon o o Secreted by the A cells of the islet Glucagon elevates blood glucose levels through the stimulation of glycogenolysis and gluconeogenesis o Major stimulants Aminoacids, Cholinergic fibers, -Sympathetic fibers

Major inhibitors Glucose, insulin, somatostatin, -sympathetic fibers



Secreted by the D cells of the islet Inhibits the release of growth hormone Inhibits the release of almost all peptide hormones Inhibits gastric, pancreatic, and biliary secretion Used to treat both endocrine and exocrine disorders



THEORETICAL Polyuria (increased urination) Polydipsia (increased thirst) Polyphagia (increase appetite) Fatigue Weakness Sudden vision change Tingling, numbness in hands Tingling, numbness in feet Dry skin Skin lesion Wound that are slow in healing Weight loss Nausea Vomiting Abdominal pain

PATHOGNOMONIC (+) (+) (+) (+) (+) (+) (-) (+) (+) (+) (+) (+) (-) (-) (-)

36 | P a g e

Precipitating factor: Obesity Excessive intake of carbonated drinks Predisposing factor: Heredity Age: 42 years old Gender: male

Beta cell dysfunction from islet of langerhans Insufficient insulin secretion Insulin resistant (insulin receptor defect) Impaired process of glucose to glycogen to enter inside the cell hyperglycemia Increased insulin demand Intracellular: hypoglycemia Extracellular: hyperglycemia

Cellular starvation

Increased blood viscosity Decrease renal threshold glucosuria

Hyperosmotic plasma Dehydration of cells polydipsia 37 | P a g e

Decreased protein synthesis polyphagia fatigue

Decrease gammaglobulins, susceptibility to infection

Osmotic diuresis -polyuria

Impaired wound healing

DM type 2
neuropathy angiopathy nephropathy ischemia sensory motor Venous insufficiency Impaired sensation of the feet Muscle wasting Decrease circulation in peripheral area peripheral edema Increase creatinineleve of 151.3 normal value 58.0-96.0

Cell injury Tissue damage infection

Altered oxygen distribution


inflammation DM foot

Gangrene (local death of soft tissues (+) pus blood streak change in skin color due to loss of blood supply) (+) swelling (+) wounds PATHOPHYSIOLOGY 38 | P a g e

COLLABORATIVE / MEDICAL MANAGEMENT URINALYSIS Patient Name: Ward: Date: URINALYSIS Procedure Color Character Reaction / pH Specific Gravity Sugar Actual Values Dark Yellow to amber cloudy 3.0 1.030 +2 Normal Values Pale yellow to amber Clear to slightly hazy 4.5-8.0 1.015-1.025 Negative Interpretation Normal Normal Normal Normal Increase Blood Sugar l Indicates Increased levels with hyperglycemia may indicate diabetes mellitus If protein is found in your urine, diabetic kidney disease is likely to be present A positive leukocyte esterase test results from the presence of white blood cells either as whole cells or as lysed cells. A positive nitrite test indicates that bacteria may be present in significant numbers in urine NL ER January 18, 2013




Increased Protein

Blood Leukocytes

+1 +1

Negative Negative Increased leukocytes




Increased Nitrate

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Pus cells

10 15 /hpf


Increased Pus Cells


8 12 / hpf


Increased RBC

Mucus Threads




Epithelial Cells Bacteria Urates / Phosphate

moderate abundant many

Few Few Few

Kidney stones: Stones cause irritation and inflammation in the urinary tract which can lead to pus cells in urine. Kidney stones nearly always also cause the appearance of red blood cells (RBCs) in urine Hematuria is the presence of abnormal numbers of red cells in urine threads may be occasionally present in normal persons especially when dehydrated.and this indicates to some sort of infection, irritation Epithelial cells are lining cells, no big deal Presencce of bacteria. Occasional urate crystals and oxalate crystals may be present in normal individuals due to dehydrationand there by leading to concentrated urine. Presence of Bacterium is suggestive of infection.


January 18, 2013 Ward: ER HEMATOLGY Procedure RH Typing Hemoglobin HCT RBC WBC Segmenters Actual Values positive 147 0.40 4.98 8.6 0.73 Normal Values 140-180 g\l 0.40-0.54 4.56.5x10/L 510x10/L 0.55-0.65 Interpretation Implication

normal normal normal Normal Increased segmenters Increased segmenters indicates patient has signs of infection Low lymphocytes count (LLC), a surrogate for inflammation. The high and low responder phenomenon of monocytes tissue factor (MTF) activity has been attributed to effects on monocytes by granulocytes, Platelets and Lipopolysaccharide (LPS) Induction of hyperglycemia has been shown to increase platelet Pselectin expression (a surface adhesion molecule) in patients with DM.

Lymphocyte s Monocytes



Decreased lymphocytes Increased monocytes



Platelet Count



January 18, 2013

Blood Typing O - POSITIVE

X-Ray: -left foot Patient: Age: Date: Ward: NL 42 y.o January 18, 2013 ER

Results: Single AP view of the Left foot shows no fracture or dislocation. Diffuse soft tissue swelling seen.

Blood Chemistry Patient Name: Ward: Date: TEST Glucose FBS Blood urea nitrogen NL Surgical January 19, 2013 RESULT 13.40 12.03 Implication increase Increase Analysis Indicates hyperglycemia kidneys are not able to remove urea from the blood normally may mean kidneys are not working properly

NORMAL VALUE 4.10 5.90 mmol/L mmol/L 2.80 mmol/L 7.20 mmol/L


58.0 umol/L

96.0 umol/L




Blood Chemistry Patient Name: Ward: Date: TEST HBA1C NL Surgical January 20, 2013 RESULT Implication 5.2 normal Analysis This indicates that the patient had normal glucose in the past 3 months.

NORMAL VALUE 4.2 6.2 %

January 22, 2013 Ward: Surgical HEMATOLGY Procedure RH Typing Hemoglobin

Actual Values positive 100

Normal Values 140-180 g\l








Decreased red blood cell count: Anaemia - a lack of red blood cells, which can lead to a deficiency in oxygen-carrying ability. Lowered hematocrit can simply signify hemorrhage

Post Operative Findings: January 22, 2013 Necrotic Tissue, plantar aspect less edematous tissue up to ankle


HGT Monitoring 5 am 01-20-13 01-21-13 01-22-13 01-23-13 01-24-13 01-25-13 01-26-13 01-27-13 01-28-13 01-29-13 155 mg/dl refused 134 mg/dl refused 147 mg/dl 127 mg/dl 134 mg/dl 198mg/dl refused 6 am 5 pm 271 mg/dl



Paracetamol 500 mg PRN Started: January 18, 2013 (8:00 pm) at ER

Generic Name Acetaminophen (APAP, Paracetamol) Tempra, Tylenol

Mechanism of Action Unknown. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heatregulating center.

Indication Mild pain or fever

Side effects Hematologic: hemolytic anemia neutropenia, leukopenia, pancytopenia Hepatic: jaundice Metabolic: hypoglycemia Skin: rash urticaria

Nursing Responsibilities Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods; poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence (withdrawal has been associated with restless and excited responses).

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TT 0.5 SQ Started: January 18, 2013 (8:50 pm) at ER

Generic Name Tetanus Toxoid

Mechanism of Action Promotes immunity to tetanus by inducting antitoxin

Indication Primary immunization to prevent tetanus

Side effects CNS: slight fever, headache, seizures, malaise, encelopathy CV: tachycardia, hypotension, flushing Musculoskeletal: aches, pain Skin: erythema, induration, nodule at injection site, urticaria, pruritus Other: chills, anaphylaxis

Nursing Responsibilities Obtain history of allergies and reaction to immunization Keep epinephrine 1:1000 available to treat anaphylaxis

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ATS 6,000 TIM (-) ANST Started: January 18, 2013 (9:00 pm) at ER

Generic Name GENERIC NAME: Anti-tetanus serum

Mechanism of Action The toxin appears to act by selective cleavage of a protein component of synaptic vesicles, synaptobrevi n II, and this prevents the release of neurotransmitters by the cells.

Indication Tetanus Toxoid is to prevent an individual from contracting tetanus. This medication is given to provide protection (immunity) against tetanus

Side effects CNS: Mild fever, joint pain, muscle aches GI: nausea, vomiting, abdominal pain, diarrhea Hematologic:transient leukopenia, easinophilia Hepatic: jaundice Skin:maculopapular rash, urticaria

Nursing responsibilities Shake well the vial before withdrawing each dose Special care should be taken to ensure that the injection does not enter the blood vessel


DRUG STUDY 47 | P a g e

Drugs given at the Ward Ketorolac 50 mg Q8 Started: January 18, 2013 Ended: January 22, 2013 (13 doses)

Generic Name Ketorolac Tromethamine Toradol CLASSIFICATION: Nonsteroidal antiinflammatory agents, nonopioid analagesics

Mechanism of Action May inhibit prostaglandin synthesis to produce anti inflammatory, analgesic, and antipyretic effects.

Indication Pain

Side effects CV: thrombophlebitis GI: nausea, vomiting, abdominal pain, diarrhea Hematologic:transient leukopenia, easinophilia Hepatic: jaundice Skin:maculopapular rash, urticaria Other: anaphylaxis

Nursing Responsibilities Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. - Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. - Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur.

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Co Amoxiclav 1.2 g TIV Q6 Started: January 18, 2013 Ended: January 22, 2013 (8 doses)

Generic Name Amoxiclav Brand Name Amoclav Classification: Bactericidal

Mechanism of Action Inhibits enzymes involved information of peptidoglycan layer of bacterial cell wall. No effect on human cell walls

Indication skin & soft tissue infections, postsurgical procedures,

Side effects Skin: itching, rashes, CNS: Hepatic: jaundice Skin: Erythema, dermatitis GI: Diarrhea, vomiting

Nursing Responsibilities before giving drug ask patrient about allergic reactions to drug. Instruct patient to take food to prevent GI upset Watch out for rash occurring that will indicate allergic reaction.

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Sitaglipin 50 mg / tab i tab P.O. Started: January 19, 2013 Ended: January 28, 2013 (4 doses)

Generic Name Sitaglipin Brand Name Januvia

Mechanism of Action helps control blood sugar levels. It works by regulating the levels of insulin your body produces after eating.

Indication Sitagliptin is for people with type 2 diabetes. Sitagliptin is sometimes used in combination with other diabetes medications, but is not for treating type 1 diabetes.

Side effects Skin: hives Respiratory: difficulty breathing Immunology: swelling of your face, lips, tongue, or throat Hepatic: pancreatitis GI: nausea and vomiting, loss of appetite; GU: urinating less than usual or not at all;

Nursing Responsibilities Monitor Blood Glucose

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Clindamycin300 mg / tab 1 cap TID P.O. Started: January 19, 2013 Ended: January 29, 2013 (11 doses)

Generic Name Clindamycin Hydrochloride Brandname: Dalacin C

Mechanism of Action inhibits bacterial protein synthesis by binding to the 50s subunit of the ribosimes

Indication infections caused by sensitive staphylococci, streptococci, pneumococci, bacteroides and other sensitive aerobic and anerobic organisms.

Side effects CV: thrombophlebitis GI: nausea, vomiting, abdominal pain, diarrhea Hematologic:transient leukopenia, easinophilia Hepatic: jaundice Skin:maculopapular rash, urticaria Other: anaphylaxis

Nursing Responsibilities monitor renal, hepatic and hematopoietic functions during prolonged Observe patient for signs and symtoms of superinfection

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Metformin 500 mg / tab P.O. O.D. Started: January 20, 2013 Ended: January 29, 2013 (7 doses)

Generic Name Metformin Hydrochloride Brandname: Fortamet, Glucophage

Mechanism of Action Decreases hepatic glucose production and intestinal absorption of glucose and improves insulin sensitivity (increases peripheral glucose uptake and use)

Indication adjunct to diet to lower glucose level in patients with type 2 (non insulin dependent) diabetes.

Side effects GI: diarrhea nausea, vomiting, abdominal bloating, flatulence, anorexia, taste perversion. Hematologic: megaloblastic, anemia Metabolic: lactic acidosis, hypoglycemia

Nursing Responsibilities Give with meals. Maximum does may be better tolerated if total dose is divided in thrice a day dosing and given with meals. Monitor patients glucose level regularly to evaluate effectiveness of therapy. Notify prescriber if glucose level increases despite therapy

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Metronidazole 500 mg TIV Q6 Started: January 22, 2013 Ended: January 27, 2013 (14 doses)

Generic Name Metronidazole Brand Name: Flagyl, Metrogyl Classification: Anti Bacterial

Mechanism of Action Direct-acting trichomonocide and amebecide that works inside and outside the intestines. \Its thought to enter cells of microorganismsthat contain nitroeductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell death

Indication Bacterial infections caused by anaerobic microorganism To prevent postoperative infection in contaminated or potentially contaminated surgery

Side effects CNS: fever, vertigo, headache, ataxia, dizziness, syncope, incoordination, confusion, irritability depression, weakness, insomnia seizures, peripheral neuropathy CV: flattened T wave, edema, flushing, thrombophlebitis after IV infusion EENT: rhinitis, sinusitis, pharyngitis GI: abdominal crampingor pain, stomatitis, vomiting GU: darkened urine, polyuria, dysuria, cystitis Hematologic:transient leukopenia, neutropenia Musculuskeletal: fleeting joint pains Respiratory: URTI Skin: rash

Nursing Responsibilities give oral form with meals. Observe patient for edema, especially if his receiving corticosteroids; Flagyl IV may cause Na retention. Tell patient to avoid alcohol and alcohol cotaining drugs during for atleast 3 days after treament course. Tell patient he may experience a metalic taste and dark or red brown urine.

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Humulin r 10 units Started: January 22, 2013

Generic Name Insulin Humulin R Regular

Mechanism Action Increases glucose transport across muscle and fat cell membranes to reduce glucose level, promotes conversion of glucose to its storage form. Glycogen: triggers amino acid uptake and conversion to protein in muscle cells and inhibits release of free fatty acids from adipose tissue; and stimulates lipoprotein lipase activity; which converts circulating lipoprotein lipase activity, which converts circulating lipoproteins to fatty

Indication Control hyperglycemia with humalog and sulfonylureas in patients with type 2 diabetes mellitus

Side Effects Methabolic: hypoglycemia, hyperglycemia, hypomagnesemia, hypokalemia

Nursing Responsibilities Make sure patient knows that drug relieves symptoms but doesn't cure disease

Skin: Rash, urticaria, pruritus, swelling, redness, stinging, warmth, at injection sites.

Others: Lipoatrophy, lipohypertrophy, hypersensitivity reaction, anaphylaxis,

Stress that accuracy of measurement is important, especially with concentrated regular insulin, aids, such as magnifying sleeve or dose magnifier, may improve accuracy, show patient and caregivers how to measure and give insulin

DRUG STUDY 54 | P a g e


Advise patient to avoid vigorous exercise immediately after insulin injection, especially of the area where injection was given, because it increase absorption and risk of high glucose episodes

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Fusidate sodium 5 grams, topical ointment Generic Name Generic Name : Sodium Fusidate Therapeutic Classification : Antibiotics Trade Name(s): India- Dicfu, Fucidin mechanism of action This medication is a bacteriostatic antibiotic, prescribed for osteomyelitis, boils, folliculitis, sycosis, and other skin infection Solcoseryl gel and ointment:

Indication Radiation dermatitis Trauma(wounds) Badly healing wounds Bed sores Chemical and thermal burns Freezings

Side effects mild irritation, burning, or redness. swelling, rash. Most Common - Jaundice and liver

Nursing Responsibilities Caution should be exercised in patients with history of liver problems, jaundice, any allergy, during pregnancy and breastfeeding. * For external use only. * Monitor liver function regularly while using this medication.

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Salcoseryl jell 10% For weeping wounds and burns Generic name Salcoseryl jell Solcoseryl enhances reparative and regenerative processes, contributes to activation of aerobic metabolic processes and oxidative phosphorylation, increases oxygen consumption in vitro and stimulate the transport of glucose into the cells Allergy Treatment Antibiotics Antif ungal Antivirals Skin Problem Solcoseryl represents deproteinized hemodialysate containing a broad spectrum of low molecular components of cellular mass and blood serum obtained from veal calfs. Solcoseryl possesses the following properties: improves the transport of oxygen and glucose to the cells being in hypoxic conditions increases the synthesis of intracellular ATP and contributes to increase the proportion of aerobic glycolysis and oxidative phosphorylation activates the reparative Mechanism of action Indications Side rffrcts Burns, scalds, skin ulcers, bed sores, prevention & treatment of radiation dermatitis, traumatic & ischaemic wounds. Start treatment w/ jelly until formation of granulation tissue, continue w/ oint until complete epithelization. Nuring responsibilities.

What should a patient know before using Solcoseryl? The Solcoseryl should not be used in cases of:

Known hypersensitivity to any of the medication ingredients

Children and adolescents under 18 years of age (for solution for injections and solution for infusion) Make sure to consult

DRUG STUDY 57 | P a g e

and regenerative processes in tissues stimulates fibroblast proliferation and collagen vascular wall.

your doctor if you are pregnant or breastfeeding Solcoseryl injectable solutions should be used with caution in patients with heart failure, pulmonary edema, oliguria, anuria, hyperhydration For the treatment of trophic skin damages it is recommended to combine parenteral and local forms of Solcosery

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Medications: Advised patient to take home medications in right time and proper dosage. Co Amoxiclav 625 mg/tab TID x 1 week Clindamycin 300 mg/tab q6 x 1 week Diclowal 100 mg/tab BID for pain Evaluate the importance of checking the expiration dates of medication.

Exercise: Encouraged patient to do ROM exercise Encouraged patient to ambulate and do active and passive ROM exercises at patients tolerance to promote circulation and reduce risks associated with immobility. Treatment: Instructed patient to comply with home medications. Advised patient and relative to support leg when moving and use assistive device, such as clutches walker within reach. Monitor blood sugar using glucometer with strip at proper time. 1 hour before meal

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Health: Instructed patient and relative to practice aseptic technique in cleaning and dressing of wounds. Advised patient and relative in doing hand washing technique before and after cleaning of wound to reduce risk of infection and cross contamination. Instructed patient and relative to use sterile gauze pad, bandage scissor, micropore using aseptic technique during wound dressing to protect the wounds and the surroundings tissues. Encouraged patient to eat nutritious foods for promoting wound healing Encouraged patient to take a bath regularly to reduce risk for infection and bacterial contamination.

OPD Follow up Advised patient about follow up check up after 1 week of discharge due on February 07, 2013

Diet (DM DIET) Instructed patient to limit intake of sweet, salty foods and soda drinks. Encouraged patients to read labels and choose foods described as having a low glycemic content, low fat and higher fiber content, this foods produce lower rise in glucose.


August 21- 28, 2012 ( 7 days) NAME OF IVF PNSS (Plain Normal Saline Solution) NO. of IV BOTTLES 12 FORMULATION/ CONCENTRATION 0.9% sodium chloride INDICATION Usede to give intravenous fluids to patients suffering from salt and water deprivation Used in blood transfusions, hyponatremia and burn victims Used for irrigation during surgery, to dilute medications. And to clean wounds out Used because it has little to no effect on the tissues and make theperson feel hydrated preventing hypovolemic shockor hypotension NURSING CONSIDERATION Monitor patient frequently for: a. Signs of infiltration/sluggish flow b. B. sign of phlebitis/infection c. C. dwell time of catheter and need to be replaced d. D. condition of catheter dressing e. Check the level of the IVF f. Correct solution, medication and volume g. Check and regulate the drop rate h. Change the IVF solution if neededd

Classification: Isotonic Table Salt (Sodium Chloride)

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Date January 18 21, 2013 Diet DM Diet - A diabetic diet is a special way of eating for people who have type (1) or type two(2) diabetes, or have been told they are at high risk of developing diabetes. A diabetic diet can range in calories from 1,200 to 2,000 calories per day. Read more: -definition-diabetic-diet/#ixzz2KTDgLSTf. Food consumed 1,200 to 2,000 calories per day 37,800 kcal was consumed by the patient in her whole stay in the hospital. Rationale DM Diet- The main purpose of the diabetic diet is to eat specific portions of carbohydrates and proteins at specific times throughout the day to keep blood sugar levels normal. Blood glucose (sugar) levels need to continually monitored throughout the day by a diabetic person to make sure that the diet is stabilizing blood sugar levels. If a diabetic goes off the diabetic diet or eats too much sugar, they may be at risk of health complications such as neuropathy and strokes.

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Date Performed:



January 22, 2013

E disarticulation of 4th digit Left foot Incision made on 3rd and 4th webspace Disarticulation and debridement done Betadinepack inserted webspace. Wet to dry dressing done.

removel of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue

Operative Record

Pre Op Dx DM Foot Left Post Op Dx Dm Left Foot

Operation Performed Disarticulation Left Foot Wagner III

Time began: Time Finished: Surgeon: Sterile Nurse: Non Sterile Nurse: Aneesthesiologist:

2:40 pm 3:00 pm Dr. Putera V. Conel R. Putera Mr. Zamudio

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Nursing Care Plan Assessment Diagnosis Impaired skin integrity related to large vessel destructi on as evidence d by draining wound on L foot secondar y to Diabetes Mellitus type 2 (NIDDM) Planning Short-term After 8 hours of nursing intervention, the client will: 1. Verbalize knowledge and understanding regarding his illness 2. Participate in treatment regimen such as proper wound care, balanced diet and regular exercise 3. Be free of purulent discharge Intervention Irrigate the wound in room temperat ure using solution #3 (30ml vinegar, 30ml zonrox and 1liter of PNSS) as prescribe d Assess blood supply and sensatio n of affected area Rationale Cleans the wound without harming the delicate tissues Evaluation Short-term After 8 hours of nursing intervention, the client was able to: 1. Verbalized knowledge and understanding regarding his illness 2. Participated in treatment regimen such as proper wound care, balanced diet and regular exercise 3. free of purulent discharge

Objective: Wound @ sole of L foot, purulent discharge, blood streaked Wound size: length -15.24 cm width 10.16 cm depth 0.5 cm Numbness o L foot Toenails

Long-term After 1 week of Assess wound

To evaluate potential for impairmen t of circulation too lower Long-term extremities Provides After 1 week of informatio nursing intervention, n about effectivene the client was able to: ss of Minimized therapy

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cracked nail beds Scaly on the surroundin g skin of L foot Blister 5cm width nursing intervention, the client will: 1. Achieve timely wound healing 2. Minimize swelling 3. Display signs of healing with wound edges clean with each dressing change and identifies additional needs To assist the bodys natural process of repair swelling 1. Displayed signs of healing with wound edges clean

Keeps the area clean and dry, by carefully dressing the wound, prevents the infection and stimulate circulatio n to surroundi ng areas Assist with the

To remove infected tissue To protect the wound and the surroundin g tissues Promotes circulation and reduces risks associated with

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debride ment Use appropri ate dressings and wound covering s Timely elevation on lower extremiti es and mobility mobility and edema formation

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Assessment ctive:

Diagnosis Ineffective peripheral tissue perfusion related to decreased arterial blood flow as evidenced by decreased peripheral pulses, paleness of L foot, numbness and brittle toenails secondary to prolonged wound healing

Planning Short-term After 8 hours of nursing intervention, the client will: 1. Verbalize understa nding of relations hip between diabetes mellitus and circulator y changes 2. Demonstr ate awarenes s of safety factors and proper foot care Long-term


Rationale Minimiz es interrup tion of blood flow, reduces venous pooling Glycosu ria may result in dehydra tion with consequ ent reductio n of circulati ng volume and further impairm ent of peripher al circulati on

Evaluation Short-term After 8 hours of nursing intervention, the client was able to: 1. Verbalized understand ing of relationshi p between diabetes mellitus and circulatory changes 2. Demonstra ted awareness of safety factors and proper foot care Long-term After 1 week of nursing intervention, the 69 | P a g e

walaakongmar amdamansakali wangpaako as verbalize by the client


Numbnes s felt on L foot Diminish ed peripher al pulses: Popliteal: 2 Posterialt ibial- 1 Dorsalisp

Elevat e feet when up in chair. Avoid long period s of standi ng or sitting Monito r intake and output and assess for signs of dehyd ration. Encou rage oral fluids

edis- 1 Paleness of L foot Dry skin Cool to touch (L foot) Capillary refill of 5 seconds Brittle toenails Edema +2 (both feet) Obesity: ht-52in. wt- 80 kg After 1 week of nursing intervention, the client will: To different iate the type of problem client was able to: 1. Demonstra ted behaviors and lifestyle changes to improve circulation such as regular exercise, balanced diet, weight loss, and cessation of smoking Maintained adequate level of hydration to maximize perfusion as evidenced by balanced intake and output, moist and warm skin, capillary 70 | P a g e

1. Demonstrate behaviors and lifestyle changes to improve circulation such as regular exercise, balanced diet, weight loss, and cessation of smoking - Maintain adequate level of hydration to maximize perfusion as evidenced by balanced intake and output, moist and warm skin, capillary refill of less than 3

Comp are the skin tempe rature and color with other foot when assess ing extre mity circula tion Assess presen ce, locatio n and degre e of swellin

Useful in identifyi ng and quantify ing edema in involved extremit y To determi ne adequac y of systemi c circulati on Weight

seconds, absence of edema and presence of strong peripheral pulses g Measu re the capilla ry refill loss makes ischemi c tissues more prone to breakdo wn. Dehydra tion reduces blood volume and compro mises peripher al circulati on To determi ne level of circulato ry damage refill of less than 3 seconds, absence of edema and presence of strong peripheral pulses

Note the clients nutriti onal and fluid status


To evaluate distribut 71 | P a g e

e arteria l pulses equali ty as well as intensi ty and compa re with unaffe cted extre mity Deter mine the pulses equali ty as well as intensi ty and compa re with unaffe cted extre mities Instruc t the client to ion and quality of blood flow

compro mised circulati on and decreas ed pain sensatio n may precipit ate or aggrava te tissue breakdo wn vascular constrict ion associat ed with smoking and diabetes impairs peripher al circulati 72 | P a g e

avoid wearin g tight clothe s on Althoug h proper control of diabetes mellitus may not prevent complic ations, severity of effect may be minimiz ed. Diabetic foot are leading cause of nontrau matic lower extremit y amputat ions

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Assessed level of consciousness

Conscious, coherent

Continuously monitor level of consciousness To monitor changes in consciousness.

Assessed Respiration

RR: 26 cpm

Monitored respirations and breathe sounds, noting the rate and sounds

(-) crackles
Elevated head of bed

Demonstrated effective airway clearance

RR: 24 cpm

(-) cough

Encouraged position changes deep breating/coughing exercise

(-) dyspnea

Assessed Circulation

BP: 110/80 mmHg PR: 80 cpm Capillary time: 3 Pale Pale conjunctiva lips secs

Monitord patients vital signs and heart rhythms every 4 hours Educated patient relaxation tachniques Educate patient about importance of to help improve vasodilation and helpprevent exercise, need for low cholesterol. Low vasoconstriction caused by anxiety Encouraged ambulation and passive ROM calorie diet, need to avoid vasoconstrictors exercises to the level of tolerance Such as cold, stress, drinking alcoholto and encourage circulation extremities

Normal Blood Pressure

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Pale skin Encouraged restful and quite atmosphere. Conserves energy Body weakness

Assessed For Tissue Perfusion

Demonstrated increase in Tissue Perfusion

Pale conjunctiva

Perform Range of Motion exercises

Capillary Refill: Blood returns 3 sec.

Cold clammy skin

Assessed Skin

Disruption of skin surface at the left foot

Carefully clean the wound Still with impaired skin integrity Keep the area clean and dry

Redness around the affected area

Offered daily cleansing of wound until theres an evidence of wound healing


(+) itching

Maintained appropriate moisture environment for particular wound Wound have dried up: (-) itching (-) pain

(+) pain 5/10

Displayed timely wound healing

(+) edema Grade +2

Carefully dress the wound in aseptic technique

(+) Pus
Instructed patient to avoid wound to be exposed from dust and pollutants to prevent progress of infection

(+) Foul odor



Assessment Procedures

Outcome of Care

Findings ( s/sx )

if symtoms are relieved

Nursing Interventions

is symptoms are not relieved


not happened



Glossary contains unfamiliar words that we encountered in these studies.

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