Diabetes

mellitus
A case presentation of Groups 1 and 2
Carl David Adriano Princess Khryzz de Borja
Eden Joy Aganan Georgia De Ocampo
Saimon Rafael Amat Juliann Nicole Del Mar
Jeff Erol Amin Maria Stephany Dela Cruz
Thomas Adrian Ampuan Jaimelyn Duran
Rachele Ann Arganda Diane Hershey Evangelista
Sarah Borja Alec Elmer Guilas
Marie Janie Mae Bularon Shady Ann Jumaoas
Anne Gelen Buyoc Quesiah Kate Junio
Fatima Suzerain Dahalan Rose Ann Lacuarin
 TABLE OF CONTENTS
01 02
cASE
eTIOLOGY
SCENARIO

03 04
ANATOMY AND
CONCEPT MAP
PHYSIOLOGY
 TABLE OF CONTENTS
05 06
pATHOPHYSIOLOGY lABORATORY AND
DIAGNOSTIC
PROCEDURE

07 08
DRUG STUDY MEDICAL AND
SURGICAL
MANAGEMENT
 TABLE OF CONTENTS

09 10
nURSING CARE PLAN dISCHARGE PLAN
01
CASE
SCENARIO
A 61 year-old male patient diagnosed with type-2
diabetes mellitus (DM2) fourteen years ago. This
diagnosis was initially accompanied by sensitive
and motor peripheral neuropathy,
metatarsophalangeal arthropathy with no signs of
osteomyelitis and diabetic arthropathy.
The patient had presented ulcers in both his feet for ten
years now, in the metatarsophalangeal area. These had
never completely healed in this period. He did not
present partial nor total amputations. He had needed
several admissions in hospital due to recurrent
infections and had needed debridement and IV
antibiotics in multiple occasions. Amputation had been
suggested before, but he had always refused it.
Currently and according to the patient himself, although
he is aware of the main considerations in managing
diabetic foot ulcers his compliance has not been as
constant as it should have been, especially regarding
pressure relief and offloading the area. He does not
smoke and has never smoked and reports no further
toxic habits. He has an appropriate metabolic control of
his disease with 7.4% glycated hemoglobin values.
Other lab results are as follows:
Medical treatment at the time of hospital admission:
Lantus® insulin 28 units: once a day in the morning
- Apidra® insulin: if hyperglycemia
- Atorvastatin® 10mg: once a day
- Adiro® 100mg: once a day
- Hidroxil B1-B6-B12®: once a day
- Currently he is under no treatment for pain although previously
he had been on Pregabalin® and Tramadol® but has discontinued
this treatment due to secondary effects.
- Treatment for the ulcer until admission:
- Cures with therapeutic honey and cleaning with soft soap.
- Offload with 1cm-thick pads as a foot sole. He uses a stick to
avoid weight bearing.
- Hyperoxygenated fatty acid compounds (HFAC): three times a day
in both legs.
- Dressing to support the pad.
- For his IV medications are Vancomycin 1 gram every 12 hours,
Piptazo 4.5gms every 6 hours
Physical exam upon admission
The patient presents sole ulcers on both feet: 2x3 cm wide on the
right foot and 4x3 cm wide on his left foot, this being more severe.
They present a large amount of hyperkeratosis, swollen borders
with exudation and bad smell. The areas between the fingers are
also moist, soft and also smell bad. Dorsal pedal and posterior
tibial pulses in the right foot are very weak. Onychomycosis is
present in all nails.
The patients reports cramps in both feet although more frequently
in the left one, intermittent claudication of less than 150 meters
and itching of the malleolar and anterior tibial regions, mostly in
the left foot. He presents nighttime pain that subsides with the
decline position. In the left leg he has an ocher pigmentation of the
skin in the malleolar region with two areas of blisters with no
further ulceration and no-pitting edema in the tibial region. He
presents dermatitis in the base of the toes with no external signs
of varicose veins. He has moderate Charcot arthropathy in his left
foot. The patient is independent for activities of daily living.
- The probing to bone test is performed to determine the degree of communication
between the surface of the ulcer and the joint, and it is negative.
- DopplerUS shows calcified laminar atherosclerotic plaques mainly in distal
territories. He presents a biphasic flow due to impaired vascular elasticity, in the
posterior retro-malleolar territories of the pedal and tibial arteries. This is compatible
with moderate chronic arterial ischemia.
- The ankle-brachial index (ABI) is determined with a result of 1.2 in the right foot and
1.3 in the left one.
- Leriche-Fontaine classification: stage IV.
- Pain visual analogue scale (VAS): 6 of nighttime predominance, forcing him to wake
up and move his legs.
- Blood pressure (BP): 102/63
- Weight: 75.900 kg
- Height: 1.76cm
- Body mass index (BMI): 24.
- Culture of wound: colonization by Staphylococcus aureus
02

ETIOLOGY
DEFINITION
Type 2 diabetes is a lifelong disease that keeps your body
from using insulin the way it should. People with type 2
diabetes are said to have insulin resistance.

People who are middle-aged or older are most likely to get

this kind of diabetes. It used to be called adult-onset
diabetes. But type 2 diabetes also affects kids and teens,
mainly because of childhood obesity.
 SIGNS/SYMPTOMS CAUSES
● Blurred vision.
Insulin resistance which is usually
● Fatigue.
caused by:
● Feeling very hungry or thirsty.
● Lifestyle factors, including
● Increased need to urinate
obesity and a lack of exercise.
(usually at night).
● Genetics, or abnormal genes,
● Slow healing of cuts or sores.
that prevent cells from working
● Tingling or numbness in your
as they should.
hands or feet.
● Unexplained weight loss.
RISK FACTORS
● Have prediabetes
● Are overweight
● Are 45 years or older
● Have a parent, brother, or sister with type 2 diabetes
● Are physically active less than 3 times a week
● Have ever had gestational diabetes (diabetes during pregnancy) or given birth
to a baby who weighed more than 9 pounds
● Are African American, Hispanic/Latino American, American Indian, or Alaska
Native (some Pacific Islanders and Asian Americans are also at higher risk)
● Have non-alcoholic fatty liver disease.
iNCIDENCE
Global
● In 2014, 422 million people have diabetes, in which 8.5% of these is adults aged 18
years and older. Prevalence has been rising more rapidly in low- and middle-income
countries than in high-income countries
● In 2019, diabetes was the ninth leading cause of death with an estimated 1.5 million
deaths directly caused by diabetes.
● More than 95% of people with diabetes have type 2 diabetes

Philippines
● As of 2019, International Diabetes Federation (IDF) data showed that 3,993,300 of the
then total 63,265,700 Filipino adult population have diabetes, with a 6.3 percent
prevalence of diabetes in adults.
COMPLICATIONS

Acute Chronic
● Hypoglycemia ● Eye problems (retinopathy)
● Hyperglycemia ● Foot problems
● Hyperosmolar Hyperglycaemic State ● Heart attack and stroke
(HHS) ● Kidney problems (nephropathy)
● Diabetic ketoacidosis (DKA) ● Nerve damage (neuropathy)
● Gum disease and other mouth problems
● Related conditions, like cancer
● Sexual problems in women
● Sexual problems in men
03
CONCEPT
MAP
theoretical
ETIOLOGY

Cells in muscle

NON-MODIFIABLE MODIFIABLE RISK

RISK FACTORS FACTORS
- Family history
- Obesity
- Race and
- Low physical
Ethnicity
activity
- Age
- Unhealthy diet
 PATHOPHYSIOLOGY

Type 2 diabetes is characterized by a combination of peripheral insulin

resistance and inadequate insulin secretion by pancreatic beta cells. Insulin
resistance, which has been attributed to elevated levels of free fatty acids and
proinflammatory cytokines in plasma, leads to decreased glucose transport into
muscle cells, elevated hepatic glucose production, and increased breakdown of
fat. A role for excess glucagon cannot be underestimated; indeed, type 2
diabetes is an islet paracrinopathy in which the reciprocal relationship between
the glucagon-secreting alpha cell and the insulin-secreting beta cell is lost,
leading to hyperglucagonemia and hence the consequent hyperglycemia.

MEDICAL DIAGNOSIS

TYPE 2- DIABETES MELLITUS


Diagnostic Test
● Glycated hemoglobin
(A1C) test
● Fasting blood sugar test
● Random blood sugar test
● Oral glucose tolerance
test
Medical Management Clinical
Manifestations
● Lantus insulin 8 units, OD in the morning
Apidra insulin; if hyperglycemia
· Increased thirst
●
● Atorvastatin 10 mg OD · Frequent urination
● Adiro 100 mg; OD
● Hidroxil B1-B6-B12; OD · Increased hunger
● Discontinued treatment due to secondary
effect: Pregabalin and Tramadol.
· Unintended weight
loss
· Fatigue
· Blurred vision
· Slow-healing sores
· Frequent infections
· Numbness or tingling
in the hands or feet
 Significant Pertinent Findings

Culture of wound:
Colonization by Expected Outcomes
Staphylococcus aureus
● Identify interventions to
Nursing Diagnosis prevent/reduce risk of
infection.
Risk for infection related to high ● Demonstrate
glucose levels decreased techniques, lifestyle
leukocyte function changes to prevent
development of
infection.
 Nursing Intervention
1. Teach and promote good hand hygiene

2. Maintain asepsis during IV insertion, administration of medications, and providing wound or site care. Rotate IV sites as
indicated

3. Provide catheter or perineal care. Teach female patients to clean from front to back after elimination

4. Provide meticulous skincare by gently massaging bony areas, keeping skin dry. Keep linens dry and wrinkle-free.

5. Place in semi-Fowler’s position.

6. Encourage coughing or deep breathing if the patient is alert and cooperative. Frequent repositioning is also recommended.

7. Provide tissues and trash bags in a convenient location for sputum and other secretions. Instruct patient in the proper
handling of secretions.

8. Encourage and assist with oral hygiene.

9. Encourage an increase in fluid intake unless contraindicated. Encourage intake of cranberry juice per day as appropriate.

10. Administer antibiotics as indicated.

client-based
ETIOLOGY
- Defective insulin secretion
by pancreatic β-cells and the
inability of insulin-sensitive
tissues to respond
appropriately to insulin.

MODIFIABLE RISK NON-MODIFIABLE

FACTORS RISK FACTORS
● Physical Inactivity ● Age: 61 year old
● Stress ● Gender: Male
● Viral infection
● Previously identified
glucose intolerance
 Pathophysiology Clinical Manifestations
Diagnostic Tests
● Altered Sensorium
(Please see the next slide) ● Paresthesia
● Blood Chemistry Test
● Complete Blood Count ● Inc Risk for Infection
with differential ● Onychomycosis
● Recurrent Infections
Medical Diagnosis ● Impaired Wound
Healing
Type-2 diabetes mellitus ● Sole Ulcers

Medical Management

Lantus insulin - 28 units: once a day in the morning Adiro - 100mg: once a day

Apidra insulin - if hyperglycemia Hidroxil B1-B6-B12®: once a day

Atorvastatin - 10mg: once a day

 Significant Pertinent Findings

Culture of wound: Expected Outcomes

Nursing Diagnosis Colonization by
Staphylococcus aureus 1. Patients skin on legs and feet
Impaired skin integrity
remains intact while the
patient is hospitalized

2. Patient will demonstrate foot

care

Nursing Interventions
● Wash feet daily with mild soap and warm water. Check the water temperature before immersing feet in the
water.
● Implement and teach foot hygiene by washing the feet with lukewarm water and mild soap.
● Instruct the patient that she should not walk barefoot.
● Change socks or stockings daily. Encourage the patient to wear white cotton socks.
● Reinforce that all cuts and blisters need to be cleaned and treated with an antiseptic preparation.
04

ANAPHY
05

PATHOPHYSIOLOGY
 Diabetes Mellitus type 2
Theoretical based

Non Modifiable Risk Factors: Modifiable Risk Factors:

➔ Age, incidence and ➔ Increased body mass index
prevalence increases Insulin Resistance (BMI)
with age. ➔ Physical Inactivity
➔ Race or ethnicity ➔ Poor Nutrition
➔ Family History Exhaustion of beta cells ➔ Hypertension
➔ History of gestational ➔ Smoking
diabetes ➔ Alcohol use
Impaired insulin secretion

Absorption of glucose by
Breakdown of fat
the cell

Uncontrolled Fatty acids & glycerol

hyperglycemia
Ketone bodies in the general circulation
 Increase viscosity Microvascular Glomerular Metabolic Acidosis
of blood vasoconstriction Hyperfiltration
Capillary Basement n/v
Thickening of blood Glomerular
membrane
vessel walls Hyperfiltration
thickening
Abnormal
Poor Appetite
Endothelial retinal vascular Dysfunction of
Occlusion of plaque autoregulatory
Hyperplasia permeability Weight Loss
response
Neural Scarring
Blood flow blocked
Hypoperfusion
Blurry Vision Increased
Decrease blood Peripheral
extracellular
volume circulation Neuropathy
Risk for
matrix deposition Imbalanced
Numbness injury nutrition less than
Possible Increase Glomerulosclerosis body requirement
delayed blood
healing of pressure Polyuria & Albuminuria
wounds Impaired Tubulointerstitial fibrosis
Fluid & electrolyte
sensation imbalance
on lower Decreased glomerular filtration
Number of solute relative
extremities to water
Risk for Increased BUN and creatinine
impaired Sodium ion lost
skin
NEPHROPATHY References: Black, J. and
integrity Tissue Dehydration Jacobs, 2012. Medical-Surgical
Fluid Volume Deficit Nursing, Brunner and Suddarth’s
POLYDIPSIA Medical and Surgical Nursing
 DIABETES MELLITUS TYPE 2
client based paTHOPHYSIOLOGY

Modifiable Risk Factors Nonmodifiable Risk Factors

● 61 years old ● Physical Inactivity
● Male ● Stress
● Viral infection
● Previously identified
glucose intolerance

Etiology
Defective insulin secretion by pancreatic
β-cells and the inability of insulin-sensitive
tissues to respond appropriately to insulin.
 INSULIN RESISTANCE

target tissues are resistant to

imaired insulin activity
insulin action

Glucose concentration exceeds

renal threshold

Insufficient to stabilize Sufficient to stabilize fat and ↑ Basal hepatic glucose production
CHO metabolism CHON metabolism

NO acidosis Fasting hyperglycemia

Extreme hyperglycemia
NO ketones
HYPERGLYCEMIC ↑ blood glucose
HYPEROSMOLAR
NONKETOTIC SYNDROME Damages blood Medium for ↓ circulation to
vessels that carry O2 microorganism to grow the extremities
Persistent osmotic diuresis and nutrients to nerves
Neuropathy Impaired
↑ Risk for infection
Paresthesia wound
Dehydration
healing
↑ Neutrophil
Hypernatremia ↑ Monocyte ↑ Platelet count
↓ Lymphocyte
Recurrent
Altered Sensorium Onychomycosis Sole ulcers
infections
06
LABORATORY AND
DIAGNOSTIC
PROCEDURE
 TEST RESULT NORMAL RANGE INTERPRETATION ANALYSIS

Creatinine 123.60 H 63.6 – 110.5 mmol/L Above Normal As your kidney fail, your
blood urea nitrogen (BUN)
levels will arise as well as
the level of creatinine in
your blood.

Albumin 25.00 L 32 – 46 g/L Below Normal Albumin synthesis is

decreased due to insulin
deficiency.

Red Blood 2.55 L L 4.5 – 5.9 Below Normal Diabetes often leads to
kidney damage, and failing
kidneys can cause anemia.

Haemoglobin 71.0 L 140 – 170 Below Normal It is associated with more

rapid decline in glomerular
filtration rate than that of
other kidney diseases.

Hematocrit g/L L 0.40 – 0.50 Below Normal An insufficient supply of

healthy red blood cells.
0.21
 TEST RESULT NORMAL RANGE INTERPRETATION ANALYSIS

DIFFERENTIAL
COUNT:
Rises in neutrophil levels
usually occur naturally due
Neutrophil 0.67% H 0.45 – 0.65 Above Normal to infections or injuries.

It occurs when the

lymphocyte count in the
Lymphocyte 0.21% L 0.25 – 0.50 Below Normal bloodstream is lower than
normal.

Increasing blood sugar

levels appear, therefore, to
Monocyte 0.08% H 0.02 – 0.06 Above Normal be associated with
monocyte metabolic
activation.

MCV 84fL 80 – 100 It could be an indication of a

MCH 25pg 27 – 31 nutrient deficiency, such as
MCHC 330g/L 320 – 360 a deficiency of iron, folate,
or vitamin B-12. These
RDW 16% 11.6 – 14.6 Above Normal
H result could indicate
macrocytic anemia, when
your body doesn’t produce
enough normal red blood
Platelet Count 421L 150 – 450 cells.
07
dRUG
STUDY
 ADVERSE NURSING
MEDICATION DOSAGE ACTION USAGE EFFECTS CONSIDERATION

Drug 100 units/mL Insulin glargine Indication: SIde effect: Do NOT mix with
Classification: vial works by indicated to Localized other insulins
long-acting promoting improve glycemic redness, Refrigerate
insulin Frequency: movement of control in adults swelling, itching unopened vial. Do
sugar from not freeze. Stable at
QD and pediatric (due to
room temperature for
Generic Name: blood into body patients with type improper insulin 28 days after
Insulin glargine Route: tissues and also 1 diabetes injection opening.
For SQ use stops sugar mellitus and in technique),
Brand Name: only. Administer production in adults with type 2 allergy to insulin Assess for
Lantus, once daily at liver. Insulin diabetes mellitus. cleansing hypoglycemia,cool,
same time. glargine is solution wet skin, tremors,
Meal timing is man-made Contraindication dizziness, headache,
not applicable. insulin that : Adverse Effect: anxiety, tachycardia,
0.28mls in 1 ml mimics the - Severe numbness in mouth,
actions of hunger, diplopia.
syringe Initially, 4–6 -low blood sugar. hypoglyc
Assess sleeping pt
units or 0.1–0.2 human insulin -low amount of emia for restlessness,
units/ kg given potassium in the - Diabetic diaphoresis.
before largest blood. ketoacid hyperglycemia:
meal of day. -liver problems. osis polyuria, polyphagia ,
-decreased polydipsia,
kidney function. nausea/vomiting, dim
- 28 units: once I vision, fatigue, deep
a day in the and rapid breathing
morning (Kussmaul
respirations)
 ADVERSE NURSING
MEDICATION DOSAGE ACTION USAGE EFFECTS CONSIDERATION

Drug Insulins inhibit Indication: SIde effect:

Dosage: May mix with
Classification: lipolysis and indicated to Localized
100 units/mL NPH (draw
Antidiabetics, proteolysis, and improve redness,
vial, glulisine into
Rapid-Acting enhance glycemic swelling, itching
3-mL cartridge. syringe first;
Insulins protein control in adults (due to inject
synthesis. The and pediatric improper insulin immediately
Generic Name: glucose patients with injection
Frequency: after mixing). •
insulin glulisine lowering type 1 diabetes technique),
QD After first use,
activities of mellitus and in allergy to stable at room
Brand Name: APIDRA and of adults with type insulin
Route: temperature for
Apidra regular human 2 diabetes cleansing
intravenous (IV) 28 days. •
100 units/mL insulin are mellitus. solution Administer 15
vial, equipotent
• (Apidra): Use min before or
3-mL cartridge. when Contraindicati Adverse
only if solution is within 20 min
administered by on: Effect:
clear. • May give after starting a
the intravenous -low blood - Severe
undiluted meal.
route sugar. hypogly
-low amount of cemia
potassium in - Diabetic
the blood. ketoacid
-liver problems. osis
 ADVERSE NURSING
MEDICATION DOSAGE ACTION USAGE EFFECTS CONSIDERATION

Drug Dosage: Indication:

Classification Myalgia, Obtain baseline
10-20mg Decreases LDL Cholesterol
: myopathy, cholesterol,
and VLDL, management
Hydroxymethyl rhabdomyolysis, triglycerides,
Frequency: plasma
glutaryl CoA headache, chest LFT. Question
QD triglyceride Contraindication:
(HMG-CoA) pain, peripheral for possibility of
levels; increases Hypersensitivity
reductase edema, dizziness, pregnancy
Route: HDL to atorvastatin.
inhibitor. rash, abdominal before initiating
Oral concentration Active hepatic
CLINICAL:Anti pain, constipation, therapy. Obtain
disease, diarrhea,
hyperlipidemic Initially, 10–20 breastfeeding, dietary history.
. dyspepsia, INTERVENTION
mg/day pregnancy or nausea,
women who may /EVALUATION
Generic flatulence, Monitor for
Range: 10–80 become increased LFT,
Name: mg/day pregnant, headache.
Atorvastatin back pain, Assess for rash,
unexplained sinusitis
Brand Name: elevated LFT pruritus,
Lipitor results malaise. Monitor
cholesterol,
10mg once triglyceride lab
per day values for
therapeutic
response
 ADVERSE NURSING
MEDICATION DOSAGE ACTION USAGE EFFECTS CONSIDERATION

Indication: Adiro
Adiro Side effects:
Drug Dosage:
(acetylsalicylic upset stomach, (acetylsalicylic
acid) is an
classification: 100mg
nonsteroidal acid) is an It works by heartburn;
antiinflammatory analgesic, reducing analgesic,
drugs
Frequency:
antipyretic, substances in the drowsiness; or antipyretic,
antirheumatic,
BID body that cause
Generic Name: antirheumatic,
acetylsalicylic Route:
and pain, fever, and mild headache. and anti-Assess
acid or aspirin Oral
anti-inflammatory inflammation. pain and/or
agent. Adiro's Adverse effect: pyrexia one hour
Brand Name: mode of action as Contraindication: Cardiac before or after
100mg once
Adiro an arrhythmia, medication.
per day - Hypersensitivity, edema,
- In long-term
antiinflammatory
and antirheumatic including asthma, hypotension,
100mg once per Max: 4 g/day.
agent may be due angioedema tachycardia, therapy monitor
renal and liver
day May also be
to inhibition of urticaria or rhinitis cerebral edema,
given rectally
synthesis and linked to aspirin coma function and
release of or non-steroidal ototoxicity
prostaglandins anti-inflammatory
drugs (NSAIDs)
 ADVERSE NURSING
MEDICATION DOSAGE ACTION USAGE EFFECTS CONSIDERATION
Indications:
Drug Dosage: The drug binds to Vancomycin is ◒ Nephrotoxicity Baseline
Classification: 1g/200mL bacterial cell used to treat and may occur. Assessment:
Tricyclic walls, altering cell prevent various Too-rapid infusion ◒ Obtain culture
glycopeptide Frequency: membrane bacterial may cause red sensitivity test
antibiotic Every 12 hours permeability, then infections caused man syndrome, a before giving first
inhibits RNA by gram-positive common adverse dose.
Generic Name: Route: synthesis. bacteria, including reaction ◒ Consider
Vancomycin IV methicillin-resista characterized by placement of
nt Staphylococcus pruritus, urticaria, central venous
Brand Name: aureus (MRSA). It erythema, line/PICC line.
Vancocin HCI is also effective angioedema,
for streptococci, tachycardia, Patient & Family
enterococci, and hypotension, Teaching:
methicillin-suscep myalgia, ◒ Assess skin for
tible maculopapular rash.
Staphylococcus rash. ◒ Check hearing
aureus (MSSA) acuity, balance. ◒
infections. ◒ Cardiovascular Monitor B/P
toxicity occurs carefully during
Contraindication rarely. infusion.
s:
Hypersensitivity to
Vancomycin.
 ADVERSE NURSING
MEDICATION DOSAGE ACTION USAGE EFFECTS CONSIDERATION

Drug Dosage: Piperacillin: Indication: ◒ Baseline

Classification: 4.5g Inhibits bacterial Tazobactam Antibiotic-associat Assessment:
Penicillin cell wall synthesis expands ed colitis, other ◒ Question for
Frequency: by binding to piperacillin activity superinfections history of
Generic Name: Every 6 hours PCN-binding to include may result from allergies, esp. to
Piperacillin/tazo proteins, which beta-lactamase–p altered bacterial penicillins,
bactam Route: inhibit the final roducing strains balance in GI cephalosporins.
IV step of of S. aureus, H. tract.
Brand Name: peptidoglycan influenzae, ◒ Overdose, more Intervention:
Vancocin HCI synthesis. Bacteroides, often with renal ◒ Monitor daily
PsAg, impairment, may pattern of bowel
Tazobactam: Acinetobacter, produce seizures, activity, stool
Inactivates Klebsiella neurologic consistency.
bacterial pneumoniae, E. reactions. ◒ Be alert for
beta-lactamase. coli. ◒ Severe superinfection.
hypersensitivity ◒ Monitor I&O,
Contraindication reactions, urinalysis.
s: including ◒ Monitor serum
Hypersensitivity to anaphylaxis, electrolytes, esp.
piperacillin/tazoba occur rarely. potassium, renal
ctam, any function tests.
penicillin.
 ADVERSE NURSING
MEDICATION DOSAGE ACTION USAGE EFFECTS CONSIDERATION

Drug Dosage: Cyanocobalamin Indications: Severe allergic ◒ Administer the

Classification: 1g (tablet) acts as a Prevention and reactions and vitamin in the
Vitamin coenzyme for fat treatment of persistent morning after
Frequency: and carbohydrate deficiency of stomach pain or waking up.
Generic Name: Once a day metabolism. It is vitamins B1, B6, cramping.
Hidroxil essential for and B12 due to ◒ Monitor for
B1-B6-B12 Route: growth, cell increased needs, possible signs of
Oral replication, reduced adverse effects.
Brand Name: hematopoiesis, consumption or
Pharex nucleoprotein, absorption.
and myelin
synthesis. Contraindication
Thiamine and s:
Pyridoxine Hypersensitivity to
respectively, acts Vitamin B1 or any
as coenzymes for component of a
various metabolic product
functions affecting containing vitamin
protein, B1, B6, or the
carbohydrate, and various forms of
lipid metabolism. vitamin B12,
cobalt or any of
the excipients.
08
MEDICAL AND
SURGICAL
MANAGEMENT
 Medical and surgical
managament

Main goal:
The main goal of goal of diabetes treatment is to normalize insulin activity
and blood glucose levels to reduce the development of vascular and
neuropathic complications. In the case of patient, the goal is to control the
infection through medical and/or surgical intervention.
Medical and surgical
managament
Medical
● Lantus insulin 8 units, OD in the morning
● Apidra insulin; if hyperglycemia
● Atorvastatin 10 mg OD
● Adiro 100 mg; OD
● Hidroxil B1-B6-B12; OD
● Discontinued treatment due to secondary effect:
Pregabalin and Tramadol.
Medical and surgical
managament
Medical
Treatment for the ulcer until admission (Pre-admission):
● Cure with therapeutic honey and cleaning with soft soap.
● Offload with 1 cm-thick pads are foot sole. He uses a stick to avoid
weight
● Hyperoxygenated fatty acid compound (HFAC): TID in both legs.
● Dressing to support the pad.
● For IV medications: Vancomycin 1 gram q 12h, piptazo 4.5 grams q
6h
09
nURSING CARE
PLAN
 Assessment Diagnosis planning intervention rationale evaluation

Subjective: Impaired skin Short Term Goal: Independent: SHORT TERM:

integrity related to After 8 hours of
“Nurse, may sugat poor circulation as After 8 hours of ● Perform a ● A complete proper nursing
po ako sa ilalim ng evidenced by sole proper nursing complete head-to-toe intervention, the
aking paa na ulcers and intervention, the body audit on audit client was able
matagal gumaling at exudation client will be able to: admission provides the partially met the goal
may mabahong and at nurse with a as evidenced by:
amoy,” as verbalized designated baseline
by the patient times. Pay condition of
● Be provided special the skin that ● The patient is
the optimal attention to can be used in optimal
Objective: conditions for bony for condition
● Sole ulcers the natural prominences comparison providing
both feet healing that are at when skin natural
process to high risk for damage is healing of the
● Swollen occur tissue injury. noted wound
borders with
exudation ● Evaluate ● The etiology LONG TERM:
Long Term Goal: what causes of
● Yellowish foot the tissue compromised After 2-3 days of
nail After 2-3 days of damage. And tissue can nursing intervention,
discoloration nursing intervention, provide tisse vary widely. the client was able to
& bad odor the client will be able care as Tissue can partially met the goal
to: needed. be as evidenced by:
●
Assessment Diagnosis planning intervention rationale evaluation

● Overproducti
on of Keratin ● will not have ● Determine ● A nurse that ● Not having
any further the type of is specialized any further
● Ocher skin wound. in wound skin
pigmentation breakdown care should breakdown
malleolar be consulted
region to assist with ● Freed from
● Be freed from
appropriate any
any
wound complications
complications
staging. Use and
and
the staging infections
infections.
criteria
recommende ● Described
● describe
d by the measures to
measures to
National protect and
protect and
Pressure heal the
heal the
Ulcer tissue,
tissue,
Advisory including
including
Panel. wound care
wound care
Assessment Diagnosis planning intervention rationale evaluation

● Note wound ● Wound odor

odor and can come
drainage. with exudate
and may be a
sign of
infection.
Color and
amount of
drainage
provide
information
about
appropriate
wound
healing
processes.
Assessment Diagnosis planning intervention rationale evaluation

● Bathe the ● Prolonged

patient daily contact of the
with skin with
pH-balanced moisture and
soap, use soil irritates
lotions and the skin and
barrier predisposes
creams, and it for skin
change breakdown.
soiled
underpads
immediately.

● Clean the ● Wound

patient’s cleaning
usually
wounds
requires an
according to aseptic
hospital technique.
policy and Sterile
orders. technique
reduces the
risk for
infection.
Assessment Diagnosis planning intervention rationale evaluation

● Discourage ● Friction can

the patient make already
from rubbing injured tissue
and worse.
scratching Bacteria
the affected could be
area. introduced
into open
wound tissue
and prolong
the healing
process

● Handwashing
● Teach the
. Changing
patient and
gloves
family about
between
the correct
“dirty” and
wound care
“clean” steps.
techniques.
Applying
topical
medication/p
owders
Assessment Diagnosis planning intervention rationale evaluation

● Educate ● RednessSwe
about the lling Warmth
signs and Discoloration
symptoms of Increased
infection and wound
when to drainageFev
notify er - Being
healthcare aware of
personnel. these
symptoms
promotes
early
intervention.
Assessment Diagnosis planning intervention rationale evaluation

Dependent:
● To reduce the
● Administer risk of infection
antibiotics as or to treat an
ordered. existing
infection, either
topical agents or
intravenous
medications are
used

Collaborative:
● Nutrition plays
a vital role in
wound
● Collaborate
healing.
with dietary Dietitians will
services to make sure the
ensure patient
nutritional receives an
needs are individualized
met diet plan that
considers the
correct diet,
calories, and
nutrients such
as protein
 Assessment Diagnosis planning intervention rationale evaluation

Subjective: Risk for Infection Short Term Goal: Independent: After 1 hour of rendering
“May sugat po ako sa related to preexisting After 1 hour of rendering ● Teach and promote ● Hand hygiene is proper nursing
magkabilang paa, at Exudative ulcer on the proper nursing good hand hygiene. the single most intervention,the Short
mas lalong lumalala pa.” metatarsophalangeal intervention, the patient effective way to Term Goal was completely
as verbalized by the area will be able to: prevent the met. As evidenced by, the
patient. ● Identify transmission of patient was able to:
interventions to diseases. Include ● Identify
Objective: prevent/reduce risk the patient’s SO in interventions to
● Exudative ulcer of infection teaching. Vera, prevent/reduce risk
on the ● Demonstrate 2022 of infection, as
metatarsophala techniques, evidenced by stating
ngeal area lifestyle changes to ● Recommend routine ● To reduce importance of strict
● Sole ulcers on prevent or preoperative body bacterial asepsis and
both feet: 2x3 development of shower or scrubs, colonization. compliance to
cm wide on the infection when indicated. Doenges, 2019 medication
right foot and ● Demonstrate
4x3 cm wide on Long Term Goal: techniques, lifestyle
his left foot After 2 days of rendering ● Maintain strict ● Increased glucose changes to prevent
● Hyperkeratosis, proper nursing asepsis during IV in the blood development of
swollen intervention, the patient insertion, creates an infection, as
borders with will be: administration of excellent medium evidenced by proper
exudation and ● Free of infection medications, and for immune demonstration of
malodor ● Achieve timely providing wound or dysfunction and wound cleaning
● Onychomycosis wound healing site care. Rotate IV for pathogens to routine
and maintain or sites as indicated. thrive.Vera, 2022
restore defenses
Assessment Diagnosis planning intervention rationale evaluation

● Independent (cont.): After 2 days of

● Provide ● An impairment or rendering proper
meticulous ineffective nursing intervention,the
skincare by gently peripheral Long Term Goal was
massaging bony circulation can completely met. As
areas, keeping place the patient evidenced by, the
skin dry. Keep at risk for patient was able to:
linens dry and increased skin ● Free of infection,
wrinkle-free. breakdown and as evidenced by
the development normal vital signs
of infection. Vera, and absence of
2022 signs and
Dependent: symptoms of
● Administer ● Early treatment infection
antibiotics as may help prevent ● Achieve timely
indicated. sepsis as patients wound healing
with diabetes are and maintain or
more prone to restore defenses,
serious infectious as evidenced by
diseases. Vera, improved skin
2022 integrity
Assessment Diagnosis planning intervention rationale evaluation

● Interdependent:
● Monitor white ● High neutrophils and
blood cell (WBC)
count.
monocytes and low
lymphocytes indicate
an elevated NLR
ratio. This is usually
caused by severe
infection or stress on
the body. In older
patients, this may
indicate a severe risk
for infection. Vera,
2022

● Assess and ● Patients with

monitor inadequate nutrition
nutritional status, may be anergic or
weight, history of unable to muster a
weight loss, and cellular immune
serum albumin. response to
pathogens, making
them susceptible to
infection. Vera, 2022
10
DISCHARGE
PLAN
Medication
● Instruct the patient and inform the family to comply with the
treatment provided by the doctor.
● Instruct the patient to take only the medicine prescribed by the
doctor and explain the dose, frequency of administration, and
possible side effects of the medicine.
Insulin pen
administration
Environment/Exercise
● Maintain a quiet environment to promote relaxation.
● Provide a clean and comfortable environment.
● Inform the patient to have a slow, gradual increase in the exercise period,
walking is a safe and beneficial form of exercise that requires no special
equipment.
● Exercise precautions - if blood glucose levels exceed 250 mg/dL
(14 mmol/L) and who have ketones in urine should not begin exercising
until test results are negative for ketones and the blood sugar is closer to
normal.
Environment/Exercise
● Instruct the client to use proper footwear and, if appropriate, other
protective equipment.
● Inform the client to avoid exercise in extreme heat or cold.
● Instruct the client to inspect feet daily after exercise.
TREATMENT
● Instruct the patient to continue the medications.
● Teach the patient about wound care.
○ Wash hands with soap and water.
○ Rinse off the wound with warm water.
○ Apply pressure to stop any bleeding.
○ Apply antibiotic cream and cover with a bandage, if prescribed.
 TREATMENT
● Teach the patient about foot care.
○ Inspect your feet daily.
○ Bathe feet in lukewarm, never hot, water.
○ Be gentle when bathing your feet.
○ Moisturize your feet but not between
your toes.
○ Cut nails carefully.
○ Never treat corns or calluses yourself.
○ Wear clean, dry socks.
○ Consider socks made specifically for patients living
with diabetes.
○ Wear socks to bed.
○ Shake out your shoes and feel the inside before
wearing.
○ Keep your feet warm and dry.
○ Consider using an antiperspirant on the soles of
your feet.
Never walk barefoot.
○
○ Take care of your diabetes.
○ Do not smoke.
○ Get periodic foot exams.
HEALTH TEACHING
● Instruct the patient to eat on time, healthy and always be active.
● Teach the client on how to check their blood sugar (glucose).
● Instruct the patient to always take their medicine on time.
● Advise the client to cope with the emotional side of diabetes.
● Educate the patient on how to reduce your risk of other health
problems.
HEALTH TEACHING
● Demonstrate to the client on how to check blood sugar.
diet
● Eating the right foods for diabetes means eating a variety of healthy foods
from all the food groups:
* Fruits and vegetables
* Whole grains, such as whole wheat, brown rice, barley, quinoa, and oats
* Proteins, such as lean meats, chicken, turkey, fish, eggs, nuts, beans, lentils,
and tofu
* Nonfat or low-fat dairy, such as milk, yogurt, and cheese
 diet
● Limit or avoid high-carb foods and drinks
Examples:
* Sugary foods, such as candy, cookies, cake, ice cream, sweetened cereals, and canned
fruits with added sugar
* Drinks with added sugars, such as juice, regular soda, and regular sports or energy
drinks
* White rice, tortillas, breads and pasta - especially those made with white flour
* Starchy vegetables, such as white potatoes, corn, and peas
diet
You may also need to limit how much alcohol you drink, as
well as how much fat and salt you eat.

OUT-PATIENT
● If you're meeting your treatment goals, visit your doctor every 6
months.
● In case of emergency, call your doctor or emergency hotline 911.
SEX
Approach sex like exercise.

SPIRITUAL
"So do not fear, for I am with you; do not be dismayed, for I am your God. I will
strengthen you and help you; I will uphold you with my righteous right hand." Isaiah
41:10
 Thanks!

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 Resources
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https://www.youtube.com/watch?v=PqgKFsK7f-Q
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https://www.youtube.com/watch?v=rMMpeLLgdgY
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