Case study presentation on “Below

Knee Amputation Secondary to Diabetic

Foot”

Prepared By
Bindu G.C.
Roll no: 9
BSN 4th year
 OBJECTIVES OF CASE STUDY

GENERAL OBJECTIVES
• To increase the level of understanding on the
knowledge on the disease which develops our
nursing knowledge on disease condition like the sign
and symptoms, prognosis and complication of
disease as well.

 
SPECIFIC OBJECTIVES
• To gain the knowledge on the disease condition.
• To identify the risk factors of the occurrence of the
disease.
• To gain the knowledge about specific medication
used in the disease condition.
• To present the case report on below knee
amputation secondary to diabetic foot.
 A.PATIENTS INFORMATION

• Name: Asta Maya Tamang

• Age /Sex: 55 years
• Address: Jhapa
• Diagnosis: Below Knee Amputation secondary
to diabetic foot ulcer
• Chief complain: Known diabetic patient
(Uncontrolled DM type-II) , with history of
hypertension with diabetic retinopathy.
 Developmental Task

According to developmental task my patient Ms. Asta

Maya Tamang, 55yrs old belongs to middle aged adult.
The developmental task of middle aged adult are:
• Maintain pleasant and comfortable home
• Assure security for later years, financially and
emotionally.
• Achieving adult civic social responsibility.
• Helping teenage children become a responsible and
happy adult.
 Contd…
• Developing leisure activities.
• Accept and adjust the physical changes, maintain
healthful ways of living attend to personal grooming
and maturity.
• Adjusting to aging parent.
• Establishing and maintaining standard of living.
• Relating to one’s spouse as a person.
 Developmental task by Erick Erickson

According to developmental task by Erick

Erickson my patient lies in Generativity vs
Stagnation care stage . (40-65 yrs)
 Diabetes
• Diabetic is a group of metabolic disease
characterized by increased levels of glucose in
the blood (hyperglycemia) resulting from
defects in insulin secretion, insulin action or
both resulting in glucose intolerance.
 EPIDEMIOLOGY

• In 2017, 425 million people had diabetes

worldwide. Type 2 makes up about 90% of the cases.
• .The WHO estimated that diabetes resulted in 1.5
million deaths in 2012, making it the 8th leading
cause of death.
• . In 2016, an estimated 1.6 million deaths were
directly caused by diabetes. WHO estimates that
diabetes was the seventh leading cause of death in
2016
 Contd…
• The percentage of diabetic patients has
increased from 19.04% in 2002 to 25.9% in
2009 in Nepal and is continuously growing
ever since.
• The total diabetes cases in Nepal were
199113 (DoHS, Annual Report 2074/2075)
{2017/2018}.
 Classification
1. Type I Diabetes / Insulin Dependent Diabetes
Mellitus (IDDM) or Juvenile Diabetes
• Secondary to destruction of beta cell in the
islets of langerhans in the pancreas resulting in
little or no insulin production; require insulin
• Usually occurs in children or non obese adults.
• It affects approximately 5% to 10% of the
people with the disease.
 Classification
2.Type II Diabetes / Non Insulin Dependent
Diabetes Mellitus (NIDDM)
• Adult or maturity onset diabetes or mild diabetes.
• May result from a partial deficiency of insulin
production or an insensitivity of the cells to insulin.
• Usually occurs in obese adults over age 40.
• It affects approximately 90 % to 95% of people
with disease..
 Classification
• Gestational Diabetes
• It develops during pregnancy and occurs about
4% of the pregnancies.
• Secondary Diabetes
• It occurs in some people because of another
condition that causes abnormal blood glucose
level such as pancreatitis, hyperthyroidism, long
term use of parental nutrition long term use of
corticosteroids, phenytoin, clozapine, etc.
 Risk Factors
For type 1 diabetes
• Family history
• Environmental factors
• Presence of damaging immune system cells
 Risk factors
For type 2 diabetes
• Weight
• Inactivity
• Family history
• Age
• Race or ethnicity
• Gestational diabetes
• Polycystic ovarian syndrome
• High blood pressure
• Abnormal cholesterol level
 Risk factors
Gestational Diabetes
• Age
• Family or personal history
• Weight
• race
 Causes
• Family history of diabetes or a personal history
of gestational diabetes
• Race
• Injury to pancreas (infection, tumor, surgery or
accident)
• Autoimmune disease
• Age
• Physical stress (surgery or illness)
 PATHOPHYSIOLOGY
• For glucose to enter cells, two conditions must
be present.
• 1st: the cells should have enough “doors” called
the receptors.
• 2nd: a substance called insulin is needed to
“unlock” the receptors.
• Once these two conditions are met glucose
enters the cells and is used by the cells to make
energy, without energy all cells die.
 CLINICAL FEATURES

• Polyyuria
• Polydipsia
• Polyphagia
• Weight loss
• Blurring of vision
• Fatigue and weakness
• Paresthesias
• Skin infection
• Pruritus and vulvovaginitis
• Slow wound healing
• Signs of inadequate circulation to the feet
• Signs of accelerated atherosclerosis
•
 DIAGNOSTIC PROCEDURES

1. History
2. Physical examination
3. Laboratory examination
• Glycosylated hemoglobin (A1C)
• Random blood sugar test
• Fasting blood sugar test
• Follow up glucose tolerance test
• Postprandial blood sugar
• Blood glucose finger sticks
• Glucose tolerance test (oral glucose tolerance test)
 Diagnostic procedure contd…
Glucose tolerance test (oral glucose tolerance
test)
• For type 2 diabetes: 237ml of a syrupy
glucose solution containing 2.6 ounces
(75grms) of sugar is given to the client and
blood glucose level is measured after two
hours. Normal= 140mg/dl, prediabetes= 140-
199 mg/dl, diabetes = 200mg/dl.
 Contd…
For gestational diabetes: the client is asked to come to
test fasting not having anything to eat for 8 hours
and fasting blood sugar is tested and 8 ounces
(237ml) of a syrupy glucose solution containing 3.5
ounces (100grms) of sugar is given to the client and
blood glucose level is measured after two hours.
Normal fasting= 95mg.dl, 1 hour after taking glucose
solution = less than 180mg/dl, 2 hours after taking
glucose solution = less than 155mg/dl, 3 hours after
taking solution= less than 140mg/dl.
 Diagnostic procedures
Urine ketone level
• normal level = less than 0.6mmol/l,
• low to moderate = 0.6 to 1.5 mmol/l (slightly
increased risk for diabetic ketoacidosis)
• high= 1.6 to 3.0 mmol/l (increased risk for
diabetic ketoacidosis)
• very high = greater than 3mmol/l (very high
risk for ketoacidosis)
 MANAGEMENT
Type I diabetes
• Insulin is the main treatment for type I diabetes. It replaces hormone that the
body isn’t able to produce.
• 4 types of insulin are used:
• Rapid acting insulin starts to work within 15 minutes and effects last for 3 to 4
hours.
• Short acting insulin starts to work within 30 minutes and lasts 6 to 8 hours.
• Intermediate acting insulin starts to work within 1 to 2 hours and lasts 12 to 18
hours.
• Long acting insulin starts to work a few hours after injection and lasts 24 hours or
longer.
• Blood sugar level rise or fall on the basis of type of food. Starchy or sugary food
makes blood sugar levels rise rapidly. Protein and fat cause more gradual
increase. The amount of carbohydrates intake should also be decreased.
 Type II diabetes

• Diet and exercise can help some people

manage type 2 diabetes. If lifestyle changes
aren’t enough to lower blood sugar levels then
medicines should be used.
The medications used in type II diabetes are:

1. First generation sulfonylurea’s

• Chlorpropamide (diabetes)
• Tolazamide (tolinase)
• Tolbutamide
• (orinase)
2. Second generation sulfonylurea’s
• Glipizide (glucotrol)
• Glyburide(micronase,
• Glynase, diabeta)
• Glymepiride(amaryl)
 Contd…
• 3. Biguanides
• Metmorfin (glucophage, Glucophage XL,
Fortamet )
• Metmorfin with glyburide (glucovance)
• 4. Alpha glucosidase inhibitors
• Acarbose (precise)
• Miglitol(glyset
 Contd…
• 5. Non sulfonylurea’s insulin secretagogeous
• Repaglinide(prandin)]
• Caterigorized as a meglitinide nateglinide
(starlix) categorized as a D- phenylalanine
derivate
• 6. Thiazolidines (Glitazones)
• Pioglitazones
• Rosiglitazones
 Contd..
• 7. Dipeptidyl Peptidase- 4 (DDP-4) inhibitors
• Sitagliptin (januvia)
• Vildagliptin (Galvus
 Management contd…
Gestational Diabetes
• Eating a well balanced diet is important for
both mother and baby. Making right food
choices can also help to avoid diabetes
medications.
 Nursing management
• Providing patient teaching about: disease
process , its clinical features, causes and
management and prevention of complication.
• Diet
• Education on injecting insulin process.
• General care : oral care, eye care, foot care
• Exercise
 Complication
Acute complication
• It arises with the events with hyperglycemia
and insulin insufficiency.
• Diabetic ketoacidosis
• Hyperglycemic hyperosmolar Non- kitonic
Coma (HHNK)
• Hypoglycemia
 Chronic complications

It is primarily of those from damage to blood vessels

(angiopathy) secondary hyperglycemia. There chronic blood
vessels dysfunctions are divided into two categories:
• Macro vascular complication
• Micro vascular complications
• Long term complications: stroke, hypertension, retinopathy,
cataract, glaucoma, blindness, coronary artery disease due
(atherosclerosis), nephropathy, gastroparesis, peripheral
neuropathy, neurogenic bladder, peripheral vascular disease,
erectile dysfunction, gangrene.
 IN MY PATIENT

Patient reported the symptom consistent with

diabetic retinopathy which is chronic
complication and she had below knee
amputation secondary to diabetic ulcer.
 Diabetic foot ulcer

• It is a full thickness penetration of the dermis of

the foot in a person with diabetes. It is the most
dreaded complications of diabetes mellitus.
• More than 80% of the amputation occurs after
foot ulceration or injury, which can result from
diabetic neuropathy. Peripheral neuropathy
may also cause muscle weakness and loss of
reflexes, especially at the ankle, leading to the
changes in the way a person walks.
 Contd…
Ulcer severity is often classified using Wagner system
• Grade 1: ulcers are superficial involving the full thickness
but no underlying tissues.
• Grade 2: ulcers are deeper; penetrating down to ligaments
and muscles, but not involving bone or abscess formation.
• Grade 3: ulcers are deep with cellulitis or abscess
formation, often complicated with osteomyelitis.
• Grade 4: ulcer with localized gangrene
• Grade 5: those with extensive gangrene involving entire
foot
 Contd…
• Below knee amputation: involves removing
the lower legs, with or without removing the
knee joint. Either way, the remaining part of
the leg may still be able to bear weight and
can move well with the use of properly- fitted
prostheses, or a device designed to function
as the part of the leg that was removed.
 Contd…
Non healing diabetic foot ulcers can lead to amputation
• Lower limb amputation is performed for the treatment of non-
healing diabetic foot ulcers in the following cases:
• Severe soft tissue infections: if an infection cannot be treated
with intravenous antibiotics and a patient’s life is at risk, then
amputation is often the only treatment option. E.g.: necrotizing
fasciitis
• Osteomyelitus: this occurs when the infection has moved into
the bone. The first treatment is weeks to months of antibiotic
medications through a vein. Occasionally this is not effective
and the area contains the infected bone needs to be removed.
 Contd…
• Critical limb ischemia: this happens if the blood supply
is cut off suddenly, like in cases of a blood clot. It is
painful and an emergency. If the blood flow is not
restored right away, the tissue could die and lead to the
gangrene.
• Gangrene: it occurs when the tissue dies and turns
black. In some cases, the first course of treatment would
be to attempt to surgically remove dead tissue, however
if this is not possible then the only other treatment is
removal of the dead tissue through amputation.
 Life after amputation

• Loss of mobility
• Conflict with family members and loved ones
• Phantom limb pain (PLP)
• Stump care
• Increased risk of death
 Diabetic Retinopathy

• Retinopathy is the damage to small blood

vessels that nourish the retina. It has 3 main
stages: non proliferative , pre proliferative,
proliferative.
 Contd…
• Clinical features
• It is a painless process.
• In non proliferative and pre proliferative retinopathy, blurry
vision secondary to macular edema occurs in some patients,
although many patients are asymptomatic.
• Even patients with a significant degree of proliferative
retinopathy and some hemorrhage may not experience
major visual changes.
• Symptoms indicative of hemorrhaging include floater in the
visual field, sudden visual changes including spotty or hazy
vision or complete loss of vision.
 Assessment
• Diagnosis is done by direct visualization of the retina
through dilated pupils with an ophthalmoscope or with
a technique known as fluoresces in angiography.
• Fluoresce angiography can document the type and
activity of retinopathy.
• Dye is injected into an arm vein and is carried to various
parts of the body through blood, but especially through
vessels of the retina of an eye. It helps to see the retinal
vessels in bright detail and gives useful information that
cannot be obtained with just an ophthalmoscope.
 Management
• The first focus on management is on primary
and secondary prevention. Control of blood
glucose level in type 1 and type 2 diabetes
mellitus.
• The main treatment is argon laser
photocoagulation. The laser treatment
destroys leaking blood vessels and areas of
neovascularization.
 Contd…
• A vitrectomy is a surgical procedure & is done
in patients with visual loss and in whom
vitreous hemorrhage has not cleared on its
own after 6 months. The purpose is to restore
useful vision; recovery to near- normal vision
is not usually expected.
 Nursing management
• Educating patient about self care: because the
course of retinopathy may be king and
stressful, patient education is essential.
• Continuing care: patient should be given
information on consulting ophthalmologists
regularly. Self management of eye care
regimens.
 OREMS THEORY OF SELF CARE DEFECIT

• The self care deficit theory is proposed by

Orem is a combination of three theories i.e.:
theory of self care , theory of self care deficit
and theory of nursing systems.
• In theory of self care she explains self care as
the activities carried out by the individual to
maintain their own health.
 Contd…
• The deficit is identified by the nurse
throughout assessment of patient.
• The care will be provided according to the
degree of deficit the patient is presenting
with.
 Orem’s theory and 4 major concepts

• Person/ client: a unity who can be viewed as functioning

biologically, symbolically and socially and who initiates and
performs self care activities on own behalf in maintaining
life health and wellbeing.
• Health: it is a state that is characterized by soundness or
wholeness of developed human structures and of bodily
and mental functioning.
• Environment: it is linked to the individual forming an
integrated and interactive system.
• Nursing: a helping or assisting services to person who are
wholly or partly dependent – infant’s children and adults.
 Contd..
Once the care is provided, the nursing activities
and the use of nursing systems are to be
evaluated to get an idea about whether the
mutually planned goals are met or not. Thus
the theory could be successfully applied into
the nursing practice.
 Assessment of basic conditioning factor of the patient

• 1. Age: 55 years
• 2. Gender: female
• 3. Developmental state: older
• 4. Health status
• known diabetic patient with uncontrolled diabetes mellitus,
• complications : reports symptom consistent with diabetic
retinopathy
• Other diseases: hypertension, below knee amputation
secondary to diabetic foot ulcer.
• 5. Sociocultural orientation: illiterate, housewife
 Contd…
• 6. Health care systems: she used the hospitals for health
check up.
• 7. Family system: widow and lives with child.
• 8. Pattern of living: used cigarette and alcohol. She did not
do physical activities except for shopping and housework.
• 9. Environmental factors: lives in a house having proper
ventilation in the room and clean environment.
• 10. Resource availability and adequacy: she stated that she
could get the medicines from the pharmacy near to the
house.
Assessment of therapeutic self- care demands and self care defecit

• Air: has proper ventilation in her room

• Water: uses purified water
• Food: no problem
• Excretion: no problem
• Activity-rest: reports problem due to her leg
• Social interaction: lives with her child and expects to be
helped by her family members.
• Prevention of hazards: visual impairment may cause
danger.
•  
 Self care requisite and self care deficit

• Seeking and securing medical assistance:

when she got ill she went to the hospital for
appropriate medical care regarding her
disease conditions.
• Being aware of and prepared for effects and
results of pathological conditions: not much
aware about her disease condition.
 Contd…
• Effective implementation of medically prescribed
diagnostic, therapeutic and rehabilitative measures:
• Do not perform physical activities regularly. She did
not apply the diabetic diet plan.
• She did not know the further complications of
diabetes.
• She had never taken eye examination. She measures
her blood pressure when she feels unwell in herself.
 Contd..
• Being aware of and prepared for effects of
medical care: she did not know the risk of
developing hypoglycemia and hyperglycemia.
• Modifying the self concept and self image in a
particular state of health : she thinks that her
image was down due to her physical condition
• Learning to live with the effects of
pathological conditions: no problem
 Nursing diagnosis
• Knowledge deficit regarding the type of diet
intake related to dietary modifications.
• Impaired physical mobility related to loss of limb;
pain/discomfort.
• Disturbed body image related to amputation of
leg.
• Risk for injury related to diabetic retinopathy.
• Risk for unstable blood glucose level related to
deficient knowledge of diabetes management.
 Diversional Therapy
• Making leisure: it helps to improve life
satisfaction, self esteem, happiness, problem
solving skills.
• Exercise: doing physical activity helps to maintain
the health in blood pressure levels.
• Social support and emotional support: to provide
happiness, self concept as well as problem
solving skills.
• Discussion: to reduce the anxiety of patient.
 Health teaching

• For patient
• Patient was instructed to take prescribed medications.
• Patient was taught about the disease conditions.
• Patient was provided knowledge on diabetic diet.
• Patient was provided knowledge on the wound care.
• Patient was instructed to come for follow up care.
• For family
• Family was provided knowledge on diabetic diet.
• Provided knowledge on follow up care.
• Provided knowledge to give support and care to the patient.
•  
 REFERENCES

• Janice, L.H., & Kerry, H.C., ( Brunner and Suddarths Textbook of

Medical- Surgical Nursing, Wolters Kluwer ( India) Pvt Ltd, New
Delhi.
• Muna, S., Kalpana, P., Roshani, G., (2017) Essential textbook of
medical surgical nursing, Samiksha Publication Pvt.Ltd, Ghattekulo
Rauthadevi Marga, Kathmandu-29.
• https://en.wikipedia.org/wiki/Diabetes
• Basina,M. (2020) everything you need to know about diabetes.
https://www.healthline.com/health/diabetes
•  
• https://www.diabetes.co.uk/diabetes-complications/diabetic-foot-
ulcers.html
•