medical surgical nursing 1 nursing care plan: diabetic...

MEDICAL SURGICAL NURSING

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Nursing Care Plan: Diabetic Foot Infection

Nicola Bancroft

Stenberg College

Cowichan Valley, BC, Canada


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Nursing Care Plan: Diabetic Foot Infection

IDENTIFYING DATA AND GENERAL DISCRIPTION

Mrs. A is a 54 year old First Nations woman. She is single and lives alone in a

subsidized, low rent apartment (Patient Chart, 2013). Mrs. A is a member of the Sechelt band but

has little connection with the band at present (P. August, personal correspondence, 06/04/2013).

Prior to admission Mrs. A was rarely physically active and approximately 40lbs over weight

(Patient Chart, 2013). Mrs. A appears calm, alert and well groomed.

CHIEF COMPLAINT/ HISTORY OF PRESENT ILLNESS:

Mrs. A has been admitted to hospital for a severe diabetic foot infection in her left foot.

Mrs. A has had diabetes mellitus for 9 years with dyslipidermia and peripheral neuropathy (Dr.

Meir, D., Patient Chart, 03.15.2013). Her diabetes remains poorly controlled with fasting sugars

averaging 14 with “frequent pre-dinner numbers as high as 20” (Dr. Meir, D., Patient Chart, para

3, 2013). Patient is non-compliant with diabetic diet at home (Patient Chart, 2013). No record of

patient’s insulin prescription pre-admission. Patient prescribed Humalog 27 units at breakfast,

Humalog 20 units at lunch and Humalog 20 units at supper, with supplementary insulin

depending upon before meal beside blood glucose (Patient Chart, 2013). Patient is compliant

with insulin administration but manages her diabetes poorly by eating high sugar and fats,

skipping meals and eating irregularly (Patient Chart, 2013).

No signs on retinopathy as per eye exam by Dr. Dam in 2012 (Patient Chart, 2013). In

03/2013 Mrs. A received a foot exam showing a callus over the left 3rd metatarsal head with

some drainage. Dr. reports that “there is likely an underlying ulceration and/or infection” (Dr.

Meir, D., 03.12.2013). Patient admitted to the Foot and Ulcer Clinic and the Royal Jubilee

Hospital (03.12.2013) for “urgent assessment for underlying ulceration and immediate


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debridement of the callus” (Patient Chart, 2013). Patient continues to bear weight on the foot

with no complaints of pain (Patient Chart, 2013). Patient prescribed non-weight bearing on left

foot via air cast walked (Patient Chart, 2013). Patient continues her prescription of

Cholecalciferol (vitamin D3) 2000 IntUnit daily, a Multivitamin / mineral 1 tab daily and

Pantoprazole magnesium 40 daily for healthy maintenance of vitamins and minerals (Patient

Chart).

PAST MEDICAL HISTORY:

Mrs. A’s past medical history includes hypertension since 2009 and depression since

2005 (Patient Chart, 2013). Patient diagnosed with depression in 2005 and prescribed Serax

(oxazapam ) 30 mg daily for depression and Effexor XR (venlafaxine) 75 mg daily for

depression as per her family physician (Patient Chart, 2013). Mrs. A was diagnosed with

diabetes in 2002 and due to non-compliance with diabetic regime is now in hospital with a severe

diabetic foot infection.

SURGICAL HISTORY:

Mrs. A received a childhood surgery, date unknown, to transfer a portion of her hip bone

to her feet due to “some sort of congenital anomaly” (Patient Chart, 2013). This has since caused

some scaring which appears on her left and right medial malleoli (Patient Chart, 2013). As such,

the left foot is foreshortened compared to the right (Patient Chart, 2013). Patient has had a hernia

repair, hysterectomy, and bowel resection (Patient Chart, 2013) at undisclosed dates. Patient is

going to repair her abdominal hernia wit Dr. Rusnak at an undecided date (Patient Chart, 2013).

ALLERGIES:

Mrs. A is “deathly allergic to penicillin” (Emergency Physician, patient chart, 2013). No

documented reaction to penicillin other than emergency physician’s conversation with Mrs. A;


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Patient has no other known allergies.

DISEASE PROCESS:

See Appendix 1

LAB RESULTS:

In 2004 Mrs. A met with an endocrinologist who stated “her diabetes remains poorly

controlled with a hemoglobin Alc being 10.4 per cent” (Patient Chart, 2013). The patient’s

albumin to creatinine ratio remains slightly positive at 3.7 mg/mmol. Her lipids and triglycerides

are nearly normal (Patient Chart, 2013). Mrs. A’s kidney function is normal according to lab

results (Patient Chart, 2013).

NURSING PHYSICAL ASSESSMENT

Mrs. A is alert and oriented X4, knowing her name, where is, the date and how long she

has been in hospital. No signs of delirium or confusion. Communication / speech is fluid and

articulate. Mrs. A has brown skin that appears normal in color, is hydrated and in tact with no

abrasions. At the head patient has no skin abnormalities, eye sight good and breathing easy.

Patient’s respirations are easy with no noted difficulty catching her breath. At the upper

extremities skin is of good color, hydrated and in tact. Patient’s radial pulse is 68 (Observation,

2013). At PICC insert site skin patent and in situ. At the abdomen bowel sounds X 3 with noted

regular bowel movement and voiding (Patient Chart, 2013). No complaints of nausea or

vomiting. Bladder output normal, urine color yellow, with appropriate volume for fluid input.

Patient has a large abdominal scare across the lower abdomen due to previous hernia operation

(Patient Chart, 2013). Patient wears a synthetic, fabric belt to hold in abdominal organs until

another hernia operation is scheduled (Patient Chart, 2013). No noted incontinence. At lower

extremities patient exhibits edema on her left, injected foot, almost doubling the size of her right


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foot. Mrs. A’s problem area in terms of skin integrity is her infected left foot, with a black,

necrotic toe and a large, open callus along the toe base (observation, 2013). No complaints of

pain associated with foot infection although at times feels body pain associated with an old car

accident 3 years ago (Patient Chart, 2013). Mrs. A has a scheduled dressing change daily with

specific instruction (see Treatment Plan). Mrs. A wears a cast padding around the left ankle and

covering her left foot. Mrs. A has good strength and muscle tone in the healthy areas of her left

foot and in the entirety of her right foot.

TREATMENT PLAN:

The treatment plan for Mrs. A is for her to remain in hospital while her severe diabetic

foot infection heals and no signs of infection remain (Patient Chart, 2013). Patient is will

continue with IV antibiotic Imipenem/cilastatin 500 mg IV every six hours until infection is

cleared (Patient Chart, 2013). Patient is required to remain off of her left foot and use a wheel-

chair to access the washroom (Patient Chart, 2013). Patient will continue to receive the anti-

coagulant Fragmin (dalteparin) 5000 units subcutaneous injection every 24 hours to prevent

pulmonary embolism and deep vein thrombosis, Serax (oxazapam ) 30 mg daily for depression,

Effexor XR (venlafaxine) 75 mg daily for depression, Lipitor (atorvastatin) 20 mg once daily for

hypertension, Nu-Cal (calcium carbonate) 1250 mg every 12 hours for calcium supplementation,

Altace (ramipril) 10 mg every 12 hours for hypertension, and Tylenol (acetaminophen) 1000 mg

three times daily for discomfort (Patient Chart, 2013). Patient prescribed Humalog (insulin

lispro) three times daily at breakfast, lunch and dinner (Patient Chart, 2013). Patient is to be

closely monitored for blood glucose levels and charted on diabetic record. Patient is prescribed

prandial insulin (short acting) 27 units subcutaneous at breakfast, 20 units subcutaneous at lunch

and 20 units subcutaneous at dinner (Patient Chart, 2013). If before meal blood glucose levels


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between 10.1 to 12 additional dose of 2 units ordered, between 12.1 to 14 additional dose of 4

units ordered, between 14.1 to 16 additional dose of 6 units ordered, and if reading greater than

16 mmol/L additional dose of 8 units ordered (Patient Chart, 2013). MRN is to check insulin

orders before administering any insulin to patient. * REFERENCE* The treatment plan for Mrs.

A’s foot infection includes a daily dressing change involving thoroughly cleansing the wound

with betadine (providine Iodine) in between toes and the bottom of the foot; rinsing with Normal

Saline; thorough drying of the foot; applying a strip of Inadine with a thin line of iodosorb

applied onto strip onto the 3rd toe, applying dry gauze and finally securing with a cast padding

around the ankle (Patient Chart, 2013). Enterostomal Therapy is to assess Mrs. A periodically “to

monitor wound and possible further debridement” (Patient Chart, 2013). Mrs. A will need home

IV for 2 weeks of IV antibiotics (Patient Chart, 2013). Patient will need a diet review while in

hospital and appropriate teaching regarding nutrition and diabetic regime (Patient Chart, 2013).

Mrs. A has been non-compliant with diabetic diet at home but is now willing to follow diabetic

regime for fear of needed amputation of left foot if infection does not heal (Patient Chart, 2013).

TEACHING AND DISCHARGE PLAN:

Before being discharged Mrs. A will need teaching in regard to the importance of

following a diabetic diet (Patient Chart, 2013). Mrs. A is a retired RN and does not need any

medication teaching (Personal Dialogue, 2013). In addition, the patient is very aware of blood

glucose monitoring and ideal levels. In order to be discharged Mrs. A’s foot infection must be

cleared and patient can then return home with a 2-wheeled walker (Patient Chart, 2013). Patient

will be discharged back to her home with no extra supports once her infection has cleared

(Patient Chart, 2013). Patient will continue to be monitored by her general physician in the

community (Patient Chart, 2013). According to Engelke & Schub (2011) teaching a patient with


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diabetes about foot care requires the patient and his/her family understanding how to inspect

daily for skin breakdown, fungus or inflammation and reporting promptly. There are no

anticipated community needs as Mrs. A is involved in her church, has many friends and past co-

workers willing and able to help in her recovery (Personal Dialogue, 2013).

STUDENT REFLECTION UPON WRITING CASE STUDY

Learning about my diabetic patient has taught me of the importance of maintaining a

healthy diet and exercise regime. Although my patient is a retired RN and has a good knowledge

of healthcare, she was unable to succeed in managing her diabetes alone, leading to a terrible

foot infection and necrotic toe. Similarly my patient was often defensive of how her blood sugars

are better maintained at home than in hospital with the high doses of insulin prescribed, at times

27 units to 31 units (Patient Chart, 2013). This defensiveness taught me the sensitivity that is

needed when working with diabetic patients. I needed to change my approach of caring for this

patient as simply stating what her needed insulin was, to explaining how her blood sugars may

change due to stress, change of environment and new diet.

PRIORITY NURSING DIAGNOSES & GOALS:

See Appendix 2


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APPENDIX 1:

TEXTBOOK DESCRIPTION OF DISEASE PROCESS CLIENTS PRESENTATION OF DISEASE PROCESS

Diagnosis Mrs. A has been diagnosed with type 2 diabetes since 2004. Diabetes mellitus is a multisystem disease related to abnormal insulin production, impaired insulin utilization or both (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007, p. 1134). Risks to developing this type of diabetes include obesity, being from a high risk population group such as First Nations, and being over 40 years old ((Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007; Nevada RNformation.,2008), all of which pertain to Mrs. A. Nevada RNformation (2008) writes that “foot wounds are among the most common and severe complications of diabetes-associated hospitalization” (p.23).

Mrs. A new she was at risk of developing type 2 diabetes because of her genetic pre-disposition, age, and weight (Patient Conversation, 2013). In 2004, after routine check-ups with her physician Mrs. A realized her blood sugars were abnormally high and she was unable to control them based solely on diet (Patient Conversation, 2013). She was prescribed insulin injections three times daily during this time (Patient Conversation, 2013).

Etiology/Pathophysiology In type 2 diabetes the pancreas usually continues to produce some endogenous insulin, however this insulin is usually either insufficient or poorly utilized by the tissues (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007, p. 1136). Some theories link the causes to genetic, autoimmune, viral or environmental factors to the development of type 2 diabetes (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007). The main pathophysiological difference between type 1 and type 2 is the latter has a presence of endogenous (self-made) insulin ((Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007).

No patient presentation of the etiology / pathophysiology of Diabetes type 2.

Clinical Signs and Symptoms With type 2 diabetes many of the signs and symptoms are non-specific. Some of the more common clinical signs include fatigue, recurrent infections, prolonged wound healing, visual acuity changes and painful

Mrs. A met with her physician in 03/2013 with complaints of a foot infection that would not heal (Patient Chart, 2013). The patient presents with sign of a necrotic third


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peripheral neuropathy in the feet ((Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007, p. 1339). Engelke & Pravikoff (2011) write that foot care is important regardless of the type of diabetes mellitus involved.

toe and severe foot infection due to her type 2 diabetes (Patient Chart, 2013). Mrs. A does not have any feeling in her foot and it at risk of needing amputation if the infection is unable to heal in hospital using IV antibiotics (Patient Chart, 2013).


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APPENDIX 2:

SHORT TERM GOAL

Nursing Diagnosis

Desired Outcomes

Interventions (I)-Independent (C) - Collaborative

Rationale & APA Reference

Evaluation of Interventions

NDX: (Problem) Falls, risk for R/T: (etiology/factor): - Mrs.A is at increased susceptibility to falling that may cause physical harm - Due to poor balance from a bandages, injured foot that must be kept from bearing weight the patient is a fall risk while in hospital (NANDA, 2012) AEB: (s/sx; defining characteristics) 1. poor balance

Goal (Reversal of Problem) Patient will remain free from falling while in hospital Client will (list measurable outcomes; reverse signs and symptoms) 1. ring call bell when needing assistance 2. use 2-W walker to the bathroom 3. will not fall Evaluation of Outcomes (address each outcome) 1. Ask patient for information on mobility and balance while going to washroom and down hallway 2. Record the number of calls made and help

N1-(I) (C) INDEPENDENT (1) While in hospital the

call button must be near with all side rails down (Patient Chart, 2013)

R1- Proper use of side-rails and appropriate assistance is essential in hospital (Lewis et al., 2007)

E1- Patient states “using the 2-wheel walker has been easy” (Patient Conversation, 2013)

N2-(I) (C) j COLLABORATIVE (C) Mrs. A must be educated on balance strengthening exercises and maintain her independence while in hospital. All nurses / staff must work to help Mrs. A maintain independence with mobility

R2- Education about balance and proper exercise in relation to a foot infection must be given by healthcare professionals and not delegated to assistive medical staff (Engelke & Pravikoff, 2011)

E2- Patient is spoken to about balance and mobility tips 1X a week by MRN


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Nursing Diagnosis

Desired Outcomes




due to uneven distribution of weight 2. obesity 3. unable to bear weight evenly on both feet 4. feeling weak from bedrest 5. feeling tired *If ‘risk for’ would exhibit:

needed with mobility 3. Assess patient strength in sitting and standing position Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met (If goal not met, describe outcomes not met) Continuation of plan: (circle one) Continue plan of care Discontinue plan of care Revise plan of care (Explain revisions as needed) * Patient was discharged from RJH on April 18th,

N3-(I) (C)

R3- E3-

N4-(I) (C)

R4-

E4-

N5- (I) (C)

R5- R5-

N6- (I) (C)

R6- E6-

N7- (I) (C)

R7- E7-


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Nursing Diagnosis

Desired Outcomes




2013 without history of a fall

N8- (I) (C)

R8- E8-

N9- (I) (C)

R9- E9-


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INTERMEDIATE GOAL

Nursing Diagnosis

Desired Outcomes




NDX: (Problem) Altered nutrition: More than body requirement related to lack of knowledge or ineffective coping R/T: (etiology/factor): -‐poor nutritional intake (excess calories) -‐need to prepare own meals, -‐peer group influence (Church activities) is negative

-‐ -‐lack of knowledge of principles of good nutrition AEB: (s/sx; defining characteristics) 1. overweight by approx. 40 lbs (Patient Chart) 2. rarely eating at home; takeout food 5+ times per week (Patient

Goal (Reversal of Problem) Patient will lose weight and begin to eat healthy / regularly within 30 days post-hospitalization Client will (list measurable outcomes; reverse signs and symptoms) 1. lose 5 pounds in the first week of diet change 2. reduce caloric intake based upon dietician recommendation 3. develop better coping skills with stress and better eating habits Evaluation of Outcomes (address each outcome) 1. Mrs. A will attend a follow up appointment with the dietician after 1 week 2. Mrs. A will keep a food journal 3. Mrs. A with work with dietician during appointment to

N1-(I) (C) INDEPENDENT Mrs. A will lose 10-20 lbs

R1- The primary goal in type 2 diabetes management is weight reduction (Engelke & Pravikoff, 2011)

E1- Mrs. A will use a food journal to log calorie consumption and exercise

N2-(I) (C) COLLABORATIVE Mrs. A will meet with a dietician to discuss a proper, lowered caloric diet

R2- Moderate weight loss (10-20 lbs) may improve the abnormalities of glucose tolerance, insulin secretion, and insulin use (Engelke & Pravikoff, 2011)

E2- Mrs. A had a scheduled appointment with a dietician in 3 days (Patient Chart, 2013)

N3-(I) (C) COLLABORATIVE Mrs. A will discuss beliefs surrounding food, nutrition and time management

R3- The client’s experiences, beliefs and activities have a profound influence on eating behaviours and exercise (Lewis et al., 2007)

E3- Mrs. A will discuss beliefs surrounding food in 2 days with MRN

N4-(I) (C)

R4-

E4-


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Nursing Diagnosis

Desired Outcomes




Conversation, 2013) 4. feeling tired, especially in the afternoon *If ‘risk for’ would exhibit:

develop better strategies to food management Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met (If goal not met, describe outcomes not met) Continuation of plan: (circle one) Continue plan of care Discontinue plan of care Revise plan of care (Explain revisions as needed)

N5- (I) (C)

R5- R5-

N6- (I) (C)

R6- E6-

N7- (I) (C)

R7- E7-

N8- (I) (C)

R8- E8-

N9- (I) R9- E9-


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LONG TERM GOAL

Nursing Diagnosis

Desired Outcomes




NDX: (Problem) Fear related to risk of acute and chronic complications of diabetes R/T: (etiology/factor): -Risk of recurring infection (Patient Chart, 2013) -Risk of needed foot amputation (Patient Chart, 2013) AEB: (s/sx; defining characteristics) 1. Mrs. A has moderate to severe anxiety related to fear of recurring infections 2. Mrs. A has moderate to severe anxiety related to fear of foot / partial leg amputation

Goal (Reversal of Problem) Reduce fear and patient anxiety in regard to complication related to diabetes Client will (list measurable outcomes; reverse signs and symptoms) 1. Patient will feel less fear 2. Patient will feel less anxiety 3. Patient will better understand complication associated with diabetes Evaluation of Outcomes (address each outcome) 1. Will meet with a counselor post hospitalization 2. Will speak with the MRN in regard to disease process 3. Will meet with family / friends and vocalize concerns

N1-(I) (C) COLLABORATIVE Encourage the client to verbalize fears and concerns

R1- Anxiety tends to feed on itself, catching the client in a spiral of anxiety and emotional / physical pan (Engelke & Pravikoff, 2011)

E1- Mrs. A plans on discussing her fears with family and friends

N2-(I) (C) COLLABORATIVE Encourage family and friends to verbalize their fears

R2- An anxious patient has a narrowed perceptual field and impaired ability to learn (Engelke & Pravikoff, 2011). Having others around with help with the education process when at home.

E2- Mrs. A plans on having a discussion with her family / friends in order to hear their fears surrounding her infection / possible amputation

N3-(I) (C) INDEPENDENT Encourage the client to practice relaxation techniques

R3- Providing resources on relaxation techniques will help with stress reduction, part of important self-care for diabetic patients (Strayer, A., & Schub, T.,2012).

E3- Mr. A is having a friend bring her library books on relaxation techniques (Patient Conversation, 2013)

N4-(I) (C) COLLABORATIVE Refer client to a clinical

R4- A person with diabetes needs support from health

E4- Mrs. A has been refered to a counselor after hospitalization (Patient


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Nursing Diagnosis

Desired Outcomes




3. *If ‘risk for’ would exhibit:

Evaluation of Goal: (circle one) Goal met Goal not met Goal partially met (If goal not met, describe outcomes not met) Continuation of plan: (circle one) Continue plan of care Discontinue plan of care Revise plan of care (Explain revisions as needed)

counselor

care professionals, including counselors (Engelke & Pravikoff, 2011)

Chart, 2013)

N5- (I) (C) COLLABORATIVE Provide current information on the disease process, risk of complications, and self treatment options

R5- It is the responsibility of healthcare professionals to explain that treatment of Diabetes Type 2 involves lifelong surveillance, education, physical assessment and lifestyle modifications (Strayer, A., & Schub, T., 2012).

R5- Mrs. A has regular discussions with her MRN in regard to Diabetes type 2 and fears surrounding her disease process

N6- (I) (C)

R6- E6-

N7- (I) (C)

R7- E7-

N8- (I) (C)

R8- E8-


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Nursing Diagnosis

Desired Outcomes




N9- (I) (C)

R9- E9-


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References:

Diabetic foot infection classification system validated. (2008). Nevada RNformation,

17(1), 23. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009803400&site=ehost-live

Engelke, Z. & Pravitoff, D. (2011). Patient education: teaching foot care to a patient with

diabetes. Nursing Reference Center. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=nrc&AN=T706311&site=nrc-live

Lewis, Heitkemper, Dirksen, O’Brien, & Bucher (2007). Medical-Surgical Nursing in

Canada (2nd ed.). Toronto, Canada: Mosby Elsevier.

Strayer, A., & Schub, T. (2012). Diabetes mellitus, type 2. Ebsco Reference. Retrieved

April 23, 2013.

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