Question

Mr. Reynolds: a 52-year-old man with type 2 diabetes mellitus presented with a painful full thickness ulcer on the right third toe, of 1-month duration. We obtained a full medical history in which the patient reported fever, 2 weeks earlier, with a maximum temperature of 38°C/100.4 F. However, the fever had resolved spontaneously and the patient had not experienced fever within the past week, patient did communicate a reduced appetite, limited mobility due to neuropathy. A previous medication in addition to metformin was a step down pack of steroids medication. At the visit to our clinic, the ulcer showed clinical signs of systemic inflammatory response. Current lab reports:

WBC 23,

HA1c 11.0, Hgb12, Hct35, wound culture is pending, x-ray shows bone involvement, albumin 2.5, K 2.5

Second X-ray improvement after

therapy

Complete a concept map for the care of this patient.

What factors place this patient at risk?

What stage of wound is presenting?

What stage of healing is taking place?

What is the infection process manifesting?

What anticipated medications would be ordered for this patient?

What precautions would be required to care for this patient?

What nursing health promotion education does this patient require?

Answer 1

Complete a concept map for the care of this patient.

Medical Diagnosis	Medical history	current problems	Nursing interventions	Nursing Education
Diabetic foot (Right third toe)	Diabetic on drug metformin history of unresolved diabetic foot from one month.	-pain on the right third toe. -infected diabetic wound.(WBC-23) -uncontrolled diabetics(HBA1c-11) -Neuropathy evidenced by impaired mobility.	-Asses to rule out the signs of infection. -Pain assessment . -Wound assessment and grading . -Blood Glucose testing -Neuro assessment. -Administer medications such us antidiabetic ,antibiotics .	Nursing education focusing on wound care ,infection and diabetics.

  

What factors place this patient at risk?

• uncontrolled diabetics(HBA1C-11)
• leokocytosis-(wbc-23)
• Anemia evidenced by low Hb and HCT
• steroid medications would hide the underlying infection.
• Undernourished(patient says poor appetite) which delays wound healing .

What stage of wound is presenting?

This wound is in healing stage 4 stage because the wound depth went Upton the involvement of bone and now it is on healing stage as the latest Xray shows without involvement of bone.

What stage of healing is taking place?

Wound healing is in the proliferative stage as evidenced from the current Xray there is no involvement of bone comparing with the previous (bone involvement)one.In proliferative phase of wound healing the filling and covering of wound happens.

What is the infection process manifesting?

Leokocytosis-(wbc-23) clearly indicates still the patients is in infection .As the fever has come down from a week and Xray shows healing from previous one ,it suggest may be infection is on a reducing stage .

What anticipated medications would be ordered for this patient?

• Antibiotic therapy-(As still leukocytosis present and high risk candidate due to diabetic and on steroids)
• Additional dose of oral antidiabetic medications or insulin as the HBA1C is still high on current medication metformin.Insulin is preferred till upto the full healing of wound.
• Potassium replacement therapy-As hypokalemia present(2.5)

What precautions would be required to care for this patient?

Standard precaution is advised for now as there is no previous organisms and the current wound  culture reports are pending.

What nursing health promotion education does this patient require?

wound management

• Advice on wound assessment.
• Teaching on wound dressing procedure and frequency.
• Advice to avoid walking as bare foot to prevent the infection.
• keep the pressure of from the wound to promote healing
• keep your feet warm and dry .

Nutrition

Limit sugar and sugary foods.

Eat three meals a day

Consider adding fruit and vegetables in the food.

Advice to take protein rich diet to increase the albumin level

Monitor weight weekly and report if you loose more than 3 pounds .

Diabetics

• Instruct the current high blood sugar level.
• Teach on blood glucose montioring in home.
• Instruct about the addition of medications for glycemic control.
• Advice to limit sugar and sugary foods.

Infection

• Advice to report if any signs of infection as fever and chills.
• Advice to take the prescribed antibiotics and follow up.
• perform hand hygiene to prevent the spread of infection.