Diabetic Ulceration | Patient Care Plan

NRSG 1015 Patient Data and Plan of Care Patient Initials: J.G. Student
Name: Delisha Lopez
The same rules apply for the care plan as with any other patient documentation:
 HIPAA (violations, including cutting and pasting from patient records and photocopying or taking pictures of patient information, will
be handled per the Nursing Student Handbook)
 Paraphrase all information from texts or recent articles (5 years max) (do not cut and paste)
SLO 1, 2, 3, 4, 5, 6
Client Profile:
Initials:J.
G.
Gender: Male Ethnicity: Latino Occupation: Retired
Business Analyst
Dates of your Care: Semester 1,
2020
Age: 68 Marital Status: S M
W D
Religion: Catholic Code Status: Full Allergies: PCN
l
Patient Summary:
Admission date & Admission diagnosis: 02/11/2020
Admission Diagnosis - Diabetic Ulceration
Surgery date/procedure (from recent or current admission): 1/28/2020
Past Health History (PHHx): (List in bullet points with dates of onset)
 T2DM – 1999
 Peripheral Neuropathy – 2017
 Sepsis secondary to diabetic foot infection – Two weeks
 HTN with familial history
 Hypercholesterolemia
 Obesity with recent weight gain over past year
 Forgets to take medication at home sometimes
History of Current Illness: What problem(s) brought patient into the hospital? How did your patient present? (Written as
a summary)
Patient has uncontrolled type 2 diabetes and was diagnosed 21 years ago. He is currently being followed by a diabetes
clinic. The Patient had a small sore that became worse over time leading to a bad smell and drainage. The patient
went to the emergency room to address the sore as well as increasing weakness that made the patient unable to
ambulate or make it to his car. The patient was diagnosed at the hospital with sepsis secondary to acute diabetic foot
1

NRSG 1015 Patient Data and Plan of Care Patient Initials: J.G. Student
Name: Delisha Lopez
infection. At the hospital the patient received wound debridement surgery and treatment for sepsis. He is being
admitted for ongoing wound care and rehabilitation.
List all Current Medications (
Add to table as necessary). Complete detailed medication forms per instructor discretion.
Medication Dose and Route Times given Medication Dose and Route Times given
Atorvastatin 10 mg PO qd Colace 100 mg PO qd
Enalapril 5 mg PO qd Enoxaparin 80 mg subcut qd
Neorontin 200 mg PO TID Acetaminophen 650 mg sup Every 4 hrs prn
for pain and fever
Lantus Insulin 16 Units subcut hs Percocet 5/325 1-2 tab PO Evry 6 hours prn
for moderate to
severe pain
Humalog Insulin Subcut per sliding
scale
Per Sliding scale
BGL 100-149: 0
units
150-199: 1
unit
200-249: 2
units
250-299: 3
units
300-349: 4
units
350-399: 5
units
Clindamycin 450 mg PO Every 6 hours
2

NRSG 1015 Patient Data and Plan of Care Patient Initials: J.G. Student
Name: Delisha Lopez
Pathophysiology SLO 1,6 (Provide an APA format reference sheet)
Lewis’ Medical-surgical nursing is your first reference. You may supplement with other
material. All in-text citations must be in APA format.
A. Summary of the disease process (
not just the definition) and effects of the disease on the body (down to the cellular
level). (Citation) –
The major risk factors for developing diabetic ulceration are sensory neuropathy and peripheral artery disease. There
are other contributing health issues that play a role in determining risk such as clotting abnormalities, impaired
immune function and smoking, but sensory neuropathy is the most important risk factor due to the inability to feel if
there has been an injury to the foot due to loss of protective sensation, or LOPS (Harding, 2020). There are a variety of
issues at the cellular level that can create sensory neuropathy. Chronic hyperglycemia can lead to ischemic damage
from loss of oxygen in blood vessel that supply peripheral nerves (Harding, 2020). Chronic hypertension can also
cause an accumulation of sorbitol and fructose in nerves which causes damage for currently unknown reasons
(Harding, 2020). There are two categories of diabetes related neuropathy, sensory and autonomic. J.G. exhibits
sensory neuropathy or distal symmetric polyneuropathy which affects the hands and feet. Typical sensory neuropathy
symptoms include loss of sensation, abnormal sensation, pain and paresthesia (Harding, 2020). Once LOPS has
happened, the chance of injury increases, and once an injury occurs, the risk for infection is higher because of clotting
abnormalities and low WBC that creates problems with wound healing.
B. What is/are the classic medical/clinical presentation(s) seen on assessment? (Harding et al., 2020 pp 1137-1139)
 Degraded skin integrity or persistent Wound on bottom of foot or leg that will not heal
 Dermopathy with reddish brown oval patches
 Sensory neuropathy – Paresthesia, pain described as burning, cramping, crushing, or tearing that’s usually worse
at night, numbness of feet, atrophy of the small muscles of the feet
 Peripheral artery disease – intermittent claudication, pain at rest, cold feet, loss of hair, delayed capillary filling,
dependent rubor
 Clotting abnormalities – persistent wound
 Loss of Protective Sensation (LOPS) – inability to feel monofilament screening
 Charcot’s foot – joint dysfunction or foot drop
C. How does your patient present on assessment (medically/clinically)
 Feet cool to touch
 Numbness of feet
3

NRSG 1015 Patient Data and Plan of Care Patient Initials: J.G. Student
Name: Delisha Lopez
 Subcutaneous wound on plantar surface of left foot proximal to left great toe with 2.5 cm long x 2.5 cm wide
rounded ulceration with serosanguinous drainage
 Non-radiating pain to left toe
 Tingling/burning pain localized in both feet
D. What are the standard medical/surgical treatments for patients with this disease(s)? (pp 1138-1139)
 Wound care – debridement, dressings, advanced wound healing products, vacuum assisted closure, ultrasound,
hyperbaric O2, and skin grafting
 Casting of foot to redistribute weight on the plantar surface
 Management of blood glucose to treat neuropathy
 Pharmacological treatment of infection
E. How is your patient being treated?
Circle one: medically surgically
Describe your patient’s treatment plan.
 Wound Care – Dressing and bandaging of diabetic ulceration
 Pharmacological Infection control
 Pharmacological management and monitoring of blood glucose levels
 Pharmacological management of pain
 Pharmacological management of hypertension and hypercholesterolemia to reduce sensory neuropathy.
 PT/OT for range of motion and difficulty ambulating due to sensory neuropathy
 1800 calorie ADA diet
 Pharmacological management of constipation due to pain medication and lack of mobility
F. What is the prognosis for patients with this/these disease(s)? (pp 1137, 1139)
Patients diagnosed with a diabetic ulceration are at a significantly increased risk for lower limb amputation. Both
diabetic ulceration and lower limb amputation significantly deceases patient mobility leading to complications related
to a sedentary lifestyle.
If infection is present, patients are at an increased risk of developing sepsis.
G. What is the prognosis for YOUR patient (must incorporate all preexisting conditions)? Take into account all
comorbidities. Hypertension etc.
4

NRSG 1015 Patient Data and Plan of Care Patient Initials: J.G. Student
Name: Delisha Lopez
Vital Signs Trending
* Please indicate the type of thermometer used i.e. oral, rectal, tympanic, temporal, axillary etc.
** Please list whether the patient is on room air (RA), nasal cannula (NC), nonrebreather (NRB), continuous positive
airway pressure (CPAP) or any other device and the amount of oxygen given (i.e. 2LNC, 100% NRB etc.).
Highlight
abnormal values
Date and Time – Make up
dates/times only need 3.
2/11/20 0700 2/12/20 0730 2/13/20 0700
Blood Pressure 148/92 140/89 142/90
Pulse 72 72 70
*Temperature 37 oral 38 oral 38 tympanic
Respirations 12 14 12
O2 Saturation 98% 99% 99%
**RA NC NRB, CPAP Etc. RA RA RA
Capillary Blood Glucose (CBGs
in mg/dL)
290 280 300
WBC
Diagnostic Tests and Laboratory Results (add pages as needed)
Highlight abnormal values
Davis’s Laboratory and diagnostic tests book is your first reference. You may supplement with
other material. All references used must be cited.
Add rows as needed
Test
Name
Facility
Normal
with unit
of
measure
Date
2/11/20
Date
2/13/20
Date Date Significance for this patient: Must answer both
questions (For EVERY lab, include page number)
1. Why is this test ordered for this patient?
2. How will the results affect your nursing care of this
patient?
WBC 4.0-11.0 x
10 mcl 10.0 9.5 May be in lab book too.
RBC
(Erythrocyt
es)
Male: 4.3-
5.7 x 10
mcL
5.5 5.5
Hematocrit Male:
39%-50% 44 44
Hemoglobi
n
Male:
13.2%- 16 16
5

NRSG 1015 Patient Data and Plan of Care Patient Initials: J.G. Student
Name: Delisha Lopez
17.3%
Platelets 1150-100
x 10 mcL 300 300
Sodium 135-145
mEq/L 141 139
Potassium 3.5-5.0
mEq/L 141 139
Carbon
Dioxide
23-29
mEq/L 4.3 4.2
Chloride 96-106
mEq/L 101 101
Glucose 70-99
mg/dL 285 301
Magnesium
Calcium
(total)
8.6-10.2
mg/dL 9 9
Blood Urea
Nitrogen
(BUN)
6-20
mg/dL 16 16
Creatine 0.6-1.3
mg/dL 0.9 0.9
Total
Protein
6.4-8.3
g/dL 7 7
Albumin 3.5-5.0
g/dL 4 4
AST 10-30 U/L 18 18
ALT 10-40 U/L 20 20
Total
Cholesterol
<200
mg/dL 240 Not
drawn
HDL Male >40
mg/dL 43 Not
Drawn
6