Nursing Case Study: Pathophysiology, Nursing Priorities, and Management

This nursing case study explores the pathophysiology of a patient with post amputation diabetic foot complications. It discusses two nursing priorities: management of complications and enhancement of patient mobility. The paper also outlines nursing management strategies for this diagnosis.

Running head: NURSING CASE STUDY
NURSING CASE STUDY
Name of the Student:
Name of the University:
Author note:

1NURSING CASE STUDY
Introduction
Using the processes outlined in the Clinical Reasoning Cycle (CRC), the first section of
this paper will attempt to explore the pathophysiology of the underlying pathogenic condition of
the patient, the second section will highlight two nursing priorities, primarily: Management of
post amputation diabetic foot complications and enhancement of patient mobility, whereas the
third section of the paper will aim to outline nursing management in terms of this diagnosis
(Levett-Jones, Courtney-Pratt & Govind, 2019).
Question 1
Taking insights from the case study, it can be implicated that the underlying
pathophysiology of Mrs. Bacci’s post operative foot status can be associated with detrimental
metabolic processes of diabetic neuropathy, delayed wound healing in diabetes and peripheral
vascular disease (Armstrong, Boulton & Bus, 2017). Such disease associations can be attributed
via consideration of the patient situation as per the CRC where it is evident that the patient has
presented with a medical history of uncontrolled type 2 diabetes mellitus and peripheral vascular
disease (PVD). The associations between the patient’s current foot status and the pathologies
underlying the above mentioned disease conditions can be attributed to the nursing processes of
collecting cues of the patient. The process of cue collection underlying the CRC is associated
with obtaining relevant patient details such as disease history and essential blood reports (Levett-
Jones, Courtney-Pratt & Govind, 2019). Likewise, symptoms of cold feet and high blood glucose
levels evident in the patient establish the link between post amputation complications and
diabetes. Additional collection of lipid profiles and angiogram results may also establish links
between PVD and foot amputation complications (Barshes et al., 2016).

2NURSING CASE STUDY
Upon collection of the required cues, the associations between patient condition and
disease pathologies will further be evaluated by processing acquired knowledge, previous
experience and enhanced evidenced based health literacy by the nurse, as per the CRC (Levett-
Jones, Courtney-Pratt & Govind, 2019). Uncontrolled diabetes associated with excessively high
blood glucose levels, evident in the reports of Mrs. Bacci, are a key causative factor underlying
the emergence of exudate secretion, dehiscence and infectious necrotized tissue proliferation post
amputation (Volmer-Thole & Lobmann, 2016). Type 2 diabetes mellitus is associated with loss
of efficiency in insulin functioning resulting in decreased glucose metabolism, increased levels
of endothelial blood glucose circulation and resultant lipid metabolism leading to hindered
lipogenesis and enhanced adiposity. Lack of timely mitigation results in uncontrolled
aggravation of diabetic symptoms such as neuropathy and delayed wound healing, which persist
despite foot amputation (Bandyk, 2019). It is worthwhile to remember that neural and vascular
functioning are closely interrelated. While appropriate nerve impulse transmission is a key
determining factor underlying healthy endothelial functioning, the nervous system is also
dependent upon the circulatory system for adequate functioning. High levels of circulating
glucose within the blood vessels results in the endothelial constriction, blood vessel narrowing
further aggravating to thickening of the capillary basement membrane and hyperplasia of
endothelial cells (Hicks et al., 2016). This results in loss of adequate blood circulation, reduced
oxygen saturated and an emergence of hypoxia which further hinder loss of neuronal functioning
and the emergence of temperature loss, decreased pain perception to damage as evident in the
cold feet of Mrs. Bacci and her inability to recognize her post amputation status until nursing
identification (Noor, Khan & Ahmad, 2017). Additional, it must be considered that high blood
glucose levels are associated with loss of immunological functioning exerted by leukocytes -

3NURSING CASE STUDY
essential physiological drivers of tissue repair and infection prevention - which are processes
further critical to wound healing. This is can be attributed to the high blood sugar levels of the
patient and the resultant infectious symptoms associated with post the amputation of her foot.
The interlinked loss of hyperglycemia induced vasoconstriction further results in the decreased
circulation of essential oxygen and nutrients to the affected tissue which additionally contribute
to the emergence of post amputation complications and stump tissue necrosis in the patient
(Ibrahim, 2018).
An additional disease pathology which can be attributed to the complications associated
with the patient’s foot is the prevalence of PVD in the patient. Peripheral vascular disease is
characterized by the occurrence of atherosclerotic adipose tissue deposits in the blood vessels
lined in the lower limbs of the patient (de Franciscis et al., 2015). Such increased prevalence of
peripheral endothelial adiposity results in the trigger of macrocyte induced phagocytic
functioning resulting in adipose oxidation, calcium based fibrous tissue formation and possible
thrombus emergence, endothelial narrowing, hindered blood circulation and the repeated
continuum of hypoxia, inflammation and delayed healing of wounds as mentioned previously
(Malyar et al., 2016). Further, PVD induced thrombus formation particular in arterial access
endothelium points may induce possibilities of ischemia which is characterized by warming,
redness, tenderness, purple discoloration and tissue necrosis due to poor circulation in the
surrounding wound tissues - which have observed evidently in the patient (Brownrigg, Schaper
& Hinchliffe, 2015).

4NURSING CASE STUDY
Question 2
As evident from the symptoms mentioned, the nursing diagnosis as per the CRC will
include: Post amputation infection and necrosis and loss of mobility and locomotion. Hence,
taking insights from the same, the nurse will formulate the following two nursing priorities in the
patient: Firstly, management of post amputation wound complications through adequate wound
healing and metabolic management and secondly, improved of mobility in the patient to prevent
occurrences of falls (Levett-Jones, Courtney-Pratt & Govind, 2019).
One of the primary priorities which must be administered by the nurse is the execution of
appropriate wound healing strategies for the purpose of mitigation of the complications emerging
due to the amputation. The patient has already presented symptoms of ischemia and tissue
necrosis as evident in the emergence of purple discoloration, sloughy tissue formation, exudates
secretion and warm temperature of the surrounding tissue (Yazdanpanah, Nasiri & Adarvishi,
2015). Lack of adequate execution of wound healing will result in the proliferation of hypoxia
and hyperglycemic inflammation induced necrotizing tissue transmission in the rest of the limb
of the patient. Hence, the resultant possibilities of wet or dry gangrene, resulting in further tissue
necrosis and amputation form the underlying rationale of this nursing priority (Hasan, Teo &
Nather, 2015). Additionally it must be remembered that metabolic complications of diabetes
associated hyperglycemia and PVD associated endothelial adiposity were the key driver of
delayed wound healing in the patient after amputation. Hence, the management of these
detrimental metabolic complications in the patient to result in long term prevention of wound
associated tissue necrosis form the underlying rationale of this nursing priority (Andrews,
Houdek & Kiemele, 2015).

5NURSING CASE STUDY
An additional nursing priority which must be considered is the administration of
appropriate mobility improvement strategies in order to enhance the locomotion and movement
of the patient within the range of motion. The prevalence of complications associated with the
amputation of the foot of the patient will result in difficulty of the patient in movement
(Tuttolomondo, Maida & Pinto, 2015). A loss of mobility in the patient due to hindered gait and
limb strength have been implicated to result in the emergence of increased susceptibility to falls
- resulting in further emergence of fracture oriented complications in wellbeing and increased
medical finances for treatment (Francia et al., 2015). Further, loss of mobility will result in
difficulties of the patient to perform activities of daily living which are key barriers to the
achievement of personal wellbeing. Hence, the prevention of falls, improvement of mobility and
prevention of possible emergence of self care deficit are the key rationale underlying
administration of the second nursing priority (Thiruvoipati, Kielhorn & Armstrong, 2015).
Question 3
Hence, as per the above rationalized nursing priorities, the nursing management of the
patient Gina Bacci will be based on the following SMART goals (Levett-Jones, Courtney-Pratt
& Govind, 2019):
1. To reduce post amputation complications and induce rapid wound healing within 1 week.
2. To prevent future metabolic complications by mitigation of diabetic and PVD pathologies
using health education, health literacy and lifestyle management strategies.
3. To improve mobility of the patient within the range of motion and prevent falls and self
care deficit complications.

6NURSING CASE STUDY
One of the most essential nursing responsibilities to be attributed the highest priority is
the management of the wound of the patient and the resultant prevention of tissue necrosis.
Hence, timely, prompt and adequate dressing of the wound is of utmost importance. Firstly, to
prevent the aggravation of wound infection and tissue necrosis, the nurse must immediately
replace the dressing of the patient with a fresh sample (Admin & Doupis, 2016). Secondly,
administration of adequate dressing is of utmost importance and must be suited to the unique
wound status of the patient, which the nurse must discuss collaboratively with the clinician or
administer a multidisciplinary approach with a diabetologist for the purpose of choosing an
appropriate dressing. Considering the loss of immune functioning in the surrounding areas of the
wound, the nurse can collaboratively administer a non-adherence dressing (Lim, Ng & Thomas,
2017). Such dressings are generally saline and coupled with external administration of
antibiotics, can prove to be useful to encourage healing and prevent infectious complications.
Alternatively, considering the moist nature of the wound and prevalence of secretion of exudates,
the hyrocolloidal, foam or alginate based dressings can be used alternatively (Mohajeri-Tehrani
et al., 2016).Such dressings contain an absorptive layer which not only absorb exudates but also
provide a environment which is hypoxic and adequately moist resulting in rapid wound healing,
prevention of dryness and enhancement of autolysis of the accumulated necrotizing tissue. In
addition to the administration of adequate dressings, the nurse must regularly inspect the
progress of the wound and report the clinician or diabetologist collaboratively for immediate
detection of any maceration (Hussain et al., 2018).
The prevalence of delayed wound healing in the patient can be attributed to ischemia,
hyperglycemia and neuropathy associated with uncontrolled diabetes and PVD. Hence, the need
of the hour is to prevent the emergence of these metabolic complications and educate the patient

7NURSING CASE STUDY
concerning mitigation and long term prevention of the same (Smith& Ryckman, 2015). It is
worthwhile to note that the patient is obese, as per her weight and Body Mass Index values.
Obesity is a key determinant of the emergence of increased adiposity, prevalence of PVD and is
also interlinked with the aggravation of metabolic symptoms such as diabetes. Hence, the nurse
must administer a multidisciplinary approach and work with a nutritionist to develop a low
sugar, high glycemic index and low fat diet to the patient (Mozaffarian, 2017). The nurse can
also administer a collaborative plan with a fitness expert to design and adequate exercise plan
since the same has been implicated to reduce obesity and diabetic complications (Böhm et al.,
2016). In addition to administration of these lifestyle modifying strategies the nurse can educate
the patient on the need to adhere to her diet, exercise and medication plan considering her low
levels of health literacy on the consequences of skipping her medications. The nurse may also
work collaboratively with the occupational therapist to mitigate her PVD associated discomfort
by administering adequate stretching and resistance training exercises (Hillegass, 2016).
Lastly, the nurse must work collaboratively with the diabetologist and occupatiomla
therapist to ensure the patient’s compliance to offloading footwear. In addition to provision of a
walking stick, the nurse must work collaboratively with the clinician to administer a monitoring
and falls prevention plan in order to supervise mobility in the patient and prevent possibilities of
falls (Harmann et al., 2017). Alternatively, the occupational therapists above mentioned
stretching interventions will aid in enhancing strength, stamina and resistance in the patient.
Timely and adequate blood glucose, lipid level and blood pressure monitoring by the nurse,
coupled with wound inspection and handover collection from the mobility monitoring workforce
will aid in efficient evaluation (Merriwether et al., 2016).

8NURSING CASE STUDY
Conclusion
Hence, to conclude, as per the CRC, the nurse must prioritize wound healing, metabolic
symptom management and mobility enhancement of the patient. An adequate nursing care plan
encompassing a multidisciplinary intervention by the nurse, clinician, diabetologist, occupational
therapist, nutritionist and fitness expert, will aid in efficient nursing management of the patient.

9NURSING CASE STUDY
References
Amin, N., & Doupis, J. (2016). Diabetic foot disease: from the evaluation of the “foot at risk” to
the novel diabetic ulcer treatment modalities. World journal of diabetes, 7(7), 153.
Andrews, K. L., Houdek, M. T., & Kiemele, L. J. (2015). Wound management of chronic
diabetic foot ulcers: from the basics to regenerative medicine. Prosthetics and orthotics
international, 39(1), 29-39.
Armstrong, D. G., Boulton, A. J., & Bus, S. A. (2017). Diabetic foot ulcers and their
recurrence. New England Journal of Medicine, 376(24), 2367-2375.
Bandyk, D. F. (2019, February). The diabetic foot: Pathophysiology, evaluation, and treatment.
In Seminars in vascular surgery. WB Saunders.
Barshes, N. R., Flores, E., Belkin, M., Kougias, P., Armstrong, D. G., & Mills Sr, J. L. (2016).
The accuracy and cost-effectiveness of strategies used to identify peripheral artery
disease among patients with diabetic foot ulcers. Journal of vascular surgery, 64(6),
1682-1690.
Böhm, A., Weigert, C., Staiger, H., & Häring, H. U. (2016). Exercise and diabetes: relevance and
causes for response variability. Endocrine, 51(3), 390-401.
Brownrigg, J. R. W., Schaper, N. C., & Hinchliffe, R. J. (2015). Diagnosis and assessment of
peripheral arterial disease in the diabetic foot. Diabetic medicine, 32(6), 738-747.
de Franciscis, S., Gallelli, L., Battaglia, L., Molinari, V., Montemurro, R., Stillitano, D. M., ... &
Serra, R. (2015). Cilostazol prevents foot ulcers in diabetic patients with peripheral
vascular disease. International wound journal, 12(3), 250-253.

10NURSING CASE STUDY
Francia, P., Seghieri, G., Gulisano, M., De Bellis, A., Toni, S., Tedeschi, A., & Anichini, R.
(2015). The role of joint mobility in evaluating and monitoring the risk of diabetic foot
ulcer. Diabetes research and clinical practice, 108(3), 398-404.
Hartmann, B., Fottner, C., Herrmann, K., Limbourg, T., Weber, M. M., & Beckh, K. (2017).
Interdisciplinary treatment of diabetic foot wounds in the elderly: low risk of amputations
and mortality and good chance of being mobile with good quality of life. Diabetes and
Vascular Disease Research, 14(1), 55-58.
Hasan, M. Y., Teo, R., & Nather, A. (2015). Negative-pressure wound therapy for management
of diabetic foot wounds: a review of the mechanism of action, clinical applications, and
recent developments. Diabetic foot & ankle, 6(1), 27618.
Hicks, C. W., Selvarajah, S., Mathioudakis, N., Sherman, R. L., Hines, K. F., Black III, J. H., &
Abularrage, C. J. (2016). Burden of infected diabetic foot ulcers on hospital admissions
and costs. Annals of vascular surgery, 33, 149-158.
Hillegass, E. (2016). Essentials of cardiopulmonary physical therapy. Elsevier Health Sciences.
Hussain, Z., Thu, H. E., Shuid, A. N., Katas, H., & Hussain, F. (2018). Recent advances in
polymer-based wound dressings for the treatment of diabetic foot ulcer: an overview of
state-of-the-art. Current drug targets, 19(5), 527-550.
Ibrahim, A. M. (2018). Diabetic Foot Ulcer: Synopsis of the Epidemiology and
Pathophysiology. International Journal of Diabetes and Endocrinology, 3(2), 23.

11NURSING CASE STUDY
Levett-Jones, T., Courtney-Pratt, H., & Govind, N. (2019). Implementation and Evaluation of the
Post-Practicum Oral Clinical Reasoning Exam. In Augmenting Health and Social Care
Students’ Clinical Learning Experiences (pp. 57-72). Springer, Cham.
Lim, J. Z. M., Ng, N. S. L., & Thomas, C. (2017). Prevention and treatment of diabetic foot
ulcers. Journal of the Royal Society of Medicine, 110(3), 104-109.
Malyar, N. M., Freisinger, E., Meyborg, M., Lüders, F., Gebauer, K., Reinecke, H., & Lawall, H.
(2016). Amputations and mortality in in-hospital treated patients with peripheral artery
disease and diabetic foot syndrome. Journal of Diabetes and its Complications, 30(6),
1117-1122.
Merriwether, E. N., Hastings, M. K., Mueller, M. J., Bohnert, K. L., Strube, M. J., Snozek, D. R.,
& Sinacore, D. R. (2016). Static and Dynamic Predictors of Foot Progression Angle in
Individuals with and without Diabetes Mellitus and Peripheral Neuropathy. Annals of
gerontology and geriatric research, 3(2).
Mohajeri-Tehrani, M. R., Variji, Z., Mohseni, S., Firuz, A., Annabestani, Z., Zartab, H., ... &
Larijani, B. (2016). Comparison of a Bioimplant Dressing With a Wet Dressing for the
Treatment of Diabetic Foot Ulcers: A Randomized, Controlled Clinical Trial. Wounds: a
compendium of clinical research and practice, 28(7), 248-254.
Mozaffarian, D. (2017). Foods, obesity, and diabetes—are all calories created equal?. Nutrition
reviews, 75(suppl_1), 19-31.
Noor, S., Khan, R. U., & Ahmad, J. (2017). Understanding diabetic foot infection and its
management. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11(2),
149-156.

12NURSING CASE STUDY
Smith, C. J., & Ryckman, K. K. (2015). Epigenetic and developmental influences on the risk of
obesity, diabetes, and metabolic syndrome. Diabetes, metabolic syndrome and obesity:
targets and therapy, 8, 295.
Thiruvoipati, T., Kielhorn, C. E., & Armstrong, E. J. (2015). Peripheral artery disease in patients
with diabetes: Epidemiology, mechanisms, and outcomes. World journal of
diabetes, 6(7), 961.
Tuttolomondo, A., Maida, C., & Pinto, A. (2015). Diabetic foot syndrome as a possible
cardiovascular marker in diabetic patients. Journal of diabetes research, 2015.
Volmer-Thole, M., & Lobmann, R. (2016). Neuropathy and diabetic foot
syndrome. International journal of molecular sciences, 17(6), 917.
Yazdanpanah, L., Nasiri, M., & Adarvishi, S. (2015). Literature review on the management of
diabetic foot ulcer. World journal of diabetes, 6(1), 37.