INTRODUCTION

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body. Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin. The most common form of diabetes is Type II, It is sometimes called age-onset or adult-onset diabetes, and this form of diabetes occurs most often in people who are overweight and who do not exercise. Type II is considered a milder form of diabetes because of its slow onset (sometimes developing over the course of several years) and because it usually can be controlled with diet and oral medication. The consequences of uncontrolled and untreated Type II diabetes, however, are the just as serious as those for Type I. This form is also called noninsulin-dependent diabetes, a term that is somewhat misleading. Many people with Type II diabetes can control the condition with diet and oral medications, however, insulin injections are sometimes necessary if treatment with diet and oral medication is not working. The causes of diabetes mellitus are unclear, however, there seem to be both hereditary (genetic factors passed on in families) and environmental factors involved. Research has shown that some people who develop diabetes have common genetic markers. In Type I diabetes, the immune system, the bodys defense system against infection, is believed to be triggered by a virus or another microorganism that destroys cells in the pancreas that produce insulin. In Type II diabetes, age, obesity, and family history of diabetes play a role. In Type II diabetes, the pancreas may produce enough insulin, however, cells have become resistant to the insulin produced and it may not work as effectively. Symptoms of Type II diabetes can begin so gradually that a person may not know that he or she has it. Early signs are lethargy, extreme thirst, and frequent urination. Other

symptoms may include sudden weight loss, slow wound healing, urinary tract infections, gum disease, or blurred vision Diabetic foot is an umbrella term for foot problems in patients with diabetes mellitus. It is better known as diabetic foot ulcer. Diabetic foot ulcer is one of the major complications of Diabetes mellitus. It occurs in 15% of all patients with diabetes and precedes 84% of all lower leg amputations. Major increase in mortality among diabetic patients, observed over the past 20 years is considered to be due to the development of macro and micro vascular complications, including failure of thewound healing process. Wound healing is a makeup phenomenon for the portion of tissue that gets destroyed in any open or closed injury to the skin. Being a natural phenomenon, wound healing is usually taken care of by the bodys innate mechanism of action that works reliably most of the time. Key feature of wound healing is stepwise repair of lost extracellular matrix (ECM) that forms largest component of dermal skin layer. Therefore controlled and accurate rebuilding becomes essential to avoid under or over healing that may lead to various abnormalities. But in some cases, certain disorders or physiological insult disturbs wound healing process that otherwise goes very smoothly in an orderly manner. Diabetes mellitus is one such metabolic disorder that impedes normal steps of wound healing process. As healthcare provider, we could help our patients by having a deep understanding of the disease, that we may learn the proper interventions for the diabetic patients. In this way, we could render quality care for them. We could as well lead them to the proper treatment to lessen their sufferings, brought by the diabetes mellitus, in anyhow. By having a wide understanding of the disease, we could impart teachings on how we could prevent further complications of the disease. As healthcare provider, it is our responsibility to render information and impart health teachings to improve the condition of our patients to the best of our abilities. One of the characteristics that we healthcare provider, should have is to be informative and only through a keen study of disease such as this way for us to gain all the information that we need to learn. May this case study served its purpose through the help of our Lord, Jesus Christ.

OBJECTIVES
At the completion of this case study, the student nurse must be able to have a broader knowledge and understanding regarding the disease involved, and specifically, is expected to: Be knowledgeable and aware about the disease condition. Identify causes, s/s, complications of the disease and other related factors. Identify patients profile and total background (e.g. family, illness, lifestyle, and others). Be well informed about the past and present illnesses of the patient. Assess patient who is experiencing a complication of the condition. Be able to know the different laboratory tests and procedures have been done. Be familiar with the sequence of how it caused the disease. Become aware of the organs involved in the disease process. Formulate nursing diagnoses that addresses the needs of a patient and his family suffering from the condition. Identify expected outcomes to minimize the risks to a patient when signs and symptoms of exacerbation occur. Plan nursing interventions to meet the needs and promote optimal outcomes for a patient and his family at the occurrence of the conditions. Implement nursing actions specific to a patient who has suffered from the condition and its complications. Evaluate for effectiveness and achievement of nursing care. Use critical thinking to analyse ways that can help prevent the progression of the disease and its complications while keeping care family-centered. Integrate knowledge of disease condition with nursing process to achieve quality nursing care.

PATIENTS PROFILE

Name: Herminiano Libereto Quirino

Age: 70 y/o Birthdate: August 7, 2012 Address: Camanggaan, Vigan City Civil status: Married Citizenship: Filipino Religion: Roman Catholic Date and Time of admission: August 16, 2012 (7:35 pm) Chief complaint: (+) vomiting, (+) body weakness, non-healing Left foot Admitting diagnosis: Diabetic Left foot Final Diagnosis: Diabetic Left foot Post below Knee Amputation Attending physician: Doctor Talaga

HISTORY OF PAST AND PRESSENT ILLNESS

A. Past Illness The patient is a 70 year old man, who lives in Camanggaan, Vigan city with her wife, son daughter, and his granddaughter. He is hypertensive and with diabetes type 2. His diabetes started 10 years ago and claims that no one in his family or his parents had diabetes. He had his hypertension since year 2005. According to Mr. Herminiano, he was an alcohol drinker, smoker, and

fun of eating fatty foods such as the sinanglao and can drink 3 liters of soft drinks in a day which preferably the cause of his diabetes and hypertension. He has been hospitalized last 2010 due to stroke and this was his second time to have second attack causing him to have hemiplegia and slurred speech. Fever, cough, and flu were usual illnesses she had encountered throughout her lifespan. Over-the-counter drugs are the medications she usually took during these illnesses.

B. Present Illness Mr. Herminiano said that his wound started as a small lesion, a watery lesion both his right and left foot. They tried to treat the wound with antibiotics but unfortunately, the right foot healed the left foot became gangrenous. Upon arrival to the hospital on August 16, 2012 at 7:35 in the evening, he was admitted with a blood pressure of 200/100 mmHg, temperature of 37.8 C and with chief complains of vomiting, body weakness, and non-healing left foot. The non-healing left foot became necrotic and gangrenous especially the bone of the first digitalis. The doctor ordered Clonidine STAT for his hypertension, metoclopramide to counteract vomiting ceftriaxone to prevent further infection to the wound site and an IVF of PNSS IL at KVO. The doctor also requested laboratory tests such as CBC with BT, CXR-APL, Urinalysis, Left foot APO, and FBS. The patient also have been on NPO that night for the preparation of Below knee amputation but the operation was only done last august 29, 2012 by Dr. Cauton and the anaesthesiologist, Dr. Rosario. He has been in the hospital for 20 days and went home last September 4, 2012.

PEARSON ASSESSMENT
DATE AUGUST 27, 2012
70 year old, married Lives at home in Camanggaan, Vigan City Pure Filipino and roman catholic

SEPTEMBER 8, 2012
Communicates with students without hesitancy Conscious and coherent Always prefer lying in bed Still appears weak

 A farmer before but cannot work anymore due to the condition Conscious and coherent Weak in appearance Slurred speech With hemiplegia Communicates with others without hesitancy

E A/R S

No vomiting Diaphoresis No bowel movement for the day No past history of renal disease No urinalysis was done Always lying in bed Positions for sleeping are supine and side lying. Sleeps approximately 3-4 hours during morning duty shift Cant stand or walk by himself Change position most of the time from lying to sitting and supine to side lying Stays on surgical ward with his wife Diabetic diet and low Na and low fat diet No known food and drug allergy With gangrenous and foul smelling left foot Afebrile V/S: At 10:00 am Bp: 120/80 mmHg T: 36.6 c RR: 18 cpm PR: 70 bpm At 2:00 pm Bp: 120/80 mmHg T: 36.8 c RR: 18 cpm PR: 76 bpm Under the medication of the following: Ketorolac 30 mg IV q8 ANST (-)

Irregular bowel movement as claimed Normal urine discharges No vomiting noted

Can sleep normally Position of sleeping is normal as usual Always stays in bed but most of the time, sits in the chair. Can walk with the help of his relatives Always try to have passive range of motion exercise every morning Stays at home with his wife, daughter, son, and grand daughter Eats vegetables and fruits and fish Afebrile, body temperature of 36.3 c With a blood pressure of 120/80 mmHg Under the medication of the following: Levofloxacin (Lotor) 500 mg I tab BID Celecoxib 200mg/cap 1 capsule BID Losartan 50 mg OD Glimiperide 1 tab OD

No environmental hazards

Losartan 50 mg 1 tab OD Galvus 50 mg 1 tab OD Glimiperide 1 tab OD Cilostazol 100mg BID Amlodipine 10 mg OD Insuget 18 units SQ am

No environmental health hazards

O N

RR: 18 cpm PR: 76 bpm No edema Capillary refill within 2 seconds

RR: 20 cpm PR: 80 bpm Incision site is intact and dry Incision site still on the process of healing Capillary refill within 2 seconds Eats vegetables, fruits and fish With good appetite Under diabetic diet, low salt and low fat diet 8-10 glasses of water per day Avoidance of smoking, alcohol, sweet foods, and carbonated drinks

With an IVF of Plain NSS 1 L at 800 cc going on inserted at Right cephalic vein, regulated on KVO Under diabetic diet, low salt and low fat diet With poor appetite

ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The bodys primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into the cell through which glucose can enter. Some of the glucose can be converted to concentrated energy sources like glycogen or fatty acids and saved for

later use. When there is not enough insulin produced or when the doorway no longer recognizes the insulin key, glucose stays in the blood rather entering the cells.

Foot Anatomy

The human foot is incredibly complex in its structures and function. This brief overview provides a basic understanding of foot anatomy and physiology as it relates to some of the more common sports injuries, such as fractures, ankle sprains, and plantar fasciitis.

Foot Structure

The forefoot includes the five metatarsal bones, and the phalanges (the toes). The first metatarsal bone is the shortest, thickest and plays an important role during propulsion (forward movement). It also provides attachment for several tendons. The second, third, and fourth metatarsal bones are the most stable of the metatarsals. They are well protected and have only minor tendon attachments and are not subjected to strong pulling forces. Near the head of the first metatarsal, on the plantar surface of the foot, are two sesamoid bones (a small, oval-shaped bone which develops inside a tendon, where the tendon passes over a bony prominence). They are held in place by tendons, and ligaments. The midfoot includes five of the seven tarsal bones (the navicular, cuboid, and three cuneiform). The distal row contains the three cuneiforms and the cuboid. The midfoot meets the forefoot at the five tarso metatarsal (TMT) joints.

There are multiple joints within the midfoot itself. Proximally, the three cuneiforms articulate with the navicular bone.Two large bones, the talus and the calcaneus, make up the hindfoot. The calcaneus is the largest tarsal bone, and forms the heel. The talus rests on top of it, and forms the pivot of the ankle.

Foot and Toe Movement

Toe movements take place at the joints. These joints are capable of motion in two directions: plantar or dorsiflexion. In addition, the joints permit abduction and adduction of the toes. The foot as a whole (excluding the toes) has two movements: inversion and eversion. All the joints of the hindfoot and midfoot contribute to these complex movements that are ordinarily are combined with movements at the ankle joint.

The Foot Arches The foot has two important functions: weight bearing and propulsion. These functions require a high degree of stability. In addition, the foot must be flexible, so it can adapt to uneven surfaces. The multiple bones and joints of the foot give it flexibility, but these multiple bones must form an arch to support any weight.

The foot has three arches. The medial longitudinal arch is the highest and most important of the three arches. It is composed of the calcaneus, talus, navicular, cuneiforms, and the first three metatarsals. The lateral longitudinal arch is lower and flatter than the medial arch. It is composed of the calcaneus, cuboid, and the fourth and fifth metatarsals. The transverse arch is composed of the cuneiforms, the cuboid, and the five metatarsal bases.

The arches of the foot are maintained not only by the shapes of the bones as well as by ligaments. In addition, muscles and tendons play an important role in supporting the arches.

Muscles of the Foot

The muscles of the foot are classified as either intrinsic or extrinsic. The intrinsic muscles are located within the foot and cause movement of the toes. These muslces are flexors (plantar flexors), extensors (dorsiflexors), abductors, and adductors of the toes. Several intrinsic muscles also help support the arches of the foot.

The extrinsic muscles are located outside the foot, in the lower leg. The powerful gastrocnemius muscle (calf) is among them. They have long tendons that cross the ankle, to attach on the bones of the foot and assist in movement. The talus, however, has no tendon attachments.

PATHOPHYSIOLOGY A. ALGORITHM

B. EXPLANATION
Ulcerated diabetic foot is a complex problem. Ischemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an etiologic triad. Neuropathy and ischemia are the initiating factors, most often together as

neuro ischemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischemia than in non-diabetics. Furthermore, the healing of a neuro ischemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuro ischemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuro ischemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed.

DIAGNOSTIC PROCEDURES A. IDEAL

1. Two hour post glucose load blood glucose assay use of an oral glucose load, usually in the form of a glucose-containing drink, with subsequent measurement of blood glucose is the basis of the oral glucose tolerance test (OGTT) the gold standard for assessment of carbohydrate tolerance. While a full supervised OGTT would represent the best possible screening test for diabetes it is not usually practical when large numbers of people are being screened.

An unsupervised glucose load test, in which a person consumes 75g of oral glucose in liquid form and has a single blood glucose assay 120 minutes later (as timed by the individual) gives a reasonable approximation to a formal OGTT and is potentially usable on a larger scale.

Studies have shown a screening laboratorymeasured capillary plasma glucose >8.6 mmol/l to have a sensitivity of 90 per cent, specificity of 93 per cent and PV+ of 18 per cent. A result above 11.1 mmol/l is diagnostic of diabetes. However, results between 7.8 mmol/l and 11.1 mmol/l would indicate the need for further testing because of the risk of Impaired Fasting Glucose and Impaired Glucose Tolerance. 2. Fasting blood glucose fasting blood glucose is a remarkably constant parameter on a day-to-day basis in both people without diabetes and those with Type 2 diabetes. In a screening context it is a useful single test which will inevitably miss those people with a carbohydrate intolerance whose hyperglycemia is only manifest after a carbohydrate load. Sensitivity can be improved by lowering the threshold for a positive test but this is achieved at the expense of a reduced specificity and PV+. 3. Random blood glucose screening with this test is not as sensitive or specific as fasting blood glucose [or a 2 hour OGTT] but may be the most practical test. However its sensitivity and specificity of readings that are slightly raised is not good. Very high results are a good indicator of IFG/IGT, but lower ranges of 6-10 mmol/l may need to be rescreened using a fasting test. 4. Post prandial/post glucose glycosuria testing for glycosuria is most sensitive following ingestion of food, either a specific glucose load or a normal meal. The technique is limited by variations in the renal threshold for glucose, especially the tendency for the threshold to rise with age and by the sensitivity or the glycosuria detection method, usually a commercial glucose-oxidase based dipstick.

5. Laboratory tests - The doctor may decide to order a complete blood cell count, or CBC, which will assist in determining the presence and severity of infection. A very high or very low white blood cell count suggests serious infection. The doctor may also check the patient's blood sugar either by fingerstick or by a laboratory test. Depending on the severity of the problem, the doctor may also order kidney function tests, blood chemistry studies (electrolytes), liver enzyme tests, and heart enzyme tests to assess whether other body systems are working properly in the face of serious infection.

6. X-rays - The doctor may order x-rays studies of the feet or legs to assess for signs of damage to the bones or arthritis, damage from infection, foreign bodies in the soft tissues. Gas in the soft tissues, indicates gangrene - a very serious, potentially lifethreatening or limb-threatening infection.

7. Ultrasound - The doctor may order Doppler ultrasound to see the blood flow through the arteries and veins in the lower extremities. The test is not painful and involves the technician moving a non-invasive probe over the blood vessels of the lower extremities.

8. Angiogram - If the vascular surgeon determines that the patient has poor circulation in the lower extremities, an angiogram may be performed in preparation for surgery to improve circulation. With an angiogram, a catheter is inserted through the artery in the groin and dye is injected while x-rays are taken. This allows the surgeon to see where the blockages are and plan an operation to bypass the blockages. This procedure is usually performed with local anesthesia and a light sedative given through a tube inserted in the patient's vein (an intravenous or IV line).

These procedures are the recommended screening methods. Method one has the best sensitivity but is the most complex procedure.

B. ACTUAL

1. Blood Chemistry Screen Purpose of Blood Chemistry Screen

To provide general information about how the body is functioning To screen for a wide range of problems, including kidney, liver, heart, adrenal, gastrointestinal, endocrine, and neuromuscular disorders

To measure chemical substances in the blood

Date: 8-17-12 Sodium Potassium Chloride Glucose Creatinine Urea Cholesterol HDL Triglycerides LDL

Results 139.9 4.12 109.4 211 1.2 20.87 189 32 139 129

Normal 135-145 3.5-5.3 mmol/L 98-107 70-105 mg/dl 0.6-1.2 mg/dl 5-23.5 mg/dl 140-200 mg/dl 30-79 mg/dl 44-200 mg/dl < 130 mg/dl

Indication of Results: From the above results, shows that there is an increased chloride and glucose and slightly increased of creatinine and LDL. Chloride binds with potassium and sodium in the blood which plays an important role in maintaining ph of the blood. Increased serum chloride or hyperchloremia resulted from vomiting of the patient and in diabetic patients, resulted from poor control of blood sugar concentration. Glucose is the main type of sugar in the blood. It comes from the foods we eat and is the major source of energy needed to fuel the body's functions. Glucose levels

that are too high or too low can cause problems. The patient have extremely high glucose in the blood due to poor control of blood sugar concentration. Creatinine is the waste product of muscle metabolism. Its level is a reflection of the bodies muscle mass. From the above results it shows that the creatinine level is in the highest normal range. The patient may be at risk of acquiring a kidney problem which is one of the major complications of poor management of diabetes mellitus II. Low Density Lipoprotein is known to be the bad cholesterol in the body. The test for LDL cholesterol is used to predict your risk of developing heart disease. Of all the forms of cholesterol in the blood, the LDL cholesterol is considered the most important form in determining risk of heart disease. The patient has slightly increased in LDL which may indicate for at risk of having a heart disease due mainly of poor management of Diabetes mellitus II.

2. Left foot AP date: 8-16-12 Impression: osteomyelitis, Left foot, and visualized portion of the leg as prescribed. Clinical correlation is suggested. Osteomyelitis is an infection of the bone. It is due to the chronic wound infection which eventually extends down to the bone surface. 3. ECG date: 8-20-12 Purpose: An electrocardiogram (ECG) is a medical test that detects cardiac (heart) abnormalities by measuring the electrical activity generated by the heart as it contracts. The ECG can help diagnose a range of conditions including heart arrhythmias, heart enlargement, heart inflammation (pericarditis or myocarditis) and coronary heart disease. Results:

HR: 80 bpm PR interval: 134 ms normal sinus rhythm QRS duration: 88 ms Normal axis QT/QTC: 412/478 ms Normal ECG 4. Hematology The CBC provides valuable information about the blood and to some extent the bone marrow, which is the blood-forming tissue. The CBC is used for the following purposes:

as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis

to identify persons who may have an infection to diagnose anemia to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia

to monitor treatment for anemia and other blood diseases

Date: 8-16-12 WBC Neutrophils Lymphocytes RBC Hemoglobin Hematocrit Platelet count Blood type

Result 24.15 x 10 9 g/L 86.9% 5.1 % 3.79 x 10 12/L 10.7 g/L 31.5 % 385 x 10 g/L O+

Normal 5.00-10.00 50.0-70.0 20.0-40.0 4.00-5.50 12.0-16.0 40.0-54.0 150-400

The results above show that there is an increased in WBC, neutrophils, and platelet count. There are also decreased in lymphocytes, RBC, haemoglobin, and haematocrit.

White blood cells are cells of the system involved in defending the body against both infectious disease and foreign materials. Increased in WBC indicates the presence of infection. Neutrophil is a type of white blood cell, a granulocyte that is filled with microscopic granules, little sacs containing enzymes that digest microorganisms. Increased neutrophils indicate that the infection present is a bacterial infection. Platelets are also called thrombocytes. They are small fragments of large bone marrow cells (megakaryocytes) that clump together to assist in the clotting of blood. Thrombocytes are smaller than red and white blood cells. There is an increased in platelet count because of the presence of infection and platelet attempts to block blood loss in the wound site of the patient.

5. Urinalysis date: 8-18-12 The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. It is ordered widely and routinely to detect any abnormalities that require follow up. Results: Color: yellow Characteristic: slightly turbid Albumin: positive (1+) Amorphous urates: few Pus cells: 10-15 hpf Ph: 6.0 Normal: 5-7

Specific gravity: 1.030 Sugar: negative

Normal: 1.005-1.030

Indication: Normally, albumin is not present in the urine. The presence of albumin may be an indicative that the patient may have a kidney problem due to diabetes. Amorphous urates indicate acid crystals in the urine. Pus cells indicate that the patient is having a urinary tract infection.

MEDICAL MANAGEMENT A. IDEAL

MEDICATIONS:

When diet, exercise and maintaining a healthy weight arent enough, it will need the help of medication. Medications used to treat diabetes include insulin. Everyone with type 1 diabetes and some people with type 2 diabetes must take insulin every day to replace what their pancreas is unable to produce. Unfortunately, insulin cant be taken in pill form because enzymes in your stomach break it down so that it becomes ineffective. For that reason, many people inject themselves with insulin using a syringe or an insulin pen injector, a device that looks like a pen, except the cartridge is filled with insulin. Others may use an insulin pump, which provides a continuous supply of insulin, eliminating the need for daily shots. The most widely used form of insulin is synthetic human insulin, which is chemically identical to human insulin but manufactured in a laboratory. Unfortunately, synthetic human insulin isnt perfect. One of its chief failings is that it doesnt mimic the way natural insulin is secreted. But newer types of insulin, known as insulin analogs,

more closely resemble the way natural insulin acts in your body. Among these are lispro (Humalog), insulin aspart (NovoLog) and glargine (Lantus). A number of drug options exist for treating type 2 diabetes, including: 1. Sulfonylurea drugs. These medications stimulate the pancreas to produce and release more insulin. For them to be effective, the pancreas must produce some insulin on its own. Second-generation sulfonylureas such as glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta, Glynase PresTab, Micronase) and glimepiride (Amaryl) are prescribed most often. The most common side effect of sulfonylureas is low blood sugar, especially during the first four months of therapy. 2. Meglitinides. These medications, such as repaglinide (Prandin), have effects similar to sulfonylureas, but it id not as likely to develop low blood sugar.Meglitinides work quickly, and the results fade rapidly. 3. Biguanides. Metformin (Glucophage, Glucophage XR) is the only drug in this class available in the United States. It works by inhibiting the production and release of glucose from the liver, which means it need less insulin to transport blood sugar into the cells. One advantage of metformin is that is tends to cause less weight gain than do other diabetes medications. Possible side effects include a metallic taste in the mouth, loss of appetite, nausea or vomiting, abdominal bloating, or pain, gas and diarrhea. These effects usually decrease over time and are less likely to occur if taking the medication with food. A rare but serious side effect is lactic acidosis, which results when lactic acid builds up in the body. Symptoms include tiredness, weakness, muscle aches, dizziness and drowsiness. Lactic acidosis is especially likely to occur if it will mix with this medication with alcohol or have impaired kidney function. 4. Alpha-glucosidase inhibitors. These drugs block the action of enzymes in the digestive tract that break down carbohydrates. That means sugar is absorbed into the bloodstream more slowly, which helps prevent the rapid rise in blood sugar that usually occurs right after a meal. Drugs in this class include acarbose

(Precose) and miglitol (Glyset). Although safe and effective, alpha-glucosidase inhibitors can cause abdominal bloating, gas and diarrhea. If taken in high doses, they may also cause reversible liver damage. 5. Thiazolidinediones. These drugs make the body tissues more sensitive to insulin and keep the liver from overproducing glucose. Side effects of thiazolidinediones, such as rosiglitazone (Avandia) and pioglitazone hydrochloride (Actos), include swelling, weight gain and fatigue. A far more serious potential side effect is liver damage. The thiazolidinedione troglitzeone (Rezulin) was taken off the market in March 2000 because it caused liver failure. If your doctor prescribes these drugs, its important to have the liver checked every two months during the first year of therapy 6. Drug combinations. By combining drugs from different classes, it may be able to control the blood sugar in several different ways. Each class of oral medication can be combined with drugs from any other class. Most doctors prescribe two drugs in combination, although sometimes three drugs may be prescribed. Newer medications, such as Glucovance, which contains both glyburide and metformin, combine different oral drugs in a single tablet.

Other pharmacologic drugs: 1. Antibacterial drugs, Infections in patients with diabetes are difficult to treat because they have impaired microvascular circulation, which limits the access of phagocytic cells to the infected area and results in a poor concentration of antibiotics in the infected tissues. For this reason, cellulitis is the most easily treatable and reversible form of foot infections in patients with diabetes. Deepskin and soft-tissue infections are also usually curable, but they can be life threatening. Antibacterial drugs such as ciprofloxacin, metronidazole, or clindamycin are best in treating infection or prevention of infection depends on the severity of the condition of the patient.

2. Cilostazol, a phosphodiesterase inhibitor, suppresses platelet aggregation and also acts as a direct arterial vasodilator. Cilostazol improved walking distances, significantly increasing initial claudication distance and absolute claudication distance. 3. Anticoagulants are drugs used to prevent clot formation or to prevent a clot that has formed from enlarging. They inhibit clot formation by blocking the action of clotting factors or platelets.

B. ACTUAL
Upon admission, patient have had vomiting, body weakness, blood pressure of 200/100 mmHg, blood sugar of 293 mg/dl and non-healing diabetic left foot. With these chief complaints, the doctor ordered; clonidine for stabilizing the blood pressure, metoclopramide to supress vomiting, ceftriaxone to treat and prevent infection to the non-healing wound, and an insulin to keep the blood sugar level of the patient in the normal range. The doctor also ordered in IVF of plain normal saline solution regulated on KVO to maintain hydration to the patient. Patient was also under diabetic diet, low salt and low fat diet. Other medications of the patient: Celecoxib it was used to the patient to manage pain and it has an antiinflammatory effect. It was prescribed after the operation of the patient Cilostazol an antiplatelet drug that is used to reduce the symptoms of intermittent claudication (pain in the legs that worsens when walking and improves when resting that is caused by narrowing of the blood vessels that supply blood to the legs). Cilostazol is in a class of medications called platelet-aggregation inhibitors (antiplatelet medications). It works by

improving blood flow to the legs. It also prevents formation of clots or thrombus. Amlodipine it is used alone or in combination with other medications to treat high blood pressure Amlodipine is in a class of medications called calcium channel blockers. It lowers blood pressure by relaxing the blood vessels so the heart does not have to pump as hard. Glimeperide - it is used along with diet and exercise, and sometimes with other medications, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). Glimepiride lowers blood sugar by causing the pancreas to produce insulin (a natural substance that is needed to break down sugar in the body) and helping the body use insulin efficiently. This medication will only help lower blood sugar in people whose bodies produce insulin naturally. Levofloxacin a fluoroquinolone antibacterial that treats infection with a bactericidal effect. Losartan - it is used alone or in combination with other medications to treat high blood pressure. Losartan is also used to decrease the risk of stroke in people who have high blood pressure and a heart condition called left ventricular hypertrophy (enlargement of the walls of the left side of the heart. Losartan is in a class of medications called angiotensin II receptor antagonists. It works by blocking the action of certain natural substances that tighten the blood vessels, allowing the blood to flow more smoothly and the heart to pump more efficiently. Ketorolac it is used to relieve moderately severe pain, usually after surgery. Ketorolac is in a class of medications called NSAIDs. It works by stopping the body's production of a substance that causes pain, fever, and inflammation.

 Metoclopramide - it is in a class of medications called prokinetic agents that prevents nausea and vomiting. Insulin treatment of type 2 diabetes that cant be treated with lifestyle modification alone. Insulin is a hormone secreted by beta cells of the pancreas that, by receptor-mediated effects, promotes the storage of the bodys fuel, facilitating the transport of metabolites and ions through cell membranes stimulating the synthesis of glycogen from glucose, of fats from lipids, and proteins from amino acids. Galvus - Adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus: As monotherapy and in dual combination with other anti-diabetic agents.

SURGICAL MANAGEMENT A. IDEAL

Amputation is the removal of a body extremity by trauma or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is the congenital amputation, a congenital disorder, where foetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands or feet is or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment. Unlike some non-mammalian animals (such as lizards that shed their tails), once removed, human extremities do not grow back. A transplant or prosthesis is the only option for recovering the loss.

LOWER BODY : 1. Foot Amputations: This is most commonly a toe amputation caused by frostbite. This type of amputation will affect walking and balance.

2. Ankle Disarticulation: This is an amputation of the entire ankle. However, even without the ankle, a person can move around without an prosthesis. 3. Below-Knee Amputation: This is an amputation above the ankle, but below the knee. Full knee use is retained, but it is hard for these amputees to put weight on the stump. 4. Knee-Bearing Amputation: This is a complete removal of the lower leg. The stump left is able to hold weight on it, but it is difficult to create a prosthetic device for the stump. 5. Above Knee Amputation: This is an amputation in the thigh. The whole body weight can't be held on the stump, but a person is able to sit with this amputation. 6. Hip Disarticulation: This involves removing the entire leg bone, but surgeons like to leave the upper femur for stability and a place or a prosthetic device.

UPPER BODY: 1. Amputation of Individual Digits: The thumb is the most common single digit loss. The loss of a thumb inhibits grasping ability. When other fingers are amputated, the hand still grasps, but with less precision. 2. Multiple-Digit Amputation: When more than one finger is amputated, surgical procedures are used to reconstruct muscles to help aid grasping capabilities. 3. Metacarpal Amputation: This is amputation of the whole hand with the wrist still intact. The amputee is completely unable to grab. 4. Wrist Disarticulation: This is a removal of the hand, but at the wrist joint. Plastic sockets are now made to serve as wrists. 5. Forearm Amputation: Forearm amputations are classified by the length of the stump left. As the stump gets smaller, so does the pronation ability. 6. Elbow Disarticulation: This is the removal of the whole forearm at the elbow. This amputation creates a bulb shaped stump that can hold weight.

7. Above-Elbow Amputation: This is a removal of the arm above the elbow. However, if the stump is long enough, this type of amputee can be fitted just like the elbow disarticulation amputee. 8. Shoulder Disarticulation and Forequarter Amputations: This is the removal of the entire arm. Just like the Hip Disarticulationsurgeons like to leave some length to the bone for stability and fitting a prosthetic device.

B. ACTUAL
The patient underwent an operation of below knee amputation last August 29, 2012. The surgeon was Doctor Cauton and the anesthesiologist was Doctor Rosarion. The medical team used a spiral anesthesia to the patient. Before the operation the vital sign of the patient was: 130/ 80 mmHg, 81 bpm, 19 cpm, and 37 c. The operation started at 4:30 pm and ended at 5:20 pm. The anesthesia ended at 4:15 pm. During the operation, patient also had a blood transfusion of 1 unit of whole blood.

PROMOTIVE AND PREVENTIVE MANAGEMENT

PROMOTION

The goals in caring for patients with diabetes mellitus are to eliminate symptoms and to prevent, or at least slow, the development of complications. Microvascular (ie, eye and kidney disease) risk reduction is accomplished through control of glycemia and blood pressure; macrovascular (ie, coronary, cerebrovascular, peripheral vascular) risk reduction, through control of lipids and hypertension, smoking cessation, and aspirin therapy; and metabolic and neurologic risk reduction, through control of glycemia.

1. Dietary Modifications For most patients, the best diet is one consisting of the foods that they are currently eating. Attempts to calibrate a precise macronutrient composition of the diet to control diabetes, while time-honored, are generally not supported by the research. Caloric restriction is of first importance. After that, individual preference is reasonable. Modest restriction of saturated fats and simple sugars is also reasonable. However, some patients have remarkable short-term success with high-fat, lowcarbohydrate diets of various sorts. Therefore, the author always stresses weight management in general and is flexible regarding the precise diet that the patient consumes. Also, the practitioner should advocate a diet composed of foods that are within the financial reach and cultural milieu of the patient. For example, patients who participate in Ramadan may be at higher risk of acute diabetic complications. Although these patients do not eat during the annual observance, they should be encouraged to actively monitor their glucose, alter the dosage and timing of their medication, and seek dietary counseling and patient education to counteract any complications. Weight loss Modest weight losses of 5-10% have been associated with significant improvements in cardiovascular disease risk factors (ie, decreased HbA1c levels,

reduced blood pressure, increase in HDL cholesterol, decreased plasma triglycerides) in patients with type 2 diabetes mellitus. Risk factor reduction was even greater with losses of 10-15% of body weight. Mediterranean-style diet Greater benefit from a low-carbohydrate, Mediterranean-style diet than from a low-fat diet in patients with newly diagnosed type 2 diabetes mellitus. High-protein versus high-carbohydrate diet It should also be noted that already-attenuated glucose disposal is not worsened by postprandial circulating amino acid concentration. Therefore, recommendations to restrict dietary proteins in patients with type 2 diabetes seem unwarranted. Trans-palmitoleate In the Cardiovascular Health Study, phospholipid trans -palmitoleate levels were found to be associated with lower metabolic risk.Trans -palmitoleate is principally derived from naturally occurring dairy and other ruminant trans -fats. Circulating trans -palmitoleate is associated with lower insulin resistance, incidence of diabetes, and atherogenic dyslipidemia. Potential health benefits, therefore, need to be explored. Advanced glycation end products Food-derived, pro-oxidant, advanced glycation end products may contribute to insulin resistance in clinical type 2 diabetes mellitus and may suppress protective mechanisms. Advanced glycation end-product restriction may preserve native defenses and insulin sensitivity by maintaining a lower basal oxidative state. Other considerations

Oral ginseng (or ginsenoside) does not improve pancreatic beta-cell function. Routine use is not recommended. Pasta enriched with biologically active isoflavone aglycons improves endothelial function in patients with type 2 diabetes mellitus and favourably affects cardiovascular disease risk markers. In patients with type 2 diabetes mellitus, impaired fasting glucose or impaired glucose tolerance at high risk for cardiovascular disease, addition of n-3 fatty acids does not reduce risk of cardiovascular events, including death from cardiovascular causes.

2. Activity modification Most patients with type 2 diabetes mellitus can benefit from increased activity. Aerobic exercise improves insulin sensitivity and may improve glycemia markedly in some patients. Structured exercise training of more than 150 minutes per week is associated with greater HbA1c reduction; however, physical activity helps lower HbA1c only when combined with dietary modifications. The patient should choose an activity that she or he is likely to continue. Walking is accessible to most patients in terms of time and financial expenditure. A previously sedentary patient should start activities slowly. Older patients, patients with long-standing disease, patients with multiple risk factors, and patients with previous evidence of atherosclerotic disease should have a cardiovascular evaluation, probably including an imaging study, prior to beginning a significant exercise regimen.

Balducci et al showed that a supervised, facility-based exercise training program, when added to standard treatments for type 2 diabetes mellitus, yields better results than does simply counseling patients to exercise. A randomized, controlled trial by Church et al emphasized the need to incorporate both aerobic and resistance training to achieve better lowering of HbA1c levels.[Aerobic exercise alone or in combination with resistance training improves glycemic control, circulating triglycerides, systolic blood pressure, and waist circumference.The impact of resistance exercise alone, however, remains unclear. Long-term endurance and strength training resulted in improved metabolic control of diabetes mellitus and significant cardiovascular risk reduction, compared with standard treatment. However, exercise training did not improve conduit arterial elasticity. In a 3-month trial, yoga can be effective in reducing oxidative metabolic stress in patients with type 2 diabetes mellitus. However, yoga did not impact waist-to-hip ratio, blood pressure, vitamin E, or superoxide dismutase.

PREVENTION:

Healthy lifestyle choices can help prevent type 2 diabetes. Even if diabetes runs in a family, diet and exercise can help prevent the disease. If diagnosed with diabetes, the same healthy lifestyle choices can help prevent potentially serious complications.

Eat healthy foods. Choose foods low in fat and calories. Focus on fruits, vegetables and whole grains. For every 1,000 calories consume, try to have at least 14 grams of fiber, because fiber helps control blood sugar levels.

Get physical. Aim for 30 minutes of moderate physical activity a day. Take a brisk daily walk. Ride a bike. Swim laps. If can't fit in a long workout, spread 10-minute or longer sessions throughout the day.

Lose excess pounds. If overweight, losing 5 to 10% of body weight can reduce the risk of diabetes. To keep weight in a healthy range, focus on permanent changes to eating and exercise habits. Motivate by remembering the benefits of losing weight, such as a healthier heart, more energy and improved self-esteem. There's some evidence that coffee and, possibly, tea drinking may decrease your risk of developing type 2 diabetes, but more research is needed.

Sometimes medication is an option as well. Metformin (Glucophage), an oral diabetes medication, may reduce the risk of type 2 diabetes but healthy lifestyle choices remain essential.

Preventive foot care that are taught to patients and families include the following: 1. Properly bathing, drying, and lubricating the feet, taking care not to allow moisture to accumulate between toes. 2. Wearing bclosed-toed shoes that fit well. A podiatrist can provide the patient inserts to remove pressure from pressure points on the foot. New shoes should be broken in slowly to avoid blister formation. Patients with bony deformities may need custom-made shoes with extra width or depth. High risk behaviours such as

walking barefoot, using healing pads on the feet, and shaving calluses, should be avoided. 3. Trimming toenails straight across and filling sharp corners to follow the contour of the toe. If the patient has visual deficits, is unable to reach the feet because of disability or has thickened toenails, a podiatrist should cut the nails. 4. Reducing risk factors, such as smoking and elevated blood lipids, that contribute to peripheral vascular disease. 5. Avoiding home remedies, over-the-counter agents and self-medicating to treat foot problems. Blood glucose control is important for avoiding decreased resistance to infection and for preventing diabetic neuropathy.

DISCHARGE PLANNING

Celecoxib 200 mg 1 cap BID for pain Levofloxacin 500 mg 1 tab BID antibacterial for 14 days Losartan 50 mg 1 tab OD for hypertension Amlodipine 10 mg 1 tab OD for hypertension

 Glimeperide 1 tab OD before breakfast for diabetes Galvus 1 tab OD for diabetes

Range of motion exercises to regain strength and balance in lower extremity especially in amputated area such as stretching, flexion of amputated area, bending on hips, twisting from side to side, reaching objects from side to side, sitting and standing, and trying to stand with and without assistance.

Compliance on prescribed take home and maintenance medications. Make range of motion exercises as part of daily routine, with the help and assistance of the significant others. Maintaining proper hygiene.

Emphasized the importance of proper hygiene Compliance to medications to prevent progression of the condition. Enough rest and sleep Avoid drinking alcohol and carbonated drinks. Maintain safe environment Regular physical activity A dietary pattern rich in fruits and vegetables, low salt and low fat, and avoiding sweet foods and drinks. Stress management

O D

Follow up check-up, September 6, 2012 to doctor cauton Symptoms to be reported immediately; increase bp, body weakness, blurred vision, pain, discharge, or swelling on the amputated area. Diabetic diet, low salt and low fat diet Foods that can be eaten are the following; fresh fruits and vegetables, nuts, seeds, legumes sprouted legumes and oatmeal. Drink plenty of water a day.

UPDATES How to manage the diabetic foot

2 April, 2011
Diabetes-related complications have a major financial impact on the NHS. A guideline offers advice on managing patients in acute settings Diabetes is one of the biggest health challenges facing the UK. In 2010, 2.3 million people in the UK were registered as having diabetes, while an estimated 3.1 million have either type 1 or type 2 diabetes. By 2030, more than 4.6 million people could have the condition. As the longevity of the population increases, so does the incidence of diabetes-related complications (Anderson and Roukis, 2007). These include foot problems, the most common cause of non-traumatic limb amputation (Boulton et al, 2005). Diabetic foot problems include neuropathy, peripheral arterial disease, deformity, infections, ulcers and gangrene. They can have a major financial impact on the NHS through increased bed occupancy, prolonged stays in hospital and outpatient costs. They can also have a considerable impact on patients quality of life, for example, damage to or loss of limbs can lead to reduced mobility that can result in loss of employment and depression.

This new National Institute for Health and Clinical Excellence guideline provides recommendations on the essential components of inpatient care of people with diabetic foot problems from hospital admission onwards.

Implications for nursing practice

The guideline recognises the importance of effectively managing diabetic foot problems. It provides evidence-based recommendations to ensure optimum treatment for patients in acute healthcare setting, and suggests a coordinated and systematic approach to patient care, to minimise the risk of complications. A key recommendation is that hospitals should have a care pathway in place for patients with diabetic foot problems who require inpatient care, and that this should be managed by a multidisciplinary foot care team. This team should normally include: a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist and a tissue viability nurse. The role of the tissue viability nurse is acknowledged, but importantly as an addition to, rather than a replacement, for the podiatrist. Whenever possible a podiatrist should be involved with an acute foot care team, as they often provide an important link between practitioners involved in the acute and primary healthcare settings. The guideline recognises the importance of treating diabetic foot problems as an emergency and of offering support for patients while they are in hospital. It recommends: The patient should have a named contact to follow the inpatient care pathway and be responsible for offering patients information about their diagnosis and treatment and the care and support that they can expect; communicating relevant clinical information including documentation before discharge, within and between hospitals and to primary and/or community care. Recommendations for appropriate patient management are given within a framework of two main phases of care: within the first 24 hours; and ongoing management. The guideline considers specific adjunctive therapies, which it recommends are used only as part of a clinical trial. These therapies comprise: dermal or skin substitutes, electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices and deltaparin. They also include growth factors (granulocyte colony-stimulating factor, platelet-derived growth factor, epidermal growth factor and transforming growth factor beta) and hyperbaric oxygen therapy, or as part of a clinical trial or as rescue therapy (negative pressure wound therapy). The clinical and cost effectiveness of negative pressure wound therapy and hyperbaric oxygen therapy are recommended as areas for further research. This is needed before these treatments can be adopted as evidence-based practice.

Conclusion
This guideline gives an overview of the importance of effective management of patients with diabetic foot problems while in acute healthcare settings, and provides evidence-based recommendations for managing them. It aims to help nurses assess their patients, be actively involved in providing appropriate treatment, and give tailored information as required. It also aims to reduce variations in the level of care that patients receive when they are in hospital, leading to fewer amputations, a better quality of life for those affected and lower NHS costs.

BIBLIOGRAPHY
Books Smeltzer, S. C. et al. (2010), Brunner and Suddarths Textbook of Medical-Surgical Nursing (12th edition). Lippincott Williams and Wilkins

Clayton, B.D. et al. (2010). Basic Pharmacology for Nurses (15 th edition). Mosby Elsvier

Websites http://emedicine.medscape.com/article/117853-treatment#a1156 http://www.nursingtimes.net/nursing-practice/clinical-specialisms/diabetes/how-tomanage-the-diabetic-foot/5028059.article http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2 http://www.ndep.nih.gov/publications/PublicationDetail.aspx?PubId=144 http://www.patient.co.uk/doctor/management-of-type-2-diabetes http://www.mims.com