Nursing Care Plan Case Study: Diabetic Foot Ulcer and Sepsis

Clinical Care Plan Fundamentals

  • HPI (History of Present Illness) Construction: The HPI must be founded on the specific disease process, injury, or clinical topic rather than the individual patient's personal narrative. The goal is to articulate the progression and nature of the pathology.

  • The "Related To" (Etiology) Factor: A frequent point of failure in nursing care plans is the inclusion of a medical diagnosis in the "related to" section. Using a medical diagnosis (e.g., "Hip Fracture") as the cause of a nursing problem (e.g., "Fall") results in an automatic 10-point deduction.

  • Identifying the Physical Cause: When formulating the "related to" statement, one must identify the exact physical cause of the patient's problem.

    • Example: A hip fracture is typically the result of a fall, not the cause. If a patient falls, the etiology might be "advanced cognitive deficit" or "impaired balance."

Case Study: 37-Year-Old Male with Diabetic Foot Ulcer

  • Patient Profile:

    • Age: 3737 years old.
    • Height/Weight: 5′9"5'9" and approximately 300 lbs300\,\text{lbs}.
    • Status: Obese with a high Body Mass Index (BMI).

  • Past Medical History (PMH):

    • Insulin Dependent Diabetes Mellitus (IDDM).
    • Hypertension (HTN).
    • Hyperlipidemia.
    • Asthma.
    • History of MRSA infection.
    • Previous amputation of digits on the left foot.
    • History of Sepsis.
    • Arthritis (Osteoarthritis) and Degenerative Disc Disease (DDD).

  • Chief Complaint and Current Symptoms:

    • Presenting symptoms: Redness, swelling, and pain in the left lower extremity (LLE).
    • Current Wound: A new wound on the plantar surface (sole) of the great toe, present for 44 weeks.
    • Progression: The wound transitioned from a callus to an open area with malodorous drainage. Redness and swelling have extended to the upper calf and shin.
    • Systemic Symptoms: Intermittent fever and general malaise.
    • Pain Scale: 6/106/10, described as throbbing and "tight."
    • Neurological: Paresthesia (burning, pins and needles sensation).

Pharmacological Profile

  • Insulin Therapy:

    • Lantus: A long-acting insulin; the patient takes 30 units30\,\text{units} every night.
    • NovoLog (Lispro/Aspart): A fast-acting insulin typically administered with meals.
      • Onset: Approximately 30 minutes30\,\text{minutes}.
      • Peak: Approximately 2 hours2\,\text{hours}.
      • Duration: Approximately 4 hours4\,\text{hours}.
    • Sliding Scale Coverage: Used for supplemental meal coverage based on Accu Chek results.
      • Low-dose scale typically starts at 150 mg/dL150\,\text{mg/dL}.
      • Increments are usually in 50 mg/dL50\,\text{mg/dL} steps (e.g., 150−200 mg/dL150-200\,\text{mg/dL} receives 2 units2\,\text{units}; 201−250 mg/dL201-250\,\text{mg/dL} receives 4 units4\,\text{units}).

  • Non-Diabetic Medications:

    • Lisinopril-Hydrochlorothiazide: A combination ACE inhibitor and thiazide diuretic for blood pressure management.
    • Simvastatin: Used for cholesterol (hyperlipidemia) management.
    • ProAir (Albuterol): A Beta-1 and Beta-2 agonist inhaler used for asthma. Potential side effect includes tachycardia, especially during continuous treatments.
    • Neurontin (Gabapentin): Prescribed for neuropathic pain and paresthesia; also utilized as an anti-seizure medication.
    • Mobic: An anti-inflammatory medication.
    • Percocet/Tylenol: Utilized for pain management.
    • Vancomycin (IV): A heavy antibiotic (classified by some as having aminoglycoside-like toxicity risks). It is not "kidney-friendly" and requires Peak and Trough level monitoring to adjust dosing based on renal function.
    • Zosyn: A broad-spectrum IV antibiotic.

Clinical Findings and Laboratory Data

  • Vital Signs:

    • Temperature: 100.8∘F100.8^{\circ}\text{F} (low-grade fever).
    • Heart Rate: 99 bpm99\,\text{bpm}.
    • Blood Pressure: "Soft"/Low for patient size.

  • Hematology and Chemistry:

    • WBC: 19.8×103/μL19.8 \times 10^3/\mu\text{L} (Leukocytosis indicating active infection).
    • Hemoglobin (Hgb): 9.7 g/dL9.7\,\text{g/dL} (Low).
    • Hematocrit (Hct): 24.6%24.6\% (Low).
    • Glucose: 301 mg/dL301\,\text{mg/dL} (Hyperglycemic).
    • A1C: 11.2%11.2\% (Indicates severe long-term glycemic non-compliance; target for diabetics is generally under 6.5%6.5\%).
    • CRP (C-Reactive Protein): An inflammatory marker.
    • Wound Culture: Positive for Gram-positive cocci and MRSA.

  • Renal Function:

    • Creatinine: 3.31 mg/dL3.31\,\text{mg/dL} (Elevated; normal is approximately 0.6−1.2 mg/dL0.6-1.2\,\text{mg/dL}). Reflects muscle breakdown products.
    • BUN: 22 mg/dL22\,\text{mg/dL} (Reflects protein breakdown).
    • GFR (Glomerular Filtration Rate): 33.2 mL/min/1.73m233.2\,\text{mL/min/1.73m}^2 (Severely depressed for a 37-year-old; expected value is closer to 8080).
    • Electrolytes: Hypernatremic (High Sodium); Potassium (5.0 mEq/L5.0\,\text{mEq/L}) is on the high end of normal due to lack of renal filtration.
    • Anion Gap: 1818. Calculation: Sodium−Chloride−Bicarbonate\text{Sodium} - \text{Chloride} - \text{Bicarbonate}. Any value above 1515 suggests Metabolic Acidosis.

  • Physical Assessment:

    • LLE Pulses: 1+1+ (weak); other pulses are 2+2+ (normal).
    • Edema: 2+2+ pitting edema in the LLE.
    • Skin Condition: Grade 4 Diabetic Foot Ulcer (DFU). Full thickness, necrotic (black/dark), and foul-smelling. Distal foot skin is dusky and cool to the touch.
    • Urinary Output: Decreased; urine is amber-colored.

Pathophysiology of Insulin Dependent Diabetes Mellitus (IDDM)

  • Pancreatic Endocrine Function:

    • Alpha Cells: Produce Glucagon, which increases blood sugar levels.
    • Beta Cells: Produce Insulin, which decreases blood sugar levels.
    • Delta Cells: Produce Somatostatin, a growth hormone analog that inhibits or "negates" the actions of both alpha and beta cells.

  • Classification:

    • Type 1 (Juvenile Onset): Typically autoimmune in nature. The pancreas produces little to no insulin. Patients are "lifers" on insulin therapy.
    • Type 2 (Adult Onset): Often associated with resistance to insulin or lifestyle factors, though many Type 2 diabetics eventually require insulin.

  • Kidney Interaction: When blood glucose exceeds approximately 150−180 mg/dL150-180\,\text{mg/dL}, the kidneys can no longer filter the excess, leading to glucose "spilling" into the urine (glycosuria).

Nursing Diagnoses (NANDA) and Care Planning

  • Ineffective Health Maintenance/Self-Management: Related to high BMI, history of non-compliance, and socioeconomic barriers (inability to afford medications).
  • Infection: Related to the septic state, MRSA-positive wound, and elevated WBC count.
  • Impaired Tissue Perfusion: Linked to soft blood pressure, low H&H, and chronic microvascular damage from HTN and Diabetes. Evidence includes decreased urine output (GFR=33.2GFR=33.2) and 1+ pulses.
  • Delayed Wound Healing: Related to chronic hyperglycemia (A1C=11.2%A1C=11.2\%) and current sepsis. High sugar levels make blood "sticky"/syrupy, impairing flow through narrowed vessels.
  • Knowledge Deficit: Patients require education on disease complexity, medication adherence, and the "teach-back" method to validate understanding.

Questions & Discussion

  • Question: Have you ever given a 100 on a care plan?
  • Response: Yes, it is possible, though usually not on the first one or in foundations courses. By Med-Surg 1 and 2, students are expected to have mastered the "related to" sections and rationales.
  • Discussion on Clinical Attendance: Two students (Casey Dolan and Shelby West) had clock-out issues in Portico. The instructor expressed frustration with the Portico software, preferring paper systems, and emphasized that students must verify their attendance once home.
  • Discussion on Hospital Ranges: Lab reference ranges vary by facility; for instance, the bicarbonate range on a blood gas might be 22−2622-26 in textbooks but 23−2923-29 at specific hospitals like CRMC.