1
Applying Nursing Process
Care of the Client with a Problem on
TN DAW NANN KYIN OO
29.3.2023
DM Foot (Rt Leg)

2
Name - Daw Toke
Age - 56 years
Sex - Female
Register No - 0317/23
Race / Religion - B / B
Marital status - married
Education - Grade 8
Occupation - မှီခို
Address - ပိုသမ်က ှီြီး ၊ ဂ ြီးက ှီြီး ိုန်ြီး ၊ မန္တဂ ြီးမမ ြို့။
Admission Date - 12:30pm, 21.2.2023
Client’s reason for seeking health care : severe pain at Rt leg due to DM foot ulceration

3
History of present Illness
• DM Foot Ulcer at Rt leg (+2months)
• She was previously well and she had household ambulatory.
• 2months ago, she had a blister at her right foot and she applied traditional medicine for
2weeks.
• And then, her wound gradually got bigger and feel painful.
• After that, she went to a private hospital( Grand Mandalay) and took treatment.
• Wound Debridement was done there on 11.2.2023.

4
Operation Report
Surgeon Prof: Dr. Si Thu
Assistant Dr. CMLO
Anaesthesia SAB
Diagosis DM Foot (Rt)
Pre Med IV Cefipime 1G (ATD)- 12hr
IV Metro (1)bot- 8hr
Date/Time 11.2.2023/4:30pm
Operation performed WD
Finding DM foot ulcer medial malleolus of Rt Foot (5×5cm)
Presence of necrotic
Posterior tibial tendon exposed
Position Supine
Hospital Grand Mandalay

5
Wound C&S (11.2.2023)
Moderate Growth of Citrobacter species isolated
Sensitive > Amoxicillin + Clavulanic acid
> Amikacin
> Cefoperazone + salbacton
> Meropenum
> Pipperacillin + Tazobactam
> Trimethropim + Sulphamethoxazole
Resistant > Cefepime
> Ceftriaxone
> Cefixime
> Ciprofloxacin

6
Past Health History
• No history of hospitalization
• No known history of TB , HT
• No prolonged use of self medication
• No history of cough, breathlessness, Dyspnea, chest pain, dizziness
• No history of surgical history
• No known drug allergy
• History of DM (10yrs ago)
• No history of bobacco chewing or alcohol drinking
• No history of any other disease ( heart disease , COPD etc )
• She eats less instead and a picky eater.
• She has normal bowel pattern ( 1 time / day )
• She has normal sleep pattern of 8hr / day

7
Family Health History (parents, siblings , spouse , children )
• She has 2 daughters and one son.
• Among them, No history of hierarchy diseases ( such as hypertension, DM , heart disease , etc).
• No history of TB or any other communicable diseases

8
Review of system
Respiratory : no obvious abnormality
Circulatory : physician noted no obvious abnormality
Reproductive : Age of menarche ( 14 ) yrs
Age of married ( 23 ) yrs
Age of 1st pregnany ( 24 ) yrs
Regular cycle 2 – 3 days / month
Regular blood flow through menstrual period
No of children (3), No of pregnancies ( 3 ) all of 3 children born in normal labour
Age of post Menarche ( 48 ) yrs

9
Physical Examination
General Examination:
• GC fair
• Heart & Lungs clear
• No scars, oedema, rashes, leasions at abdomen
• No papable of spleen / liver
• Bowel sounds (+)

10
Local Examination:
• Open wound : exposed bone and tendon
• Eschar or black tissue surrounding the ulcer
• Dry and scaly skin
• Foul odor
• Presence of necrosis
• Diabetic neuropathy (+)
• Inability to bear weight

11

12
Vital signs
Temperature – 102.6F
Pulse rate – 102bpm
Respiration rate – 24/min
Blood pressure – 110/70 mmHg
SPO2 – 98% on air
Activities of Daily Living
Feeding : assistant with person
Bathing :assistant with person
Dressing :assistant with person
Grooming : total independence
Toileting : total dependence
Ambulation : assistant with person and device

13
Diagnosis - DM foot(Rt)
High Risk Factors - structural foot deformity
- diabetic neuropathy/ peripheral neuropathy
- duration of DM more than 10 yrs
- poor circulation, dry skin
- poor glycemic control
Opreative Treatment- 1.3.2023 (wound debridement was done)
- 10.3.2023 (BKA was done)
Discharge - 14.3.2023

14
Treatment
8.3.23 Issued (3) units of packed cell ( ‘ B ’ (+) )
Injection
20.2.23 IV Curum 1.2G -8hr (ATD)(omitted at 23.2.23)
23.2.23 IV CS1 (1) G – 12 hrly ( ATD )
27.2.23 IV Levo 500mg – OD (ATD)
3.3.23 IV NS 500ml + KCL 2G – 8hr (over 4 hr)(omitted at 9.3.23)
10.3.23 pack cell(1) issued for OT ‘ B’ ( + )
IV Tramadol ( 50 mg ) + ( dil H2O 2ml ) -12 Hr (2days)

15
Oral
21.2.23 O’Aztor 10mg –(1) hs
O’ cardivas 3.125mg –(1) bd
O’ coralan 5mg –(1/2) bd
O’ Repace 50mg- (1) od
O’ Sitaglip 100mg –(1)od
O’ Lactofer –(1) od
O’ DMR 30 –(2)od
O’Aceclofenac 100mg (1) bd
O’Pantocid 20 mg (1)bd
9.3.23 O’Slow K(1) tds (×5days)
O’ Milical (1)od

16
Sliding Scale 6 hrly (started at 23. 2. 23 , omitted at 9. 3. 23)
RBS mmol/L - sd : Insulin
< 7 - skip
7 – 10 - 6
10 – 15 - 10
15 – 20 - 14
> 20 - 18 & inform
s/c Glargine 10 unit at 10 pm
25.2.2023 Plan for WD on 1.3.2023
3.3.2023 Plan for BKA on 10.3.2023

17
Operation Report
Surgeon PG3 Dr. Pyae Phyo Aung
Assistant PG1 Dr. Thaw Zin Maung
Anaesthesia SAB
Diagosis DM Foot (Rt)
Pre Med IV CS1 (1) G – 12 hrly
IV Levo 500mg – OD (ATD), IV NS (1)bot
Date/Time 1.3.2023/1:45pm to 2:25pm
Operation performed WD
Finding DM foot ulcer medial malleolus of Rt Foot (10×10cm)
Presence of necrotic tissue
Pus discharge(+)
Position Supine
Hospital Mandalay Orthopedic Hospital

18
Operation Report
Surgeon SCS Dr. Tin Myo Hlaing
Assistant PG2 Dr. NLT, PG1 Dr. HMO
Anaesthesia SAB
Diagosis Ulcer Rt medial malleolus u/l DM
Pre Med IV GIK 1hr before operation, O’ cardivas 3.125mg –(1)
IV CS1 (1) G – 12 hrly , IV Levo 500mg – od
Date/Time 10.3.2023/1:45pm to 2:25pm
Operation performed Below Knee Amputation
Finding/
Operation Note
DM foot ulcer medial malleolus of Rt Foot
Ulcer tourniquet ē aseptic condition, BKA was done by equal flap
And then, wound was closed back after glove drain inserted and
POP slab was applied .
Position Supine
Hospital Mandalay Orthopedic Hospital

19
Dressing Note ( Pre – op )
At 21.2.23, the patient had dressing under sterile technique
At 24.2.23, the patient had dressing under sterile technique.
At 28.2.23, the patient had dressing under sterile technique
Dressing Note ( Post – op )
At 4.3.23, the patient had dressing and warp the wound carefully.
At 13.3.23, the patient had dressing and glove drain out.

20
Investigation
( 21.2.23)
G & M Blood Group “ B ” , Rh (+)
BCR non – reactive
Electroytes Test Result Normal Range
Sodium 133.2 mmol/L 135.0 – 145
Potassium 4.16 mmol/L 3.50 – 5.30
Chloride 101.1 mmol/L 98.0 – 107.0
Urea 28 mg/dl 13 – 43
Creatnine 0.6mg/dl 0.5 – 1.1
ECG physician noted no obvious abnormalities

21
CXR (PA) Radiologist noted no obvious abnormalities

22
Test Description Result Normal Range
OSPT 6.8 /  L 4.0 – 11.0
INR 3.8 x 106 /  L 3.50 – 5.80
ESR 13.3 g/dL 11.0 – 16.0
CRP 24 mg/L Positive : > 6
Negative : <6
Glucose (Fasting) 200 mg/dl 70-109
Liver Function Test Result Normal Range
Total Bilirubin 0.3 mg/dL Up to 1.2
Alkaline Phosphatase 3.8 U/L 40-129
ALT/GPT 8.0 Up to 40
ALT/GOT 11.0 Up to 38
21. 2. 23
21. 2. 23

23
CP(AUTO)
( 21.2.23)
Test Result Normal Range
WBC 9.8 /  L 4.0 – 11.0
RBC 3.29 x 106 /  L 3.50 – 5.80
HGB 10.5 g/dL 11.0 – 16.0
PLT 388 x 103 /  L 150 – 400
Test Result Normal Range
HbA1C 9.18% 4.0- 6.5
( 22.2.23)

24
Test Description Result Normal Range
OSPT 13.5 10-14
INR 1.14 0.8-1.2
HBG 9.1 11.5-16.0
Test Result Normal Range
Sodium 128 mmol/L 133 – 145
Potassium 3.5 mmol/L 3.50 – 5.4
Chloride 89 mmol/L 95 – 105
Bicarbonate 25 mmol/L 23-29
28. 2. 23
Electroytes
28. 2. 23

25
Test Result Normal Range
Sodium 126 mmol/L 135 – 145
Potassium 2.24 mmol/L 3.50 – 5.5
Chloride 82.6 mmol/L 96 – 106
Bicarbonate 26.82 mmol/L 23-30
7.3. 23
Electroytes
Test Result Normal Range
WBC 7.84 4.0 – 11.0
RBC 2.73 4.0-5.0
HGB 7.1 g/dL 11.0 – 15.0
PLT 322 150 – 400
CP(AUTO)
(7.3.23)

26
Test Result Normal Range
Sodium 128.2 mmol/L 135.0 – 145
Potassium 3.23 mmol/L 3.50 – 5.30
Chloride 87.0 mmol/L 96-106
Bicarbonate 26.1 mg/dl 23-30
Electroytes
9.3.23
Test Result Normal Range
WBC 6.8 /  L 4.0 – 11.0
RBC 3.8 x 106 /  L 3.50 – 5.80
HGB 13.3 g/dL 11.0 – 16.0
PLT 363 x 103 /  L 150 – 400
CP(AUTO)
(9.3.23)

27
Date FBS 2HPPL 2HPPD BED TIME
22.2.23 13.5 15 12.2 8.4
23.2.23 8.6
SI -6U
7.8
SI -6U
16.4
SI -14U
8.6
Glar- 10U
24.2.23 7.9
SI -6U
7.7
SI -6U
10
SI -10U
8.6
Glar- 10U
25.2.23 6.6
SI -skip
12.2
SI -6U
8.1
SI -6U
4.6
Glar- skip
26.2.23 10.3
SI -10U
12.2
SI -6U
6.3
SI -skip
8.6
Glar- 10U
27.2.23 6.0
SI -skip
12.5
SI -10U
5.3
SI -skip
10.3
Glar- 10U
28.2.23 6.3
SI -skip
8.6
SI -6U
7.6
SI -6U
5.8
Glar- 10U
1.3.23 5.1
SI -skip
5.1
SI -skip
6.3
SI -skip
8.0
Glar- 10U
Daily Blood Glucose Monitoring (mmol/L)

28
Date FBS 2HPPL 2HPPD BED TIME
2.3.23 3.7
SI -skip
7.2
SI -6U
4.0
SI -skip
7.2
Glar- 10U
3.3.23 5.9
SI -skip
9.1
SI -6U
4.0
SI -skip
11.9
Glar- 10U
4.3.23 6.4
SI -skip
8.3
SI -6U
2.4
SI -skip
8.3
Glar- 10U
5.3.23 8.5
SI -6U
6.8
SI -skip
7.0
SI -skip
6.7
Glar- 10U
6.3.23 6.2
SI -skip
11.7
SI -10U
3.5
SI -skip
8.2
Glar- 10U
7.3.23 5.2
SI -skip
7.0
SI -skip
8.2
SI -6U
7.3
Glar- 8U
8.3.23 4.9
SI -skip
4.6
SI -skip
12.0
SI -10U
5.3
Glar- 10U
9.3.23 8.5
SI -6U
12.5
SI -10U
13.7
Glar- 10U
Daily Blood Glucose Monitoring (mmol/L)

29
Date FBS 2HPPL 2HPPD BED TIME
10.3.23 9.4
SI -6U
6.8
Glar- 10U
11.3.23 12.7
SI -10U
7.0
SI -skip
7.5
SI -6U
8.3
Glar- 10U
12.3.23 9.5
SI -6U
8.8
SI -6U
12.9
SI -10U
13.9
Glar- 10U
13.3.23 6.7
SI -skip
8.1
SI -6U
12
SI -10U
11.5
Glar- 10U
14.3.23 5.2
SI -skip
11.8
SI -10U
Daily Blood Glucose Monitoring (mmol/L)

30
3.1 Definition
The International Consensus on the Diabetic Foot currently defines a diabetic foot ulcer as a full-
thickness wound below the ankle in a patient with diabetes, irrespective of duration.

31
3.2 Epidemiology
• The prevalence of foot ulceration in the general diabetic population is 4–10%, being lower (1.5–
3.5%) in young and higher (5–10%) in older patients.
• The annual incidence of foot ulceration ranges from less than 1 to 3.6% among people with type 1
or type 2 diabetes.
• The majority (60–80%) of foot ulcers will heal, 10–15% will remain active, and 5–24% will end
up in amputation within a period of 6–18months after first evaluation.

• 77% of diabetic foot ulcers heal within one year.
• 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years,
and 65% within 5 years.
• 3.5–13% of patients die with active ulcers
• Neuropathic wounds are more likely to heal over a period of 20weeks if they are smaller, of
small duration and superficial.
• Neuro‐ ischemic ulcers take longer to heal and are more likely to lead to amputation.
• The patient’s vascular status is the strongest predictor of healing rate and outcome.
32

• Approximately 40–70% of all non‐traumatic amputations of the lower limbs are
performed on patients with diabetes.
• approximately 85% of all amputations performed in patients with diabetes.
• In addition, amputations in patients with diabetes are performed at a younger age.
• the prevalence of amputation in diabetic patients was 1.6% for the age range 18–44years,
3.4% for ages 45–64 and 3.6% in patients over 65 years.
• The most common cause of amputation in diabetes is ischemia and infection; critical limb
ischemia or non‐ healing foot ulcer is the cause of amputation in 50–70% and infection in
30–50% of patients with diabetes.
33

3.3 Economic Aspects
• Foot ulceration and amputation affect largely patients’ quality of life and place an economical
burden on both the patient and the healthcare system.
• direct costs related to hospital (hotel) charges, antibiotics, diagnostic and therapeutic
procedures, dressings and off‐loading devices.
• indirect costs related to value lost in terms of income from work, early retirement and the cost
of rehabilitation.
• Quality of life is another important issue in patients with foot ulcers that cannot be measured in
economic terms.
• Foot ulceration affects a patient’s ability to perform simple daily tasks and leisure activities.
• Patients with foot ulcers or amputation suffer more often from depression and have a poorer
quality of life than those without foot problems.
34

35
• It is a worst combination of neuropathy and ischemia , more complicated by infection.
• leads to impaired wound healing, decreased cell growth factor response, reduced tissue perfusion, and
decreased local angiogenesis.
• More than half of foot ulcers were caused by neuropathy .
• Multiple neuropathies are involved in diabetic foot ulcer, which cause impaired pain sensation and
impaired temperature sensation.
• reduced sweating and dryness of the skin predisposing to cracks, which become potential sites for
frequent ulceration and portals for bacterial entry.
• Peripheral arterial disease is a macrovascular complication and an essential contributor to diabetic foot.

36

 Wagner classification system: This system focused on physical characteristics of ulcer, depth,
and the presence of osteomyelitis or gangrene (0–5) .
 SINBAD assesses site, ischemia, neuropathy, bacterial infection, and depth and uses a scoring
system 0–6. It has been focused on clinical and gross pathological changes of ulcer.
 PEDIS classification: This system was designed by the International Working Group on the
Diabetic Foot and uses the same five components of SAD: perfusion, extent, depth, infection,
and sensation. It does not include ulcer location.
 DEPA classification: This system looks at four aspects of ulcers: depth, extent of bacterial
colonization, phase of healing, and associated etiology. Each category is scored from 1 to 3
according to severity. 37

38
 University of Texas has been proven effective at predicting lower extremity amputation when
combined with Wagner classification, and it comprises four grades, A to D, and four stages, 1–4.
 Kobe’s Classification focused on neuropathy, infection and vasculopathy: Type 1, mainly peripheral
neuropathy (PN); type 2, mainly peripheral arterial disease (PAD); type 3, mainly infection; and type
4: all three combined, neuropathy, peripheral arterial disease with infection .
 SAD stands for sepsis, arteriopathy, and denervation system. The major drawback of this
classification is that it is potentially complex and is primarily intended for selecting population for
prospective research .
 Diabetic Ulcer Severity Score (DUSS) Assessment using the DUSS system includes the presence of
pedal pulses, the ability to probe to the bone within the ulcer, and ulcer quantity and location. The sum
of points determines severity, with the score ranging from 0 to 4

Grade Description of the ulcer
Grade 0 Pre‐ or post‐ulcerative lesion completely epithelialized
Grade 1 Superficial, full‐thickness ulcer limited to the dermis, not extending to the
subcutis
Grade 2 Ulcer of the skin extending through the subcutis with exposed tendon or bone and
without osteomyelitis or abscess formation
Grade 3 Deep ulcers with osteomyelitis or abscess formation
Grade 4 Localized gangrene of the toes or the forefoot
Grade 5 Foot with extensive gangrene
Table 3.1 Meggitt‐Wagner classification of foot ulcers.
39

40
Fig. 3.1 Wagner-Meggitt Classification System for Diabetic Foot wounds

Box 3.2 Advantages and Disadvantages of the Meggitt‐Wagner Classification System
Advantages
● It is simple in use and has been validated in many studies
● Higher grades are directly related to increased risk for lower limb amputation
● It provides a guide to plan treatment
● It is considered the gold standard against which other systems should be validated
Disadvantages
● Although the presence of infection and ischemia are related to poor outcome, ischemia is
not taken into account in patients with grades 1–3 and infection in grades 1, 2 and 4
● The location and size of the ulcer are not evaluated
● Neuropathy status is not evaluated
41

Grade
Stage 0 1 2 3
A Pre‐ or post‐ulcerative lesion
completely epithelialized
Superficial wound
not involving
tendon, capsule or
bone
Wound penetrating
to tendon or
capsule
Wound penetrating
to bone or joint
B With infection With infection With infection With infection
C With ischemia With ischemia With ischemia With ischemia
D With infection and ischemia With infection and
ischemia
With infection and
ischemia
With infection and
ischemia
Table 3.3 The University of Texas classification system for diabetic foot wounds.
42

This system showing that the greater the grade and stage of an ulcer, the greater the risk for
non‐healing and amputation. Thus, the healing rate of foot ulcers was
90% for stage A,
89% for stage B,
69% for stage C and
only 36% for stage D.
43
The University of Texas classification system

44
Box 3.4 Advantages and Disadvantages of the University of Texas Classification
System for Diabetic Foot Wounds
Advantages
● It is simple in use and more descriptive
● It has been evaluated and has shown greater association with the outcome of an ulcer, healing or
amputation, compared with the Meggitt‐Wagner classification
● Cases with infection and/or ischemia are classified
● It provides a guide to plan treatment
Disadvantages
● The location and size of the ulcer are not evaluated
● Neuropathy status is not evaluated

In 2003, the International Working Group on the Diabetic Foot proposed the PEDIS system
(P, perfusion; E, extent/size; D, depth/tissue loss; I, infection; S, sensation) to classify foot ulcers
for prospective research (Box 3.5).
The PEDIS system is more complex and classifies foot ulcers into five categories.
It also includes subcategories (grades) according to
• the severity of ischemia (grades 1–3),
• depth/tissue loss (grades 1–3) and
• infection (grades 1–4),
as well as taking into consideration the dimensions of the ulcer.
45

46

47

3.6 Pathways to Diabetic Foot Ulceration
Pathways to foot ulceration are summarized in Figure 3.6, with key contributory factors also
listed below.
 Distal sensorimotor peripheral neuropathy
 Autonomic neuropathy
 PAD
 Deformity
 Age, sex, and duration of diabetes.
 Ethnicity
 Repetitive minor trauma.
 Past foot ulceration or amputation
 Other microvascular complication
 Transplantation
48

PATHWAY TO ULCERATION
The combination of two or more of the above risk factors commonly results in ulceration.
(See Figure3.6) Examples include:
⊲ Neuropathy, deformity, and trauma.
Inappropriate footwear is the most common cause of trauma in Western countries.
⊲ Neuropathy plus chemical trauma.
Inappropriate use of over-the-counter corn treatments on a neuropathic foot can lead to
ulceration.
49

FIGURE 3.6 Pathways to diabetic foot ulceration.
50

 Males are affected more than females, and it is more common in the elderly above 60 years of
age.
 Several studies have reported racial predisposition. One author has evaluated that the increased
risk of amputation in African blacks was 2- to 3-fold higher than that in whites .
 The diabetic foot ulcer is seen in lower socioeconomic class (78.2%) .
 Smoking aggravates microvascular complications including peripheral arterial disease.
 It has been observed that 47% of patients who had previous ulceration walked barefooted
within the house and 17% walked barefooted outside.
51

• Neuropathy was involved in more than half of diabetic foot ulcers ,while peripheral
vascular disease accounts for about 15% alone and 35% in conjunction with neuropathy.
• The unequilibrated distribution of pressure in the foot during walking exposes pressure
bearing points to ulceration.
• The previous foot ulcers have tendency to develop recurrent diabetic foot ulcers. Previous
amputation is undoubtedly a big risk factor in 50% of the diabetic foot ulcers.
• Inappropriate footwears produce foot ulcer frequently in diabetes.
• Poor vision contributes due to diabetic retinopathy with the patient unable to properly
identify injurious objects.
• Minor or major trauma to foot could be an origin of a chronic ulcer or wound.
52

Feature Neuropathic Ischemic Neuroischemic
Sensation Sensory loss Pain Degree of sensory loss
Callus/necrosis Callus present Necrosis common Minimal callus; prone
to necrosis
Wound bed Pink and granulating,
surrounded by callus
Pale and sloughy with
poor granulation
Poor granulation
Foot temperature and
pulses
Warm with bounding Cool with absent pulses Cool with absent pulses
Other Dry skin and fissuring Delayed healing Risk of infection
Typical location Weight-bearing areas of
the foot, such as
metatarsal heads, the
heel, and over the dorsum
of clawed toes
Nail edges and between
the toes and lateral
borders of the foot
Margins of the foot and
toes
Prevalence 35% 15% 50% 53

Risk category 0 Risk category 1 Risk category 2 Risk category 3
Normal plantar
sensation
Loss of plantar
sensation
Loss of plantar
sensation or poor
circulation or foot
deformity or
onychomycosis
History of ulceration,
neuropathic fracture,
or amputation
Low risk Moderate risk High risk Very high risk
54

55
Self-care and self-monitoring, including
• daily examination of the feet for problems (colour change, swelling, breaks in the skin, pain or
numbness);
• footwear (the importance of well-fitting shoes and hosiery);
• hygiene (daily washing and careful drying);
• nail care;
• dangers associated with practices such as skin removal (including corn removal);
• methods to help self-examination/monitoring (e.g. the use of mirrors if mobility is limited).
PREVENTION

56
When to seek advice from a health care professional?
• if any colour change, swelling, breaks in the skin, pain or numbness is found;
• if self-care and -monitoring is not possible or difficult (e.g. because of reduced mobility).
Possible consequences of neglecting the feet:
• foot problems can often be prevented by good diabetes overall management as well as specific
foot care;
• prompt detection and management of any problems is important, and thus the importance of
seeking help as soon as the problem is noticed;
• complications of diabetes such as neuropathy and ischaemia can lead to foot problems such as
ulcers, infections and, in extreme cases, gangrene and amputation.

3.10 Foot care advice and education to be given to patients with at-risk feet
If neuropathy is present, the resulting numbness means that problems may not be noticed, so extra
care and vigilance is needed, and the following advice/precautions to keep the feet protected should
be given:
• not walking barefoot;
• seeking help to deal with corns and callus;
• dangers associated with over-the-counter preparations for foot problems (e.g. the corn cures);
• potential burning of numb feet, checking bath temperatures, avoiding hot water bottles, electric
blankets, foot spas and sitting too close to fires;
• moisturise areas of dry skin.
57

58
Footwear advice to be given:
• regular checking of footwear for areas that will cause friction or trauma;
• seeking help from a health care professional if footwear causes difficulties or problems;
• wearing specialist footwear that has been prescribed or supplied.
Additional advice about foot care on holiday:
• not wearing new shoes;
• planning adequate rest periods to avoid additional stress on feet;
• if flying, walk up and down aisles;
• use of sun block on feet especially on dry skin;
• take a first-aid kit and cover any sore places with sterile dressing;
• seek help if problems develop;
• holiday insurance issues (ensure diabetes cover).

3.11 The Common Complications of Diabetic Ulcers on the Foot
o Skin Infections
o Abscess Formation
o Sepsis
o Foot Deformities
o Gangrene
o Foot Amputation
59

Foot Amputation
• Many people with diabetes have peripheral arterial disease (PAD), which reduces blood
flow to the feet and neuropathy, a condition that numbs pain usually in the hands and feet.
• Together PAD and neuropathy make it easier to get ulcers and infections.
• Severe infections that do not respond to treatment threaten to spread into the bloodstream.
• To prevent this from happening, the affected foot may have to be amputated.
• One of the biggest threats to feet is smoking. Smoking affects small blood vessels.
• It can cause decreased blood flow to the feet and make wounds heal slowly.
• A lot of people with diabetes who need amputations are smokers.
60

Figure 3.7 Risk factors and mechanism for foot ulcer and amputation
61

62
4.1 History
A comprehensive evaluation should include the foot and ankle and pay special attention to
a. Tobacco use
b. Prior treatments
c. Medical comorbidities
d. Assessment of Achilles tendon tightness.

4.2 Vascular evaluation
a. More than 60% of diabetic ulcers have diminished blood flow secondary to
peripheral vascular disease.
b. Physical examination of the lower extremity vascular system includes
• Assessment of the dorsalis pedis and tibialis pulses
• Examination of the condition of the skin, noting the absence of hair on the
feet and toes.
63

64
c. When the physical examination indicates further evaluation,
• the ankle-brachial index (ABI),
• Doppler ultrasonography with digital arterial pressures,
• transcutaneous toe oxygen measurement, and
• arteriography can be used.
An ABI of at least 0.45 and toe pressures greater than 40 mm Hg are necessary to heal an
ulcer in the diabetic foot.
Transcutaneous oxygen measurement greater than 30 mm Hg indicates that blood flow is
adequate for healing.

4.3 Ulcer classification
The Wagner ulcer classification system (Table 3.1) and the Brodsky depth-ischemia
classification (Table 4.1) are commonly used.
4.4 Physical examination on ulcer
Key features of the ulcer evaluation include
a. Depth of ulcer
b. Presence of infection
c. Nonviable tissue (gangrene)
d. Pressure at location of ulcer
(see Table 4.2)
65

Table 4.1 The Brodsky Depth/Ischemia Classification of Diabetic Foot Lesions
Grade Definition Treatment
Depth Classification
0 The at-risk foot. Previous ulcer or
neuropathy with deformity that may cause
new ulceration
Patient education, regular examination, appropriate footwear and insoles
1 Superficial ulceration, not infected External pressure relief using total contact cast, walking brace , or special footwear
2 Deep ulceration exposing tendon or joint
(with or without superficial infection)
Surgical debridement, wound care, pressure relief if closed and converts to grade 1;
antibiotics as needed
3 Extensive ulceration with exposed bone
and/or deep infection (osteomyelitis or
abscess)
Surgical débridement, ray or partial foot amputation, intravenous antibiotics,
pressure relief if wound converts to grade 1
Ischemic Classification
A Not ischemic Adequate vascularity for healing
B Ischemia without gangrene Vascular evaluation (Doppler ultrasonography with assessment of digital arterial
pressures, transcutaneous toe oxygen measurement, and arteriography), vascular
reconstruction as needed
C Partial (forefoot) gangrene of foot Vascular evaluation, vascular reconstruction (proximal and/or distal bypass or
angioplasty), partial foot amputation
D Complete foot gangrene Vascular evaluation, major extremity amputation (transtibial or transfemoral) with
possible proximal vascular reconstruction 66

Table 4.2 Diabetic foot examination
67

4.5 Imaging
a. Weight-bearing AP, lateral, and oblique radiographs of the foot and ankle are obtained.
b. Nuclear studies using technetium Tc-99m, gallium Ga-67, or indium In-111 may help
differentiate between soft-tissue infection and osteomyelitis, Charcot arthropathy, or a
combination of infection and Charcot arthropathy.
c. MRI also can help but may not distinguish between Charcot arthropathy and infection
with high specificity.
68

4.6 Investigations
• CBC
• Renal function tests
• CRP and ESR
• Blood sugar levels
• HbA1C
• Blood culture and sensitivity
• X-ray of the foot
• MRI of the foot
• PET scan in osteomyelitis
• Ankle brachial index
• Ultrasound Doppler vascular studies
• CT angiogram
69

70
5.1. Nonsurgical
a. Debridement
b. Wound care
c. Total contact casting (TCC) and mechanical relief.
d. Pneumatic walking brace
e. Therapeutic Shoes

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Therapeutic shoes and insoles are alternative
methods to off‐load wounds located at the
forefoot (Figure 5.1).
Other types of shoe can be used for ulcers
on the dorsal aspect of the feet (Figure 5.2).

72
5.2. Surgical
a. Soft-tissue management—Drainage of deep infections often is necessary to prevent
tissue necrosis, rid the area of infection, and achieve wound healing without tension.
b. Management of deformity— Ostectomy or realignment arthrodesis may be needed
to remove the internal pressure caused by bony prominences. Achilles tendon
lengthening can help reduce plantar forefoot pressure.
c. Osteomyelitis— Before antibiotic treatment is begun, specimens for culture should be
obtained by biopsy, ulcer curettage, or aspiration, rather than by wound swab.
Osteomyelitis is present in 67% of ulcers that can be probed to bone.

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5.3 Amputation
General amputation considerations (Figure 5.3)
I. Great toe (hallux) amputation
II. Lesser toe amputation
III. Ray amputation
IV. Transmetatarsal amputations (TMA)
V. Lisfranc amputation
VI. Chopart amputation
VII. Syme amputation

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FIGURE 5.3 Illustration shows
the surgical levels for
transtibial (A),
Syme (B), and
transmetatarsal (C) amputations.

75

76

77
• Transtibial (below knee)
• Long transtibial (below knee)
• Ankle Disarticulation (Symes)
• Tansmetatarsal
• Partial Foot/ray resection
• Toe disarticulation
• Partial Toe
• Hemicorporectomy
• Hemipelvectomy/ Hindquarter amputation
• Hip Disarticulation
• Short transfemoral(above knee)
• Transfemoral (above Knee)
• Long transfemoral (above knee)
• Knee Disarticulation
• Short transtibial (below knee)

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FIGURE 5.4 Illustration shows
Levels of amputation

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 Goals of nursing intervention in diabetic foot care
There are several reasons for the presence of nurses in the health care team, but in general, the
four major goals are included
• health promotion,
• prevention of diseases,
• patients care, and
• simplify patients’ compliance.

80
To achieve these goals, nurses can play different roles.
There are seven main roles for nurses including:
1. providing health care,
2. care connector,
3. educator,
4. consultant,
5. leader,
6. researcher,
7. supporting the rights of patients

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 Nurse’s role in education
 Nursing role in diabetic foot care at prevention
 Nurses’ role in care
 Nurse cooperation in the diabetic foot treatment
 Nursing care of the patient after amputation
 Nursing role in rehabilitation
Nurse’s Roles in diabetic foot care

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FIGURE : METHODS FOR BANDAGING
AMPUTATION STUMPS

83
Subjective Data Objective Data
Patient said that: I observed that:
• I feel severe pain at Rt Leg. • Pain score 7/10
• DM foot ulcer at Rt malleolus(10×10cm)
• I feel so weak and I have a fever. • Body temperature above 102°F.(axillary)
• I have a big wound. • Presence of necrotic tissue,
• Dry and scaly skin ,
• Wound exposed bone and tendon
• I feel discomfort and I have problems
in finishing toilet tasks.
• Inability to bear weight
• Unable to mobilize or transfer
independently
• I am having a hard time to move unlike
before.
• Loss of lower extremity ,
• Postural instability
• Protective gestures for her wound • History of poor wound healing
6.1 Assessment Data

84
Subjective Data Objective Data
Patient said that: I observed that:
• I have loss of appetite and look thinner.
• Previously, I had 120lb.
• A picky eater and eats less instead ,
• Weight loss (100lb )
• It’s hard to understand about this
treatment.
• History of poor compliance with ulcer treatment,
• History of poor glycemic control
• Can I go on crutches on next few days? • Unfamiliarity with the use of ambulatory aids.
• Request for information • Development of preventable complications
• Unfamiliarity with dietary modifications
• Inadequate knowledge about protective skin
integrity
• I haven’t Rt Leg now. • Making meaning of loss
• Statement of concerns
Assessment Data

85
6.2 Nursing Diagnosis with Prioritization
(1) Acute pain related to tissue injury (presence of necrotic tissue) secondary to poor circulation as
evidenced by report of 7/10 pain in right leg.
(2) Hyperthemia related to increased metabolic rate as evidenced by increased body temperature above
102°F.
(3) Impaired skin integrity related to poor circulation as evidenced by disruption of skin layers.
(4) Self-care deficit (toileting) related to inability to mobilize or transfer as evidenced by problems in
finishing toilet tasks.
(5) Impaired physical mobility related to loss of a lower extremity as evidenced by postural instability.
(6) Risk for infection related to inadequate primary defenses secondary to invasive procedures.

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(7) Inbalanced nutrition less than body requirement related to inadequate intake of essential nutrients as
evidenced by dry and scaly skin turgor and weight loss.
(8) Risk for ineffective therapeutic regimen management related to complexity of lifestyle changes
possibly evidenced by reports difficulty with prescribed regimen.
(9) Risk for injury related to unfamiliarity with the use of ambulatory aids.
(10) Knowledge deficit (learning need) related to unfamiliarity with information resources about health
care as evidenced by inadequate knowledge about protective skin integrity.
(11) Grieving related to loss of lower extremity as evidenced by making meaning of loss.
6.2 Nursing Diagnosis with Priorization

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6.3 Nursing Care Plan 1
Assessment Nursing
Diagnosis
Expected
Outcome
Intervention Evaluation
Subjective
Data
Patient said
that
“I feel severe
pain at my
right leg.”
Objective data
I observed that
• Pain score
7/10
• DM foot
ulcer at Rt
malleolus(1
0×10cm)
Acute pain
related to
tissue injury
(presence of
necrotic tissue)
secondary to
poor
circulation as
evidenced by
report of 7/10
pain in right
leg.
After 6 hr of
nursing
intervention,
the patient
will express
the reduction
of discomfort
and appear
relaxed,
able to rest
appropriate.
1. Assess level of pain , severity , site and
characteristics of pain.
2. Maintain immobilization of affected part by
mean of bedrest.
3. Administer medication as indicated , such as
opoid or non-opoid analgesics.
4. Administer antibiotics as ordered.
5. Monitor effects of medications for relief of
pain, note side effects of medication.
6. Provide emotional support to enhance
coping abilities in the management of stress
of ulcer and pain.
After 6 hr of
nursing
intervention,
goal met as
evidenced by;
expression of
the reduction
of discomfort
and appear
relaxed,
able to rest
appropriate.

88
Nursing Care Plan 2
Assessment Nursing
Diagnosis
Expected
Outcome
Intervention Evaluation
Subjective
Data
Patient said
that
“I feel so weak
and I have a
fever.”
Objective data
I observed that
Body
temperature
above 102°F.
(axillary)
BP-
110/70mmHg
PR- 102bpm
RR- 24/min
Hyperthemia
related to
increased
metabolic rate
as evidenced
by increased
body
temperature
above 102°F.
After 6 hr of
nursing
intervention,
the patient’s
temperature
will be within
normal range
and has no
associated
complications.
1. Monitor body temperature , degree and
pattern as needed.
2. Provide tepid sponge baths.
3. Administer antipyretics as indicated.
4. Provide cooling blanket , or hypothermia
therapy as ordered.
5. Note drug effects and monitor signs of
toxicity.
6. Observe for fever associated with
tachycardia, hypotension , and subtle
mental changes.
7. Promote rest, thereby reducing metabolic
demands and to relieve fatigue.
After 6 hr of
nursing
intervention,
goal met as
evidenced by;
the patient’s
temperature
waswithin
normal range
and had no
associated
complications
.

89
Nursing Care Plan 3
Assessment Nursing
Diagnosis
Expected
Outcome
Intervention Evaluation
Subjective Data
Patient said that
“I have a big
wound.”
Objective data
I observed that
• Presence of
necrotic
tissue,
• Dry and
scaly skin ,
• Wound
exposed
bone and
tendon
Impaired
skin integrity
related to
poor
circulation
as evidenced
by disruption
of skin
layers.
After 6 hr of
nursing
intervention,
the patient will
have
progressive
improvement.
1. Assess, monitor and document wound
history and potential for delayed wound
healing.
2. Select wound dressing that is appropriate to
the wound environment: Wet-to-
dry,absorptive dressing.
3. Review laboratory results which affects
healing.
4. Keep linens dry and free of wrinkles.
5. Administer medications as indicated.
6. Maintain sterile techniques for all invasive
procedures.
7. Maintain adequate hydration.
After 6 hr of
nursing
intervention,
goal met as
evidenced by;
the patient
had
progressive
improvement.

90
Nursing Care Plan 4
Assessment Nursing
Diagnosis
Expected
Outcome
Intervention Evaluation
Subjective Data
Patient said that
“I feel discomfort
and I have
problems in
finishing toilet
tasks.”
Objective data
I observed that
• Inability to
bear weight
• Unable to
mobilize or
transfer
independently
Self-care
deficit
(toileting)
related to
inability to
mobilize or
transfer as
evidenced
by problems
in finishing
toilet tasks.
After 6 hr
of nursing
interventio
n, the
patient will
express
desire to
enhance
self-care.
1. Note age, presence of comorbidities, and
client's understanding of Current situation.
2. Assess availability and use of resources and
supportive persons and assistant devices.
3. Demonstrate and assist with transfer techniques
and use of mobility aids, such as crutches.
4. Evaluate usual dietary and fluid intake,
compared with current intake.
5. Provide privacy and routinely scheduled time
for defecation based on usual pattern as
appropriate.
After 6 hr of
nursing
intervention,
goal met as
evidenced by;
expression of
desire to
enhance self-
care.

91
Nursing Care Plan 5
Assessment Nursing
Diagnosis
Expected
Outcome
Intervention Evaluation
Subjective
Data
Patient said
that
“I am having a
hard time to
move unlike
before.”
Objective data
I observed that
• Loss of
lower
extremity ,
• Postural
instability
Impaired
physical
mobility
related to loss
of a lower
extremity as
evidenced by
postural
instability.
After 6 hr of
nursing
intervention,
the patient
verbalize
understanding
of individual
situation and
safety
measures.
1. Provide residual limb care on a routine
basis; inspect the area, dean and dry it
throughly.
2. Assist with specified range of motion
exercises for both the affected and
unaffected limbs, beginning early in post-
operative stage.
3. Increases mulees strength to facilitate
transfers and ambulation and promotes
mobility and more normal lifestyle.
4. Demonstrate lassist with transter
techniques and uses of mobility aids.
5. Instruct client in residual limb-
condiboning exercises, e.g pushing residual
limb against a pillow initially, then
progressing to harder surfaces
After 6 hr of
nursing
intervention,
goal met as
evidenced by;
the patient
expressed
understanding
of individual
situation and
safety
measures.

92
6.3 Narrative Note 1
Date/
Time
Nursing Action Sign
8.3.23/
2:30pm
S- Patient complaint of fatigue and malaise.
O- Laboratory studies show that decreased HGB level of 7.1 g/dl.
A- It is assumed that patient’s hemoglobin reflects anaemia.
P- To prevent tissue hypoxia and restore blood volume.
I
• Disussed blood transfusion procedures with the patient
• The blood was been run slowly for the first 15 mins.
• The rate of transfusion was been increased after that period as the patient was stable and
did not display any signs of reactions.
• During that transfusion , the patient’s vital signs were T-99F, PR- 104bpm, RR-24/min,
BP- 110/80mmHg, SPO2 -96% on air
E – The patient was issued 3 units of PC without any signs of reactions.
On 9.3.23 , HGB was elevated with the result of 13.3 g/dl.

93
Narrative Note 2
Date/
Time
Nursing Action Sign
9.3.23/
1:00pm
S- Patient complaint of fever.
O- T-102F, PR- 102bpm, RR-24/min, BP- 110/80mmHg, SPO2 -98% on air
A- It is assumed that patient has elevated body temperature.
P- The patient’ s temperature will be normal range.
I
• Monitored body temperature , degree and pattern 4hourly.
• Provided tepid sponge for 20 min.
• Administered medication as indicated such as IV PARA infusion 8hrly, and other antibiotics
injections( IV CS1/ IV LEVOFLOX)
• Promoted bed rest by giving care without waking the patient or as possible while patient was still
awake.
• Provided cooling blanket or cooling bed linens.
E – After 4 hr of nursing interventions, the patient’s temperature was within normal range.(98.6F)

94
Narrative Note 3
Date/
Time
Nursing Action Sign
8am /
13.3.23
S- Patient’s attendance complaint of patient’s weight loss and less eat instead ,also a picky eater.
O- The patient’s body weight was lost from 120lb to 100 lb.
A- It is assumed that imbalanced nutrition less than body requirements
P- To be improved nutritional level.
I
• Assessed reason for imbalanced nutrition: underlying DM and the patient is also a picky eater.
• Reviewed laboratory results and provided nutritional supplements as ordered (O’ Slow K(1) tds ,O’
Milical (1)od )
• Provided good oral hygiene to improve patient’s appetite.
• Educated the patient on the body’s nutritional status: to offer balanced meals everydays.
E – The patient understood appropriate nutritional requirements.

95
Narrative Note 4
Date/
Time
Nursing Action Sign
13.3.23/
8:15pm
S- Patient has protective gestures for her wound.
O- History of poor healing, poor glycemic control, poor compliance with ulcer treatment.
A- It is assumed that high risk for infection.
P- To achieve timely wound healing.
I
• Evaluated patient’s risk for infection , lower extremity amputation was associated with surgical wound and
history of poor wound healing and poor glycemic control were risks for surgical sites infection.
• Maintained aseptic techniques when chaning dressings and care for wound.
• Educated wound care to patient and family; to maintain hand hygiene , to cover dressing with plastic when
using bed pan.
• Administered antibiotics as prescribed (such as IV CS1/ IV LEVOFLOX)
E – After nursing intervention, the patient had optimal level of healing.

96
Narrative Note 5
Date/
Time
Nursing Action Sign
8.3.23/
2:30pm
S- Patient report of difficulty of treatment regimen.
O- Complexity of lifestyle changes.
A- It is assumed that risk for ineffective therapeutic regimen management.
P- To regain proper knowledge to prevent the risk of developing DM and associated complications.
I
• Provided education regarding dietary intake (such as limiting carbohydrate intake),exercises and self-monitoring of
blood glucose and how to administer insulin injection.
• Encouraged general residual limb care , for example , to wash daily with mild soap and water , rinse and pat dry, to
message the residual limb after dressing is discontinued and suture line is healing , to decrease tenderness and
stimulates circulation.
• Instructed signs and symptoms requiring medical evaluation, edema, erythema, increased or odorus drainage from
incision, changes in sensation, movement, skin color and persistant phantom pain.
E – After nursing intervention, the patient verbalized understanding of importance of health maintaince.

97
Discharge Instructions after BKA
1. Seek care immediately
2. Take medication exactly as prescribed.
3. Secure safe use of mobility aids.
4. Follow up with the orthopedist as ordered.
5. Care for the residual limb
6. Help the residual limb healing
7. Activity

98
Discharge Instructions for DM
1. Change diet
2. Stop smoking
3. Exercise regularly
4. Always carry a carbonhydrate snack to eat if the patient has
sudden low blood sugar level or hypoglycemia.
5. Test blood sugar level as directed .
6. Giving an insulin injection.

99
References

100