Case Study

Clinical case
(Case Study)
About

Diabetic
foot
Under Supervision of

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Case Study

Prepared by

2017

Outlines:

Introduction
Patient assessment
Demographic data
Past history
Physical examination
Diagnostic procedure
Initial treatment:
Medication
Action
Side effect

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Caution with drug

Disease over view
Suggested plan of care (Used the nursing process)
Nursing diagnosis
Objectives
Implementation
Evaluation
Foot care guide lines

Introduction:

Our case study talk about, married female patient 65

years old, admitted to Specialized Military Service Production
Center at 20/2/2010, after taking a history, we know that patients
illness started from 2 months ago by complicated foot lesion
between fingers, cerebro vascular stroke, ischemic heart disease,
while the duration of diabetes 25 years, the patient conscious
level intact, immobile due to CVS and complicated foot wound,
till now the patient undergo completion of diagnostic studies to
overcome of foot problem.

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Interview Data

1) Demographic data:

-Patient name:
- Sex: Female
- Age: 43 years old
- Address: Assist governorate, Manfalut city, Bany rafa
- Telephone. No: not available
- Marital status: Married
- Education: Illiterate
- Occupation: House wife
- Religion: Christian
- Number of family: 5 members
- Smoking habit: No
- Close contact person: alone

2) Medical data:
Diagnosis:
RHD, MS, TR, Cardiac Cirrhosis, controlled AF,
Congestive heart failure, frequent premature ventricular
contraction, digitalis Toxicity.
Current Medical History: - The patient presented by shortness
of breath, orthopinia, central cyanosis, bilateral lower limb
edema also she suffered from tense abdominal ascites,
distension ( umbilical hernia )
Constipation, Bp: 100/70 mmHg, Pulse: 55 b/min, Tem: 37c

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Past Medical History: -------------She is previously admitted to

the hospital by Cardio genic-pulmonary edema, DKA (Diabetic
keto-acidosis), left sided hemi-plagia result from CVS.

3. Patient physical examination:

Vital signs: BP: 100/ 60mmHg. Pulse: 80 b/
min.

TEMP. 37 C0 R.R: 20 C /
min

Head:
Vision: clear
Hearing: Hearing ability intact.
Nose: Clear nostril, no discharge
Throat and Mouth: dryness of the tong,
inflammation in patient lips( harps mucus membranes)
Neck: raised jugulars vein with abnormal pulsated
pulse

Chest: --------- Equal air entry, medium sized cripitation mainly

basal
Circulatory system: ------------------------No abnormality was
detected.

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Gastro-intestinal system: abdominal distention

Nutritional status:
- Special diet: --------------------------------------------------- Sault
free diet
-Frequency/day: ------------------------------------------------2 times
/ day
-Food intolerance: ----------------------------------------------No
-Food allergies: -------------------------------------------------No
-Amount of fluid intake/day: ------------------------- 100ml every
1 hrs
-Type of fluids intake :----------------------( juice, water, tea, and
milk)
-Caffeine intake: -----------------------------------------------No
-Nausea: -----------------------------------present from (digitalis
Toxicity)

-Vomiting: --------------------------------- present from (digitalis

Toxicity)

Neurological: -------------The patient conscious, pupils equal

and reactive, left sided hemi plagia, CT showed pontine
infarction.
Musclo skeletal: ----------Show limited movement of left side
especially in arm joints.

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Skin: ---------------Dryness, swelling, redness and inflammation

of left leg
Redness in both two heels of feet & old scare in the sacral area.
Extremities: both lower limp pitting edema
Elimination:
Bladder:
Frequency /day-------------------------------------------------5
times / day
Amount/Once: 200 cc at one time
Complains: Presence of albumin, epithelial cells,pus cells .

Bowel
Usual time: --In the morning while she not constipated
Frequency/day: -The patient constipated for 3 days
Intestinal sounds: Abdominal distension (gases)

Personal hygiene & dressing:

General appearance:
----------------------------------------------------clean
Self care ability for:
Feeding-----------------dependent
Dressing----------------dependent
Bathing-----------------dependent
Toileting---------------dependent

Mobilization:

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Exercise habits (activity level) ----------------The patient

immobile
The perform passive exercise by health team and her daughter
History of physical disability: ---------------------------------------
No

Sleeping pattern:
Hours of sleep/night- 4 hrs
Hours of day naps :- 1 hr separate
Difficult falling sleep--------------------------------------------------
No
Difficult remaining sleep----------------------------------------------
No
Sleeping aids-----------------------------------------------------Warm
drink
Factors contributing to sleep alteration during
hospitalization------no

Communication:
Ability to
read---------------------------------------------------------------No
Ability to write:
-------------------------------------------------------------No
Ability to
understand----------------------------------------------------- yes

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Ability to communicate
clearly----------------------------------------- yes
Barriers of communication:
-----------------------------------------------No

4. Treatment plan:
Name Route Dose Main Action Side Effects
1.Cipro 500 mg oral 1 tab. /12 Antibiotics Swelling or tearing of

tablet hrs a tendon

Drug cautions: Do not take ciprofloxacin with dairy products such as milk or yogurt, or with calcium-
fortified juice. You may eat or drink dairy products or calcium-fortified juice with a regular meal, but do
not use them alone when taking ciprofloxacin. They could make the medication less effective.
2.Unasyn 1.5gm I.V 1 vial / Antibiotics Cause diarrhea,

vial 12hrs allergic effects

Drug cautions: Before using Unasyn tell the doctor if any allergic to cephalosporins such as Ceclor,
Ceftin, and if you have asthma, kidney disease, a bleeding or blood clotting disorder, mononucleosis
(also called "mono"), or a history of any type of allergy.
3.Clexane 40mg Subcut 1 amp. / 12 Anti-coagulant (blood
Increase risk of
ampoule aneous hrs thinner)
bleeding

Drug cautions: Identify presence of eye problems caused by diabetes, an infection of the heart,
uncontrolled high blood pressure, a history of stroke, a bleeding or blood clotting disorder, stomach or
intestinal bleeding or ulcer, kidney or liver disease, a genetic spinal defect or recent surgery, recent eye
or brain surgery.

4.Plavix 75mg Oral 1 tab. / 24 Anti-coagulant (blood Increase risk of

tablet hrs thinner) bleeding

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Drug cautions: Detect any have black or bloody stools, or if cough up blood or vomit that looks like
coffee grounds. These could be signs of bleeding in your digestive tract.
5.Nitro-derm Dermal 16 hrs Nitrates. Dilates (widens) Cause severe

patch 10 mg patch cont. blood vessels, making it headaches, especially

easy... when first start using
it.
Drug cautions: Avoid drinking alcohol. It can increase some of the side effects of nitroglycerin
transdermal.
6.Capotien 25mg Oral 0.25 tab. / Hydrochlorothiazide Can cause blood

(Capozide) tablet 8 hrs pressure to get too low

Drug cautions: Avoid regular use of salt substitutes in diet, and do not take potassium supplements
while taking hydrochlorothiazide and captopril, unless your doctor has told you to.

7. Lasix 20mg I.V. 1 amp. / loop diuretic Allergy to sulfa drugs

(furosemide) 8hrs
Ampoule
Drug cautions: Using potassium supplements or getting enough salt and potassium in diet.

Oral 1 tab. / 24 Diuretic Evidence of fluid or

8. Aldactone electrolyte imbalance,
25mg tablet hrs
(spironolactone) e.g., hypomagnesemia,
hyponatremia,
hypochloremic
alkalosis, and
hyperkalemia.

Drug cautions: Avoid drinking alcohol, which can increase some of the side effects of spironolactone.

Avoid a diet high in salt. Too much salt will cause body to retain water and can make this medication less
effective.

Do not use salt substitutes or low-sodium milk products that contain potassium. These products could
cause your potassium levels to get too high while you are taking spironolactone.

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9.Trental 40 mg Oral 1 tab. / 12 Improve blood flow Belching; bloating;

tablet hrs blurred vision;

diarrhea; dizziness;
flushing; gas;
headache; indigestion;
nausea; stomach
discomfort.
Drug cautions: Do not break, crush, or chew the tablets. Swallow them whole. They are specially coated

to protect stomach. Do not stop taking this medication suddenly.

10.Insulin Subcut According Hypoglycemic agent Headache, nausea,

regular aneous to glucose hunger, confusion,

drowsiness, weakness,
test
dizziness, blurred
vision, fast heartbeat,
sweating, tremor, or
trouble concentrating
Drug cautions: Should be eating after insulin directly, Carry a piece of non-dietetic hard candy or
glucose tablets.

5. Diagnostic Studies:
1. CT angiography L.L
2. Stress ECG-------Revealed hypertensive heart disease,
concentric LVH with normal systolic functions and LV stiffness,
sclero-calcific aortic and mitral valves with moderate mitral
regurge.

3. Abdominal Ultra sound-------------Revealed that mildly

enlarged liver displaying coar echogenic pattern of its
parenchyma with periportal fibrosis for lab correlation

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- Chronic calcular cholecystitis

- Right pleural effusion

4. Upper GI endoscopy-------------Mild gastritis

5. Arterial Doppler study of the lower limp
arteries-------------------Bilateral Chronic PAOD as detailed
further assessment by conventional angiographic study would
be recommended

6. Urine analysis:
Urine characteristics Patient results Unit Normal Range
Color yellow ---------------- -------------
Aspect turbid ------------- ------------------
Reaction acidic ------------ -----------------
Specific gravity 1025 g/mL 1.003-1.030
Sugar Nil IU 525 IU/24 h
Acetone Nil ----------------- ------------------
Protein Nil mg <150 mg/24 h
Urobinlinogen N. Trace mol <0.42 mol/24 h
Pus cell 20-25 ------------------- n/a
RBCs 40-50 (HPF) n/a
Epithelial cell few --------------------- n/a
Castes Nil ------------------ -----------------
Blood +++ ---------------------- -----------------
Yeast + ------------------ --------------------
7. Blood chemistry
Lap. investigation Patient results Unit Normal Range
1. Renal function test:
- Blood urea 81 mg/dl 1020 mg/dL
- S.Creatinine 1.9 mg/dl 0.71.4 mg/dL
- Sodium (Na) 141 mmol 135145 mmol/L

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- Potassium (k) 3.2 mmol 3.55 mmol/L

2. Liver function test
-Amylase 10 u/L 25-125U/l
3. Cardiac enzymes
- LDH 700 u/L
90176 U/L
- CPK 70 u/L 50250 U/L
15.361 mol/L
- Ck (MB) 22 u/L
4. Coagulation
factors 13.7 Sec. 9.2-12 sec.
- Prothrombin time 83% Sec. 10-14sec.
- Prothrombin
concentration 1.2 1.0
- INR 1 Min. 1.5-9.5 min.
- Bleeding time 1 Min. 4-5min
- Coagulation time

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Disease overview:

Diabetes mellitus (DM) represents several diseases in

which high blood glucose levels over time can damage the
nerves, kidneys, eyes, and blood vessels. Diabetes can also
decrease the body's ability to fight infection. When diabetes is
not well controlled, damage to the organs and impairment of the
immune system is likely. Foot problems commonly develop in
people with diabetes and can quickly become serious. With
damage to the nervous system, a person with diabetes may not
be able to feel his or her feet properly.

Normal sweat secretion and oil production that lubricates

the skin of the foot is impaired. These factors together can lead
to abnormal pressure on the skin, bones, and joints of the foot
during walking and can lead to breakdown of the skin of the
foot. Sores may develop. Because of the poor blood flow,
antibiotics cannot get to the site of the infection easily. Often,
the only treatment for this is amputation of the foot or leg. If the

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infection spreads to the bloodstream, this process can be life-

threatening.

People with diabetes must be fully aware of how to

prevent foot problems before they occur, to recognize problems
early, and to seek the right treatment when problems do occur.
Although treatment for diabetic foot problems has improved,
prevention - including good control of blood sugar level -
remains the best way to prevent diabetic complications. People
with diabetes should learn how to examine their own feet and
how to recognize the early signs and symptoms of diabetic foot
problems. They should also learn what is reasonable to manage
routine at home foot care, how to recognize when to call the
doctor, and how to recognize when a problem has become
serious enough to seek emergency treatment.

Definition of disease:
Damage to blood vessels and impairment of the immune
system from diabetes makes it difficult to heal these wounds.
Bacterial infection of the skin, connective tissues, muscles, and
bones can then occur. These infections can develop into
gangrene

Disease pathophysiology:
Peripheral neuropathy and peripheral arterial disease
(PAD) predispose to the development of ulcers and to their slow
healing. Neuropathy inhibits healing by increasing forces on

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certain parts of the foot while walking (as a result of motor

neuropathy and wasting of the small muscles of the foot) and by
a loss of protective behavior (as a result of reduced sensation).
Peripheral arterial disease inhibits healing though its impact on
local blood flow and a disruption of the processes needed for re-
epithelialization

When an ischemic foot becomes infected, gangrene can

follow: the local inflammatory reaction leads to thrombosis of
arteries that are already narrowed by disease. It follows that the
early expert assessment focuses on the assessment of the
presence and extent of any PAD that might be present, and on
whether the patient should undergo investigations to determine
if revascularization (by angioplasty or bypass surgery) should be
considered and, if so how soon. It is vital that the generalist be
able to the recognize symptoms and signs of critical limb
ischemia

Etiology:
According to patient According to literature
- Nerve damage - Nerve damage
- Poor circulation - Poor circulation
------------------------------ - Trauma to the foot
------------------------------ - Infections
------------------------------ - Smoking
------------------------------ - Footwear

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- Peripheral arterial disease (PAD) - Peripheral arterial disease (PAD)

- Diabetic neuropathy - Diabetic neuropathy
----------------------------- - Biomechanical alterations
- Lower limb edema - Lower limb edema
---------------------------- - Deformity
- Hyperglycemia - Hyperglycemia

Clinical manifestation:
According to patient
- Sever pain of foot to mid calf
- Redness
- Swelling and inflammation
--------------------------------------
----------------------------------------
---------------------------------------
- Localized warmth
According to literature
- Persistent pain can be a symptom
of sprain, strain, bruise, overuse,
improperly fitting shoes, or
underlying infection
- Redness, especially when
surrounding a wound, or of
abnormal rubbing of shoes or socks.
- Swelling of the feet or legs can be
a sign of underlying inflammation or
infection, improperly fitting shoes,
or poor venous circulation. Other
signs of poor circulation include the
following:
- Pain in the legs or buttocks that
increases with walking but improves
with rest (claudication)
- Hair no longer growing on the
lower legs and feet
- Hard shiny skin on the legs
- Localized warmth

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- Fissure, corns and calluses
-------------------------------------
- Limited limp movement
- ---------------------------------
- Numbness in the feet
Complications:
According to patient
- Infection
- Corns and calluses
- Dry, cracked skin
- Nail disorders. Ingrown toenails
----------------------------------------
----------------------------------------
----------------------------------------
--------------------------------------
------------------------------------------
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- Calluses and corns may be a sign
of chronic trauma to the foot. Toenail
fungus, athlete's foot, and ingrown
toenails may lead to more serious
bacterial infections.
- Drainage of pus
- A limp or difficulty walking can
be sign of joint problems
- Fever or chills
- Numbness in the feet or legs can
be a sign of nerve damage from
diabetes
According to literature
- Infections and ulcers (sores) that
dont heal
- Corns and calluses
- Dry, cracked skin
- Nail disorders. Ingrown toenails
- Hammertoes and bunions
- Charcot foot.
- Ischemia
- Gangrene
- Amputation
 Case Study
Diagnostic measures:
According to patient
- The complete history take from
the patient
- The feet examined for redness,
swelling, calluses and
inflammation
- Neurological examination
- Arterial Doppler study on the left
lower limp
- CT angiography L.L
- Stress ECG
- Abdominal Ultra sound
- Upper GI endoscopy
- Urine analysis
- Blood chemistry
19
According to literature
- Patient history
1.Duration of illness
2.Type of medication
3.Diet; exercise and footwear
4.Symptoms relating to eyesight
5.Renal status
6.Previous foot problems
- Physical examination
- Neurological examination
1.Semmes-Weinstein 5.07
monofilament (SWM)
- Noninvasive vascular
assessment
1.Hand held Doppler
2.Ankle/brachial index (ABI)
3.Transcutaneous oxygen
measurement (TCOM)
- Radiological study
----------------------------------
-----------------------------------
--------------------------------------
--------------------------------------
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Suggested plan of care (Used the nursing process)

Nursing diagnosis
Objectives
Implementation
Evaluation

1. Nursing Diagnosis
- Actual nursing diagnosis
- Potential nursing diagnosis

A. Actual Nursing Diagnosis:

1. Altered nutrition (less than body requirement)
related to inadequate feeding intake & insufficient
nutritional elements as manifested by decrease
subcutaneous fat and muscles mass and anemia.

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2. Bowel elimination alteration (constipation) related

to inadequate feeding, fluids& lack of fiber and
immobility
3. Impaired skin integrity related to mechanical
destruction of tissue secondary to pressure, friction &
immobility.
4. Impaired physical mobility secondary to CVS
5. Self care deficit (eating, bathing, grooming, and
hygiene) related to immobility
6. Deficient knowledge about diabetes self-care skills
(caused by lack of basic diabetes education or lack of
continuing diabetes education)

B. Potential Nursing Diagnosis:

1. Risk for altered oral mucus membrane related to
inadequate fluids intake
2. Risk for infection (septicemia) related to use of
invasive lines
3. Risk for chronic foot ulceration due to disease
process
4. Inadequate control of blood glucose levels
(hyperglycemia)

Planning and Goals:

The major goals for the patient may include:
Improved nutritional status
Maintenance of skin integrity
Ability to perform basic diabetes care

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Self-care skills as well as preventive care for the

avoidance of chronic diabetes complications, and absence
of complications
Improve bowel elimination
Return to normal physical activity

Nursing Interventions
1. Improving nutritional status
The patients diet is planned with the primary goal
of glucose
Control.
Dietary prescription must also consider the
patients primary health problem in addition to lifestyle,
cultural background, activity level, and food preferences.
If alterations are needed in the patients diet
because of the primary health problem (eg, GI problems),
alternative strategies to ensure adequate nutritional intake
must be implemented.
The patients nutritional intake is monitored
carefully along with blood glucose, urine ketones, and
daily weight.
Blood glucose records are assessed for patterns of
hypoglycemia and hyperglycemia at the same time of day,
and findings are reported to the physician for alteration in
insulin orders.

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In the patient with elevated blood glucose levels

that are prolonged, laboratory values and the patients
physical condition are monitored for signs of DKA or
HHNS.
Measure subcutaneous fat and muscle mass via
triceps skin fold and mid arm muscle circumference or
other anthropometric measurements to establish baseline
parameters and compare measures to assess nutritional
status.
Auscultate bowel sounds. Note characteristics of
stool (color, amount, frequency, etc.).
Review indicated laboratory data (e.g., serum
vitamins, minerals and HB).
Consult dietitian/nutritional team as indicated to
make nutritional assessment of the patient and to
implement interdisciplinary team management.
Provide diet modifications as indicated. For
example: Increase protein, carbohydrates, and calories
Mechanical soft or blenderized tube feedings
(instead of milk and yogurt only)
Dietary supplements
Administer pharmaceutical agents as indicated:
Vitamin/mineral (iron) supplements.
Avoid foods that cause intolerances and increase
gastric motility (e.g., gas-forming foods, hot/cold and
milk products).

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2. Maintaining skin integrity

The skin is assessed daily for dryness or breaks.
The feet are cleaned with warm water and soap.
Excessive soaking of the feet is avoided.
The feet are dried thoroughly, especially between
the toes, and lotion is applied to the entire foot except
between the toes.
For bedridden patients (especially those with a
history of neuropathy), the heels are elevated off the bed
with a pillow placed under the lower legs and the heels
resting over the edge of the pillow.
Dermal ulcers are treated as indicated and
prescribed.
The nurse promotes optimal blood glucose control
in patients with skin breakdown.
1. Apply pressure ulcer prevention principles:

Apply range-of-motion (ROM) exercise and

weight-bearing mobility five to six times a day.
Keep the bed as flat as possible (lower than 30
degrees) and support feet with a foot board.
Use pillows to provide a bridging effect to support
the body above and below the high-risk or ulcerated area;
this prevents the affected area from touching the bed
surface.

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Alternate or reduce pressure on the skin surface

with devices such as air mattresses.
Use sufficient personnel to lift the client up in bed
without sliding or pulling the skin surface.
Inspect other areas at risk for developing ulcers
with each position change, like ear, elbows, heels,
sacrum, scapula and scrotum.
Observe for erythema and blanching, and palpate
surrounding area for warmth and tissue sponginess with
each position change.
Change position and inspect skin every 2 hours for
signs of injury.
2- Apply aseptic technique while done dressing on the
bed sore.
3- Change dressing daily & observe for signs of wound
healing.

3. Addressing knowledge deficits

Hospital admission of the patient with diabetes
provides an ideal opportunity for the nurse to assess the
patients level of knowledge about diabetes and its
management.
Uses this opportunity to assess the patients
understanding of diabetes management, including blood
glucose monitoring, administration of medications (ie,
insulin, oral agents), dietary requirements, exercise, and

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strategies to prevent long- and short-term complications

of diabetes.
Assesses the adjustment of the patient and family
to diabetes and its management and identifies any
misconceptions they have.
Determine existing conditions affecting ability of
individual to care for own needs:
Develop plan of care appropriate to individual
situation, Scheduling activities to conform to clients
normal schedule.
Assist with rehabilitation program to enhance
capabilities and enhance patient independence in all of his
activities as much as possible according to his abilities
and consciousness level.
Provide privacy during personal care activities.
Provide personal hygiene for the patient by
providing care of oral cavity, teeth, eyes, face, ears, and
hair.
Instill artificial tears or lubrication ointment to eyes
every 4 hours and PRN as ordered.
Care of patient regarding defecation and diaper
hygiene in humanistic manner.
Put a schedule for the patient to provide him with
bed bathing to maintain cleanliness and eliminate
pathogens.

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4. Monitoring and managing potential

complications
Inadequate control of blood glucose levels may
hinder recovery from the immediate health problem.
Blood glucose levels are monitored, and insulin is
administered as prescribed.
It is important for the nurse to ensure that insulin
prescribed is modified as needed to compensate for
changes in the patients schedule or eating pattern.
Treatment is given for hypoglycemia (with oral
glucose) or hyperglycemia (with supplemental regular
insulin no more often than every 3 to 4 hours).
Blood glucose records are assessed for patterns of
hypoglycemia and hyperglycemia at the same time of day,
and findings are reported to the physician for
modification in insulin orders.
In the patient with elevated blood glucose levels
that are prolonged, laboratory values and the patients
physical condition are monitored for signs of DKA or
HHNS.
Development of acute complications of diabetes
secondary to inadequate control of blood glucose levels
may be associated with other health care problems
because of changes in activity level and diet and
physiologic alterations related to the primary health
problem itself.

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The patient must be monitored for acute

complications (hyperglycemia, hypoglycemia) and
measures must be implemented for their prevention and
early
1. Perform passive ROM on affected limbs five to
six times daily. Do the exercises slowly to allow the
muscles time to relax, and support the extremity
above and below the joint to prevent strain on joints
and tissues. Stop at the point when pain or resistance
is met.
2. Take steps to maintain alignment at bed:

Use a footboard.
Avoid prolonged periods of lying in the same
position.
Change position of shoulder joints every 2 to 4
hours.
Use a small pillow or no pillow when in Fowlers
position.
Support hand and wrist in natural alignment.
If client is in the lateral position, place pillow(s) to
support the leg from groin to foot and a pillow to flex the
shoulder and elbow slightly; if needed, support the lower
foot in dorsal flexion with a sandbag.
Use handwrist splints.
3. Consult physical and occupational therapists in
creating exercise program and identifying assistive

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devices to provide message and early manage any

stricture
4. Assess patient degree of Immobility.
5. Observe skin for redness, warmth, or tenderness.
6. Provide kinetic bed or alternating pressure mattress
for patient.

5. Improving bowel elimination

Assess the patient bowel habits through review the
history, & any signs for abdominal distension.
Auscultate bowel sounds. Note characteristics of
stool (color, amount, frequency, etc.).
Provide diet modifications as indicated. For
example:
Increase carbohydrates, and fibers
Mechanical soft or blenderized tube feedings
(instead of milk and yogurt only)
Dietary supplements.
Give adequate fluids intake if not contraindicated.
Repositioning pt every 2 hrs in bed & done bowel
exercises.
Give stool softener as prescribed.
Done effective enema as prescribed.

Evaluation
Expected patient outcomes may include: Objectives were met,
as evidenced by

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1. Achieves optimal control of blood glucose

a. Avoids extremes of hypoglycemia and hyperglycemia
b. Takes steps to resolve rapidly any hypoglycemic episodes

2. Maintains skin integrity

a. Demonstrates intact skin without dryness and cracking
b. Avoids ulcers caused by pressure and neuropathy

3. Demonstrates/verbalizes diabetes survival skills and

preventive care
4. Understands treatment modalities
a. Demonstrates proper technique for administering insulin or
oral antidiabetic medications and assessing blood glucose
b. Demonstrates appropriate knowledge of diet through proper
menu selections and identification of pattern used for selecting
foods at home
c. Verbalizes signs, appropriate treatment, and prevention of
hypoglycemia and hyperglycemia
5. Demonstrate proper foot care a. Inspects feet (using mirror if
necessary to see bottom of foot), including inspection for cracks
or fungal infections
between toes
b. Washes feet with warm water and soap; dries feet thoroughly
c. Applies lotion to entire foot except between toes
d. Verbalizes behaviors that decrease the risk of foot ulcers,
including wearing shoes at all times; using hand or elbow, not

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foot, to test temperature of bath water; avoiding use of heating

pad on feet; avoiding constrictive shoes; wearing new shoes for
brief periods; avoiding home remedies for treatment of corns
and calluses; having feet examined at every appointment with
the physician; and consulting a podiatrist for regular nail care if
necessary

6. Takes steps to prevent eye disease

a. Verbalizes need for yearly or more frequent thorough dilated
eye examinations by an ophthalmologist (starting at 5 years
after diagnosis for type 1 diabetes or the year of diagnosis for
type 2 diabetes)
b. Verbalizes that retinopathy usually does not cause change in
vision until serious damage to the retina has occurred
c. States that early laser treatment along with good control of
blood glucose and blood pressure may prevent visual loss from
retinopathy
d. Identifies hypoglycemia and hyperglycemia as two causes of
temporary blurred vision

7. States measures to control macrovascular risk factors

a. Smoking cessation
b. Limitation of fats and cholesterol
c. Control of hypertension
d. Exercise
e. Regular monitoring of renal function

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8. Reports absence of acute complications

a. Maintains blood glucose and urine ketones within normal
limits
b. Experiences no signs or symptoms of hypoglycemia or
hyperglycemia
c. Identifies signs and symptoms of hypoglycemia or
hyperglycemia
d. Reports appearance of symptoms so that treatment can be
initiated

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Guide lines for foot care

To avoid serious foot problems that could result in

losing a toe, foot, or leg, follow these guidelines.

Inspect the feet daily. Check for cuts, blisters,

redness, swelling, or nail problems. Use a magnifying
hand mirror to look at the bottom of the feet. Call the
doctor if you notice anything.

Wash your feet in warm (not hot!) water. Keep

the feet clean by washing them daily.

Be gentle when bathing your feet. Wash them

using a soft washcloth or sponge. Dry by blotting or
patting, and carefully dry between the toes.

Moisturize your feet but not between your

toes. Use a moisturizer daily to keep dry skin from
itching or cracking. But DONT moisturize between the
toes that could encourage a fungal infection.

Cut nails carefully. Cut them straight across and

file the edges. Dont cut nails too short, as this could lead
to ingrown toe nails. If you have concerns about your
nails, consult your doctor.

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Never treat corns or calluses yourself. No

bathroom surgery or medicated pads. Visit doctor for
appropriate treatment.

Wear clean, dry socks. Change them daily.

Avoid the wrong type of socks. Avoid tight elastic

bands (they reduce circulation). Dont wear thick or bulky
socks (they can fit poorly and irritate the skin).

Wear socks to bed. If your feet get cold at night,

wear socks. NEVER use a heating pad or hot water bottle.

Shake out the shoes and feel the inside before

wearing. Remember, the feet may not be able to feel a
pebble or other foreign object, so always inspect your
shoes before putting them on.

Keep feet warm and dry. Dont let your feet get
wet in snow or rain. Wear warm socks and shoes in
winter.

Never walk barefoot. Not even at home! Always

wear shoes or slippers. You could step on something and
get a scratch or cut.

Take care of your diabetes. Keep blood sugar

levels under control.

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Case Study

Dont smoke. Smoking restricts blood flow in the

feet.

Get periodic foot exams. Seeing the foot and

ankle surgeon on a regular basis can help prevent the foot
complications of diabetes.

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