Republic of the Philippines

Southern Luzon State University

College of Allied Medicine
Lucban, Quezon
A.Y. 2022-2023

CASE STUDY:
Below-Knee Amputation of Right Foot

Submitted by:

Añola, Quisiah Jurimei A.

Gaela, Estelle S.
Glorioso, John Benedict B.
Gomez, Trixie G.
Ligon, Jules Chelsea V.
Lucito, Jovelyn M

Submitted to:
Roylan A. Almacen, RN, BSM, MSN

Date Submitted:
November 2022
 TABLE OF CONTENTS
a. General Objective
b. Specific Objective
II. Introduction of the Disease
III. Anatomy and Physiology
IV. Overview of the Disease
a. Review of the Related Literature
V. Case Study Proper
a. Gender Data
b. Physical Assessment
c. History of Clients (Past Medical, Family Health, Present Illness)
d. Laboratory Analysis
e. Pathophysiology
f. Nursing Care Plan
g. Drug Study
VI. Evaluation
I. Objective of the Study
a. General Objective
This study aims to develop familiarity and describe the situation of the Below
Knee Amputation (BKA) patient with Type 2 Diabetes Mellitus as well as to
demonstrate the practices in assessing the overall impact of BKA. It also enhances, and
skill of the students as a group in handling and studying a patient’s overall situation with
this kind of condition.
b. Specific Objective
1. To educate the people about the case and treatment for minimizing death and
disability and to protect vulnerable people.
2. To discuss the signs and symptoms, pathophysiology, diagnostic tests, and
treatment to come with BKA.
3. To develop and improve the awareness of the patient and significant others to
increase their knowledge regarding the disease.

II. Introduction of the Disease

Type 2 diabetes mellitus is characterized by hyperglycemia, insulin resistance, and
relative impairment in insulin secretion (Robertson, R. P., 2022). It is a metabolic disorder
that causes the blood sugar levels to increase. The severity of diabetes can vary quite a bit.
Some people get the disease well under control, and in others it leads to other health
problems over time (National Center for Biotechnology Information, 2020). Its pathogenesis
is only partially understood but is heterogeneous and both genetic factors affecting insulin
release and responsiveness and environmental factors, such as obesity, are important
(Robertson, R. P., 2022).
There are two main types of diabetes, mainly type 1 and type 2. Type 1 diabetes
usually develops in childhood or the teenage years. This disease is a result of damage to the
pancreas that leaves it producing either very little insulin or none. Things are different in type
2 diabetes, where insulin is made by the pancreas, but the body’s cells gradually lose the
ability to absorb and use the insulin. In the past, type 2 diabetes was often referred to as
“adult-onset” diabetes because it is commonly diagnosed later in life. Type 2 diabetes is
much more common than type 1 diabetes. About 90% of people who have diabetes have type
2 diabetes (National Center for Biotechnology Information, 2020). There is no cure for type 2
diabetes, but losing weight, eating well and exercising can help manage the disease. If diet
and exercise are not enough to manage the blood sugar, it may also need diabetes medications
or insulin therapy (Mayo Clinic Staff, 2021).
According to the National Diabetes Statistics Report, more than 34 million people in
the United States have been diagnosed with type 2 diabetes. Risk factors for type 2 diabetes
include excess body weight and physical inactivity. People from many ethnic groups (Asian,
Pacific Islander, Latino, and African American) are at higher risk of developing type 2
diabetes than White people. These include individuals of Filipino ancestry, despite having a
lower body mass index (BMI) than other ethnic groups. In the Multiethnic Cohort (MEC)
Study, an epidemiologic study of chronic disease risk among more than 200,000 residents of
Hawaii and Los Angeles, Filipino-American adults had a mean body mass index (BMI) of
23.9 kg/m2, compared with 24.6 kg/m2 and 27.7 kg/m2 in White and Native Hawaiian adults,
respectively. According to 2017–2018 National Health and Nutrition Examination Survey
data, Filipino-American adults had the second highest type 2 diabetes prevalence (10.4%)
among Asian Americans, following Asian Indians at 12.6%. The rate of type 2 diabetes for
Chinese adults was 5.6%. A California report showed incidence rates of 14.7 cases per 1,000
person-years for Filipino-American adults compared with 7.5 for Japanese adults and 6.5 for
Chinese adults. Only South Asian adults (17.6), Pacific Islander adults (19.9), and Korean
adults (20.3) had higher rates. In the MEC, the risk of developing incident type 2 diabetes
was 2.5-fold for Filipino-American adults compared with White adults and was higher than
for all other Asian Pacific Islander adults. Moreover, nonobese Filipino-American adults
were twice as likely to develop type 2 diabetes as nonobese non-Hispanic White adults in a
population-based study. A geographic comparison showed a greater type 2 diabetes
prevalence in San Diego (14.1%) and Hawaii (14.7%) than in the Philippines (11.8%), just as
higher rates were reported for multiple American Asian groups in comparison to those in
their native country.

A high prevalence of risk factors for chronic diseases, including obesity, smoking,
and binge drinking, has also been reported for Filipino-American people. In terms of diet,
rice, fruits, vegetables, and fish or meat were reported as typical parts of daily meals, and
intake of vegetables, fruits, plants, whole grains, and fiber was inversely associated with type
2 diabetes. With acculturation, intake of total energy and percentage of calories from fat
increased, like increases in BMI. Although Filipino-American people constitute 15.1% of
Hawaii’s population and 0.9% of the US population as of 2019, they are understudied
because they are commonly aggregated under the racial and ethnic groups of Asian or Pacific
Islander (Dela Cruz, R., et. al., 2021).

One of the surgical treatments that type 2 diabetes mellitus patients undergo is below
knee amputation. Fletcher, J. (2022) states that people with diabetes may be more likely to
develop nerve damage and circulation issues. Factors such as high blood sugar levels and
smoking can increase the risk of foot-related complications, which can lead to a need for
amputation. In some cases, this can make a foot or lower leg amputation necessary. Not
everyone with diabetes will need an amputation. If a person with diabetes does need this
procedure, it is likely to be due to a wound or ulcer on the foot or lower leg that did not heal.
In some cases, a doctor may also recommend an amputation to help prevent an infection from
spreading.
Most amputations are progressive, which means that a doctor will start by removing
the smallest possible amount of tissue that is necessary. However, a person may need further
surgery to remove more tissue if the wound does not heal or the limb does not have sufficient
blood flow.
Ways of lowering the risk of needing an amputation include managing blood sugar
levels through diet, exercise, and medicine, avoiding smoking, and taking care of the feet.
People with diabetes should seek prompt treatment for any issues that affect their feet.
Treating problems early may help a person avoid ulcers and infection, and this can reduce the
risk of needing an amputation.
In a study cited by Buenaluz-Sedurante, M., Macalalad-Josue, A. A. & Panuda, J. P
(2019), diabetic foot disease remains the leading cause of non-traumatic lower extremity
amputation. Foot ulcers, in association with infection or gangrene, precede amputations in
75-85% of cases. Approximately 9% of patients with diabetes admitted at hospitals have
active foot disease. Half of this group will have active foot disease as the reason for
admission. After an initial event of hospitalization for diabetic foot ulcer, the rates are high
for ulcer recurrence (60.9%) and amputations (43.8%). Furthermore, long-term studies have
found poor quality of life and increased mortality among these patients even after amputation
and discharge.
Management of diabetic foot disease requires a multidisciplinary approach to
adequately address the various pathological processes contributing to the disease. At the
University of the Philippines-Philippine General Hospital (UP-PGH), the Diabetes Extremity
Care Team (DECT) was established in 1996 with the aim of providing comprehensive
surgical and medical care. The major objective of this team approach is to decrease the rates
of major amputations and mortality. A retrospective study done 3 years after the formation of
the DECT reported a decrease in the mortality rate of patients from 13.8% to 8%. However,
no decrease in major amputation rate was observed. Furthermore, additional retrospective
studies published last 1999 and 2009 showed suboptimal quality of care in this patient group.
There was a non-significant trend in mortality increase during 2005, 2006 and 2007 (2.6%,
9% and 8.5%, respectively) compared to 1999 (4.6%). From 1998 to 2007, the time from
admission to surgery ranged from 7.5 to 10.9 days. In addition, the mean time to antibiotic
administration ranged from 7.5 to 16.7 hours. This is far from the recommended window of 1
hour from recognition of severe sepsis/septic shock to first antibiotic administration and
likely contributed to increased mortality. Department data from June 2014 to August 2016
showed a significantly higher mortality rate compared to previous reports, wherein there were
53 in-hospital deaths among 445 admissions (11.9%) under the DECT.
Diabetic patients with foot disease have prolonged hospital stay and greater in-
hospital mortality, which widely ranged from 1.1% to 40.5%. Few studies have examined the
factors that are associated with mortality among hospitalized diabetic patients with foot
disease. However, potential factors such as delay in surgery and initiation of antibiotics, and
development of in-hospital complications such as infection, hypoglycemia, MI, renal failure,
stroke and respiratory failure and their influence on in-hospital death among diabetic patients
with lower extremity infection has not been adequately studied.
The goal of this case study is to learn more about type 2 diabetes and other
management issues to enhance skills and attitudes toward providing treatment that will
improve patient outcomes, prevent further complications, and give health education to
patients and other care providers.

III. Anatomy and Physiology

Adams, C.T. & Lakra, A. (2022) stated that important neurovascular structures and
muscles for the leg and foot are located in four fascial compartments in the lower leg. A
below-knee amputation (BKA) divides all compartments, and a thorough understanding of
the underlying anatomy is essential to reducing intraoperative blood loss to prevent
complications.

SKELETAL SYSTEM: Bones of the Lower Limbs

 According to Marieb E.N. & Keller, S.M. (2018), the lower limbs are composed of
three segments, the thigh (between hip and knee joints), leg (below knee and ankle), and foot
(calcaneus and distally). They carry our total body weight when erecting, which is why it is
thicker and more robust to the upper limb bones.

Leg
The leg is the lower limb area between the knee and the
foot. The skeleton of the leg formed by the tibia and fibula are
connected along the length by an interosseous membrane. These
two bones provide stability and support the tibia or shinbone is
the body's second-biggest bone and is more medial. It is an
important inability to stand and supports important muscles,
tendons, nerves, and ligaments. The medial and lateral condyle,
located at the proximal end, articulates with the distal end of the
femur to form the knee joint. The patellar or kneecap ligament
encloses a sesamoid bone called the patella, which attachments to
the tibial tuberosity, a roughened region on the anterior tibial surface. Medical malleus forms
the inner bulge of the ankle. The anterior surface of the tibia is a sharp ridge, while the
anterior border is easily felt beneath the skin because muscles unprotect it. The fibula is thin
and sticklike, lies alongside the tibia laterally, and forms proximal and distal joints with it. It
is not a weight-bearing bone, but its function is to combine with the tibia and to provide
stability to the ankle joint. It has no part connecting the knee joint. However, the lateral
malleolus (distal end) forms the outer part of the ankle. (E.N. & Keller, S.M., 2018)

Foot
According to Marieb E.N. & Keller, S.M.
(2018), the foot has two essential supports for our body
weight and acts as a lever to drive us forward as we
walk and run. It is composed of tarsals, metatarsals, and
phalanges.
The tarsus, composed of seven (7) tarsal bones,
forms the posterior half of the foot. The two largest tarsals, calcaneus, and talus, hold most of
our body weight. The talus is located superior to the calcaneus, articulates with the tibia, and
allows the pointing of the toes. The sole comprises five (5) metatarsals, while the toes are
composed of fourteen (14) phalanges. The foot's bones are positioned to form three strong
arches: two longitudinal and one transverse. Ligaments bind the foot bones together, and
tendons muscles keep the bones firmly arched while still allowing an amount of giving or
springiness. Fallen arches or flat feet are weak arches.

MUSCULAR SYSTEM: Muscles of the Lower Limb

Marieb, E.N., & Keller, S.M. (2018)
defined the lower limb muscles control
movement at the hip, knee, and foot joints.
They specialize in walking and balancing the
body, making them the largest and strongest
muscles.

Muscles Causing Movement at the Knee

Joint
A. Hamstring Group
The hamstring muscles lie on the posterior thigh consisting of the biceps femoris,
semimembranosus, and semitendinosus. It arises on the ischial tuberosity and runs down
the thigh to insert on both sides of the proximal tibia. They are the main contributors to
thigh extension and knee flexion.

B. Sartorius
Sartorius is the thigh's most superficial muscle. It is thin, straplike sartorius, and
not that significant. It is a weak thigh flexor that runs obliquely across the thigh from the
anterior iliac crest to the medial side of the tibia. It is also called the tailor because it is a
synergist that helps to position their leg while working.

C. Quadriceps Group
The quadriceps group is comprised of four muscles, including the rectus femoris
and three (3) vastus muscles. Only two (2) vastus muscles are visible, while the third one
is not because the rectus femoris muscle covers it. The vastus muscles arise from the
femur; the rectus femoris arises from the pelvis. The patellar ligament connects all four
muscles to the tibial tuberosity. The Quadriceps group acts powerfully to extend the knee
 like kicking a soccer ball. Because the rectus femoris crosses two joints, the hip, and the
knee, it can also aid in hip flexion. In infants who poorly developed gluteus muscles, the
vastus lateralis and rectus femoris are used in an intramuscular injection.

Muscles Causing Movement at the Ankle and Foot

A. Tibialis Anterior
The outermost muscle on the anterior leg is the tibialis anterior. It starts from the
upper tibia and continues to parallel to the anterior chest as it enters the long tendon in the
tarsal bonds. It allows the foot to dorsiflex and invert.

B. Extensor Digitorum Longus

The Extensor digitorum longus is lateral to the tibialis anterior muscle. It emerges
from the lateral tibial condyle and the proximal three-quarters of the fibula and inserts
two-five into the phalanges of toes. It is a major contributor (prime mover) of toe
extension.

C. Fibularis Muscle
The fibularis muscle lies on the lateral part of the leg. It consists of three fibularis
muscles: the longus, brevis, and tertius. It emerges from the fibula and connects into the
foot's metatarsal bones. The plantar flexes and everts the foot, antagonistic to the tibialis
anterior.

D. Gastrocnemius
Gastrocnemius muscle is a two-bellied muscle that makes the curved calf of the
posterior leg. It has two heads, one on each side of the distal femur, and enters into the
foot's heel through the big calcaneal (Achilles) tendon. It is the prime mover in plantar
flexion of the foot, which is why it is also known as the "toe dancer's" muscle. Walking
becomes extremely difficult when the calcaneal tendon is significantly injured or severed.
The foot drags because it cannot "push off" the toe (raise the heel).

E. Soleus
 The soleus muscle is located deep
within the gastrocnemius. It does not affect
knee movement because it arises on the tibia
and fibula. However, like the gastrocnemius, it
is a powerful plantar flexor of the foot that
inserts into the calcaneal tendon.

CARDIOVASCULAR SYSTEM: Arteries and Veins of Lower Limb

Arteries that Supply the Lower Limb

Marieb E.N., & Keller, S.M. (2018) defined that the femoral artery supplies the lower
limb, which gets blood from the abdominal aorta via the external iliac artery. Alongside this,
it serves the thigh together with the deep artery of the thigh. The femoral artery becomes the
popliteal artery in the knee, which then divides into the anterior and posterior tibial arteries,
known for supplying the leg and foot. The anterior tibial artery ends in the dorsalis pedis
artery, which via the arcuate artery, supplies the dorsum of the foot.

Veins that Drain the Lower Limb

The leg, calf, and foot drain through the anterior tibial, posterior tibial, and fibular
veins. At the knee, the posterior tibial vein becomes the popliteal and femoral veins in the
thigh. Great saphenous veins are the longest vein in the body and receive superficial drainage
of the leg. They start at the dorsal venous arch in the foot and proceed up the leg to the
medial aspect before emptying into the femoral vein in the thigh.

ENDOCRINE SYSTEM: The Pancreatic Islets

The endocrine system is comprised of several organs known as glands. It is located
throughout our body, creating and secreting (releasing) hormones. These hormones aid in the
coordination of various functions in our bodies by conveying messages through our blood to
our organs, skin, muscles, and other tissues. and signal our body what to do and when
(Cleveland Clinic, 2020).
Pancreas
The pancreas is a mixed gland near the stomach in the abdominal cavity. It plays a
significant factor in digestion by making pancreatic juices called enzymes. It is responsible
for breaking down sugar, fats, and starches. It also produces hormones that travel to the
blood. These pancreatic hormones help regulate blood sugar levels and appetite, stimulate
stomach acids, and tell when to empty.

Pancreatic Islets
Marieb E.N., & Keller, S.M. (2018) stated that pancreatic islets, also known as islets
of Langerhans, are small masses of hormone-producing, endocrine tissue that is scattered
throughout the enzyme-producing or the pancreas' exocrine tissue. Exocrine or acinar tissues
act as part of the digestive system. Islet cells produce two (2) significant hormones: insulin
and glucagon. During fed and fasting states, the islet cells become a fuel sensor, releasing
insulin and glucagon appropriately. An elevated blood glucose level stimulates insulin
secretion from the islet's beta cells. Insulin increases the ability of nearly all body cells to
import glucose across their plasma membranes. When glucose enters the cells, it is either
oxidized for energy or converted to glycogen or fat for storage. Insulin also accelerates these
"use it" or "store it" activities resulting from hypoglycemia as the insulin sweeps the glucose
out of the body. Negative feedback control happens if the blood glucose level decreases and
the stimulus for insulin release stops. Glucagon, glucocorticoids, epinephrine, and other
hormones have a hyperglycemic effect. Only insulin can reduce blood glucose. Insulin is
required for body cells to utilize glucose. Without it, no glucose can enter and be utilized by
the cells.

Diabetes Mellitus
The average blood glucose level ranges from 80 to 120 mg/100 ml of blood. If insulin is
absent, glucose level will dramatically increase, for
instance, 600 mg/100 ml of blood. With this, the
glucose will spill into the urine because the kidney
tubule cells cannot reabsorb it fast enough. It will
lead to dehydration because the glucose flushes from
the body, followed by water. It is called diabetes
mellitus, meaning something sweet passes through the body. Fats and proteins are broken
down to meet the needed energy requirements because the cells do not have access to
glucose. It will result in weight loss and decreased ability to fight infection, making them
prone to minor cuts and bruises. Ketosis, a type of acidosis, means that the blood becomes
very acidic because large amounts of fats are used for energy instead of sugar, which can lead
to coma and death. Diabetes mellitus has three cardinal signs:
1. Excessive urination to flush glucose and ketones (polyuria).
2. Excessive thirst resulting from water loss (polydipsia).
3. Hunger is due to the inability to use sugars and the body's loss of fats and proteins
(polyphagia).
Type 2 diabetes mellitus patients experience insulin resistance. It means they cannot produce
insulin, or their insulin receptors cannot respond. Special diets or oral hypoglycemic
medication are used to treat it because it stimulates the sluggish islets and increases the
sensitivity of target tissues to insulin and beta cells to the stimulating effects of glucose. In
type 1 (juvenile) diabetes, insulin is infused continuously by an insulin pump or an insulin
injection administered throughout the day.

IV. Overview of the Disease

a. Review of Related Literature
i. Definition
A below-the-knee amputation (BKA) is a transtibial amputation in which the foot,
ankle joint, distal tibia, fibula, and associated soft tissue components are removed.
Amputation of the lower extremities is a life-saving treatment. Lower limb ischemia,
peripheral artery disease, and diabetes mellitus are thought to be the leading causes of limb
amputation in more than half of cases. The second major cause of lower-extremity
amputations is trauma. Amputations below the knee relate to better functional results than
amputations above the knee (NCBI, 2022).

Causes
Diabetes mellitus, peripheral vascular disease, neuropathy, and trauma are the main
causes of amputation. The viability of the soft tissues used to obtain bone covering will
determine how much of an amputation is necessary. The prevalence of diabetes mellitus, is
present in 82% of all lower extremity amputations caused by vascular disease in the US.
When compared to individuals without diabetes mellitus, patients with diabetes mellitus have
an incredible 30 times higher lifetime chance of having an amputation, which places a
financial burden on healthcare systems of over $4.3 billion annually in the USA alone. When
a lower extremity injury is combined with extensive wound contamination and considerable
soft tissue loss, approximately 20% of patients may require an amputation. Approximately
2% of combat victims require limb amputation, while 93% of battle-related explosive
incidents result in amputation.

Risk Factors
All surgical procedures carry a risk of potential problems, such as those related to anesthesia,
infection, harm to the nerves and blood vessels, bleeding, or blood clots. Aiming to
reconstruct the limb as best as possible, surgeons will take soft tissue viability, bone length,
and other anatomical considerations into account. However, problems from the underlying
illness state and postoperative care are possible, and the most frequent ones are:
 Oedema - Stump oedema develops as a result of stress and tissue mishandling during
surgery. There is an imbalance between fluid transfer through capillary membranes
and lymphatic reabsorption following amputation. This, combined with decreased
muscular tone and inactivity, can result in stump oedema. Wound disintegration, pain,
decreased movement, and problems with prosthetic fitting are all possible symptoms
of stump oedema. Compression stockings, tight removable dressings, exercise,
wheelchair stump boards, and PPAM assisting are all used to treat and avoid post-
operative stump oedema. The BACPAR post-operative oedema guidance (2012)
discussed the evidence supporting these therapies and suggests the use of rigid
removable dressings when expertise, time, and resources permit. This
recommendation also states that the PPAM assist, stump boards, and compression
stockings have some evidence for oedema control, but it is not their primary use.
 Wounds and infection - It is typical for patients to develop surgical site infections
after amputation, which can worsen patient morbidity and delay the time it takes for a
prosthetic to be fitted. Diabetes mellitus, old age, and smoking are risk factors for a
stump infection and are all prevalent among amputees. The decision to place a drain
and employ clips rather than sutures is also linked to a higher risk of infection.
 Pain - It is an unavoidable side effect of amputation. When discussing pain after
amputation, numerous types of sensations following an amputation should be
considered. Some are exceedingly painful and unpleasant, while others are simply
strange or disturbing. Pain after amputation might be localized to the residual limb or
 it can manifest as phantom pain. For many, the pain will be caused not only by the
trauma of the surgery but also by a neuropathic condition known as phantom limb
pain (PLP). When amputation occurs as a result of a traumatic experience, such as a
disaster, this can be complicated by co-existing injury to the same limb or other parts
of the body. The issue for physiotherapists working in the early and post-acute stages
of rehabilitation is identifying the nociceptive and neuropathic reasons that must be
addressed in order to manage the patient and allow good rehabilitation to proceed.
 Muscle weakness, Contractures, and Joint Instability- It is not uncommon for
patients to experience discomfort, muscle weakness, or instability in structures that
are not immediately related to the amputation. These compensatory mechanisms are
the muscles and joints that must perform additional functions following amputation,
which frequently results in stiffness, spasm, or pain. To avoid contractures, ROM
exercises should be included, as well as prone lying to prevent hip flexion
contractures; a sandbag could be positioned next to the residuum to prevent a hip
abduction contracture. When the patient is prone, a sandbag could be placed over the
lower half of the transtibial residuum to prevent hip flexion contractures.
 Autonomic dysfunction- Complex regional pain syndromes (CRPS) are neuropathic
pain disorders that emerge as a disproportionate result of limb injuries. Distal
discomfort, allodynia, and autonomic and motor dysfunction are all symptoms.
Because of the altered modulation of the sympathetic nervous system, the residual
limb may appear hot, swollen, and trophic. Because of the lack of understanding of
the pathophysiological anomalies that underpin CRPS, treatment should be multi-
disciplinary, involving neurologists, physiotherapists, and psychologists, to list a few.
Along with nerve blocks, TENS, graded exercise, and mobilization, antidepressants
have been shown to be effective in relieving neuropathic pain.

Prognosis
The number of BKA as index amputation (first amputation) decreased by 40% from
20 in 2008 to 12 in 2019, while a 73% increase was identified in both below the ankle (BAA,
from 41 to 71) and above knee (AKA, from 11 to 19) amputations. The incidence of BKA
decreased by 46.2% (from 13 to 7 per 100 000 person-years), while BAA increased by
104.3% (from 23 to 47 per 100 000 person-years) and AKA remained unchanged (16 per 100
000 person-years). Crude and index minor-major ratios increased from 1.33 (95%CI 1.23-
1.44) and 1.13 (95%CI 1.03-1.24) in 2008 to 1.93 (95%CI 1.79-2.08) and 1.49 (95% CI 1.36-
1.62) in 2018, respectively. In addition, previous studies also reported that BKA patients face
a 77%–86% 1-year survival rate, a 28%–58% 5-year survival rate, and a 35% 10-year
survival rate.21–23 The survival of the cohort of patients with ESRD on dialysis is
significantly less with a 51.9% 1-year survival rate and a 14.4% 5-year survival rate.

Mortality/Morbidity
The 30-day all-cause death rate after major lower limb amputation has been reported
as 8.6%, which is substantially higher for above-knee amputation (AKA) than for below-knee
amputation (BKA) (16.5% and 5.7%, respectively, p<0.001). One-year mortality rates of
48% and 71%, respectively, have been reported. Age and concomitant cerebrovascular illness
are risk factors for higher 30-day mortality. Diabetes mellitus has also been linked to a lower
five-year survival rate. Heart failure, chronic kidney disease (CKD), and chronic obstructive
pulmonary disease (COPD) have also been proven to be independent predictors of mortality
(COPD).

Sign and Symptoms

According to Sachdev (2021), the signs and symptoms of Type 1 DM are often subtle,
but they can become severe. They include:

 Extreme thirst
 Increased hunger 
 Dry mouth
 Upset stomach and vomiting
 Frequent urination
 Unexplained weight loss, even though you’re eating and feel hungry
 Fatigue
 Blurry vision
 Heavy, labored breathing
 Frequent infections of your skin, urinary tract, or vagina
 Crankiness or mood changes
 Bedwetting in a child who’s been dry at night
Signs of an emergency with type 1 diabetes include:
  Shaking and confusion
 Rapid breathing
 Fruity smell to your breath
 Belly pain
 Loss of consciousness (rare)

According to Robinson (2021), the signs and symptoms of Type 2 DM includes:

 Increased thirst: The kidneys have to work harder to flush out the additional sugar when
blood sugar levels are higher. A person becomes thirsty as a result of the body becoming
dehydrated and losing fluid.
 Increased hunger – People with diabetes may experience increased hunger even after
eating because diabetes might hinder glucose from reaching cells.
 Frequent urination – A person will urinate more frequently as their kidneys work to
remove more sugar from the body system.
 Dry mouth – Dehydration and frequent urination both drain moisture from the mouth.
 Weight loss without trying: When a person urinates regularly, they also lose calories and
sugar. She can still lose weight even if she eats properly.
 Fatigue – When the body cannot utilize the energy from food, it causes a feeling of
weakness and exhaustion. This is how someone who is dehydrated could feel.
 Blurred vision – Having problems focusing is a sign of high blood sugar.
 Headaches: People who have high blood sugar may get headaches.
 Loss of consciousness - If a person exercises, skips a meal, or takes too much
medication, their chance of passing out rises.
 Infections or sores that don't heal – When blood flow is delayed by high blood sugar,
the body may have a harder time healing.
 Tingling in the hands and feet – Nerves in the hands and feet might be affected by
type 2 diabetes.

Laboratory Studies
According to Centers for Disease Control and Prevention (n.d.), a doctor will have
taken one or more of the following blood tests to confirm the diagnosis:

 A1C Test
           The average blood sugar level over the previous two to three months is determined by
the A1C test. An A1C of 5.7% or less is considered normal, 5.7% to 6.4% denotes
prediabetes, and 6.5% or more denotes diabetes.

 Fasting Blood Sugar Test

           After a fasting period, the blood sugar level is measured. The result of fasting blood
sugar of 99 mg/dL or less is considered normal, 100 to 125 mg/dL denotes prediabetes, and
126 mg/dL or more denotes diabetes.
 Glucose Tolerance Test
Using this, blood sugar is measured both before and after consuming a beverage
containing glucose. A person will fast the night before the test, and blood will be collected to
measure fasting blood sugar levels. A person will then consume the liquid, after which their
blood sugar will be monitored for 1 hour, 2 hours, and perhaps 3 hours later. At 2 hours,
blood sugar levels of 140 mg/dL or less are regarded as normal, 140 to 199 mg/dL as
prediabetes, and 200 mg/dL or above as diabetes.

 Random Blood Sugar Test

           This measures a person's blood sugar level at the time of the test. This test can be
taken at any time; one does not need to fast beforehand. A 200 mg/dL blood sugar level or
greater implies diabetes.

Result* A1C Test Fasting Blood Glucose Tolerance Random Blood

Sugar Test Test Sugar Test
Diabetes 6.5% or 126 mg/dL or above 200 mg/dL or 200 mg/dL or above
above above
Prediabetes 5.7 – 6.4% 100 – 125 mg/dL 140 – 199 mg/dL  N/A
Normal Below 99 mg/dL or below 140 mg/dL or  N/A
5.7% below

According to John Hopkins Medicine (n.d.), before a patient is admitted to the

hospital or before some outpatient treatments, many surgeons order routine lab tests. The
tests aid in identifying potential issues that, if not identified and addressed right away, could
complicate surgery. Before surgery, the following tests are frequently performed:
  Chest X-rays. X-rays can be used to diagnose of certain fevers, coughing, and chest
pain. Additionally, they can aid in the diagnosis of lung and cardiac issues.
 Electrocardiogram (ECG). The heart's electrical activity is obtained by this test. It
reveals irregular heartbeats (arrhythmias), identifies cardiac muscle injury, and aids in
determining the origin of chest pain, palpitations, and heart murmurs.
 Urinalysis. This test can help identify diabetes, kidney, bladder, and other illnesses.
In some cases, urinalyses can also detect the presence of illicit narcotics in the body.

SPECIMEN: URINE
Normal Range Normal Range
Color Clear to slightly MICROSCOPIC
turbid
Transparency Clear to slightly WBC: 2–5 /HPF
turbid
CHEMICAL TEST RBC: ≤2 /HPF
Blood: NEGATIVE Epithelial Cells: FEW
Bilirubin: NEGATIVE Mucus Thread: FEW
Urobilinogen: NORMALLY Bacteria: NEGATIVE
PRESENT
Ketones: <0.6 mmol/L A. Phosphate: NEGATIVE
Protein: 0 – 14 mg/dL A. Urates: FEW
Nitrite: NEGATIVE Calcium Carbonate: FEW
Glucose: 0 – 0.8 mmol/L Calcium oxalate: FEW
pH 7.35 – 7.45 Fine Granular: /LPF
Specific Gravity: 1.005 – 1.030 Coarse Granular: /LPF
Leukocytes: NEGATIVE Hyaline Cast: 0–2 /LPF
Ascorbic Acid: 0.6-2 mg/dL
PREGNANCY < 5 mIU/mL= negative pregnancy
TEST: > 20 mIU/mL= positive pregnancy
One Step Hcg
Urine/Serum Test
(WONDFO)
Others:
REMARKS:

 Complete blood count (CBC). This test looks for infection, low platelet counts, and
anemia.
TEST NAME UNIT NORMAL VALUES
Complete Blood Count
WBC x10^9/L 4.00 – 10.00
Segmenter % 50.0 – 60.0
Lymphocyte % 35.0 – 45.0
Monocyte % 2.0 – 4.0
Eosinophil % 2.0 – 5.0
Basophil % 0.0 – 1.0
RBC x10^12/L 3.50 – 5.00
Hemoglobin g/dL 11.0 – 15.0
Hematocrit % 37.0 – 47.0
MCV fL 80.0 – 100.0
MCH pg 27.0 – 34.0
MCHC g/dL 32.0 – 36.0
RDW-CV % 11.0 – 16.0
RDW-SD fL 35.0 – 56.0
Platelet x10^9/L 150 – 450
MPV fL 6.5 – 12.0
PDW fL 9.0 – 17.0
PCT % 0.108 – 0.282
  Electrolytes. The electrolytes in the blood, including potassium, sodium, and other
substances, are measured by this test. Other bodily processes and cardiac rhythms are
regulated by these substances.
ELECTROLYTES
SODIUM (Na) 135 – 148 mmol/L
POTASSIUM (K) 3.50 - 5.30 mmol/L
CHLORIDE (Cl) 98-107 mmol/L
CALCIUM (Ca) 0.80 – 1.20 mmol/L
BUN (STAT) 7 – 18 mg/dL
CREATININE (STAT) 0.3 – 1.3 mg/Dl
HbA1C (HPLC) 4.2 – 6.2 %

 Coagulation studies (PT/PTT). These tests find out how well the blood clots.
COAGULATION
TEST Normal Values
PROTHROMBIN TIME 11.7 – 14.1 seconds
% ACTIVITY 68.9% - 103.4%
INR 0.81 – 1.22
Activated Partial Thromboplastin Time 25.0 – 39.0 seconds

 Arterial blood gas (ABG)- A blood test that measures the blood's levels of oxygen
and carbon dioxide using a sample from an artery in the body. The pH balance, often
known as the acid-base balance, of the blood is also examined during the test.
ARTERIAL BLOOD GAS ANALYSIS
PARAMETERS NORMAL RANGE
PH 7.35 – 7.45
PCO2 35.0 – 45.0 mmHg
PO2 80.0 – 100 mmHg
HCO3 22.0 – 26.0 mEq/L
BASE EXCESS -2.0 + 2.0
OXYGEN SATURATION 94 – 100%

 Clinical chemistry- The test is often used as part of a lipid panel to monitor risk of
heart disease, and the relation of blood glucose level.
Clinical Chemistry
Tests Type Unit Ref. ranges
CHOL HDL DIRECT SER mg/dL 0.00 – 35.00
CHOLESTEROL SER mg/dL 0.00 – 200.00
GLUCOSE SER mg/dL 70.00 – 105.00
TRIGLYCERIDES SER mg/dL 0.00 – 150.00
LDL SER mg/dL 130.00 – 159.00

Treatment
According to Mayo Clinic (n.d.), treatment for type 1 diabetes includes:

 Taking insulin- Anyone who has type 1 diabetes needs insulin therapy throughout
their life. There are many types of insulin, including:
 Short-acting insulin- This type of insulin, often known as normal insulin,
begins to function about 30 minutes after injection. It lasts between 4 and 6
hours and reaches its full effect around 90 to 120 minutes. Examples are
Humulin R, Novolin R and Afrezza.
 Rapid-acting insulin- Within 15 minutes, this kind of insulin begins to
function. It lasts roughly 4 hours and has its peak effect after 60 minutes. This
kind is frequently taken 15 to 20 minutes prior to meals. Examples are
glulisine (Apidra), lispro (Humalog, Admelog and Lyumjev) and aspart
(Novolog and FiAsp).
 Intermediate-acting insulin - Also known as NPH insulin, this kind of insulin
takes one to three hours to begin working. It lasts 12 to 24 hours and has its
 full effect around 6 to 8 hours. Examples are insulin NPH (Novolin N,
Humulin N).
 Long- and ultra-long-acting insulin- This type of insulin may provide coverage
for as long as 14 to 40 hours. Examples are glargine (Lantus, Toujeo Solostar,
Basaglar), detemir (Levemir) and degludec (Tresiba).

 Monitoring blood sugar often

Before meals and snacks, before night, before exercising or driving a vehicle,
and whenever suspect to have low blood sugar, the American Diabetes Association
advises monitoring the blood sugar levels. The only way to guarantee that the blood
sugar level stays within desired range is through careful monitoring. A1C levels can
be reduced with more frequent monitoring.

Blood sugar levels are monitored via continuous glucose monitoring (CGM).
For preventing low blood sugar, it might be very beneficial. This device has been
shown to lower A1C.

 Eating healthy foods and carbohydrates carbohydrates, fats and protein. It’s important
to center your diet on nutritious, low-fat, high-fiber foods such as:
 Fruits
 Vegetables
 Whole grains
The quantity of carbs in the foods one consumes must be counted by the
individual. It can provide the body with enough insulin this way. This will enable the
body to utilize those carbohydrates in the right way. An individualized food plan can
be made with the assistance of a trained dietitian.

 Exercising regularly and keeping a healthy weight

Everyone, including those with type 1 diabetes, should engage in regular
aerobic activity. Get the provider's permission before exercising. Aim for no more
than two days without any exercise, and at least 150 minutes of moderate aerobic
activity per week.
 The goal is to keep the blood sugar level as close to normal as possible to
delay or prevent complications. Generally, the goal is to keep the daytime blood sugar
levels before meals between 80 and 130 mg/dL (4.44 to 7.2 mmol/L). After-meal
numbers should be no higher than 180 mg/dL (10 mmol/L) two hours after eating.

 Healthy eating- It's important to center your diet around:

 A regular schedule for meals and healthy snacks
 Smaller portion sizes
 More high-fiber foods, such as fruits, nonstarchy vegetables and whole grains
 Fewer refined grains, starchy vegetables and sweets
 Modest servings of low-fat dairy, low-fat meats and fish
 Healthy cooking oils, such as olive oil or canola oil
 Fewer calories

 Regular exercise
Exercise is crucial for shedding pounds or keeping a healthy weight.
Additionally, it aids in controlling blood sugar levels. Before beginning or adjusting
an exercise program, consult a primary healthcare physician to make sure that the
activities are safe.
 Aerobic exercise. Adults should strive for 150 minutes or more of weekly
moderate aerobic exercise, or 30 minutes or more, on most days. Every day,
children should engage in 60 minutes of moderate to strenuous aerobic
activity.
 Resistance exercise. Resistance exercise increases strength, balance and ability
to perform activities of daily living more easily.
 Limit inactivity. Long periods of inactivity, such working at a computer, can
be broken up to assist manage blood sugar levels. Every 30 minutes, spend a
few minutes standing up, moving around, or engaging in some light exercise.

 Weight loss
Weight loss results in better control of blood sugar levels, cholesterol,
triglycerides and blood pressure. If a person is overweight, he may begin to see
improvements in these factors after losing as little as 5% of the body weight.
 However, the more weight a person loses, the greater the benefit to the health and
disease management.

 Blood sugar monitoring

A healthcare professional will give guidance on how frequently to monitor the
blood sugar level to ensure that it stays within the desired range.

A blood glucose meter, which measures the quantity of sugar in a drop of

blood at home, is typically used for monitoring. Keep a record of measurements to
give to the medical personnel.

 Possibly, diabetes medication or insulin therapy. Drug treatments for type 2 diabetes
include the following.
 Metformin (Fortamet, Glumetza, others)- Generally the first medication
prescribed for type 2 diabetes. It primarily works by reducing the amount of
glucose produced by the liver and increasing the body's sensitivity to insulin,
resulting in improved insulin utilization.
 Sulfonylureas- It help the body secrete more insulin. Examples include
glyburide (DiaBeta, Glynase), glipizide (Glucotrol) and glimepiride (Amaryl).
 Glinides- Increase the pancreas's ability to produce more insulin. They work
more quickly than sulfonylureas and have a shorter effect on the body.
Examples include repaglinide and nateglinide.
 Thiazolidinediones- It make the body's tissues more sensitive to insulin.
Examples include rosiglitazone (Avandia) and pioglitazone (Actos). High
cholesterol (rosiglitazone).
 DPP-4 inhibitors- It help reduce blood sugar levels but tend to have a very
modest effect. Examples include sitagliptin (Januvia), saxagliptin (Onglyza)
and linagliptin (Tradjenta).
 GLP-1 receptor agonists- An njectable drugs that slow digestion and assist in
reducing blood sugar. They are frequently used in conjunction with weight
loss, and some of them may lower the risk of heart attack and stroke.
Examples include exenatide (Byetta, Bydureon), liraglutide (Saxenda,
Victoza) and semaglutide (Rybelsus, Ozempic).
 SGLT2 inhibitors- Limiting the blood's ability to absorb glucose has an impact
on the kidneys' blood-filtering processes. Consequently, glucose is eliminated
 through the urine. In patients with a high risk of developing certain illnesses,
these medications may lower the risk of heart attack and stroke. Examples
include canagliflozin (Invokana), dapagliflozin (Farxiga) and empagliflozin
(Jardiance).
 Other medications- Blood pressure, cholesterol, and low-dose aspirin may also
be recommended by a doctor in addition to diabetic drugs to help avoid heart
and blood vessel damage.

Surgical management
The patient's aims can be pain alleviation, including the elimination of phantom limb
pain, wound healing, acceptance of a changed body image, closure of the grief process,
independence in self-care, regaining physical mobility, and the absence of problems (Hinkle
et al., 2022).

In addition to being incisional, pain can also be brought on by hematomas, pressure

on bony prominences, inflammation, infection, or phantom limb pain. Spasms of the muscles
may make the patient feel worse. The patient's degree of comfort may be increased by
moving the patient or applying a light sandbag to the remaining limb to relieve the muscle
spasm. Painkillers containing opioids may help treat postoperative pain. Beta-blockers,
anticonvulsants, and tricyclic antidepressants can help with stabbing, cramping, dullness, and
burning pain. Beta-blockers can also help with mood and coping, while anticonvulsants can
reduce stabbing and dull pain (Hinkle et al., 2022).

After an amputation, the wound should be checked frequently for infection signs.
Once every 8 to 12 hours following surgery, the residual limb should be measured to check
for edema formation. To confirm that there is an adequate blood supply, neurovascular
examinations including the most distal pulse, movement, feeling, and skin temperature are
also carried out at these 3272 intervals. By voiding infection and potential osteomyelitis, the
dressing is changed as directed whenever it becomes soiled. The application of consistent
pressure to the residual limb reduces edema formation and helps to shape the residual limb so
that it may fit a prosthetic. The wound should be assessed to ensure that it is healing and that
there are no signs of infection (Hinkle et al., 2022).
 Amputation changes the patient's perception of their body. The nurse must convey
acceptance of the patient who has undergone an amputation if they have built a rapport of
trust with them. For examining, feeling, and taking care of the residual limb, the nurse
counsels the patient. The nurse aids the patient in returning to their prior level of
independence. When a patient is accepted as the whole person, they are better able to take
back control of their care, their self-concept improves, and any changes to their body image
are accepted (Hinkle et al., 2022).

Even if the patient was well-prepared before surgery, the loss of a limb can still be
unexpected. The nurse fosters an environment that is accepting and encouraging so that the
patient and family can express their thoughts and go through the grieving process. The
patient's ability to accept the loss is aided by the support of family and friends. The nurse aids
the patient in addressing urgent needs and orienting them toward reasonable rehabilitation
goals and eventual independent functioning (Hinkle et al., 2022).

The patient's capacity to offer proper self-care is affected by amputation. The patient
was urged to active participation in their care. It is important not to rush the patient because
they require time to do these chores. Balance, transfer skills, and physiologic tolerance of the
activities are necessary for independence with dressing, using the restroom, and taking a
shower. To instruct and monitor the patient in these self-care activities, the nurse collaborates
with the physical therapist and occupational therapist (3276). (Hinkle et al., 2022).

In patients who have had a lower limb amputated, proper placement of the residual
limb helps to prevent the development of hip or knee joint contracture. After an amputation,
the limb needs to be raised for 24 hours to encourage venous return and reduce swelling. The
residual limb should not be put on a pillow because doing so could lead to hip flexion
contracture. To stretch the flexor muscles and avoid hip flexion contracture, the nurse advises
the patient to turn from side to side and lie down for 20 to 30 minutes’ multiple times a day.
To avoid an abduction deformity, the legs should remain closed. Contracture deformities
progress quickly so postoperative ROM exercises are started as soon as possible. For patients
with BKAs, ROM exercises include hip and knee exercises. For joint mobility and
strengthening, the patient must be aware of the value of exercising both the unaffected and
residual extremities. Activities are gradually increased to avoid becoming fatigued after
assessing strength and endurance. The nurse places a strong emphasis on safety issues when
the patient advances to autonomous wheelchair use, the use of ambulatory aids, or
ambulation with a prosthesis. Environmental obstacles are recognized, and strategies for
controlling them are put into practice. It's critical to anticipate, recognize, and handle issues
that may arise when using mobility aids. Early transfer instruction is given to the patient, who
is also urged to stand up straight when getting out of bed. It is recommended to wear well-
fitting shoes with nonskid soles. The patient should be stabilized and guarded by a transfer
belt at the waist during position adjustments to prevent falling. The lower limb amputation
patient is helped as soon as possible to stand between side rails so that the temporary
prosthesis can be extended to the floor with little weight bearing. Crutches or parallel bars are
used to start ambulation when endurance builds and balance is gained. The patient gains the
ability to walk normally while using crutches, swinging the residual limb back and forth. The
residual limb shouldn't be held up in a bent position to avoid a permanent flexion deformity
(Hinkle et al., 2022).

An accurate fit, optimal comfort, and proper functionality of the prosthetic device
require conditioning and shaping of the residual limb once the prosthesis has been checked
for any issues. The residual limb is shaped and conditioned using elastic bandages, an elastic
residual limb shrinker, or an air splint. The nurse instructs the patient or a member of the
family on the appropriate way to bandage. When the residual limb is in a dependent position,
bandaging provides support for the soft tissue and reduces the development of edema.
Applying the bandage ensures that the remaining muscles needed to control the prosthesis are
as stiff as possible. An improperly applied elastic bandage contributes to circulatory problems
and a poorly shaped residual limb (Hinkle et al., 2022).

Immobilization or pressure from a variety of factors can cause skin disintegration.

Pressure points could appear as a result of the prosthesis. The patient and the nurse look for
skin breaks. To avoid skin irritability, infection, and breakdown, careful skin hygiene is
necessary. At least twice daily, the repaired residual limb is cleaned and dried. Blisters,
dermatitis, pressure sores, and chronic inflammation are all looked for on the skin. Preventing
further skin breakdown, if they are present, the prosthesis should not be used until the
problem was assessed and addressed. A residual limb sock is typically worn to absorb sweat
and keep the skin from encountering the prosthetic socket. The sock is changed daily and
must fit smoothly to prevent irritation caused by wrinkles. The socket of the prosthesis is
washed with mild detergent, rinsed, and dried thoroughly with a clean cloth. It must be
thoroughly dry before the prosthesis is applied (Hinkle et al., 2022).
 ii. Current Trends and Issues
The prevalence of diabetes among adults aged 20 to 79 over the world was estimated
to be 536.6 million in 2021 and 783.2 million in 2045. Diabetes prevalence was comparable
between genders and was highest in people aged 75 to 79. According to estimates, prevalence
was higher in urban (12.1%) than rural (8.3%) areas and high-income (11.1%) than low-
income countries (5.5%) nations in 2021. Between 2021 and 2045, middle-income countries
are expected to see the largest relative increase in the prevalence of diabetes (21.1%),
followed by high-income (12.2%) and low-income (11.9%) nations. Global diabetes-related
health expenditures were estimated at 966 billion USD in 2021, and are projected to reach
1,054 billion USD by 2045 (Sun et al., 2021). Diabetes is responsible for 6.7 million deaths
in 2021 for 1 person every 5 seconds (International Diabetes Federation, n.d.).
Adults with diabetes are two to three times more likely to experience a heart attack or
stroke. Nerve damage in the feet raises the risk of foot ulcers, infection, and ultimately the
requirement for limb amputation when combined with diminished blood flow. A significant
contributor to blindness, diabetic retinopathy results from cumulative long-term harm to the
retina's tiny blood vessels. Diabetes has caused nearly 1 million people to become blind.
Among the main causes of kidney failure is diabetes. Additionally, those who have diabetes
are more prone to experience negative consequences from a number of viral diseases, such as
COVID-19 (World Health Organization, 2022).
Amputations are more common among African Americans. In the United States,
about 2 million people have some form of limb loss, and by 2050, that number is expected to
rise to 3.6 million (Hinkle et al., 2022).
Regular control of Type 2 diabetes frequently entails significant dietary and exercise
modifications. And for many people, particularly those who use insulin to control their blood
sugar, the condition may call for daily blood-glucose monitoring, which involves poking a
finger to draw blood and then smudging the blood onto a test strip for a glucose monitor.
Multiple times every week, month after month can result in overlapping difficulties. A 2013
study published in the journal Diabetes Spectrum found that people dislike finger-prick
glucose monitoring because it hurts and the results are frequently unclear or useless (Heid,
2022).

Continuous glucose monitors

In a study published in 2021 in the Journal of the American Medical Association,
continuous glucose monitoring to standard finger-prick tests among people with Type 2
diabetes who were using insulin. They found that continuous monitoring was associated with
a significantly greater drop in HbA1c. They also found that continuous monitoring helped
people avoid risky and severe drops in blood sugar (Heid, 2022). 
More than 90% of people with diabetes have Type 2 diabetes, and roughly 30% of
these people are using insulin. In other words, there are many people with Type 2 diabetes
who stand to benefit from continuous glucose monitoring (Heid, 2022).
Continuous glucose monitoring could be helpful. For example, monitoring blood
sugar in real-time could help people make diet or lifestyle changes that reduce their risks for
long-term health complications. But based on factors like diet, meal timing, and exercise
habits, someone with Type 2 diabetes may experience post-meal blood-sugar spikes that
surpass 200 or even 300 mg/dL. Over time they can contribute to the development of
common diabetes-related complications such as kidney failure, heart disease, or diabetic
retinopathy (Heid, 2022).

Bariatric surgery for Type 2 diabetes

Bariatric (weight-loss) surgery has traditionally been used to treat severe obesity,
which the U.S. A BMI of 40 or greater that's what the Centers for Disease Control and
Prevention classify as. In addition to causing weight loss, surgery also improves glycemic
management, which takes place before weight loss. A person with Type 2 diabetes may
benefit from bariatric surgery if it alters their appetite, food intake, caloric absorption, and
various neuroendocrine pathways, among other things (Heid, 2022).

New pharmaceutical drugs

GLP-1, a hormone involved in maintaining the balance of blood sugar, is released in
the gut after digestion. For persons with Type 2 diabetes, a class of medications known as
GLP-1 receptor agonists can interact with GLP-1 receptors to reduce hunger, decrease
digestion, and have other positive effects (Heid, 2022).
The second class of medication has additionally distinguished itself in the
management of Type 2 diabetes. These medications, also referred to as sodium-glucose
cotransporter-2 (SGLT-2) inhibitors, support the kidneys in removing sugar from the blood.
This not only helps those with Type 2 diabetes better control their blood sugar levels, but it
also helps prevent heart failure and renal disease—two common and serious consequences.
These drugs are so effective that they’re now being used in people with heart failure or
kidney disease who do not have Type 2 diabetes (Heid, 2022).
V. Case Study Proper
a. Gender Data
BIOGRAPHICAL DATA
Name: Lolita R. Sugabo Address: Brgy. San Lorenzo, Mauban, Quezon
Age: 60 y/o Birthday: 08/25/1962 Nationality: Filipino
Sex: Female Religion: INC
Height: NA Weight: 50 kg
Place of Birth: NA Language Spoken: Tagalog
Educational Level: NA Occupation: NA
Marital Status: Single Spouse: None
Contact Person: NA Relationship: NA
Contact No: NA

b. Physical Assessment
Vital Signs
BP: 185/95 mmHg PR: 68 bpm RR: 18 bpm
Measurements
Weight: 50 kg Height: Oxygen Saturation: 98%
Physical Assessment
Patient Name: Lolita R. Sugabo
Age: 60 years old

Assessment Findings
General Appearance
Mental Status - The client is aware of her environment, knows her name
and address.
- Can easily speak without stuttering. The client can also
tell where she is.
Skin - Skin color is light brown, and evenly distributed. No
sign of unusual or prominent discoloration.
- Skin is thin, smooth, and even.
- Reddened area in the lower part of the back due to bed
sore.
- No sign of edema.
- Non-healing wound at right foot.
Hair - The client's hair is slightly thin, gray hair visible
Nails - Clean, well-groomed, with tiny vertical ridges.
Head - Head can be held still and erect; firm and smooth with
no lesions; round in
appearance with no aberrant motions;
Neck - Trachea and landmarks in the midline.
- No bruits auscultated, no swelling or enlargement
noticed;
- No swelling or enlargement recorded.
Eyes - Conjunctiva and EOM are normal
- The pupils are equal, round, and reactive to light
- No redness, swelling, or lesions on either eyelid
Iris is round and equally colored.
Ears - With elongated earlobes; skin is smooth; no lesions,
lumps, or nodules are detected; color is consistent with
facial color.
Nose and Sinuses The color of the nose is the same as the rest of the face
- The nasal structure is smooth and symmetric; the client
reports
- No tenderness; no ability to sniff through each nostril
while the other is occluded
- The nasal mucosa is watery, moist, and free of
exudate
Mouth and Throat - Lips are symmetrical, pale lips.
- No edema on a sore throat is noted.
Thorax and Lungs - Skin tone on the face, lips, and chest is uniform
- The scapulae are symmetric and non-protruding.
Breast - There are no lesions or lumps on the skin or
subcutaneous tissue, and there is no edema or bulging
lymph nodes.
Heart - The heart rate is near normal
- The look of the external chest is normal, with no lifts.
Abdomen - Skin is free of blemishes, homogeneous in
color, has a symmetric
Musculoskeletal – Upper - Limited ROM against gravity and resistance
and Lower Extremities - Difficulty moving lower extremities related to
nonhealing wound @ right foot.

c. History of Clients (Past Medical, Family Health, Present Illness)

Patient’s Data:
Bed no: 38
Admission No.: IN-92022-0326343
Name: SUGABO, LOLITA RICO
Age: 61Y, 1M, 5D
Sex: FEMALE
Birthday : 08-25-2022
Marital Status: SINGLE
Address: BRGY. SAN LORENZO, MAUBAN, QUEZON
Religion: I.N.C.
Citizenship: FILIPINO
Date Admitted: 09-30-2022
Admission Time: 3:30PM
Discharge Date: 11-01-2022
Discharge Time: 11:00PM

Chief of complain: NON HEALING WOUNDS FOR 10 DAYS

Admitting Diagnosis: DM FOOT RIGHT
Final Diagnosis: DM FOOT RIGHT, DM TYPE II
Operation Procedure: S/P DEBRIDEMENT, FOOT R
FRACTURE CLOSED, COMPLETE,
DISPLACED, TRANSVERSE, DISTAL 3RD,
RADIUS-ULNAR, LEFT S/P CLOSED
REDUCTION APPLICATION OF VOLAR
SPLINT, WRIST, LEFT
ANEMIA SEE TO CHRONIC DISEASE
Date Initiated: 10-13-2022
Surgeon: DR. BUSTOS

History and Physical Examination Form

PHIC Hospital 142-456-00000-7 History of Present 10 DAYS PTC,

Accreditation No.: Illness: PATIENT NOTED
NON-HEALING
WOUND AT R
FOOT
Admitting Diagnosis: DM FOOT R Pertinent Past POSITIVE
Medical History: MELLITUS
CONTINUED OF
INSULIN

1st Surgical Operation

Tentative Diagnosis: DM FOOT RIGHT

Final Diagnosis: DM FOOT RIGHT, DM TYPE II

Operation Date: 10-13-2022 Ward: SLR

Circulating Nurse: NURSE PEREZ Surgeon: DR. BUSTOS
Instruments Nurse: NURSE YAMBALLA Operation DEBRIDEMENT
Performed: FOOT AND LEG
 RIGHT

Anesthesiologist: DR. YIP Anesthesia Began: 2:42PM

Anesthetic: X-SAB Operation Started: 2:50PM
Time Finished: 3:00PM

Surgical Technique
- General anesthesia
- Asepsis antiseptics
- Excision of necrotic tissue edges and thorough scrub with a combination of brush and os to
remove dirt and scrubs of raw surface of burned areas.
- Through washing with plain NSS done
- Patient tolerated the procedure
- Bone subcutaneous discoloration
- For necrotic tissue

2ND Surgical Operation

Tentative Diagnosis: FRACTURE CLOSED COMPLETE TRAUMA

DISTAL 3RD RADIUS ULNA AFFECTED
Final Diagnosis: DM FOOT RIGHT, DM TYPE II

Operation Date: 10-21-2022 Ward: SLR

Circulating Nurse: Surgeon: DR. WONG
Instruments Nurse: Operation CLOSED
Performed: REDUCTION,
APPLICATION OF
SPLINT LEFT
WAIST

Anesthesiologist: --NOT INDICATED Anesthesia Began:

Anesthetic: --NOT INDICATED Operation Started: 10:20PM
Time Finished: 10:35PM

Operation Performed:

- Manual fraction done on left waist

- Reduction done
- Wadding sheet applied
- Splint applied
- Elastic bandage applied
- End of procedure
3RD Surgical Operation

Tentative Diagnosis: DM FOOT RIGHT

T2 DM
Final Diagnosis: DM FOOT RIGHT, DM TYPE II

Operation Date: 10-28-2022 Ward: SW

Circulating Nurse: NURSE Surgeon: DRA. GARCIA
VILLAFRANCA
Instruments Nurse: NURSE DELEZ Operation S/P BKA, RIGHT
Performed:

Anesthesiologist: DRA. AGASER Anesthesia Began: 12:57AM

Anesthetic: SAB Operation Started: 1:09AM
Time Finished: 2:02AM

Surgical Procedure:

- Patient supine, under spinal anesthesia

- Asepsis/ antiseptic technique
- Sterile drapes applied
- Incision done creating long posterior flap
- Superficial vessels ligated
- Anterior muscle group cut
- Anterior tibial vessels identified and ligated
- Deep peroneal nerve ligated
- Lateral muscle group cut
- Posterior tibial vessels identified and ligated
- Posterior tibial nerve ligated proximally
- Periosteum elevated
- Tibia-fibula individually cut with giggle saw
- Fibular vessels identified and ligated
- Posterior muscle group cut
- Bone edges filed
- Copious irrigation
- Hemostasis done
- Applied penrose drain
- Posterior myofascial flap anchored anteriorly
- Closure by layer
- Applied antiseptic and sterile gauze
- End of procedure
 d. Laboratory Analysis
Patient Name: Lolita Rico Sugabo

Age: 58 years old

TYPE 2 DIABETES MELLITUS

Date: September 30, 2022 (2:42 pm)

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Arterial Blood Gas
PH 7.41 7.32 – 7.45 Normal For low PCO2:
PCO2 34.7 35.0 – 45.0 Low - Encourage client to breathe slowly in a paper bag to rebreathe CO2
PO2 81.1 80.0 – 100 Normal - Breathe with the patient. Provide emotional support and reassurance, anti-
HCO3 22.8 22.0 – 26.0 Normal anxiety agents, sedation
BASE EXCESS - 2.8 - 2.0 + 2.0 Low - On ventilator, adjustment of ventilation settings (decrease rate
OXYGEN 96.7 94% – 100 % Normal and tidal volume)
SATURATION - Pre-procedure teaching, preventative emotional
support, monitor blood gases as indicated
For low base excess:
- Medications: Correcting underlying cause will often improve
acidosis
- Restore fluid balance, prevent dehydration with IV fluids
- Correct electrolyte imbalances
- Administer Sodium Bicarbonate IV if acidosis is severe and does not
respond rapidly enough to treatment of primary cause. (Oral bicarbonate is
sometimes given to clients with chronic
metabolic acidosis) Be careful not to overtreat and put client
into alkalosis
- As acidosis improves, hydrogen ions shift out of cells and potassium
 moves intracellularly. Hyperkalemia may become hypokalemia and
potassium replacement will be needed.
- Assessment (vital signs, intake and output, neuro, GI, and respiratory
status, cardiac monitoring, reassess repeated arterial blood gases and
electrolytes)

Analysis:

 Arterial Blood Gas

o Low PCO2 may indicate respiratory alkalosis which may be primary or secondary to a primary metabolic acidosis.
o Low base excess may suggest primary metabolic acidosis or a compensated respiratory alkalosis

Date: September 30, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Electrolytes (1)
SODIUM (Na) 130.9 135 – 148 Low For low sodium:
mmol/L - Restoration of blood volume and sodium levels. Medications
POTASSIUM 3.90 3.50 – 5.30 Normal include isotonic IV solution (Ringer’s, 0.9% NaCl), hypertonic IV Na
(K) mmol/L solution (3% NaCl) is used to treat the client with severe
CHLORIDE 90.0 98 – 107 Low hyponatremia (Na:
(Cl) mmol/L 110 – 115 mEq/L), loop diuretics (e.g., Furosemide) to promote
BUN (STAT) 17.6 7-18 mg/dL Normal isotonic diuresis
CREATININ 1.43 0.3 – 1.3 High - Fluid and Dietary Management. It includes increase foods high in
E (STAT) mg/dL sodium and restrict fluid in volume
Electrolytes (2) - Assessment of signs/symptoms of hyponatremia,
SODIUM (Na) 128.8 135 – 148 Low especially in continual mental status assessment, seizure precautions,
mmol/L strict intake and output and monitoring weight daily, reassess lab
POTASSIUM 3.82 3.50 – 5.30 Normal results
(K) mmol/L Low chloride:
CHLORIDE 89.5 98 – 107 Low - The nurse monitors intake and output, arterial blood gas values, and
(Cl) mmol/L serum electrolytes, as well as the patient’s level of consciousness and
BUN (STAT) 17.6 7-18 mg/dL Normal muscle strength and movement. Changes are reported to the physician
CREATININ 1.12 0.3 – 1.3 Normal promptly. Vital signs are monitored ang respiratory assessment is
E (STAT) mg/dL carried out frequently. The nurse teaches the patient about foods with
high chloride content.
For high creatinine:
- Correlate the elevated creatinine levels to clinical problems.
- As ordered by the physician, hold all medications for 24 hours
before the test as some medications may affect the result.
- Check the urine output in 24 hours.
Complete Blood Count
WBC 22.08 x 10^3/uL 4.00 – 10.00 High For high WBC and PCT:
Neu% 88.0% 50.0 – 60.0 High - Consider the overall WBC count plus abnormalities in differential.
Evaluate patient signs or symptoms of trauma, inflammation, and
Lym% 7.0% 35.0 – 45.0 Low
infection
Mon% 4.0% 2.0 – 4.0 Normal
- Antibiotic therapies if indicated by infection (followed by cultures
Eos% 1.0% 2.0 – 5.0 Low
to determine efficacy of antibiotics)
Bas% 0.0% 0.0 – 1.0 Normal - Anti-inflammatories for inflammation
RBC 3.78 x 10^6/uL 3.50 – 5.50 Normal - Provide neutropenic precautions when necessary
HGB 10.8 g/dL 11.0 – 16.0 Normal - Interventions to lower the effects of high neutrophil such as below
HCT 33.4% 37.0 – 54.0 Low normal sodium level
MCV 88.3 fL 80.0 – 100.0 Normal - Educate patient on the finishing any antibiotics completely. Do not
MCH 28.5 pg 27.0 – 34.0 Normal stop prior, even if the patient says they are feeling better.
MCHC 32.3 g/dL 32.0 – 36.0 Normal For low HCT:
RDW-CV 11.6% 11.0 – 16.0 Normal - Assess the patient with a low hematocrit for his/her ability to
RDW-SD 43.1 fL 35.0 – 56.0 Normal tolerate physical activity. Using the "tilt test", the nurse takes the
PLT 366 x 10^3/uL 150 – 450 Normal patient's pulse before and after sitting up. Assess the extent of the
MPV 8.2 fL 6.5 – 12.0 Normal patient's weakness and fatigue on exertion when planning physical
PDW 16.1 9.0 – 17.0 Normal
 PCT 0.300 % 0.108 – 0.282 High care activities.
- Increase amounts of protein and iron to help the bone marrow
produce additional red blood cells. Encourage the patient to eat foods
that are high in protein and iron, such as liver, egg yolk, beef, and
dried fruits such as prunes and apricots.

Analysis

 Electrolytes
o Low sodium may indicate too much fluid consumption, leading to hyponatremia
o Low chloride may indicate hypochloremia leading to dehydration
o High creatinine may indicate poor kidney function
 Complete Blood Count
o High WBC level may indicate presence of infection
o High neutrophil may indicate sodium level below normal and infection
o Low lymphocyte may indicate higher risk of infection
o Low eosinophil may indicate increased production of cortisol, leading to stress
o Low HCT may indicate insufficient supply of health RBCs, leading to anemia
o High PCT may indicate serious bacterial infection

Date: October 1, 2022

Lab Test Res Time Normal Interpretation Nursing Responsibilities

ult Values
Serum Cholesterol
 CHOL HDL 5.58 12:14 0.0 – 35.0 Normal For high glucose:
pm mg/dL - Assess intake and output
CHOLESTEROL 74.8 10.54 0.0 – 200.0 Normal - Assess for polyphagia
2 am mg/dL - Assess for risk factors for developing hyperglycemia such as
GLUCOSE 233. 10:59 70.0 – 105.0 High critical illness, parenteral nutrition, culprit medications, etc. Assess
79 am mg/dL for complications of hyperglycemia such as wounds that are not
TRIGLYCERIDES 119. 10:54 0.0 – 150.0 Normal healing, impaired vision, neuropathy, and neuropathic pain. Assess
45 am mg/dL the patient’s feet as many patients with chronic hyperglycemia
LDL 45.3 12:14 130.0 – 159.0 Low easily develop wounds that go unnoticed due to the neuropathy.
5 pm mg/dL Monitor vital signs as many times hyperglycemia accompanies a
severe infection or can progress into DKA or HHS.
For low LDL:
- Monitor LDL levels
- Diet modifications to raise LDL, if indicated
Urinalysis (SLR)
RESULTS
Color DARK CLEAR TO High For urine color analysis:
YELLOW SLIGHTLY - Assess voiding pattern and symptoms
Transparency SLIGHTLY TURBID Normal - Monitor lab work and urinalysis
TURBID - Review medications. Educate on medications.
- Compare intake and output
- Review diagnostic tests
- Encourage water intake
- Limit other fluids
CHEMICAL TEST
Blood TRACE NEGATIVE Should be - Monitor vitals
negative - Bodyweight
Bilirubin NEGATIVE NEGATIVE Normal - Check for the presence of edema
Urobilinogen NORMAL PRESENT Normal - Dip urine to check for blood and proteins
Ketones 2+ NEGATIVE Should not be - Check labs to assess renal function and coagulation parameters
present - Check the list of patient medications (warfarin can cause
Protein 1+ NEGATIVE Should not be hematuria)
 present- Check blood pressure
Nitrite NEGATIVE NEGATIVE Normal - Check blood sugars and treat with insulin as ordered
Glucose 4+ NEGATIVE - Start two large-bore IVs
Should not be
present- Administer fluids as recommended
pH 5.5 7.35 – 7.45 Low - Check electrolytes as potassium levels will drop with insulin
Specific Gravity 1.020 1.005 – 1.030 Normal treatment
Leukocytes NEGATIVE NEGATIVE Normal - Check renal function
Ascorbic Acid NEGATIVE NEGATIVE Normal - Assess mental status
- Look for signs of infection (a common cause of DKA)
- Educate the patient on the importance of compliance with diabetic
medications
- Educate the patient on the importance of follow up
- Check urine output
- Encourage patient to quit smoking and abstain from alcohol
- Encourage a healthy diet
- Check urine and blood cultures
- Listen to the lungs for rales and crackles
MICROSCOPIC
WBC 7-9 /HPF 2-5 High For high WBC in urine:
RBC 2-4 /HPF <2 High - Consider the overall WBC count plus abnormalities in differential.
Epithelial Cells FEW FEW Normal Evaluate patient signs or symptoms of trauma, inflammation, and
Mucus Thread MODERAT FEW High infection
E - Antibiotic therapies if indicated by infection (followed by cultures
to determine efficacy of antibiotics)
- Anti-inflammatories for inflammation
- Provide neutropenic precautions when necessary
- Educate patient on the finishing any antibiotics completely. Do not
stop prior, even if the patient says they are feeling better.
For high RBC and mucus thread in urine:
- Assess voiding pattern and symptoms
- Monitor lab work and urinalysis
- Check urine and blood cultures
 - Review medications. Educate on medications.
- Compare intake and output
- Review diagnostic tests
- Encourage water intake
- Limit other fluids
Urinalysis (ER/SLR-14)
RESULTS
Color YELLOW CLEAR TO High For urine color analysis:
Transparency SLIGHTLY SLIGHTLY Normal - Assess voiding pattern and symptoms
TURBID TURBID - Monitor lab work and urinalysis
- Review medications. Educate on medications.
- Compare intake and output
- Review diagnostic tests
- Encourage water intake
- Limit other fluids
CHEMICAL TEST
Blood NEGATIVE NEGATIVE Normal - Monitor vitals
Bilirubin NEGATIVE NEGATIVE Normal - Bodyweight
Urobilinogen NORMAL PRESENT Normal - Check for the presence of edema
Ketones TRACE NEGATIVE Should be - Dip urine to check for blood and proteins
negative - Check labs to assess renal function and coagulation parameters
Protein 1+ NEGATIVE Should not be - Check the list of patient medications (warfarin can cause
present hematuria)
Nitrite NEGATIVE NEGATIVE Normal - Check blood pressure
Glucose 4+ NEGATIVE Should not be - Check blood sugars and treat with insulin as ordered
present - Start two large-bore IVs
pH 5.0 7.35 – 7.45 Low - Administer fluids as recommended
Specific Gravity 1.015 1.005 – 1.030 Normal - Check electrolytes as potassium levels will drop with insulin
Leukocytes NEGATIVE NEGATIVE Normal treatment
Ascorbic Acid NEGATIVE NEGATIVE Normal - Check renal function
- Assess mental status
- Look for signs of infection (a common cause of DKA)
 - Educate the patient on the importance of compliance with diabetic
medications
- Educate the patient on the importance of follow up
- Check urine output
- Encourage patient to quit smoking and abstain from alcohol
- Encourage a healthy diet
- Check urine and blood cultures
- Listen to the lungs for rales and crackles
MICROSCOPIC
WBC 5-7 /HPF 2-5 High For high WBC in urine:
RBC 2-3 /HPF <2 High - Consider the overall WBC count plus abnormalities in differential.
Epithelial Cells FEW FEW Normal Evaluate patient signs or symptoms of trauma, inflammation, and
Mucus Thread FEW FEW Normal infection
Course Granular 10- /LPF 0-2 High - Antibiotic therapies if indicated by infection (followed by cultures
12 to determine efficacy of antibiotics)
- Anti-inflammatories for inflammation
- Provide neutropenic precautions when necessary
- Educate patient on the finishing any antibiotics completely. Do not
stop prior, even if the patient says they are feeling better.
For high RBC and course granular:
- Assess voiding pattern and symptoms
- Monitor lab work and urinalysis
- Dip urine to check for blood and proteins
- Review medications. Educate on medications.
- Compare intake and output
- Review diagnostic tests
- Encourage water intake
- Limit other fluids
Electrolytes
SODIUM (Na) 135.6 135 – 148 Normal
mmol/L
POTASSIUM (K) 3.64 3.50 – 5.30 Normal
 mmol/L

Analysis

 Serum Cholesterol
o High glucose level indicates high blood sugar common in diabetes patients
o Low LDL level is usually normal but may also indicate some health problems. Further lab analysis may be performed if indicated.
 Urinalysis
o Yellow/dark yellow urine may indicate dehydration and low urine output
o Blood in urine may indicate inflammation in the genitourinary tract, leading to hematuria
o Ketones in urine may indicate patient’s body being acidic
o Protein in urine may indicate damaged kidneys
o Glucose in urine indicates presence of sugar common in diabetes patients
o Low pH in urine may indicate presence of ketones
o High WBC in urine may indicate presence of infection
o High RBC in urine may indicate dehydration
o High mucus thread in urine may indicate sign of UTI
o Granular casts are casts that contain either proteins, tubular cells or leukocytes that have broken down.

Date: October 2, 2022

 Lab Test Result Normal Interpretation Nursing Responsibilities
Values
Electrolytes
SODIUM (Na) 134.8 135 – 148 Low For low sodium:
mmol/L - Restoration of blood volume and sodium levels. Medications
include isotonic IV solution (Ringer’s, 0.9% NaCl), hypertonic IV Na
solution (3% NaCl) is used to treat the client with severe
hyponatremia (Na:
110 – 115 mEq/L), loop diuretics (e.g., Furosemide) to promote
isotonic diuresis
- Fluid and Dietary Management. It includes increase foods high in
sodium and restrict fluid in volume
- Assessment of signs/symptoms of hyponatremia,
especially in continual mental status assessment, seizure precautions,
strict intake and output and monitoring weight daily, reassess lab
results
Coagulation
PROTHROMBI 16.3 11.7 – 14.1 High -Assess for any signs of bleeding and should teach the patient and
N TIME seconds family how to lower the risk of bleeding and what symptoms to look
% ACTIVITY 49.10% 68.9% – Low for at home that require medical attention. Patient and family
103.4% teaching includes preventing bleeding episodes (avoiding contact
INR 1.35 0.81 – 1.22 High sports or other activities in which head injury might occur, avoiding
Activated Partial 29.3 25.0 – 39.0 Normal accidental cuts by using an electric razor and taking care when using
Thromboplastin seconds sharp tools or kitchen implements, avoiding intramuscular injections,
Time and brushing teeth with a soft toothbrush to decrease gum bleeding)
and recognizing bleeding symptoms (headache or changes in
neurological status can indicate intracranial bleeding, vomiting frank
blood or coffee ground material, a backache or flank pain may
indicate internal bleeding, urine that appears dark or smoky looking
may indicate bleeding in the urinary tract, unexplained increase in
pulse rate and decrease in blood pressure, and joint pain may indicate
bleeding into a joint).
Analysis

 Electrolytes
o Low sodium may indicate too much fluid consumption, leading to hyponatremia
 Coagulation
o High prothrombin time may indicate higher risk for bleeding
o Low % activity of coagulation slow blood clot formation
o High INR may indicate slow blood clot formation and may result to higher risk for bleeding

Date: October 3, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Coagulation
PROTHROMBI 15.3 11.7 – 14.1 High -Assess for any signs of bleeding and should teach the patient and family
N TIME seconds how to lower the risk of bleeding and what symptoms to look for at home
% ACTIVITY 62.07% 68.9% – Low that require medical attention. Patient and family teaching includes
103.4% preventing bleeding episodes (avoiding contact sports or other activities in
INR 1.20 0.81 – 1.22 Normal which head injury might occur, avoiding accidental cuts by using an electric
Activated Partial 28.7 25.0 – 39.0 Normal razor and taking care when using sharp tools or kitchen implements,
Thromboplastin seconds avoiding intramuscular injections, and brushing teeth with a soft toothbrush
Time to decrease gum bleeding) and recognizing bleeding symptoms (headache
or changes in neurological status can indicate intracranial bleeding,
vomiting frank blood or coffee ground material, a backache or flank pain
may indicate internal bleeding, urine that appears dark or smoky looking
may indicate bleeding in the urinary tract, unexplained increase in pulse rate
and decrease in blood pressure, and joint pain may indicate bleeding into a
joint).
Analysis

 Coagulation
o High prothrombin time may indicate higher risk for bleeding
o Low % activity of coagulation slow blood clot formation
Date: October 6, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Complete Blood Count
WBC 9.92 x 10^3/uL 4.00 – 10.00 Normal For high neutrophils and monocytes and low lymphocytes:
Neu% 73.0% 50.0 – 60.0 High - Consider the overall WBC count plus abnormalities in
Lym% 18.0% 35.0 – 45.0 Low differential. Evaluate patient signs or symptoms of trauma,
Mon% 7.0% 2.0 – 4.0 High inflammation, and infection
Eos% 2.0% 2.0 – 5.0 Normal - Antibiotic therapies if indicated by infection (followed by
Bas% 0.0% 0.0 – 1.0 Normal cultures to determine efficacy of antibiotics)
RBC 2.99 x 10^6/uL 3.50 – 5.50 Low - Anti-inflammatories for inflammation
HGB 8.6 g/dL 11.0 – 16.0 Low - Provide neutropenic precautions when necessary
HCT 26.3% 37.0 – 54.0 Low - Interventions to lower the effects of high neutrophil such as
MCV 88.2 fL 80.0 – 100.0 Normal below normal sodium level
MCH 28.9 pg 27.0 – 34.0 Normal - Educate patient on the finishing any antibiotics completely. Do
MCHC 32.7 g/dL 32.0 – 36.0 Normal not stop prior, even if the patient says they are feeling better.
For low RBC, HGB, and HCT:
RDW-CV 11.6% 11.0 – 16.0 Normal
- Prioritize activities. Assist the patient in prioritizing activities and
RDW-SD 43.5 fL 35.0 – 56.0 Normal
establishing balance between activity and rest that would be
PLT 388 x 10^3/uL 150 – 450 Normal
acceptable to the patient.
MPV 7.1 fL 6.5 – 12.0 Normal
- Assess the patient with a low hematocrit for his/her ability to
PDW 15.6 9.0 – 17.0 Normal tolerate physical activity. Using the "tilt test", the nurse takes the
PCT 0.277 % 0.108 – 0.282 Normal patient's pulse before and after sitting up. Assess the extent of the
patient's weakness and fatigue on exertion when planning physical
 care activities
- Exercise and physical activity
- Increase amounts of protein and iron to help the bone marrow
produce additional red blood cells. Encourage the patient to eat
foods that are high in protein and iron, such as liver, egg yolk,
beef, and dried fruits such as prunes and apricots.
- The nurse should inform the patient that alcohol interferes with
the utilization of essential nutrients and should advise the patient to
avoid or limit his or her intake of alcoholic beverages.
- Dietary teaching
- The nurse should monitor the patient’s vital signs and pulse
oximeter readings closely
- The nurse should assist the patient to develop ways to incorporate
the therapeutic plan into everyday activities
- Patients receiving high-dose corticosteroids may need assistance
to obtain needed insurance coverage or to explore alternative ways
to obtain these medications

Analysis

 Complete Blood Count

o High neutrophil may indicate sodium level below normal and infection
o Low lymphocyte may indicate higher risk of infection
o High monocyte may indicate chronic infections
o Low RBC may indicate anemia
o Low HGB may indicate low levels of oxygen in the blood ang may result in anemia
o Low HCT may indicate insufficient supply of health RBCs that may result in anemia
Date: October 9, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Complete Blood Count
WBC 7.79 x 10^3/uL 4.00 – 10.00 Normal - Consider the overall WBC count plus abnormalities in
Neu% 73.0% 50.0 – 60.0 High differential. Evaluate patient signs or symptoms of trauma,
Lym% 15.0% 35.0 – 45.0 Low inflammation, and infection
Mon% 8.0% 2.0 – 4.0 High - Antibiotic therapies if indicated by infection (followed by
Eos% 5.0% 2.0 – 5.0 Normal cultures to determine efficacy of antibiotics)
Bas% 0.0% 0.0 – 1.0 Normal - Anti-inflammatories for inflammation
RBC 4.15 x 10^6/uL 3.50 – 5.50 Normal - Provide neutropenic precautions when necessary
HGB 12.2 g/dL 11.0 – 16.0 Normal - Interventions to lower the effects of high neutrophil such as
HCT 37.3% 37.0 – 54.0 Normal below normal sodium level
MCV 89.9 fL 80.0 – 100.0 Normal - Educate patient on the finishing any antibiotics completely. Do
MCH 29.3 pg 27.0 – 34.0 Normal not stop prior, even if the patient says they are feeling better.
MCHC 32.6 g/dL 32.0 – 36.0 Normal
RDW-CV 12.0% 11.0 – 16.0 Normal
RDW-SD 45.5 fL 35.0 – 56.0 Normal
PLT 406 x 10^3/uL 150 – 450 Normal
MPV 7.1 fL 6.5 – 12.0 Normal
PDW 15.5 9.0 – 17.0 Normal
PCT 0.288 % 0.108 – 0.282 High

Analysis

 Complete Blood Count

 o High neutrophil may indicate sodium level below normal and infection
o Low lymphocyte may indicate higher risk of infection
o High monocyte may indicate chronic infections
o High PCT may indicate serious bacterial infection

Date: October 19, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Coagulation
PROTHROMBI 13.7 11.7 – 14.1 Normal
N TIME seconds
% ACTIVITY 74.97% 68.9% – Normal
103.4%
INR 1.08 0.81 – 1.22 Normal

Date: October 23, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities
Values
Complete Blood Count
WBC 5.38 x 10^3/uL 4.00 – 10.00 Normal For low neutrophils and high monocytes and eosinophils:
Neu% 41.0% 50.0 – 60.0 Low - Consider the overall WBC count plus abnormalities in
Lym% 40.0% 35.0 – 45.0 Normal differential. Evaluate patient signs or symptoms of trauma,
Mon% 7.0% 2.0 – 4.0 High inflammation, and infection
Eos% 12.0% 2.0 – 5.0 High - Antibiotic therapies if indicated by infection (followed by
Bas% 0.0% 0.0 – 1.0 Normal cultures to determine efficacy of antibiotics)
RBC 3.61 x 10^6/uL 3.50 – 5.50 Normal - Anti-inflammatories for inflammation
HGB 10.3 g/dL 11.0 – 16.0 Low - Check medications for adverse effects
 HCT 32.3% 37.0 – 54.0 Low - Provide neutropenic precautions when necessary
MCV 89.6 fL 80.0 – 100.0 Normal - Monitor the white blood cell count to watch for downward trends
MCH 28.6 pg 27.0 – 34.0 Normal and the patient should be carefully assessed for any signs of
MCHC 31.9 g/dL 32.0 – 36.0 Low infection
RDW-CV 12.9 % 11.0 – 16.0 Normal - Promote excellent hygiene and prevent infection from food,
RDW-SD 48.5 fL 35.0 – 56.0 Normal medical equipment, and environment
PLT 313 x 10^3/uL 150 – 450 Normal - Educate patient on the finishing any antibiotics completely. Do
MPV 7.0 fL 6.5 – 12.0 Normal not stop prior, even if the patient says they are feeling better.
PDW 15.5 9.0 – 17.0 Normal For low RBC, HGB, and MCHC:
PCT 0.218 % 0.108 – 0.282 Normal - Prioritize activities. Assist the patient in prioritizing activities and
establishing balance between activity and rest that would be
acceptable to the patient.
- Assess the patient with a low hematocrit for his/her ability to
tolerate physical activity. Using the "tilt test", the nurse takes the
patient's pulse before and after sitting up. Assess the extent of the
patient's weakness and fatigue on exertion when planning physical
care activities
- Exercise and physical activity
- Increase amounts of protein and iron to help the bone marrow
produce additional red blood cells. Encourage the patient to eat
foods that are high in protein and iron, such as liver, egg yolk,
beef, and dried fruits such as prunes and apricots.
- The nurse should inform the patient that alcohol interferes with
the utilization of essential nutrients and should advise the patient to
avoid or limit his or her intake of alcoholic beverages.
- Dietary teaching
- The nurse should monitor the patient’s vital signs and pulse
oximeter readings closely
- The nurse should assist the patient to develop ways to incorporate
the therapeutic plan into everyday activities
- Patients receiving high-dose corticosteroids may need assistance
to obtain needed insurance coverage or to explore alternative ways
 to obtain these medications

Analysis

 Complete Blood Count

o Low neutrophil a weakened immune system
o High monocyte may indicate chronic infections
o High eosinophil may indicate a mild condition of drug reaction or allergy and other blood disorders
o Low HGB may indicate low levels of oxygen in the blood ang may result in anemia
o Low HCT may indicate insufficient supply of health RBCs, leading to anemia
o Low MCHC may indicate iron deficiency leading to anemia and thalassemia

Date: October 25, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Complete Blood Count
WBC 4.69 x 10^3/uL 4.00 – 10.00 Normal For low neutrophils and high monocytes and eosinophils:
Neu% 39.0% 50.0 – 60.0 Low - Consider the overall WBC count plus abnormalities in
Lym% 42.0% 35.0 – 45.0 Normal differential. Evaluate patient signs or symptoms of trauma,
Mon% 7.0% 2.0 – 4.0 High inflammation, and infection
Eos% 12.0% 2.0 – 5.0 High - Antibiotic therapies if indicated by infection (followed by
Bas% 0.0% 0.0 – 1.0 Normal cultures to determine efficacy of antibiotics)
RBC 3.41 x 10^6/uL 3.50 – 5.50 Low - Anti-inflammatories for inflammation
HGB 9.8 g/dL 11.0 – 16.0 Low - Check medications for adverse effects
 HCT 30.5% 37.0 – 54.0 Low - Provide neutropenic precautions when necessary
MCV 89.6 fL 80.0 – 100.0 Normal - Monitor the white blood cell count to watch for downward trends
MCH 28.7 pg 27.0 – 34.0 Normal and the patient should be carefully assessed for any signs of
MCHC 32.0 g/dL 32.0 – 36.0 Normal infection
RDW-CV 13.1 % 11.0 – 16.0 Normal - Promote excellent hygiene and prevent infection from food,
RDW-SD 49.3 fL 35.0 – 56.0 Normal medical equipment, and environment
PLT 299 x 10^3/uL 150 – 450 Normal - Educate patient on the finishing any antibiotics completely. Do
MPV 7.1 fL 6.5 – 12.0 Normal not stop prior, even if the patient says they are feeling better.
PDW 15.6 9.0 – 17.0 Normal For low RBC, HGB, and HCT:
PCT 0.214 % 0.108 – 0.282 Normal - Prioritize activities. Assist the patient in prioritizing activities and
establishing balance between activity and rest that would be
acceptable to the patient.
- Assess the patient with a low hematocrit for his/her ability to
tolerate physical activity. Using the "tilt test", the nurse takes the
patient's pulse before and after sitting up. Assess the extent of the
patient's weakness and fatigue on exertion when planning physical
care activities
- Exercise and physical activity
- Increase amounts of protein and iron to help the bone marrow
produce additional red blood cells. Encourage the patient to eat
foods that are high in protein and iron, such as liver, egg yolk,
beef, and dried fruits such as prunes and apricots.
- The nurse should inform the patient that alcohol interferes with
the utilization of essential nutrients and should advise the patient to
avoid or limit his or her intake of alcoholic beverages.
- Dietary teaching
- The nurse should monitor the patient’s vital signs and pulse
oximeter readings closely
- The nurse should assist the patient to develop ways to incorporate
the therapeutic plan into everyday activities
- Patients receiving high-dose corticosteroids may need assistance
to obtain needed insurance coverage or to explore alternative ways
 to obtain these medications

Analysis

 Complete Blood Count

o Low neutrophil a weakened immune system
o High monocyte may indicate chronic infections
o High eosinophil may indicate a mild condition of drug reaction or allergy and other blood disorders
o Low RBC may indicate anemia
o Low HGB may indicate low levels of oxygen in the blood ang may result in anemia
o Low HCT may indicate insufficient supply of health RBCs, leading to anemia

Date: October 27, 2022 (11:40 pm)

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Arterial Blood Gas
PH 7.37 7.32 – 7.45 Normal For low PO2 and high PCO2:
PCO2 47 35.0 – 45.0 High - Early recognition of respiratory status and treat cause
PO2 73 80.0 – 100 Low - Restore ventilation and gas exchange (CPR for respiratory
HCO3 25.9 22.0 – 26.0 Normal failure with oxygen supplementation and intubation and ventilator
BASE EXCESS 2.0 - 2.0 + 2.0 Normal support if indicated)
OXYGEN 94.6 94% – 100 % Normal - Treatment of respiratory infections with bronchodilators, antibiotic
SATURATION therapy
- Reverse excess anesthetics and narcotics with medications such as
 naloxone (Narcan)
- Breathe in response to low oxygen levels
- Adjusted to high carbon dioxide level through metabolic compensation
(therefore, high CO2 not a breathing trigger)
- Treat with no higher than 2 liters O2 per cannula
- Continue respiratory assessments, monitor further arterial blood gas
results
Electrolytes
SODIUM (Na) 142.5 135 – 148 Normal For low potassium:
mmol/L - Medications include potassium supplements (oral or parenteral_. Never
POTASSIUM 3.41 3.50 – 5.30 Low give potassium IV push, only as IV infusion
(K) mmol/L - Dietary management include potassium-rich foods (fruits and vegetables)
CHLORIDE 99.8 98 – 107 Normal - Health promotion for prevention of hypokalemia include using balanced
(Cl) mmol/L electrolyte fluids with GI loss, diet teaching and/or potassium supplements
BUN (STAT) 8.5 7-18 mg/dL Normal with meds that predispose to hypokalemia, and regular monitoring of serum
CREATININE 0.79 0.3 – 1.3 Normal potassium levels
(STAT) mg/dL - Assessment of nursing history for precipitating factors as stimuli (mental
status, vital signs, and reassess lab results)

Analysis

 Arterial Blood Gas

o High PCO2 may be caused by decreased ventilation secondary to increase CO2 in the blood
o Low PO2 may indicate low oxygen levels
 Electrolytes
o Low potassium may indicate hypokalemia due to excessive loss of potassium in urine secondary to medications

Date: October 27, 2022 (4:14 pm)

 Lab Test Result Normal Interpretation Nursing Responsibilities
Values
Complete Blood Count
WBC Count 6.2 4.00 – 10.00 x Normal For low HCT:
10^9/L - Assess the patient with a low hematocrit for his/her ability to
Hemoglobin 11.5 11.0 – 15.0 Normal tolerate physical activity. Using the "tilt test", the nurse takes the
g/dL patient's pulse before and after sitting up. Assess the extent of the
Hematocrit 34.5 37.0% – 47.0% Low patient's weakness and fatigue on exertion when planning physical
RBC Count 3.98 3.50 – 5.00 x Normal care activities.
10^12/L - Increase amounts of protein and iron to help the bone marrow
MCV 87.0 80.0 – 100.0 fL Normal produce additional red blood cells. Encourage the patient to eat
MCH 29.0 27.0 – 34.0 pg Normal foods that are high in protein and iron, such as liver, egg yolk,
MCHC 33.4 32.0 – 36.0 Normal beef, and dried fruits such as prunes and apricots.
g/dL
RDW-CV 13.7 11.0% – 16.0% Normal
RDW-SD 43.0 35.0 – 56.0 fL Normal
Platelet Count 292 150 – 450 x Normal
10^9/L
MPV 6.8 6.5 – 12.0 fL Normal
Differential Count
Segmenter 34 50.0% – 60.0% Low For low segmenter:
Lymphocyte 49 35.0% – 45.0% High - Consider the overall WBC count plus abnormalities in
Monocyte 5 2.0% – 4.0% High differential. Evaluate patient signs or symptoms of trauma,
Eosinophil 12 2.0% – 5.0% High inflammation, and infection
Basophil 0 0.0% – 1.0% Normal - Antibiotic therapies if indicated by infection (followed by
cultures to determine efficacy of antibiotics)
- Anti-inflammatories for inflammation
- Check medications for adverse effects
- Provide neutropenic precautions when necessary
- Monitor the white blood cell count to watch for downward trends
and the patient should be carefully assessed for any signs of
infection
 - Promote excellent hygiene and prevent infection from food,
medical equipment, and environment
For high lymphocytes, monocytes, and eosinophils:
- Consider the overall WBC count plus abnormalities in
differential. Evaluate patient signs or symptoms of trauma,
inflammation, and infection
- Antibiotic therapies if indicated by infection (followed by
cultures to determine efficacy of antibiotics)
- Anti-inflammatories for inflammation
- Check medications for adverse effects
- Monitor the white blood cell count to watch for downward trends
and the patient should be carefully assessed for any signs of
infection
- Promote excellent hygiene and prevent infection from food,
medical equipment, and environment
- Educate patient on the finishing any antibiotics completely. Do
not stop prior, even if the patient says they are feeling better.

Analysis

 Complete Blood Count

o Low HCT may indicate insufficient supply of health RBCs, leading to anemia
 Differential Count
o Low segmenter may indicate low levels of neutrophils, leading to neutropenia
o High lymphocyte may indicate bacterial or viral infection
o High monocyte may indicate chronic infections
o High eosinophil may indicate a mild condition of drug reaction or allergy and other blood disorders
Date: October 27, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Coagulation
PROTHROMBI 13.3 11.7 – 14.1 Normal
N TIME seconds
% ACTIVITY 78.57% 68.9% – Normal
103.4%
INR 1.05 0.81 – 1.22 Normal
Activated Partial 29.1 25.0 – 39.0 Normal
Thromboplastin seconds
Time

Date: October 28, 2022 (11:06 am)

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Complete Blood Count
WBC Count 6.6 4.00 – 10.00 x Normal For low HGB, and HCT, and RBC:
10^9/L - Prioritize activities. Assist the patient in prioritizing activities and
Hemoglobin 9.0 11.0 – 15.0 Low establishing balance between activity and rest that would be
g/dL acceptable to the patient.
 Hematocrit 27.7 37.0 – 47.0% Low - Assess the patient with a low hematocrit for his/her ability to
RBC Count 3.15 3.50 – 5.00 x Low tolerate physical activity. Using the "tilt test", the nurse takes the
10^12/L patient's pulse before and after sitting up. Assess the extent of the
MCV 88.0 80.0 – 100.0 Normal patient's weakness and fatigue on exertion when planning physical
fL care activities
MCH 28.6 27.0 – 34.0 pg Normal - Exercise and physical activity
MCHC 32.6 32.0 – 36.0 Normal - Increase amounts of protein and iron to help the bone marrow
g/dL produce additional red blood cells. Encourage the patient to eat
RDW-CV 13.4 11.0 – 16.0% Normal foods that are high in protein and iron, such as liver, egg yolk,
RDW-SD 42.0 35.0 – 56.0 fL Normal beef, and dried fruits such as prunes and apricots.
Platelet Count 270 150 – 450 x Normal - The nurse should inform the patient that alcohol interferes with
10^9/L the utilization of essential nutrients and should advise the patient to
MPV 6.7 6.5 – 12.0 fL Normal avoid or limit his or her intake of alcoholic beverages.
- Dietary teaching
- The nurse should monitor the patient’s vital signs and pulse
oximeter readings closely
- The nurse should assist the patient to develop ways to incorporate
the therapeutic plan into everyday activities
- Patients receiving high-dose corticosteroids may need assistance
to obtain needed insurance coverage or to explore alternative ways
to obtain these medications
Differential Count
Segmenter 58 50.0% – 60.0% Normal For low lymphocyte and high eosinophil:
Lymphocyte 29 35.0% – 45.0% Low - Consider the overall WBC count plus abnormalities in
Monocyte 4 2.0% – 4.0% Normal differential. Evaluate patient signs or symptoms of trauma,
Eosinophil 9 2.0% – 5.0% High inflammation, and infection
Basophil 0 0.0% – 1.0% Normal - Antibiotic therapies if indicated by infection (followed by
cultures to determine efficacy of antibiotics)
- Anti-inflammatories for inflammation
- Check medications for adverse effects
- Monitor the white blood cell count to watch for downward trends
and the patient should be carefully assessed for any signs of
 infection
- Promote excellent hygiene and prevent infection from food,
medical equipment, and environment
- Educate patient on the finishing any antibiotics completely. Do
not stop prior, even if the patient says they are feeling better.

Analysis

 Complete Blood Counts

o Low HGB may indicate low levels of oxygen in the blood ang may result in anemia
o Low HCT may indicate insufficient supply of healthy RBCs, leading to anemia
o Low RBC may indicate anemia
 Differential Count
o Low lymphocyte may indicate higher risk of infection
o High eosinophil may indicate a mild condition of drug reaction or allergy and other blood disorders

Date: October 29, 2022

Lab Test Result Normal Interpretation Nursing Responsibilities

Values
Complete Blood Count
WBC 8.41 x 10^3/uL 4.00 – 10.00 Normal For low lymphocyte and high monocyte and eosinophil:
Neu% 57.0% 50.0 – 60.0 Normal - Consider the overall WBC count plus abnormalities in
Lym% 32.0% 35.0 – 45.0 Low differential. Evaluate patient signs or symptoms of trauma,
Mon% 5.0% 2.0 – 4.0 High inflammation, and infection
Eos% 6.0% 2.0 – 5.0 High - Antibiotic therapies if indicated by infection (followed by
Bas% 0.0% 0.0 – 1.0 Normal cultures to determine efficacy of antibiotics)
 RBC 3.66 x 10^6/uL 3.50 – 5.50 Normal - Anti-inflammatories for inflammation
HGB 10.5 g/dL 11.0 – 16.0 Low - Check medications for adverse effects
HCT 33.2% 37.0 – 54.0 Low - Monitor the white blood cell count to watch for downward trends
MCV 90.8 fL 80.0 – 100.0 Normal and the patient should be carefully assessed for any signs of
MCH 28.7 pg 27.0 – 34.0 Normal infection
MCHC 31.6 g/dL 32.0 – 36.0 Low - Promote excellent hygiene and prevent infection from food,
RDW-CV 13.5% 11.0 – 16.0 Normal medical equipment, and environment
RDW-SD 51.8 fL 35.0 – 56.0 Normal - Educate patient on the finishing any antibiotics completely. Do
PLT 266 x 10^3/uL 150 – 450 Normal not stop prior, even if the patient says they are feeling better.
MPV 7.0 fL 6.5 – 12.0 Normal For low HGB, HCT, and MCHC:
PDW 15.4 9.0 – 17.0 Normal - Prioritize activities. Assist the patient in prioritizing activities and
PCT 0.186% 0.108 – 0.282 Normal establishing balance between activity and rest that would be
acceptable to the patient.
- Assess the patient with a low hematocrit for his/her ability to
tolerate physical activity. Using the "tilt test", the nurse takes the
patient's pulse before and after sitting up. Assess the extent of the
patient's weakness and fatigue on exertion when planning physical
care activities
- Exercise and physical activity
- Increase amounts of protein and iron to help the bone marrow
produce additional red blood cells. Encourage the patient to eat
foods that are high in protein and iron, such as liver, egg yolk,
beef, and dried fruits such as prunes and apricots.
- The nurse should inform the patient that alcohol interferes with
the utilization of essential nutrients and should advise the patient to
avoid or limit his or her intake of alcoholic beverages.
- Dietary teaching
- The nurse should monitor the patient’s vital signs and pulse
oximeter readings closely
- The nurse should assist the patient to develop ways to incorporate
the therapeutic plan into everyday activities
- Patients receiving high-dose corticosteroids may need assistance
 to obtain needed insurance coverage or to explore alternative ways
to obtain these medications

Analysis
 Complete Blood Count
o Low lymphocyte may indicate higher risk of infection
o High monocyte may indicate chronic infections
o High eosinophil may indicate a mild condition of drug reaction or allergy and other blood disorders
o Low HGB may indicate low levels of oxygen in the blood ang may result in anemia
o Low HCT may indicate insufficient supply of healthy RBCs, leading to anemia
o Low MCHC may indicate iron deficiency leading to anemia and thalassemia
 e. Pathophysiology
Amputations can be both elective and distressing. Peripheral vascular disease and
arteriosclerosis are linked to elective amputations. Ischemia occurs in distal parts of the lower
extremity as a result of complications.

In 5-8% of diabetic ulcer patients, amputation will be required within a year. 85% of all
diabetic amputations are preceded by a foot ulcer that progresses to a severe infection or
gangrene. Diabetes increases the risk of amputation by 8-fold in patients over 45 years old, 12-
fold in patients over 65 years old, and 23-fold in those 65-74 years old.
Ischemia, neuropathy, and infection are the three pathological components that lead to
diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy
and ischemia are the initiating factors, with different weights in different patients, and infection
is mostly a result. Due to a lack of protective sensation, the foot is vulnerable to unattended
minor injuries caused by excess pressure, mechanical or thermal injury. Motor neuropathy alters
biomechanics and, eventually, foot anatomy. Foot deformities, limited joint mobility, and altered
foot loading are obvious outcomes of these disarrays. The most important aspect of treating any
ulcer with neuropathy, regardless of the presence of ischemia, is to restrict weight bearing.
Poor glucose control hastens the development of PAD. Every 1% increase in hemoglobin
A1c (HbA1c) results in a 25-28% increase in the relative risk of PAD. Diabetes increases the risk
of symptomatic PAD by 3.5 times in men and 8.6 times in women.
Neuroischaemia is a synergistic consequence of diabetic neuropathy and ischemia that
impairs oxygen supply to meet metabolic tissue needs. Both macrovascular disease and
microvascular dysfunction impede perfusion in the diabetic foot. Neuroischaemia is the
combined effect of diabetic neuropathy and ischaemia, decreasing oxygen delivery to meet
metabolic tissue needs in a synergetic manner. Both macrovascular disease and microvascular
dysfunction impair perfusion in the diabetic foot. Microvascular dysfunction is further
characterized by subsequent capillary leakage and venous pooling, as well as hormonal activity
in the vessel and inflammation in the wall, indicating that decreased perfusion in the diabetic foot
is more complex and not only related to diabetes.
 f. Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objectives: Impaired After 8 hours of 1. Communicate and 1. To connect with After 8 hours of
-Alteration in gait physical nursing establish rapport. patient and to build the foundation of trust. nursing intervention,
-Postural mobility intervention, the the client has partially
instability related to loss patient can 2. Monitor vital signs. 2. Provides baseline data of assessment. met the goal. The
-Decrease in of limb on verbalize patient understands
range of motion right foot understanding of 3. Assess client’s developmental level, motor 3. To determine presence of characteristics of her situation, and
-Difficulty secondary to the situation and skills, ease and capability of movement, posture, client’s unique impairment and to guide choice of safety measure and
turning T2DM individual and gait. interventions. seen performing ROM
treatment regimen exercises and ADLs.
V/S taken as and safety 4. Explain to the client about her situation and 4. To provide understanding of the situation and
follows: measures, the importance of early ambulation. reduces potential for injury. V/S taken as follows:
RR: 18 BPM demonstrate RR:16 bpm
O2 Sat: 98 BPM techniques that 5. Note emotional/behavioral responses to 5. Feelings of frustrations may impede attainment of O2 Sat: 100 %
HR: 68 BPM enable resumption problems of immobility. goals. HR: 72 bpm
BP: 185/95 mmHg of activities, and, BP: 165/85 mmHg
participate in 6. Encourage and teach patient with specified 6. Prevents contracture deformities, which can
activities of daily ROM exercises for both the affected and develop rapidly and could delay prosthesis usage.
living (ADLs). unaffected limbs beginning early in the
postoperative stage.

7. Teach patient for different activities of 7. To limit fatigue and maximizing participation.
energy-conserving techniques of ADLs.

8. Demonstrate and assist with transfer 8. Facilitates self-care and patient’s independence.
techniques and use of mobility aids like trapeze, Proper transfer techniques prevent shearing
crutches, or walker. abrasions.

9. Change the patient’s position every 2 hours. 9. To prevent bed sores.

10. Don’t place a pillow under the residual limb. 10. because a flexion contracture of the hip may
result.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired skin After 8 hours of 1. Establish rapport 1. To gain trust and create harmonious relationship with After 8 hours of nursing
“Nahihirapan ako integrity nursing intervention, 2. the client. intervention, the client
gumalaw kaya related to the client will get 2. Determine the client’s age and general condition 2. Elderly clients have less elastic skin, less moisture, has partially met the
hindi ako prolonged stage-appropriate of the skin. less padding and have thinning of the epidermis, making goal. The client got
makalakad o kahit immobility and wound care and has it more prone to skin impairment. stage-appropriate wound
tumagilid sa unrelieved controlled risk 3. Assess for a history of preexisting chronic 3. Clients with chronic diseases typically exhibit multiple care and has controlled
kama.” as pressure factors for diseases risk factors that predispose them to pressure ulceration risk factors for
verbalized by the secondary to prevention of (poor nutrition, poor hydration, incontinence, and prevention of additional
patient. below knee additional ulcers. immobility). ulcers. The client
amputation The client will 4. Assess the surface that the clients spend the 4. Clients who spend the majority of time on one surface experienced healing of
Objective: and diabetes experience healing majority of time on need a pressure reduction or pressure relief device to pressure ulcers and
o Redness on mellitus II of pressure ulcers reduce the risk of skin breakdown experiences pressure
the lumbar and experiences 5. Assess client’s ability to move 5. Immobility is a huge risk factor for pressure ulcer reduction
area pressure reduction. development among adult hospitalized clients.
o Warmer to 6. Encourage the implementation of a turning 6. Turning every 2 hours is the key to prevent V/S taken as follows:
touch than schedule, restricting time in one position to 2 hours breakdown. Head of bed should be kept at 30 degrees or RR:16 bpm
others or less, if the patient is restricted to bed. less to avoid sliding down on bed. O2 Sat: 100 %
o Tenderness 7. Encourage the patient to change position every 15 7. During sitting, the pressure over the sacrum may HR: 72 bpm
minutes and change chair-bound positions every exceed 100 mm Hg. The pressure needed to close BP: 165/85 mmHg
V/S taken as hour. capillaries is around 32 mm Hg;
follows: 8. Encourage ambulation if the patient is able. 8. Ambulation reduces pressure on the skin from
RR: 18 bpm immobility thus lessening the factors that may result in
O2 Sat: 98 % impaired skin integrity.
HR: 68 bpm 9. Encourage adequate nutrition and hydration 9. Sufficient hydration and nutrition help maintain skin
BP: 185/95 mmHg turgor, moisture, and suppleness, which provide
resilience to damage caused by pressure. Patients with
limited cardiovascular reserve may not be able to tolerate
much fluid.
10. Educate patients and caregivers about proper 10. This information can assist the patient or caregiver in
skin care. finding methods to prevent skin breakdown.
11. Apply a topical vasodilator (e.g., Proderm) 11. It increases skin circulation
12. Apply a flexible hydrocolloid dressing (e.g., 12. It prevents shear and friction.
Duoderm) or a vapor-permeable membrane dressing
(Tegaderm).
13. Apply a vitamin-enriched emollient to the skin 13. It moisturizes the skin.
every shift.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Risk for Short-term 1. Monitor for signs of infection 1. To prevent pathogens entering the After nursing
Infection goal: such as redness, swelling, or body through surgical incisions. intervention
- Incision related to After 8 hours drainage. shows no
made via compromised of nursing 2. To note presence of infection. signs and
long defense intervention, 2. Monitor Sepsis and SIRS symptoms of
posterior flap mechanism patient will not criteria. 3. Any equipment during the infection and
technique. secondary to manifest signs patient’s hospital stay can pose an recovers from
broken skin and symptoms 3. Verify sterility of all medical access point for pathogens into the surgery
- Procedure and of infection. equipment such as tubes, drains, body without any
should last traumatized IV access sites frequently and complications.
for more tissue Long-term adhere to facility infection
than an hour. goal: After a control, sterilization, and aseptic Latest:
week of policies and procedures. 4. To promote and lessen the effect BP: 165/85
VS taken as nursing of infection. mmHg
follows: intervention, 4. Practice meticulous hand PR: 72 bpm
BP: 185/95 the patient will hygiene and teach patients about RR: 16 bpm
mmHg be able to the importance of handwashing T: 36.8 ℃
PR: 68 bpm recover from 5. To provide comfort.
RR: 18 bpm surgery 5. Ensure the patient receives
T: 37℃ without any daily baths
complication 6. Adequate amount of nutrients
and infections. 6. Encourage nutritional intake helps in immune system response.
rich in calories and protein,
vitamins, and carbohydrates
7. Hydration aids in reducing the risk
7. Encourage adequate fluid of infection.
intake if not contraindicated
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain After 8 hours 1. Document the location, 1. Aids in determining the need for After 8 hour of nursing
related to of nursing intensity, and efficacy of interventions. intervention, the patient
Objective: amputation intervention, aggravating elements of Changes could suggest the onset was able to appear relaxed
-facial grimace possibly the patient the patient’s pain (0-10). of problems including necrosis and capable of getting
-guarding evidenced will appear Examine numbness and or infection. adequate sleep, reports
behavior by reports relaxed and tingling as pain features that the discomfort has
Pain scale: 6/10 of phantom capable of alter. been eased, lastly the
pain getting patient was able to explain
V/S taken as adequate 2. Provide encourage 2. It refocuses attention, her understanding of
follows: sleep, report general comfort encourages relaxation, improves phantom and on how to
BP: 128/76 that the measures. Like stress- coping capacities, and reduces relieve it.
Temp: 36.5 discomfort reduction practices like the recurrence of phantom limb
HR: 76bpm has been deep breathing, discomfort. Pain scale: 3/10
RR: 20bpm eased, lastly therapeutic touch, V/S taken as follows:
SO2 Sat: 100% the patient is visualization, guided BP: 120/80
able to imagery and exercises. Temp: 36.3
explain her HR: 65bpm
understanding 3. Investigate reports of 3. It is possible that the patient is RR: 16bpm
of phantom analgesic resistant pain suffering from compartment SO2 Sat: 100%
and on how to that is progressive or syndrome, especially after a
relieve it. poorly localized. traumatic injury

4. Patient-controlled 4. PCA allows for consistent and

analgesia should be timely medication
taught and monitored administration, avoiding pin
(PCA). fluctuations, muscular tension,
and spasms that might occur
during surgical operations.
 g. Drug Study
DRUG DRUG CLASS MECHANISM INDICATION CONTRAINDI ADVERSE NURSING CONSIDERATIONS
NAME OF ACTION CATION REACTION/ SIDE
EFFECTS
Generic PHARMACOLOGIC Proton pump  Gastro- Patients with COMMON SIDE 1. Advise patient to avoid alcohol and
name: : Proton-Pump inhibitors (PPIs) esophageal known EFFECTS: foods that may cause an increase in GI
omeprazole Inhibitors (PPIs) effectively block reflux hypersensitivity  headache irritation.
gastric acid  Esophageal to ay component  abdominal
Brand THERAPEUTIC: secretion by gastric of the pain 2. Instruct patient to report bothersome
name: antiulcer agent irreversibly varices formulation.  diarrhea or prolonged side effects, including skin
PriLOSEC binding to and bleeding Treatment with  nausea problems (itching, rash) or GI effects
PriLOSEC inhibiting the prophylaxis omeprazole may  vomiting (nausea, diarrhea, vomiting,
OTC hydrogen- , erosive mask the  gas constipation, heartburn, flatulence,
Zegerid potassium esophagitis symptoms of (flatulence) abdominal pain).
ATPase pump  Acid peptic other gastric
 dizziness
that resides on disease diseases. 3. Instruct the patient to take this drug
 upper
the luminal resistant to Caution should 30-60 minutes prior to eating as well as
respiratory
surface of the ranitidine be exercised in report if black tarry stool occurred and,
infection
parietal cell  Helicobacte patients with the capsules should be swallowed
membrane. hepatic  acid reflux whole.
r pylori  constipation
eradication impairment.
 rash
 Fat
 cough
malabsorpti
on despite
LESS COMMON
optimal use
SIDE EFFECTS:
of
 bone fracture
replacement
(osteoporosis
in cystic
related)
fibrosis.
 deficiency of
granulocytes
in the blood
  loss of
appetite
 gastric
polyps
 hip fracture
 hair loss
 chronic
inflammation
of the
stomach
 destruction of
skeletal
muscle
 taste changes
 abnormal
dreams

RARE SIDE
EFFECTS:
 liver damage
 inflammation
within the
kidneys
 pancreatitis
 dermatologic
disorder,
potentially
life
threatening
(toxic
epidermal
 necrolysis)

WARNING:
This medication
contains omeprazole.
Do not take Prilosec
or Prilosec OTC if
you are allergic to
omeprazole or any
ingredients
contained in this
drug.
Generic PHARMACOLOGIC Ketorolac It is indicated for It is not COMMON SIDE 1. Monitor signs of GI bleeding,
name: : pyrrolizine inhibits key short term indicated for use EFFECTS: including abdominal pain, vomiting
ketorolac carboxylic acid pathways in management of in pediatric  headache blood, blood in stools, or black, tarry
tromethamine prostaglandin acute pain that patients and it is  heartburn stools. Report these signs to the
THERAPEUTIC: synthesis which requires the calibre NOT indicated  upset physician immediately.
Brand name: nonsteroidal anti- is crucial to it's of pain for minor or stomach
Toradol inflammatory agents, mechanism of management chronic painful  nausea 2. Monitor signs of allergic reactions
Acular nonopioid analgesics action.4 offered by conditions.  vomiting and anaphylaxis, including pulmonary
Acuvail (NSAIDS) Although opioids.14 Increasing the  diarrhea symptoms (laryngeal edema, wheezing,
Omidria ketorolac is non- Clinicians may dose of cough, dyspnea) or skin reactions (rash,
 stomach pain
Readysharp selective and choose to initiate TORADOL pruritus, urticaria). Be especially alert
 bloating
Anesthetics inhibits both ketorolac to (ketorolac for exfoliation, dermatitis, and other
Plus COX-1 and manage post- tromethamine)  gas severe skin reactions that might indicate
Ketorolac, COX-2 operative pain, ORAL beyond a  constipation serious hypersensitivity reactions
Sprix, enzymes, it's spinal and soft daily maximum  dizziness (Stevens-Johnson syndrome, toxic
Toronova clinical efficacy tissue pain, of 40 mg in  drowsiness epidermal necrolysis). Notify physician
Suik is derived from rheumatoid adults will not  sweating immediately if these reactions occur.
it's COX-2 arthritis, provide better  and ringing
inhibition. The osteoarthritis, efficacy but will in the ears. 3. Assess pain and other variables
COX-2 enzyme ankylosing increase the risk (range of motion, muscle strength) to
is inducible and spondylitis, of developing WARNING document whether this drug is
is responsible menstrual disorders serious adverse Indicated for the successful in helping manage the
for converting and headaches events. short-term (up to 5 patient's pain and decreasing
arachidonic acid among other days in adults), impairments.
to ailments.12 management of
prostaglandins Regardless of the moderately severe 4. Assess signs of paresthesia, including
that mediate etiology of pain, acute pain that numbness and tingling. Perform
inflammation patients should use requires analgesia at objective tests, including
and pain. By the lowest possible the opioid level and electroneuromyography and sensory
blocking this dose, and avoid only as continuation testing to document any drug-related
pathway, using ketorolac for treatment following neuropathic changes.
ketorolac an extended period IV or IM dosing of
achieves of time (ideally ≤ 5 ketorolac 5. Assess blood pressure (BP)
analgesia and days).14 A benefit tromethamine, if periodically and compare to normal
reduces of choosing necessary. The total values (See Appendix F). NSAIDs can
inflammation.3 ketorolac over combined duration increase BP in certain patients.
Ketorolac is other analgesics of use of
administered as with similar TORADOLORAL 6. Be alert for signs of prolonged
a racemic potency is that that and ketorolac bleeding time such as bleeding gums,
mixture; there does not tromethamine should nosebleeds, and unusual or excessive
however, the appear to be a risk not exceed 5 days. bruising. Report these signs to the
"S" enantiomer of dependence or NOT Indicated for physician.
is largely tolerance with use in pediatric
responsible for ketorolac use. patients and it is 7. Assess symptoms of bronchospasm
it's NOT indicated for and asthma, including wheezing,
pharmacological minor or chronic coughing, dyspnea, and tightness in
activity painful conditions. chest. Perform pulmonary function tests
Increasing the dose to quantify suspected changes in
of TORADOL ventilation and respiration.
(ketorolac
tromethamine) 8. Monitor signs of kidney toxicity,
ORAL beyond a including blood or pus in urine,
 daily maximum of increased urinary frequency, decreased
40 mg in adults will urine output, weight gain from fluid
not provide better retention, and fatigue. Report these
efficacy but will signs to the physician.
increase the risk of 9. Assess dizziness and drowsiness that
developing serious might affect gait, balance, and other
adverse events. functional activities (See Appendix C).
Report balance problems and functional
limitations to the physician, and caution
the patient and family/caregivers to
guard against falls and trauma.

10. Monitor and report euphoria,

abnormal thinking, or other psychic
disturbances.
injection site reactions to the physician.
Generic PHARMACOLOGIC Butorphanol  Relief of  Patients COMMON SIDE 1. Monitor for respiratory depression.
name: : Opioid Analgesic blocks pain moderate to with EFFECTS: Do not administer drug if respiratory
Butorphanol Partial Agonist. impulses at severe pain significa  nausea rate is <12 breaths/min.
tartrate specific sites in  Nasal nt  vomiting
THERAPEUTIC: the brain and spray: respirato  drowsiness 2. Monitor vital signs. Report marked
Brand Opioid Analgesics spinal cord. The Relief of ry  dizziness changes in BP or bradycardia.
name: exact migraine depressio  dry mouth
Stadol mechanism of headache n  warmth or 3. Note: If used during labor or
Torbutrol action is pain and  Patients redness under delivery, observe neonate for signs of
Torbugesic unknown, but is relief of with the skin respiratory depression.
Dolorex believed to moderate to acute or
interact with an severe pain severe SERIOUS SIDE 4. Note: Drug can induce acute
opiate receptor  For bronchial EFFECTS: withdrawal symptoms in opiate-
site in the CNS preoperativ asthma dependent patients.
 noisy
(probably in or e or in an 5. Schedule gradual withdrawal
breathing
associated with preanestheti unmonit following chronic administration.
 sighing
the limbic c ored  shallow Abrupt withdrawal may produce
system). medication, setting or breathing vomiting, loss of appetite, restlessness,
to in the  breathing that abdominal cramps, increase in BP and
supplement absence stops during temperature, mydriasis, faintness.
balanced of sleep Withdrawal symptoms peak 48 h after
anesthesia, resuscitat  slow heart discontinuation of drug.
and to ive rate
relieve equipme  weak pulse
prepartum nt  fast or
pain  Patients pounding
(parenteral) with heartbeats
known  problems
or with
suspecte urination
d  lightheadedn
gastroint ess,
estinal
 confusion
obstructi
 feeling like
on,
you are
including
floating
paralytic
ileus  agitation
 Patients  hallucination
with s
hypersen  fever
sitivity  sweating
to  shivering
butorpha  muscle
nol stiffness
tartrate  loss of
or any of coordination
the  nausea
 formulati  vomiting,
on and diarrhea
excipient
s (e.g.,
anaphyla
xis)
 Find
butorpha
nol
tartrate
injection,
USP
medical
informati
on:
Drug Name Specific Indications Mechanism of Adverse Contraindications Nursing Responsibilities
Actions Action Reaction

Generic name: To prevent -Recommended It functions as -Anaphylactoid -Phytonadione -Check properly the doctor’s order then
bleeding in Dietary a cofactor reactions hypersensitivity check the medication's label for the
vitamin K1 people with Allowances required for name, dose, and expiration date.
blood clotting (RDAs) the activity of -Dyspnea -Hereditary - Before using, check the solution is
problems vitamin K- hypoprothrombinemia normally clear and yellow in color,
-Hypopro- -Chest tightness
Brand name: dependent -Heparin over- check this product visually for particles
thrombinemia (VKD) -Injection site anticoagulation. or discoloration. If either is present, do
Phytonadione caused by reaction
proteins, not use the liquid.
vitamin K which include -Administer medication according to
malabsorption, factors II doctor’s order for correct dosage of 1mg
Therapeutic Class: drug therapy, or (prothrombin), IV 8x3 doses
excessive VII, IX, and X, -Monitor VS upon IV administration
hemostatics
vitamin A in addition to -Monitor for hypersensitivity reactions
dosage protein C and upon IV administration
Pharmacologic protein S. In -Monitor prothrombin time test to assess
Class: vitamin K for effectiveness and for the need to
-To prevent deficiency, administer another dose.
Fat-soluble vitamin hemorrhagic phytonadione -Monitor for adverse reaction.
disease of therapy
newborn replenishes Patient teaching:
Route, Dosage, stores. -Advise patient to inform the healthcare
Duration, and provider if having adverse reaction such
Frequency: as dyspnea, chest tightness, injection site
reaction.
vitamin K 1amp IV
q8, 3 doses - Educate about maintaining consistency
in diet and avoid significant increases in
daily intake of vitamin K–rich foods
when drug regimen is stabilized. Know
sources rich in vitamin K: Asparagus,
broccoli, cabbage, lettuce, turnip greens,
pork or beef liver, green tea, spinach,
watercress, and tomatoes.

Drug Name Specific Action Indications Mechanism of Adverse Contraindications Nursing Responsibilities
Action Reaction

Generic name: Lowers blood To improve Regulates -Hypoglycemia -Contraindicated -Don’t use combination insulin if it
isophane insulin glucose by glycemic control glucose -Lipodystrophy during episodes of contains precipitate that is clumped or
suspension– stimulating in patients with metabolism by -Injection-site hypoglycemia or granular.
insulin injection peripheral diabetes mellitus binding to reactions ketoacidosis. -Check properly the doctor’s order then
combinations glucose uptake insulin -Swelling of -Contraindicated in check the medication's label for the name,
by skeletal receptors on hands and feet patients with a dose, and expiration date.
Brand name: muscle and fat, muscle, liver, history of -Administer combination insulin
Humulin 70/30 and by and fat hypersensitivity to according to doctor’s order for correct
inhibiting cells; drug. dosage the subcutaneous route only, 30
Therapeutic hepatic glucose facilitates -Use cautiously in minutes before breakfast.
Class: production cellular uptake pregnant women -Roll the vial gently between palms to
antidiabetics of glucose; and and breastfeeding mix; don’t shake it.
Pharmacologic promotes women and only if -When injecting the insulin, it’s important
Class: uptake and clearly needed. to rotate sites to keep the skin healthy and
intermediate-acting storage of avoiding lipodystrophy.
insulin glucose -Dispose the syringe properly, put the
in the form of needle in sharp container and the syringe
Route, Dosage, glycogen in the in yellow bin.
Duration, and liver. -Monitor VS upon IV administration.
Frequency: -Monitor glucose level, and adverse
Insulin 70/30 effects such as hypoglycemia.
-20 units Pre- -Repeat administer combination insulin
breakfast according to doctor’s order for correct
-10 units Pre- dosage by the subcutaneous route only,
dinner 30 minutes before dinner.

Patient teaching:
- Advise patient that allergic and
hypersensitivity reactions can occur,
including injection-site reactions (local
pain, redness, or swelling), and to report
symptoms to health care provider.

Drug Study Specific Indications Mechanism of Adverse Contraindication Nursing Responsibilities

Actions Action Reaction
Generic Name: To reduce or - Moderate to Binds to opiate - Bradycardia Contraindicated in - Reassess patient’s level of pain at least 15
nalbuphine eliminate severe pain receptors in the patient hypersensitive and 30 minutes after parenteral
hydrochloride moderate to CNS. Alters the - Respiratory to nalbuphine or administration.
severe pain, - Adjunct to perception of depression bisulfites and with - Carefully monitor vital signs, pain level,
Brand Name: especially for balanced anesthesia and response to significant respiratory respiratory status, and sedation level in all
Nubain stump and painful stimuli - Dizziness depression, suspected patient receiving opioids, especially those
phantom limb - Preoperative and while producing GI obstruction, and receiving IV drugs, even those given
Therapeutic Class: pain postoperative generalized - Nausea acute or severe postoperatively.
Opioid analgesics analgesia CNS depression. asthma in - Assess patient’s risk of opioid abuse,
In addition, has - Vomiting unmonitored setting misuse, and addiction.
Pharmacologic - Obstetric partial or in the absence of - Monitor patient for respiratory depression
Class: analgesia during antagonist - Clamminess resuscitative patients. especially within first 24 to 72 hours of the
Opioid agonist- labor and delivery properties, Patients physically start of therapy and after dosages increases
antagonists-opioid which may - Constipation dependent on
partial agonists result in opioid opioids and who have Patient Teaching:
 withdrawal in not been detoxified - Encourage patient to report all medicatio
Route, Dosage, physically being taken, including prescriptions and
Duration, and dependent OTC medications and supplements
Frequency: 10mg Iv patients. - Counsel patient not to discontinue opioid
q8 x3 doses without first discussing with prescriber the
Therapeutic need for a gradual tampering regimen
Effects: - Caution ambulatory patient about getting
Decreased pain out of bed waking.
- Teach patient how to manage troublesom
effects such as constipations
- Caution patient to avoid taking drug with
alcohol

Drug Study
Patient Name: Lolita R. Sugabao Below Knee Amputation of Right Foot secondary to Diabetes Mellitus II
Age: 60 years old
Drug Study Specific Actions Indications Mechanism of Adverse Contraindication Nursing Responsibilities
Action Reaction
Generic Name: To reduce or - Moderate to Unknown. Binds to - - Seizures Contraindicated in - Assess patient’s risk of addiction,
tramadol eliminate moderate moderately opioid receptors. patients’ abuse, and misuse, which can lead
to severe pain, severe chronic Inhibits reuptake of - Respiratory hypersensitivity to to overdose and death.
Brand Name: especially for pain serotonin and distress drugs or opioids and - Assess type, location, and
Conzip, Durela, stump and norepinephrine in the with severe or renal intensity of pain before and 2–3 hr.
Ralivia, phantom limb pain CNS. - Dizziness impairment, suicidal (peak) after administration.
Tridural, patients, GI - Assess BP and respiratory rate
Ultram, Therapeutic Effects: - Headache obstruction, severe before and periodically during
Zytram XL Decreased pain respiratory or acute administration.
- Somnolence or severe asthma in - Assess bowel function routinely.
Therapeutic unmonitored setting - Assess previous analgesic history.
Class: - Constipation or in the absence of Tramadol is not
analgesics resuscitative recommended for patients
- Nausea patients. Also, in dependent on opioids or who have
Pharmacologic those acutely previously received opioids for
Class: synthetic - Serotonin intoxicated with more than
centrally active syndrome alcohol, 1 wk.; may cause opioid withdrawal
analgesics sedatives/hypnotics, symptoms.
centrally
Route, Dosage, acting analgesics, Patient Education:
Duration, and opioid analgesics, or - Instruct patient on how and when
Frequency: psychotropic to ask for pain
50mg IV q8 agents. medication.
- May cause dizziness and
drowsiness. Caution patient to avoid
driving or other activities requiring
alertness until response to
medication is known.
- Advise patient to change positions
slowly to minimize orthostatic
hypotension.
- Caution patient to avoid
concurrent use of alcohol or other
CNS depressants with this
medication. Advise patient to notify
health care professional before
taking other RX, OTC, or herbal
products concurrently
- Advise patient to notify health
care professional if seizures or if
symptoms of serotonin syndrome
occur.
- Encourage patient to turn, cough,
and breathe deeply every 2 hrs to
prevent atelectasis.
 Drug Name Mechanism of Specific Action Indications Contraindication Adverse Nursing
Action Reactions Responsibilities
Generic Name: Tranexamic acid Tranexamic acid - Treatment of - Hypersensitivity - Nausea Before:
Tranexamic acid competitively and completely hereditary to tranexamic acid - Vomiting - Monitor blood
reversibly inhibits inhibits the angioedema or any of the - Diarrhea pressure, pulse,
Brand Name: the activation of activation of - Cyclic heavy ingredients - Hypotension and respiratory
Cyklokapron plasminogen via plasminogen to menstrual - Acquired - status as indicated
binding at several plasmin. bleeding in defective color Thromboembolic by severity of
Drug Class: distinct sites, Therefore, it premenopausal vision, since this - Visual bleeding
Antifibrinolytic including four or prevents females prohibits impairment - Monitor overt
Agents five low-affinity bleeding. - Bleeding in the measuring one - Convulsions bleeding every 15-
sites and one context of endpoint that - Headache 30 min.
Route, Dosage, high-affinity site, hyperfibrinolysis should be followed - Mental status - Monitor
Duration, and the latter of which as a measure of changes neurologic status
Frequency: 1 gm is involved in its toxicity - Myoclonus (pupils, level of
now binding to fibrin. - Subarachnoid - Rash consciousness,
The binding of hemorrhage motor activity) in
plasminogen to - Active patients with
fibrin induces intravascular subarachnoid
fibrinolysis by clotting hemorrhage
occupying the - Assess for
necessary binding thromboembolic
sites. Tranexamic complications
acid prevents this (especially in
dissolution of patients with
fibrin, thereby history). Notify
stabilizing the clot physician of
and preventing positive Homans’
hemorrhage. sign, leg pain
hemorrhage,
edema,
 hemoptysis,
dyspnea, or chest
pain.
- Monitor platelet
count and clotting
factors prior to
and periodically
throughout
therapy in patients
with systemic
fibrinolysis
During:
- Stabilize catheter
to minimize
thrombophlebitis.
Monitor site
closely.
After:
- Instruct patient
to notify the nurse
immediately if
bleeding recurs or
if thromboembolic
symptoms
develop
- Caution patient
to make position
changes slowly to
avoid orthostatic
hypotension
Generic Name: Ondansetron is a Ondansetron is - Nausea and - Hypersensitivity - Headaches - Monitor
Ondansetron selective used alone or vomiting to the drug - Fatigue improvements in
 antagonist of the with other - Patients taking - Dry mouth GI symptoms
Brand Name: serotonin receptor medications to apomorphine - Malaise (decreased nausea
Zofran subtype, 5HT3. prevent nausea - Phenylketonuria - Constipation and vomiting,
Cytotoxic and vomiting increased
Drug Class: chemotherapy and caused by cancer appetite) to help
Antiemetics & radiotherapy are drug treatment document whether
Selective 5-HT3 associated with (chemotherapy), drug therapy is
Antagonist the release of radiation successful
serotonin (5-HT) treatment, or - Assess motor
Route, Dosage, from drugs used to put function and
Duration, and enterochromaffin to sleep before report any
Frequency: 4 mg cells of the small surgery. extrapyramidal
IV PTOR intestine, Ondansetron reactions.
presumably works by Common
initiating a blocking one of extrapyramidal
vomiting reflex the body’s symptoms include
through natural uncontrolled
stimulation of 5- substances rhythmic
HT3 receptors (serotonin) that movement of
located on vagal causes vomiting. mouth, face, and
afferents. extremities, lip
Ondansetron may smacking or
block the puckering, puffing
initiation of this of cheeks,
reflex. Activation uncontrolled
of vagal afferents chewing, rapid or
may also cause a worm-like
central release of movements of
serotonin from the tongue, shuffling
chemoreceptor gait, rigidity,
trigger zone of the tremor, pill-rolling
area postrema, motion, loss of
located on the balance control,
floor of the fourth difficulty
ventricle. Thus, speaking or
the antiemetic swallowing,
effect of masklike face,
ondansetron is restlessness, or
probably due to desire to keep
the selective moving, dystonic
antagonism of 5- muscle spasms,
HT3 receptors on twisting motions,
neurons located in twitching,
either the inability to move
peripheral or eyes, and
central nervous weakness of arms.
systems, or both. - Assess dizziness
and drowsiness
that might affect
gait, balance, and
other functional
activities. Report
balance problems
and functional
limitations to the
physician and
nursing staff and
caution the patient
and
family/caregivers
to guard against
falls and trauma.
- Instruct patient
to report
 bothersome side
effects such as
severe or
prolonged
headache,
weakness, fatigue,
or GI problems
(diarrhea,
constipation,
abdominal pain,
and dry mouth).

MEDICATION CARDS
VI. Evaluation

First Parag – Patient

2nd – Learning about disease condition and

3rd – Case Study

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