Nursing Interventions For Post-Amputation And Type II Diabetes Mellitus Care: A Case Study

Kath is a 62 year old Indigenous Australian woman who has a history of peripheral vascular disease (PVD) secondary to Type II Diabetes which is controlled by diet and oral hypoglycaemic medication. Kath lives independently in her own home in a rural setting, works part time at the local news agent, is divorced and has two sons who are mine workers. Kath developed a large vascular ulcer on the medial aspect of her right calf following a fall, where she sustained a large graze and bruising, subsequently becoming infected and turning gangrenous over 6 months and which was unresponsive to treatment, resulting in a right below knee amputation which was performed electively in a regional hospital under spinal anaesthesia. Kath has had an uneventful post-operative period; has recovered well from the surgery and the amputated stump appears to be healing well. Kath is now 5 days post op and needs to be discharged to an inpatient rehabilitation facility to learn how to mobilise safely with a prosthesis as well as education to effectively manage her Type II diabetes, as she wishes to return to her independent lifestyle.

Medications:

• Metformin 1g TDS.

1. Distinguish the roles and responsibilities of a nurse in the selected speciality practice area.

2. Utilise a collaborative approach to plan, coordinate and implement, after meticulous and comprehensive assessment, evidence based, safe person-centred care of individuals experiencing alterations in health specific to the elected specialty; and their families;(GA6)

3. Demonstrate safe use of selected technologies in the environment of the elected specialty.

4. Utilise effective communication skills when interacting with people and the health care team;(GA9).

5. Utilise a clinical decision-making framework in the provision of appropriate ethical, legal, evidence-based, holistic care to people and their families/carers;

6. Promote the rights of clients and carers and their role in treatment planning and recovery. (GA1)

7. Reflect upon personal perceptions and meanings of health, illness, dying and death as appropriate in the specialty practice area; (GA4)

8. Extend your professional portfolio reflecting on your learning and development towards the NMBA Registered nurse standards for practice using examples of skill development and nursing. (GA4,10)

9. Explain how health and illness and health care practices are constructed by people within the culture of a host country.

10.Discuss factors that can impact on the roles and functions of health care professionals within the host country.

Patient’s History and Current Information

There are various reasons that could necessitate an amputation of the limb(s). Type II diabetes mellitus is amongst the leading causes. After the amputation has been conducted, the affected patient requires high levels of consumer-centered care for the amputated limb to recover quickly. For amputations resulting from type II diabetes, the patient should also receive relevant care and education on how to handle his/her blood sugars at levels that will not result in another amputation. This essay, therefore, contains details of the nursing interventions applied in the provision of patient-centered post-amputation and type II diabetes mellitus care.

Kath, the patient, is aged 62 years and is a native Australian woman. In the past, she has suffered from Peripheral Vascular Disease (PVD) which is known to result from type II diabetes mellitus. Kath is an independent woman who lives in the rural setting and earns a living by working as a part-time local newsagent. She is divorced and a mother of two Males who are both mine employees. About six months ago, Kath fell and subsequently developed a bruising and large graze. It later attained infections, turned gangrenous and have been unresponsive to treatment in the preceding six months.

Having no other option, the doctors resolved to perform a below-knee amputation for the right leg. 5 days after the operation, she is now recovering well and the amputated stump is also healing promisingly. She will now have to be discharged and relocated to a rehabilitation facility where she will receive the proper care she needs to facilitate her mobility as well as ease any post-amputation trauma. She is also to receive relevant education on how to effectively manage her type II diabetes. She is currently on Metformin medication at 1g TDS.

From the above patient’s information, it goes without saying that the functionality of the patient’s right leg has been altered by the amputation. More antibodies will, however, have to be produced in the body and relocated to the stump to counter any kind of infection that could prevail in the stump (Abramson & Miller, 2012). Additionally, prescription of the right medication will be necessary to ease pain and aid natural antibodies in preventing any kind of infection (Benzon, Rathmell, Wu, Argoff, & Turk, 2014). It is worth noting that there are several complications that could arise in the stump over time and hence close monitoring is crucial. Oedema could occur as a result of mishandled tissues during the surgery. It is most likely to occur if there is an existence of inter-capillary membrane fluid transfer and lymphatic reabsorption imbalance.

There are several post-amputation problems that Kath is likely to suffer in the course of her healing. First, she will have to cope with trauma and emotional pain of losing her lower right leg (Malchow, 2016). She is also likely to experience post-amputation pain at the wound site. Additionally, present will be phantom limb pain which is classified as neuropathic pain (Sherman, 2013). The intensity of the pain is varied across the remaining part of the leg but is most intense in the distal portion of the phantom limb. Factors that could stimulate pain include exertion of pressure on residual limb, weather and emotional stress.

Analysis and Interpretation of Information

Kath also likely to experience muscle weakness, muscle contractures and joint instability (Braddom, 2010). All the aforementioned are results of compensatory structures performing additional functions to cover for the phantom limb. Additionally, deconditioning will result in diminished muscle mass, shortening of the sarcomere, changes in cartilaginous structures and reduced muscle strength. Finally, Kath will receive valuable education pertaining to management of type II diabetes which will reduce chances of another amputation (Burant, 2012).

The first nursing goal will be post-amputation wound management and care (Dougherty, Lister, & West-Oram, 2015). This will speed up healing of the stump and avoid any infections that could arise. Secondly, Kath will have to receive counselling to counter post-amputation trauma and effect acceptance of the reality. Acceptance is known to speed up the entire healing process. The last nursing goal is offering type II diabetes management education. Essential information will be availed to Kath and will subsequently help her in maintaining her blood sugars at the right levels and therefore avoid any future complications arising from the same.

Sufficient nursing interventions should be implemented to get Kath accustomed to her situation and subsequently get to her normal daily living. To begin with, Kath is overwhelmed by feelings of depression, loss, anxiety, and fear in addition to changes in physical appearances and presumed roles in the society (Gulanick & Myers, 2013). She has even testified of being afraid of looking at her residual limb due to unacceptance of what has already happened. Arrangements will, therefore, be made to avail a psychologist to help her overcome her grief. Emotional support of the nurse is of significant weight as she is most likely to spend her recovery time with nurses.

Physiotherapy will also be conducted to aid Kath in regaining her functional and physical abilities in addition to improving the quality of her life. She will also require a below-knee prosthesis and trained adequately on how to navigate using it (Lusardi, Jorge, Jorge, & Nielsen, 2013). Kath will be guided into ambulating in a heel to toe pattern. She will also be educated on how to decrease trunk flexion and hip/body swaying while simultaneously increasing hip extension and making larger strides. To work on balance, nurses will guide her on walking between parallel bars while she is on the prosthesis (Brooker, Nicol, & Alexander, 2011). She will begin with weight shifting sideways and forward and backward with support. She will then progress to shifting weight and standing without any support. The last balance trial will be catching a ball thrown at her to her sides.

For her to achieve maximum levels of flexibility, hamstring and hip flexors are to be implemented at 30 seconds hold for three to four times a day or for as many times as she is willing to participate (Lusardi, Jorge, Jorge, & Nielsen, 2013). She will undergo an endurance test to maximize her endurance while walking on the prosthesis. She is to start off with one-two minutes and then increase the timeframe until she achieves the six-minute walk test.

Problem Identification

Kath will also receive highlights on how to observe skin on the residual limb when changing dressings on the wound. She will be taught how to use a knee immobilizer to prevent contracture and to also keep the area protected in case of a fall. To manage pain, any Oedema present in the stump should be controlled. Establishing a sleeping pattern that is restful will also be of great aid. Counselling and open talks with friends and family will help Kath ease anxiety, depression, and stress and subsequently, the pain will reduce. For the remaining limb, desensitization techniques.

It will not be possible for Kath to receive care from nurses even while in her home. She will, therefore, have to learn various self-management strategies to effectively handle her condition at home. First, she will have to adhere strictly to medications prescribed for her (Nejaddadgar, Solhi, Jegarghosheh, Abolfathi, & Ashtarian, 2017). Due to her age, she is bound to forget constantly but setting reminders could be an effective counter. She can also link her pill taking to her activities, such as, whenever she is going to work. Kath should also monitor her glucose levels frequently.

She will also be familiarized with the A1C standard which assesses glycemic control by measuring the average blood sugar. It will be advisable for her to conduct self-monitoring of blood glucose at least twice per day (Mertig, 2011). Additionally, proper dietary will be recommended to Kath. Carbohydrates that she is to consume should contain low glycemic load and are to be sourced primarily from vegetables. The proteins and fats that she is to consume should be from plant sources. Glycemic load/index are measures of the impact of carbohydrates on blood sugars. Foods of a low glycemic index are known to raise the blood sugars modestly. She will be recommended to feed on complex carbohydrates which are usually in their whole food form. They contain additional nutrients such as fiber, vitamins and lesser quantities of lards and proteins (Bagchi & Nair, 2012). Brown rice, quinoa, beans, steel-cut oatmeal and whole wheat are the top complex carbohydrates recommended for Kath.

Since starchy vegetables are essential sources of important nutrients such as vitamin C, Kath is highly recommended to include them in her diet. They include; potatoes, corn, squash and a wide variety of other root vegetables (Ezrin & Kowalski, 2011). She should also include loads of non-starchy vegetables in her diet. Such include green vegetables that can be eaten raw. Proteins are known to stabilize blood sugars in addition to eradicating sugar cravings. Since animal sources are springs of harmful and saturated fats, Kath could obtain healthy proteins from beans, legumes, eggs, organic dairy products, fish, and seafood. Lastly, it is advisable for Kath to perform physical activities. Shae was recommended to walk for at least fifteen minutes a day.

Patient-centered care has been delivered effectively on Kath who has shown positive responses to treatment and care administered to her. Sufficient and relevant emotional support aided in countering depression as well as lowering anxiety and stress. It also aided in giving her self-acceptance to her condition. Physiotherapy care availed to her will help her attain mobility over time. The prosthesis will help her get back to her normal undertakings as if she is still on her two feet. Wound dressing education will help her change her bandages successfully until the stump is fully healed. She will also be able to identify any infection that could be developing on the residual limb and seek help in time and thus avoiding any complications. She will additionally be able to manage her blood sugars through the right diet.

Conclusion

Various post-amputation care strategies have been discussed in details. In the spotlight are wound dressing, pain management, physiotherapy techniques as well as counselling initiatives all aimed at ensuring quick recovery of the patient. With the patient also being type II diabetic, various interventions have been highlighted indicating how self-management techniques can be used to effectively tame the disease.

References

Abramson, D. I., & Miller, D. S. (2012). Vascular Problems in Musculoskeletal Disorders of the Limbs (illustrated ed.). Springer Science & Business Media.

Bagchi, D., & Nair, S. (2012). Nutritional and Therapeutic Interventions for Diabetes and Metabolic Syndrome. Academic Press.

Benzon, H. T., Rathmell, J. P., Wu, C. L., Argoff, C. E., & Turk, D. C. (2014). Practical Management of Pain (illustrated ed.). Elsevier Health Sciences.

Braddom, R. L. (2010). Physical Medicine and Rehabilitation E-Book (4 ed.). Elsevier Health Sciences.

Brooker, C., Nicol, M., & Alexander, M. F. (2011). Alexander's Nursing Practice E-Book: Hospital and Home - The Adult (4 ed.). Elsevier Health Sciences.

Burant, C. (2012). Medical Management of Type 2 Diabetes. American Diabetes Association.

Dougherty, L., Lister, S., & West-Oram, A. (2015). The Royal Marsden Manual of Clinical Nursing Procedures (illustrated ed.). John Wiley & Sons.

Ezrin, C., & Kowalski, R. E. (2011). The Type 2 Diabetes Diet Book, Fourth Edition (4, illustrated, revised ed.). McGraw Hill Professional.

Gulanick, M., & Myers, J. L. (2013). Nursing Care Plans - E-Book: Nursing Diagnosis and Intervention (8, revised ed.). Elsevier Health Sciences.

Lusardi, M. M., Jorge, M., Jorge, M., & Nielsen, C. C. (2013). Orthotics and Prosthetics in Rehabilitation (illustrated ed.). Elsevier Health Sciences,.

Malchow, D. (2016). Alive & Whole Amputation: Emotional Recovery (2 ed.). CreateSpace Independent Publishing Platform.

Mertig, R. G. (2011). Nurses' Guide to Teaching Diabetes Self-Management, Second Edition (2 ed.). Springer Publishing Company.

Nejaddadgar, N., Solhi, M., Jegarghosheh, S., Abolfathi , M., & Ashtarian, H. (2017, April 18). Self-Care and Related Factors in Patients with Type 2 Diabetes. Asian Journal of Biomedical and Pharmaceutical Sciences, 7(61). Retrieved Aug 8, 2018, from https://www.alliedacademies.org/articles/selfcare-and-related-factors-in-patients-with-type-2-diabetes.html

Sherman, R. A. (2013). Phantom Pain (illustrated ed.). Springer Science & Business Media.