Toe Amputation Secondary to Type 2 Diabetes Mellitus

Toe amputation secondary to Diabetes Mellitus L.B. is a 56-year-old female who lives at home with her adult son and a brother that lives close in the same community. She has two dogs and three cats and no grandchildren. She is on disability and hasn’t worked outside the home in almost ten years. She has a history of type 2 diabetes uncontrolled, schizophrenia, depression, tobacco abuse. She informed ER doctor that she was compliant with her Effexor, Risperidone and Metformin at home but did not use insulin unless she could obtain samples from the clinic which was not often.

She did not follow a diabetic diet at home and has smoked 2-3 packs of cigarettes since her teenage years.

Family history shows a father, mother and brother with type 2 diabetes. She was being treated in the clinic for right great toe ulcer and cellulitis after picking off a callous and the ulcer began to progress two weeks prior to admission.

At home treatment of Augmentin then a trial of ceftriaxone with at home wound care were unsuccessful. She was sent to the ER where hospital admission was discussed and agreeable to her for IV antibiotic therapy, pain management and wound care. When she was admitted, most of her vital signs were within normal limits. She had a blood pressure of 137/78, respiratory rate of 20 breaths per minute, a heart rate of 100 beats per minute, oxygen saturation of 97%, and an oral temperature of 98.1 degrees F, and a 6 on the pain scale. L.B. was then scheduled for a right great toe amputation on 1/22/19.

Before admission to the hospital, L.B. was taking a number three medications at home. First is Metformin, used in her diagnosis of type 2 diabetes mellitus. It decreases hepatic glucose production, decreases intestinal glucose absorption and helps maintain blood glucose levels. Common side effects for Metformin are abdominal bloating, diarrhea, nausea, and vomiting. It is important for nursing staff to monitor and assess for signs and symptoms of hypoglycemic reactions such as abdominal pain, dizziness, headache, tremors, tachycardia, anxiety, sweating and weakness. Monitor for signs and symptoms of lactic acidosis and ketoacidosis. Monitor lab values of electrolytes, glucose, ketone levels and renal function of patients taking Metformin (Vallerand, Sanoski, & Deglin, 2015).

L.B. takes Risperidone for her diagnosis of Schizophrenia; it works by antagonizing dopamine and serotonin in the central nervous system and helps decrease symptoms of psychoses, bipolar mania, or autism. Common side effects for Risperidone are Neuroleptic Malignant Syndrome with this monitor for fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension and hypotension. Assess for suicidal thoughts, aggressive behaviors, headaches, increased dreams and insomnia. Perform orthostatic blood pressures and electrocardiogram (ECG’s). Lab monitoring of increased AST, ALT (liver functions), complete blood count (CBC) and fasting glucose levels.

L.B. takes Venlafaxine (Effexor), an antidepressant and antianxiety medication for her depression. It works by inhibiting serotonin and norepinephrine reuptake in the central nervous system assisting in decreasing depressive behaviors and panic attacks. Common side effects are neuroleptic malignant syndrome, seizures and suicidal thoughts, dizziness, insomnia, nervousness and abnormal dreams. Monitor electrolytes (hyperglycemia, hypoglycemia, hyperkalemia and hypokalemia), complete blood count (CBC) with differential, platelet count as it may cause anemia. Nursing staff should assess mental behaviors, suicidal behaviors or talk, blood pressure as it can cause hypertension, serotonin syndrome signs and symptoms of agitation, hallucinations, tachycardia, nausea, vomiting and diarrhea (Vallerand, Sanoski, & Deglin, 2015).

After admission, L.B. was prescribed Acetaminophen (Tylenol) for her mild to moderate pain. Acetaminophen inhibits synthesis of prostaglandins that may serve as mediators of pain and fever. It is used to treat mild to moderate pain. Common side effects agitation, anxiety headache, fatigue, dyspnea, hepatotoxicity, constipation, Stevens Johnson Syndrome. Nursing staff should monitor for patient history of alcohol abuse or who are malnourished patients, rashes. Monitor hepatic levels such as bilirubin, AST, ALT, prothrombin time, renal functions, blood glucose levels (Vallerand, Sanoski, & Deglin, 2015).

L.B. was prescribed Acidophilus/L-Sporogenes for her GI system. This is a probiotic used to improve digestion and restore normal flora. It is used to treat bowel problems such as diarrhea, irritable bowel, urinary tract infections and lactose intolerance. Common side effects are intestinal gas or bloating, upset stomach and diarrhea. (www.naturesway.com)

L.B. was prescribed Ceftraixone (Rocephin) IVPB for her infected right great toe which was positive for Staph infection. Rocephin binds to the bacterial cell wall membrane, causing cell death and is a bactericidal action against susceptible bacteria. Common side effects are seizures, headache, diarrhea, nausea, vomiting, rash and Steven Johnsons Syndrome. Nursing staff should assess for infection (vital signs, appearance of wound, urine, WBC). Monitor prothrombin time, guaiac stools, hematuria, bleeding gums, increased levels of AST, ALT, bilirubin, BUN, and creatinine (Vallerand, Sanoski, & Deglin, 2015).

L.B. was also prescribed after admission Docusate sodium (Colace) as needed for stool softener. Colace incorporates water into the stool keeping stools soft. Common side effects mild abdominal cramps, diarrhea, and rashes. Nursing staff should monitor abdominal distention, presence of bowel sounds, assess color, consistency, and amount of stool produced (Vallerand, Sanoski, & Deglin, 2015).

L.B. was prescribed Insulin Glargine (Lantus) long acting insulin to control hyperglycemia with her type 2 diabetes. It lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Common side effects are hypokalemia, hypoglycemia, erythema and anaphylaxis. Nurses should monitor for signs and symptoms of hypoglycemia (anxiety, restlessness, mood changes, tingling in hands, feet, lips and tongue, cool pale skin, drowsiness, headache, irritability, tachycardia, weakness and unsteady gait). Monitor blood glucose levels, A1C, serum potassium levels (Vallerand, Sanoski, & Deglin, 2015).

L.B. was also given Glucagon that she uses on a as needed basis for acute hypoglycemic events. Glucagon stimulates hepatic production of glucose from glycogen stores. Increases blood glucose levels. Common side effects are hypotension, nausea, and vomiting. Nursing staff should monitor for signs of hypoglycemia, neurological status to prevent falls and injury (Vallerand, Sanoski, & Deglin, 2015).

Also prescribed was Lispro (Humalog) this is a rapid acting insulin that she uses to control hyperglycemia with type 2 diabetes. Lispro lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. It has a rapid acting insulin and has a shorter duration than regular insulin. Nurses should monitor for symptoms of hypoglycemia, hyperglycemia (confusion, drowsiness, flushed, dry skin), monitor body weight, rash. Labs should be monitored especially blood glucose levels, serum potassium levels (Vallerand, Sanoski, & Deglin, 2015).

Lorazepam (Ativan) was also prescribed as needed for her anxiety. Lorazepam is used for anxiety disorders and decreases preoperative anxiety and provides amnesia. Nurses should assess for central nervous system reactions which can cause falls. Assess anxiety levels and the need for the medication. Common side effects dizziness, drowsiness, lethargy, slurred speech, confusion. Monitor renal, hepatic functions. If overdose occurs Romazicon is the antidote (Vallerand, Sanoski, & Deglin, 2015).

Type 2 diabetes mellitus is caused by insulin resistance and impaired regulation of hepatic glucose production. The deficit in insulin secretion and the insulin deficiency causes peripheral insulin resistance in the body. The pancreas has the capability to produce some of its own insulin, but it is not enough for what the body is needing or there is poor use by the tissues and may be caused by them both combined. Abdominal obesity is a large risk factor in type 2 diabetes (Lewis Dirksen, Heitkemper, & Bucher, 2014).

Genetic factors are thought to also play a part in having type 2 diabetes. They have found that if there is a close family history of a Father and Mother with diabetes then their offspring are 10 times more likely to be diabetic. Insulin receptors are found mostly in fat, liver cells and skeletal muscles. If insulin is not properly used the glucose gets blocked from getting into the cells and causes the blood sugars to elevate or the person becomes hyperglycemic (Lewis Dirksen, Heitkemper, & Bucher, 2014).

Type 2 diabetes mellitus has a slow onset. People may go for several years not having any signs or symptoms of having hyperglycemic levels throughout the day. Years of uncontrolled glucose levels can cause multiple health problems in the future. Most people find out they have diabetes through labs that are not normally drawn for routine labs unless patients are symptomatic or at the age of having a baseline drawn. Fasting glucose >126mg/dl and Hemoglobin A1C > 6.5% is the most accurate test used to diagnose diabetes (Lewis Dirksen, Heitkemper, & Bucher, 2014).

The pathophysiological affects for L.B. came about after noncompliance of not following a diabetic diet, exercising and not taking her insulin as directed. Her hemoglobin A1C of 11 and not testing her blood sugars regularly caused a nonhealing diabetic ulceration on her right great toe that required amputation due to the spread of necrosis and infection after picking a scab. Psychologically she is concerned about how her foot looks as she stated “it is so ugly” after seeing the wound postoperatively. Her emotional affects were not displayed as she appeared to be empowered as she stated at discharge that now she is going to eat better, exercise and take her medications as directed.

The manifestations patients experience with Type 2 Diabetes Mellitus with toe amputation. Some of the signs and symptoms are not specific and come on slowly. Some of the typical signs and symptoms are fatigue, recurrent yeast infections or other general infections, prolonged healing of wounds, and visual changes. Close monitoring of the amputation are to check for fevers, foul smelling drainage and red streaking up the leg should be reported to the physician (Lewis Dirksen, Heitkemper, & Bucher 2014).

On the day of L.B. was assessed, she was orientated to person, place and time. She verified her allergy to Sulfa. She was resting comfortably in bed watching television. She is five feet four inches tall, weighs 106.2 Kg, making her body mass index 40. Finger stick blood sugar level was 162 mg/dl. She rated her pain today as a zero. Dressing to right foot was dry and intact. Her axillary temperature was 98 degrees F. She wears glasses, has a postoperative boot for right foot and uses a walker when ambulating in her room and hallway. L.B. has no teeth and states she doesn’t use dentures. She’s able to transfer by herself and uses a walker when up out of bed, otherwise did not have assistive devices at home prior to hospital stay. Her lung sounds where clear bilaterally in all lobes. Her oral mucosa was moist, fingernails were clean and intact, and skin was warm and dry to the touch with notable dry skin on feet and legs. Her capillary refill time was less than three seconds. She had a normal appetite and eats three meals a day and states she likes to snack. Auscultation of her heart was normal rhythm and rate with no irregularity or murmurs heard. Her muscle strength was equal bilaterally on upper and lower extremities. When asked, L.B. stated that her last bowel movement was yesterday. Her bowel sounds were active in all four quadrants. She denies any urinary problems.

After entering the emergency department prior to admission on 1/18/19, the emergency room physician ordered a comprehensive metabolic panel (CMP), C-Reactive protein, white blood cell count (WBC), sed rate, and a Hemogram panel which includes WBC, RBC, Hemoglobin, Hematocrit, MCV, MCH, platelet count, Neutrophils, Lymphocytes, Monocytes, Eosinophils, Basophils.