TOMAS CLAUDIO COLLEGES

COLLEGE OF NURSING

“NON-HEALING
WOUND OF LEFT
LEG ”

Areola, Melissa D.P

BSN 2-A
I. INTRODUCTION

A non-healing wound on the left foot refers to an injury, ulcer, or sore that fails to
heal within the typical timeframe, often persisting for several weeks or months
despite treatment. This condition is a significant medical concern, as it can indicate
underlying health issues and carries a high risk of complications, such as infections,
chronic pain, or tissue damage.

Wound healing is a complex process involving multiple stages, including

inflammation, tissue regeneration, and repair. When this process is disrupted, the
wound remains open and vulnerable to further damage. Common causes of non-
healing wounds on the foot include diabetes, poor circulation, prolonged pressure,
and infections. Conditions such as diabetic neuropathy, peripheral arterial disease,
and venous insufficiency are frequently associated with these wounds, making
prompt diagnosis and intervention crucial.

Left untreated, non-healing wounds can escalate, leading to severe complications

like gangrene or the need for amputation. Effective management involves addressing
both the wound itself and any underlying health conditions. This may include wound
care, infection control, improving circulation, and lifestyle modifications to promote
overall healing and prevent recurrence.

Diabetic foot ulcers are among the most common non-healing wounds. High blood sugar
level impair circulation and delay tissue repair. Diabetic neuropathy, which reduces
sensation in the feet, makes it easier for minor injuries to go unnoticed until they worsen.

A non-healing wound on the left foot is more than just a localized problem; it often reflects
broader systemic issues requiring comprehensive care. By addressing both the wound and its
underlying causes, healthcare providers can minimize complications, promote healing, and
improve the patient’s overall quality of life. Early recognition and prompt intervention remain
key to achieving successful outcomes.
II.MEDICAL AND PATIENT’S PROFILE

A. Patient’s Profile
Name: Patient M.
Age: 67 years old
Gender: Male
Religion: Roman Catholic
Address:Matienzo St. Bayugo Jala Jala Rizal
Civil Status: Married
Nationality: Filipino

B. Medical Profile

Hospital: Rizal Provincial Hospital System - Morong

Ward: Medical
Bed No.: 5 A
Date of Admission: 12/03/24
Attending Physician:
Chief Complaint: Non healing wound on Left foot
Admitting Diagnosis: Non healing wound on Left plantar area

III.PAST AND PRESENT HISTORY

3.1 PAST HISTORY:

Patient M had a 1-month history of non-healing wounds in the left foot, diabetes mellitus, UTI.

3.2 PRESENT HISTORY:

Patient M. was presented by his wife at Rizal Provincial Hospital System - Morong this Decemver
3,2024, with a chief complaint of Non-Healing wound on Left Foot.
IV. GENOGRAM (if the case is hereditary like DM, but if not proceed to objectives)

Paternal Grandpa and Grandma

-Diabetic -Lung Cancer

---

x -Diabetic x -Diabetic

x x X X X X -Wife

-Diabetic -Diabetic -Diabetic -Diabetic -Diabetic -Diabetic

X
 -Accident

V.OBJECTIVES

GENERAL OBJECTIVES
> The purpose of this case presentation was to create a holistic approach to nursing care and patient
duties. This is intended to improve skills and attitudes in the application of nursing process and disease
management, as well as to increase the presenters' and the audience's knowledge of Non-healing wound
of Left foot

STUDENTS CENTERED OBJECTIVES

To develop students to practically apply skills and their understanding of learned facts to a real situation
and to train to develop critical -decision making ability. Moreover, to find the reason or causes that create
a particular situation in the case and assess the appropriate action in a given situation.

CLIENTS CENTERED OBJECTIVES

>To screen clients effectively for NHW L foot , risk factors, and relevant medical history to prompt early
diagnosis and to increased knowledge of preventive measures and treatment modalities.
>Understand the importance of seeking medical attention promptly for concerning symptoms and
advocating for her health needs effectively
>Recognize when to seek medical help for worrisome symptoms and engage in decisions about her
health

SPECIFIC OBJECTIVES
> To identify the sign and symptoms manifested by the patient with NHW L foot and perform further
assessment to be able to recognize appropriate nursing intervention to be rendered
> To put into action what we have learned in school (such as the nursing process) and apply our
knowledge in providing quality and individualized nursing care
VI. THEORETICAL FRAMEWORK

Orem’s Self-Care Deficit Nursing Theory

Orem’s self-care nursing theory proposes that caring for oneself is essential for maintaining optimal
health and well-being. While self-care includes basic tasks like physical and nutrition, Orem expands
this concept to include activities that not only help us stay alive, but also nurture our sense of overall
well-being.

Dorothea Orem's theory of nursing focuses on a person's self-care abilities and needs. It has three
related parts: the theory of self-care, theory of self-care deficits, and theory of nursing systems. The
theory of self-care identifies universal, developmental, and health-derived self-care requisites. The
theory of self-care deficits specifies when nursing is needed to support a person's self-care abilities.
The theory of nursing systems describes how a nurse can meet a person's self-care needs through
wholly compensatory, partly compensatory, or supportive-educative systems. Orem's theory provides
a framework for the nursing process and clinical practice focused on assessing a person's self.

Self-Care Agency
(Patient’s Wife Capabilities)
-Recognize symptoms of Diabetes
(elevate blood pressure, loss of
conscious)
-Monitor Vital Signs
-Provide Nutrition
-Maintain a safe home environment

Self- Care Demands Self-Care Deficit

(Patient Needs) (Patient Inabilities)
-Symptoms monitoring
-Proper nutrition -Cannot monitor Symptoms
-Range of Motion Exercises -Emotional Support
-Monitoring -Pain, swelling, and risk of
further injury can make
walking or standing difficult.
 Nursing Agency

-Educate wife about

-Train Patient wife in symptoms
monitoring
-Offer emotional Support

VII. ANATOMY AND PATHOPHYSIOLOGY

The foot is a complex anatomical region, consisting of various layers of skin, tissue,
blood vessels, nerves, and bones. When a wound fails to heal, it typically affects
several aspects of these structures, often due to underlying conditions like diabetes,
poor circulation, or infection. Below is an overview of the anatomy and physiology
related to a non-healing wound on the left foo
VIII.LABORATORY DIAGNOSIS / DIAGNOSTIC PROCEDURES

COMPLETE BLOOD COUNT

PARAMETER RESULTS REFERENCE VALUE SIGNIFICANT

FINDING
EVALUATION
Hemoglobin L 85.0 123.0-153.0 g/L Low hemoglobin
concentration in
patients with diabetes
mellitus is associated
with a more rapid
decline in glomerular
filtration rate than that
of other kidney
diseases
Hematocrit 0.26 0.36-0.45 vol% A low hematocrit level
L in a diabetic
patient indicates
anemia, which is
relatively common in
people with diabetes,
and can be caused by
complications like
diabetic nephropathy
(kidney damage) which
reduces the body's
production of
erythropoietin, a
hormone crucial for red
blood cell
production; leading to a
decrease in red blood
cells, resulting in a low
hematocrit reading.
Red Blood Cells 3.1 4.5-5.1 x10^12/L A low RBC count is
L often caused by blood
loss or by inadequate
RBC production, often
due to low iron.
White Blood Cells 14.16 4.4-11.3 x10^9/L A low white blood cell
H High White Blood Cell
Count Is Associated
With Worsening of
Glucose Metabolism.
DIFFERENTIAL COUNT

PARAMETER RESULTS REFERENCE VALUE

Neutrophils H 0.74 0.40-0.65 %
Lymphocytes 0.14 0.28.0.35 %
L

Monocytes H 0.07 2-8%

Eosinophils H 0.04 0.02-0.05%

PARAMETER RESULTS REFERENCE VALUE

Blood Uric Acid 456mg/dl 0.40-0.65 %
H
Blood Urea Nitrogen 7.52 mmol/L 0.28.0.35 %
L

Creatinine H 137umol/L 2-8%

HDL Cholesterol L 0.74 0.02-0.05%

IX. 13 AREAS OF ASSESSMENT

1. Social Status
Name of Client: Manalo Buenaventura
Age : 67 yrs old
Sex : male
Social Status: Married
Address :Bayugo Jala-Jala Rizal
Religion:Roman Catholic
Educational Attainment:
Present Job/Work Social Related Activity (smoking, drinking habits, substance abuse):Smoking
Family History of Disease Related: Asthma and Diabetes Mellitus

2. Mental Status
*Verify/Check/Observe If patient is alert and oriented to person, place and time
“Ako si Manalo Buenaventura. Ako ay nasa ospital”
*Able to answer the questions correctly
-The patient answers the questions correctly.
*Affect (the appropriateness and degree of affect should say with the topic)
*Cooperative Able to maintain eye-to-eye contact
*Dress, Grooming and Personal Hygiene (patient should be clean and well groomed) Facial Expression
(should be appropriate to the content of the conversation)
- Patient appears neat and appropriately dressed.
- "I’m doing okay. I’m just a little tired."
- Patient smiles when talking about positive topics, looks serious or concerned when discussing problem
3. Emotional Status
*Present stress factor
“Money is tight, and it’s affecting everything, even how we eat."
*Ways of handling stress Financial concerns
*Relationship status
"My partner and I have been arguing a lot, and it’s really affecting me."
*Feeing of (helplessness, hopelessness, powerlessness)

4. Sensory Perception
Vision -
*Vision loss 2º cataract/glaucoma - Blurred, hazy, or dim vision. Colors may appear faded, and glare
sensitivity increases.
* Eyelids
*Distance Vision (Snellen chart)- Blurred, hazy
* Discharges (illness related) - None
* Visual Fields (confrontation technique)

Smell -
History of sinus infection- None
History of Allergy -None
Nose deviation: Size and Shape
Presence of deviation in the nose
Can Identify and differentiate smell Able to breathe room air- "I’m not experiencing any shortness of
breath or difficulty breathing."
History of epistaxis (illness related) – None

Hear
Hearing loss; _ The patient hear sounds clearly
history of ear infection/trauma -none
Discharges from the ear -none
Presence of cerumen/earwax
Symmetrical deviation in terms of size and shape
Ability to hear sounds lie tick of the clock at a specific distance “Naririnig ko ng malinaw sa malapit pero
pag malayo hindi ko na halos marinig”
Voice Whisper Test
Weber Test
Rinne Test

Taste
Describe appearance of the lips- Round shape
Describe shape according to symmetry
Describe condition of teeth (teeth loss, tooth decay, dentures) – teeth loss
Describe appearance of gums, buccal cavity and tongue - pale pink tissue that tightly fits around the
base of the teeth, while the buccal cavity (inner lining of the cheeks) is also smooth and pink, and the
tongue presents a slightly rough
Can differentiate/identity taste of salty, sweet, bitter and sour -“ I can differentiate and identify tastes of
salty, sweet, bitter, and sour”
Touch
React to pain
Can feel other sensation like tingling, numbness, weakness

C-character 5-severity scale (1-10) – Tingling and weakness 7/10

0-onset
P-pattem
L-location – Foot
A-associated factor
D-duration

5. Motor Ability
R-O-M in all extremities
Proper symmetry between (L and R sides )
Presence of deformity- None
Can tum from side to side – The patient can turn from side to side
Can move (from lying to siting position) Coordination, Stature and Gait- the patient can move from sitting
position, stand and walk

6.Temperature
36.3

7. Circulatory Status
-B.P 130/100
-Apical Heart Rate 85
-Quality of Pulse – Regular, Strong.
-Chest Pain- None
-Check for Peripheral edema (especially if illness related)- Edema on left lower extremity
-Capillary refill – quick

8. Respiratory System -
Rr – 24
Describe symmetry of chest expansion -
describe breathing pattern/rise and fall of chest – “My breaths feel steady and even”
presence of phlegm hemoptysis (illness related) – None
use of respiratory aids (O2, tracheostomy...) – Nebulizer (asthma)

9. Nutritional Status
- diet of the patient
-Appetite
describe current weight (56) /height and body build (BMI)
- IVF if dehydrated -PNSS

10. Elimination -
usual pattern of bowel moverment - none
character of stool (esp. if illness related)
history of bleeding (illness related) -Sometimes
Constipation/loose bowel movement - none
usual pattern of voiding/micturition -
character of urine (illness related) -
pain/burning/difficulty of voiding- Pain and burning sometimes

11. Reproductive system

Male
age circumcised 7 yrs old
penile discharges -None
surgery/diagnostic procedure -none

12. State of Physical Rest and Comfort

sleeping
inability to sleep related to -Pain
quality of rest/sleep
feeling boredom/dissatisfaction

13. State of Skin and Appendages Skin

check skin for o
color -Black
o temperature 36.3
o skin turgor (fullness) -the skin springs back after being pinched
o history of skin allergy -none
o history of skin disease -none
o presence of any mark (tattoo) on the body -Abdomen area
• presence of bedsore -None

< Hair
check hair for
o presence of dandruff -none
o presence of lice o hair distribution (baldness, thin hair)

> Nail check nails for:

o color -light pink
o condition
o appearance-smooth pink color

VIII.NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLANNING RATIONALE EVALUATION

Monitor for Non healing Monitor Perform -Monitoring 
changes in wound on blood Handwashing/Hand vital signs,  No signs of
blood pressure Left foot pressure hygiene before and including increased ICP
(especially (watch for after assessing the blood (i.e., stable
signs of hypertension) patient. pressure, pupils, no
increased ICP), and allows for posturing,
heart rate,  - Observe and early controlled
oxygen Positioning: assess behavioral detection of blood
saturation, and Keep the patterns if there is hypertension pressure).
temperature. head of the any manifestation or other 
 Frequent bed elevated of pain. changes
assessment of at 30° to help - Promote proper Hypertension
blood pressure decrease ICP. positioning. Assist can worsen
to detect signs Ensure the patient to the
of proper comfortably rest on hemorrhage
hypertension,. alignment of the bed with or prevent
 Assess for the head and precautionary effective
changes in neck. measures.
mental status, -Correct intake of
speech, and medications
motor function. according to the
 Monitor for Doctor’s order.
signs of
deterioration,
including
confusion,
weakness,

DISCHARGE PLAN

MEDICATI TREATME HEALTH OUTPATI DIET SPIRITUAL/

ON EXERCISE/ECON NT TEACHI ENT SEXUAL
OMIC FACTORS NG FOLLOW ACTIVITIES
UP
-  Regular low- - The -Clean The Vitamin C Mindfulness
Identify impact exercises wound the healthcare (for practices help
and treat (e.g., walking, should be wound provider collagen reduce anxiety
the ankle exercises, cleaned daily will assess formation and create
underlying cycling) improve daily with with the wound and mental clarity,
cause of blood flow, saline or a saline for signs immune allowing the
the wound particularly in the mild solution of healing support) body to focus on
(e.g., legs, which helps antiseptic or as (e.g.,  Citrus healing.
diabetes, deliver oxygen and to prevent directed granulatio fruits Physical
poor nutrients to the infection. by your n tissue (oranges, activities that put
circulation) wound site. - If an healthca formation) lemons, direct pressure
.  Better infection is re or grapefruit or strain on the
 Prevent circulation present, a provider. deteriorati s) wound can
infection enhances tissue healthcare Avoid on (e.g.,  delay healing or
through repair and provider using increased Strawberri cause
proper prevents further may harsh redness, es, kiwi, discomfort.
hygiene complications. prescribe antisepti swelling, pineapple
and -Exercise topical or cs like or s
dressing strengthens the systemic hydroge drainage).  Bell
changes. immune system, antibiotics. n - The peppers,
 improving the peroxide wound’s broccoli,
Encourage body's ability to or size and tomatoes,
proper fight infection and alcohol, depth may spinach
nutrition promote healing. which be rink plenty
and can measured of water
hydration delay to track or herbal
to support healing. healing tea to
tissue - progress stay
repair. Apply and hydrated.
the determine
prescrib if further
ed interventio
dressing ns are
to the required.
wound,
ensuring
it stays
clean
and dry.
Change
the
dressing
as
instructe
d
(typically
every 1-
3 days
or when
it
becomes
wet or
soiled).
 Use
sterile
gloves
when
changing
dressing
s to
reduce
the risk
of
infection.