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PNC 220

Stephanie Pham

Wound Care - Diabetic Foot Ulcer

Types of Diabetic Foot Ulcers

Kahoot!!

Patient Education

Learning Goal

Let's Test your knowledge! :)

  • Demonstrate my knowledge and understanding about wound care specifically for diabetic foot ulcer patients.
  • Providing information such as pathophysiology, causes, symptoms, diagnosis, treatments and preventions.
  • Provide a handout with facts and information about the topic.
  • Provide patient education for those who are diabetic with foot ulcers.
  • Mini Quiz!!
  • Patients must understand and adhere to optimal wound care for good outcomes in diabetic foot ulcers.

  • The first step is to reduce repetitive pressure on the foot that caused the ulcer.

  • Various pressure-reducing devices and shoe modifications may be used.

  • Explain to patients that addressing causes of limb ischemia will require many office visits. Ischemia is a restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive).

  • Encourage patients to stop smoking and to gain control of hyperglycemia.

  • Patients also must adhere to antibiotic therapy (which may be adjusted periodically) to control wound infection.

  • Patients also must change wound dressings daily to encourage formation of healthy tissue and wound healing.
  • Determining which diabetic foot ulcer is important to determine an effective treatment.
  • Neuropathic ulcers arise when the nerve damage from diabetic neuropathy causes the individual with diabetes to not feel pain from an injury, which often leads to the ulcer progressing substantially before the person is even aware of it. Foot and toe deformities, corns, calluses and areas repetitive stress are likely places of injury. Footwear can not only hide these issues, but can aggravate the injury if the shoe is ill-fitting.

  • Ischemic ulcers or arterial ulcers may occur due to lack of blood flow to the extremity. When an ulcer occurs as the result of an injury to the extremity, the lack of blood flow makes these ulcers difficult to heal.

  • Neuroischemic ulcers occur in individuals with both neuropathy and poor arterial blood flow and are the most difficult to heal.

  • Infected wounds occur in about half of patients with a diabetic foot ulcer and require particularly close care.

(Anderson, 2015)

Caring For Your Wound

https://create.kahoot.it/share/wound-care-diabetic-foot-ulcer/9356c6d6-2afb-4971-9ea1-2df43e28d740

Here are the steps you’ll need to take to properly care for your wound:

PREPARE

• Get your supplies together and clean a work surface with plenty of room

WASH HANDS

• Remove all jewelry and point hands down, under warm water

• Add soap and wash for 15 to 30 seconds, cleaning under your nails

• Rinse and dry well with a clean towel

REMOVING DRESSING

• Carefully loosen the dressing, and pull off gently

• If the dressing sticks, wet the area

• Put old dressing in a plastic bag, and set aside

• Wash your hands AGAIN

INSPECT

• Inspect wound for any drainage, redness, pain or swelling

CLEAN WOUND

• Fill syringe with recommended fluid

• Hold 1 to 6 inches away from the wound and spray gently

• Use soft, dry cloth or piece of gauze to pat the wound dry

APPLY DRESSING

• Place and secure the clean dressing onto your wound

FINISH

• Throw used supplies into waterproof, tightly closed, double plastic bag

• Wash your hands AGAIN

• Wash any soiled laundry separately

REMEMBER, USE A DRESSING ONLY ONCE,

AND NEVER REUSE.

(WoundSource Editors, 2017)

(The North East LHIN, 2021)

Causes

Diagnosis & Treatment

Preventing Complications

  • The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.

  • There are several key factors in the appropriate treatment of a diabetic foot ulcer:
  • Prevention of infection
  • Taking the pressure off the area, called “off-loading”
  • Removing dead skin and tissue, called “debridement”
  • Applying medication or dressings to the ulcer
  • Managing blood glucose and other health problems
  • Not all ulcers are infected; however, if your podiatrist diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.

  • To keep an ulcer from becoming infected, it is important to:
  • keep blood glucose levels under tight control;
  • keep the ulcer clean and bandaged;
  • cleanse the wound daily, using a wound dressing or bandage; and
  • avoid walking barefoot.

  • Surgical Options: A majority of non-infected foot ulcers are treated without surgery; however, if this treatment method fails, surgical management may be appropriate. Examples of surgical care to remove pressure on the affected area include shaving or excision of bone(s) and the correction of various deformities, such as hammertoes, bunions, or bony “bumps.”
  • Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes.

  • Patients who have diabetes for many years can develop neuropathy, a reduced or complete lack of ability to feel pain in the feet due to nerve damage caused by elevated blood glucose levels over time. The nerve damage often can occur without pain, and one may not even be aware of the problem.

  • Anyone who has diabetes can develop a foot ulcer.

  • Native Americans, African Americans, Hispanics, and older men are more likely to develop ulcers.

  • People who use insulin are at higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and heart disease.

  • Being overweight and using alcohol and tobacco also play a role in the development of foot ulcers.

  • At high risk if you have or do the following:
  • Neuropathy (damage or dysfunction of one or more nerves that typically results in numbness, tingling, muscle weakness and pain in the affected area.)
  • Poor circulation
  • A foot deformity (e.g., bunion, hammer toe)
  • Wear inappropriate shoes
  • Uncontrolled blood sugar
  • History of a previous foot ulceration

(Ampa, 2021)

Infection Prevention: Aggressive infection control is necessary to prevent infection. High morbidity and mortality rates are associated with diabetic foot ulcers which means oral and topical antibiotics are recommended if there is any sign of infection. Typically, wound dressings with antimicrobial agents are used. Simple gauze may actually damage the skin. For a diabetic foot ulcer with dying tissue, hydrogels or dressings with collagen is the most effective. Most important is matching the absorptive ability of the wound dressing to the amount of wound drainage.

Pressure Offloading: Pressure on the diabetic foot ulcer prevents healing. That is why one key aspect of treatment can be a device to redistribute pressure more evenly throughout the lower leg. This can be done with a non-removable total contact cast or a removable offloading device. Unfortunately, studies have shown that many patients with removable devices only wear them 30% of the day, which can affect the outcomes of the treatment significantly.

Preventions

(Ampa, 2021)

Symptoms

  • The best way to treat a diabetic foot ulcer is to prevent its development.

  • Recommended guidelines include seeing a podiatrist on a regular basis; The podiatrist can determine if the patient is at high risk for developing a foot ulcer and implement strategies for prevention.

  • Good diabetic control and lifestyle modification include:
  • Keeping blood glucose levels optimal.
  • Good nutrition and eating habits.
  • Reducing additional risk factors, such as smoking, drinking alcohol, high cholesterol, and elevated blood glucose.

  • Wearing the appropriate shoes and socks will go a long way in reducing risks.

  • Learning how to check your feet is crucial so that you can find a potential problem as early as possible.
  • Inspect your feet every day—especially the sole and between the toes—for cuts, bruises, cracks, blisters, redness, ulcers, and any sign of abnormality.
  • Some drainage on your socks.

  • The drainage coming from the wound becomes thick, tan, green or yellow, or smells bad (pus).

  • Redness, swelling and bleeding.

  • If it has progressed significantly, odor may be present.

  • Since many people who develop foot ulcers lose the ability to feel pain, pain is not a common symptom.

  • The wound is larger or deeper.

  • The wound looks dried out or dark.

(WoundSource, 2017)

https://www.youtube.com/watch?v=3D_zQxEG-G0&ab_channel=SKSITFIRM

(Ampa, 2021)

(WoundSource, 2017)

(Ampa, 2021)

References

Pathophysiology

What is Diabetic Foot Ulcer?

Patient Handout

  • A diabetic foot ulcer is an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot.

  • Of those who develop a foot ulcer, 6 percent will be hospitalized due to infection or other ulcer-related complication.

  • Diabetes is the leading cause of non-traumatic lower extremity amputations, and approximately 14-24 percent of patients with diabetes who develop a foot ulcer will require an amputation.

  • Foot ulceration precedes 85 percent of diabetes-related amputations. Research has shown, however, that development of a foot ulcer is preventable.

American Podiatric Medical Association . (2021). Diabetic Wound Care: Foot Health: Patients. Retrieved April 07, 2021, from https://www.apma.org/diabeticwoundcare

Anderson MD, A. D., Wade PhD, Anderson MD, H. D., DollahiteD. (2015, May). Pathogenesis and management of diabetic foot ulcers. Retrieved April 07, 2021, from https://journals.lww.com/jaapa/fulltext/2015/05000/pathogenesis_and_management_of_diabetic_foot.6.aspx#:~:text=10%20Box%202-,PATHOPHYSIOLOGY,the%20hyperglycemic%20state%20of%20diabetes.&text=Hyperglycemia%20produces%20oxidative%20stress%20on%20nerve%20cells%20and%20leads%20to%20neuropathy.

Lipsky, B. A., Berendt, A. R., Deery, H. G., Embil, J. M., Joseph, W. S., Karchmer, A. W., . . . Tan, J. S. (2004, October 01). Diagnosis and Treatment of Diabetic Foot Infections. Retrieved April 07, 2021, from https://academic.oup.com/cid/article/39/7/885/493357

The North East LHIN. (2021). Your Guide to Woundcare - Diabetic Foot Ulcers. North East Local Health Integration Network. http://healthcareathome.ca/northeast/en/care/patient/Documents/Wound%20Care/Wound%20Care%20-%20Diabetic%20Foot%20Ulcers.pdf

WoundSource Editors. (Ed.). (2017, November 09). Diabetic Foot Ulcer: Treatment and Prevention. Retrieved April 07, 2021, from https://www.woundsource.com/blog/diabetic-foot-ulcer-treatment-and-prevention

  • The pathophysiology of diabetic foot ulcers has neuropathic, vascular, and immune system components, which all show a base relationship with the hyperglycemic state of diabetes.

  • Hyperglycemia produces oxidative stress on nerve cells and leads to neuropathy.

  • Neuropathy plays the central role, with disturbances of sensory, motor, and autonomic functions leading to ulceration due to trauma or excessive pressure on a deformed foot that lacks protective sensation.

  • Once the protective layer of skin is breached, underlying tissues are exposed to bacterial colonization. This wound may progress to become actively infected, and, by contiguous extension, the infection can involve deeper tissues.

  • This sequence of events can be rapid (occurring over days or even hours), especially in an ischemic limb. Various poorly characterized immunologic disturbances, especially those that involve polymorphonuclear leukocytes, may affect some diabetic patients, and these likely increase the risk and severity of foot infections

  • Damage to motor neurons of the foot musculature may lead to an imbalance of flexors and extensors, anatomic deformities, and eventual skin ulcerations.

  • Damage to autonomic nerves impairs sweat gland function, and the foot may develop decreased ability to moisturize skin, leading to epidermal cracks and skin breakdown.

  • Lastly, patients may not notice foot wounds because of decreased peripheral sensation. Because the blood supply required to heal a diabetic foot ulcer is greater than that needed to maintain intact skin, chronic ulceration can develop.

(Ampa, 2021)

(Anderson, 2015)

(Lipsky, 2004)

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