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Diabetic Foot Ulcers

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by

Wanda Newton

on 25 February 2014

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Transcript of Diabetic Foot Ulcers

Diabetic Foot Ulcers
Overview
2010 approx 24 million Americans with Diabetes
5.7 million are undiagnosed
15% of Diabetics - Foot Ulcer
85% of LE amputations preceded by Foot Ulcer
Neuropathy - associated with Foot Ulcer
Assessment & Recommendations
VIP Assessment:
- V = Vascular Supply
- I = Infection
- P = Pressure
Circulation
Check ABI
Check for pulses in the Dorsalis Pedis and Posterior Tibialis
- Absent: refer to further testing
- Diminished: refer if lack of improvement
Culture
When is it appropriate to culture?
- If the patient exhibits signs or symptoms of infection.
Diabetes is the Leading cause of:
Adult Blindness
LE amputation
Heart Disease
Kidney Disease
Nerve Damage
Recommendations: (
1-6 Focus on Prevention
)
1.
Take a careful Hx-glucose control
2.
Ensure patient is aware of risks
3.
Recognize LOPS is greatest risk factor. Monofilament.
4.
Classify (Texas) - Vascular/ABI, Sensory Neuropathy, Bony Deformities, Hx of Ulcer
5.
Pressure offloading-insoles
6.
Foot Care Teaching
7. Classify Plantar Ulcerations (Texas)
8. Optimal Wound Environment- debride, moisture balance, and infection control (if healable). Collagenase study.
9. Assess and Treat for infection (A1c>12 may not have inflammatory process)
10. Identify and modify related co-factors
11. Team
Quiz
10/08/20**, patient is a 66 years old male with a 12 year history of type 2 DM.
He presents with an open wound on his Plantar surface of the heel with a thick rim of callous formation around the margins of the wound. The wound base has 90% moist granulation tissue. The wound probes to bone.
Occupation
: patient is a floor supervisor for a home improvement store. He works 9-12h/day on his feet.
Social
: patient is married with attentive and supportive spouse.
Radiographic findings
: plain film showed no bony destruction.
Laboratory Findings
:
BUN = 24H (7-20 mg/dL)
Creatinine = 1.4H (0.6-1.1 mg/dL)
GFR = >60N (>60)
Fasting Glucose = 234H (80-100mg/dL)
Hemoglobin A1C = 7.2% H (3.9-6.1%)
Hemoglobin = 14N (11.3-15.4 g/dL)
Hematocrit = 40N (34-46%)
Albumin = 4.2N (3.5-4.8 g/dL)
Medication:
Metformin
Glyburide
Lisinopril

- What is the apparent etiology of this wound?

*
Arterial


*
Neuropathic

*
Pressure

*
Venous
(Generally due to a decreased in the arterial supply)
(Generally due to the loss of protective sensation LOPS)
(Localized area of necrosis due to unrelieved pressure and/or pressure in combination with friction and pressure)
(Sustained venous hypertension)
ABI is 0.71 - What would be the least appropriate action?
Debride the wound
Care Instruction
Whirlpool wound
Vascular Consult
Don' t forget!!!!
Take a Picture
Assess the wound's characteristics: base, edge periwound
Wound Bed
50% granular, 50% slough, 10% epithelial, 5% bone etc.
Wound Margins/Edge
Smooth, defined, jagged, irregular, etc.
Periwound
hyperkeratotic, Signs of infection, moisture, macerated, etc.
Wound classification
Partial or full thickness
Diabetic foot ulcers can also be classified by using the Wagner or Univ. of Texas Classification System
Time to Irrigate
19 gauge angiocatheter tip with 35mL syringe (8psi) using Saline or Water.
Classify using Wagner Scale
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
(Bony deformity, Callus, skin changes that are at risk for developing wounds, or post-ulceration that has healed)
(Full thickness skin loss with no infection)
(Subcutaneous involvement infection, no bone involvement)
(Deep ulcer, infection with cellulitis, osteomyelitis or abscess formation)
( Partial foot gangrene)
(Full foot gangrene)
What form of debridement would be appropriate at this time?
Autolytic
Enzymatic
Mechanical
Sharp
(Endogenous enzymes to digest necrotic material)
(Exogenous enzymes to remove necrotic material)
(Physical removal-whirlpool, irrigation, pulsatile, wet/dry)
(Selective removal using forceps, scissors, or scalpel)
Which primary dressing would be appropriate?
Hydrogel

Hydrocolloid

Silver Impregnated Collagen

Saline Moistened gauze
What is the best choice for off-loading?
Prefabricated removable device

Post operative cast shoe

Depth shoe with insert

Tennis shoe
Epidemiology

Diabetes - United States (Jan, 2011)
Total: 25.8 million children and adults in the United States- 8.3% of the population have Diabetes.

1 in 12 adults Americans have Diabetes.

1 in 4 adults Americans Indians have Diabetes.

March 2013 - 245 Billion: total cost of diagnosed Diabetes in the US in 2012.
Diabetic Foot Ulcer (DFU) refers to Neuropathic Ischemic Ulcers.

The primary cause of diabetic foot ulceration is peripheral neuropathy.

Motor Neuropathy compounds the problem.

Autonomic Neuropathy leads to decreased perspiration and dry cracked feet.
Summary
Adequate debridement is one of the most important aspects of foot ulcer management. Continual removal of the necrotic burden is necessary.
Infection is an ever present and serious threat to the diabetic patient.
Off loading the ulcer is vital.
Perform patient education!
Test Questions:
5- The primary cause of diabetic foot ulcer?
a) Peripheral Neuropathy
b) Frequent blisters
c) Dry skin
6- Diabetes
a) Reduces the body's ability to fight infection
b) Increases the body's ability to fight infection
c) Makes no difference in the body's ability to fight infection
What to do?
Full transcript