Diabetic Foot Ulcers Outline Diabetic foot ulcers and wounds; Prevalence, patient risk factors; Patient assessments; Clinical accepted wound-ulcer classifications; Sign and symptoms; Nursing treatments including dressings, wound care, medications; Patient education and prevention. Diabetic foot ulcers and wounds Diabetes is considered to be a disease in which high blood glucose levels over time can damage the nerves, kidneys, eyes, and blood vessels. [2]. Also diabetes may lead to diminishing in the bodys ability to fight infection. If diabetes is not controlled, the organs and the immune system are likely to be damaged. As a result, foot problems may occur. According to Bill O’Halloran, a diabetic foot ulcer is an open sore or wound on the foot of a person with diabetes.
Because of loss of pain sensation, it is usually not painful. [1]. Because of diabetes, the nervous system is impaired and a person with diabetes may not feel his feet properly. More than that, normal functioning of sweat secretion and oil production is damaged as well. All this factors can cause abnormal pressure of the skin, joints and bones of the foot when the person walks, and consequently result in breakdown of the skin and stimulate the development of sores. However, it is difficult to heal diabetic foot ulcers and wounds because blood vessels are damaged and, as it has been mentioned above, the immune system of a person with diabetes is impaired. Thus, these wounds are often infected with bacteria and they occur in such places as the connective tissues, skin, muscles, and bones. Then, the infections may develop into gangrene. Antibiotics can not easily reach to the site of the infection because the blood flow is very poor. And in this way, amputation can be the only treatment in such cases.
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Otherwise, the infection may spread to the bloodstream and this process is threatening to the patients life. Prevalence, patient risk factors According to the statistics estimated by the National Institute of Diabetes and Digestive and Kidney Diseases, there more than 16 million American that are known to be diabetics and more than million are at risk of developing this disease. 15% among the patients with diabetes suffer form a foot ulcer and more than that, 12-24% of individuals with a foot ulcer need amputation of the leg or the foot. Indeed, as the National Institute states, diabetes may be considered as the leading cause of nontraumatic lower extremity amputations in America “In fact, every year approximately 5% of diabetics develop foot ulcers and 1% require amputation. [8]. Diabetic peripheral neuropathy is found in 60% all persons with diabetes and in 80% of diabetic persons who have foot ulcers. Thus, it confers the greatest risk of foot ulceration; microvascular disease and suboptimal glycemic control contribute.
[8]. Even if the management resulting from the ulcer healing is successful, the ordinary recurrence rate is not more than 66% and the amputation rate grows to 12%. Thus, the National Institute concluded in the report, that one half of all nontraumatic amputations are a result of diabetic foot complications, and the 5-year risk that a contralateral amputation also will be required is 50%. [8]. In addition, about 15-20% of all persons with diabetes in the United States will be hospitalized with foot complications that occur during the course of their disease. Thus, such foot disorders as infection, ulceration, and gangrene are considered to be the leading cause of hospitalization in persons with diabetes mellitus. So, in order to prevent foot disorders, patients with diabetes should be aware of predisposing factors.
Such factors are those that increase the chance that a person with diabetes may develop foot ulcer. So, according to Robert G. Frykberg, (2002), there are known eleven risk factors that may stimulate foot ulcer. They are the following : Diabetic neuropathy, with damage to the nerves supplying the feet Peripheral vascular disease, with decreased blood flow to the feet A history of 10 years or more of diabetes Smoking Male gender Blood sugar levels that are not under control Diabetic retinopathy, or damage to the retina of the eye from diabetes Cardiovascular problems caused by diabetes Kidney problems caused by diabetes, including chronic renal failure A history of skin ulcers or amputation of a limb Conditions caused by increased pressure on the feet, such as corns and calluses Foot bones that are deformed or have limited movement, such as bunions Thick toenails [9]. Patient assessments Any ulcer should be thoroughly evaluated and after that managed. It is important that an adequate description of ulcer characteristics, such as size, depth, appearance, and location, also provides for the mapping of progress during treatment.
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According to the Centers for Disease Control and Prevention (CDC, 2011), 25. 8 million Americans, 8. 3 percent of the population, have diabetes and nearly 27 percent of those 26 million Americans, are undiagnosed. In 2010, the CDC reported nearly 2 million Americans aged 20 years and older were diagnosed with diabetes. Diabetic education is an important part of helping those with diabetes ...
[9]. In addition an evaluation of an ulcer should determine the etiology and ascertain if the lesion is neuro-ischemic, neuropathic or ischemic. The proven indicator of peripheral sensory neuropathy is believed to be ones failure to perceive the pressure of a 10-g monofilament. In this case there is a loss of protective sensation. Other common things that help to detect insensitivity are neurologic reflex hammer and a standard tuning fork (it should have 128 cycles per second).
After the physician describes the appearance of the ulcer, he should examine it with a blunt sterile probe. This is very important because gentle probing can detect sinus tract formation, undermining of ulcer margins, and dissection of the ulcer into tendon sheaths, bone, or joints.
[9]. In addition, a positive probe-to-bone finding has a high predictive value for osteomyelitis. Failure to diagnose underlying osteomyelitis often results in failure of wound healing. The existence of odor and exudate, and the presence and extent of cellulitis must be noted. [9]. As a rule, limb-threatening infections may be defined by a deep abscess, as well as cellulitis extending beyond 2 cm from the ulcer perimeter, critical ischemia or osteomyelitis. When signs of infection (purulence or inflammation) are present, anaerobic and aerobic cultures should be taken.
Cultures should be taken from curetted material or purulent drainage from the base of ulcer. All ulcers are contaminated and that is why culture of noninfected wounds is not recommended. In severe diabetic foot infections polymicrobial infections predominate and they may include a many of gram-negative rods, aerobic gram-positive cocci, and anaerobes. Not less important for thorough examination of ulcers are radiographs. They should be obtained in the patients who have deep or longstanding ulcers in order to rule out osteomyelitis. However, radiographs are known as not very sensitive indicators of acute bone infection.
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A wound may be described in many ways; by its aetiology, anatomical location, by whether it is acute or chronic1, by the method of closure, by its presenting symptoms or indeed by the appearance of the predominant tissue types in the wound bed. All definitions serve a critical purpose in the assessment and appropriate management of the wound through to symptom resolution or, if viable, healing. A ...
If radiographs are negative, but osteomyelitis is still indicated by clinical suspicion, additional leukocyte or bone scanning may help to ascertain bone involvement. However, bone scans may be falsely positive in the neuropathic patients because of Charcot’s arthropathy or hyperemia. Magnetic imaging resonance or leukocyte scanning can offer better specificity in such cases. Finally, bone biopsy can firmly establish such diagnosis as osteomyelitis. Clinical accepted wound-ulcer classifications It is necessary to classify ulcerations because this can help to find out logical approach to treatment and also aid in the outcome prediction. Thus there are many wound classifications that are based on the following parameters: neuropathy, extent of infection, ischemia, location and depth or extent of tissue loss.
For diabetic foot ulcers one of the most accepted classifications is the Wagner ulcer classification system. Wagner based ulcer classification on the presence of osteomyelitis or gangrene, the depth of penetration, and the extent of necrosis of tissue. But the drawback of this classification system lies in the fact that it does not specifically address two critically important parameters: ischemia and infection. [7]. Thus, the Wagner classification system, according to the article Diabetic Foot Ulcers: Pathogenesis and Management, lies in the following: Grade Lesion 0No open lesions; may have deformity or cellulitis 1Superficial diabetic ulcer (partial or full thickness) 2Ulcer extension to ligament, tendon, joint capsule, or deep fascia without abscess or osteomyelitis 3Deep ulcer with abscess, osteomyelitis, or joint sepsis 4Gangrene localized to portion of forefoot or heel 5Extensive gangrenous involvement of the entire foot. [9]. 5) Sign and symptoms In its early stages a diabetic foot ulcer may be characterized with such signs of irritation: redness of the skin, and blistering. Later symptoms may develop into an open wound draining fluid onto bedding or socks.
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Corneal Ulcer (Introduction) The eye is one of the vital organs in a human being. As seen on figure 1, the eye is composed of many different parts and function. The cornea is a clear covering over the colored iris and the pupil of the eye. The function of cornea is to help focus light on the retina and protect the iris, lens, etc. so that the eye can see. The cornea is best to compare with a ...
In this stage the wound becomes infected and can swell, grow red, and have drainage of pus. Then the person may have a fever and his blood sugar level may rise higher than usual. On the whole, diabetic foot ulcers have their signs and symptoms that should be borne in mind by every nurse because they help to recognise the disease easily. There are the following signs, according to Bill O’Halloran. (2005): Hair is no longer growing on the feet and lower legs There is hard shiny skin on the legs Pain in patients legs or buttocks that increases when the patient walks and improves when the patient has a rest (this is called claudication) Localized warmth can be a sign of infection or inflammation, perhaps from wounds that won’t heal or are ….
