Diabetic Foot Ulcer
Overview
Diabetes mellitus posse a burden on health and the healthcare resources all over the world and is one of the most debilitating chronicdisease (Rice et al, 2014). The disease causes several complications and is the leading cause of kidney disease and amputation than road traffic accidents. One of the main complications of diabetes mellitus is the development of a diabetic foot ulcer. Foot ulcers have a number of causes including changes in bony architecture, peripheral neuropathy and atherosclerotic peripheral arterial disease but the condition is higher in intensity and frequency among the diabetic patients. Diabetic mellitus leads to non-enzymatic glycation which causesthe ligaments to become stiff. There is also neuropathy from diabetes mellitus which causes loss of protective sensation and muscle coordination which increase mechanical stress during movement.
Diabetic foot lesions are one of the most common complications of poorly controlled diabetes mellitus. The ulcers result from breakdown of the skin which leads to the exposure of the tissues underneath the skin. The ulcers mostly form under the big toes and the balls of the feet but can cause effect down to the bones. All people with diabetes are at risk for developing a diabetic foot ulcer but they can be prevented with good foot care. The main predisposing factors of diabetic foot ulcers include neuropathy, poor blood circulation, insufficiently well controlled diabetes mellitus, wearing poor fitting footwear and also walking barefoot (Alavi et al, 2014). The risk for developing a diabetic foot is also increased by smoking, lack of physical exercise, being overweight and having high cholesterol or high blood pressure.
Poor blood circulation in the feet causes tissue breakdown and also interferes with the ability of the foot ulcers to heal. The healing of a diabetic foot ulcer is slowed down in the presence of high blood glucose levels and this outlines the need for proper glucose level management. Immunity is impaired in type two diabetes and as a result the ulcers take very long to heal. Nerve damage causes loss of feeling and predisposes the diabetic patients to injuries which may lead to the development of diabetic foot ulcer (Alavi et al, 2014). Nerve damage can also cause tingling sensation and pain in the patients in addition to the painless wounds. Diabetic patients commonly experience dry foot and as a result cracking may occur accompanied by calluses, corn and bleeding.
Diagnosis
The diagnosis of a diabetic foot ulcer is made by a local examination whereby an ulcer draining can be visible. A patient may demonstrate odor from the foot which is the obvious sign before the examination. The affected area is swollen and red in color on physical examination. a patient with a diabetic foot ulcer may also present with black tissue around the ulcer which is called eschar. A gangrene, which is death of tissues due to infectioncan also be evident around the ulcer. A patient can therefore present with odorous discharge, pain and numbness at the affected foot. A diabetic foot ulcer is grade in a scale of 0 to 3 where 0 is no foot ulcer but the foot is at risk (Alavi et al, 2014). A score of 1 implies that there is an ulcer but no infection while a score of 2 indicates that there is a deep ulcer exposing the joints and tendons. Thehighest score is a 3 which is the most severe score and indicates that there is an extensive ulcers and abscesses from infection.
Signs and Symptoms of Diabetic Ulcer
The signs of foot ulcers are not obvious, and it is wise that a diabetic patient performs adequate foot care and actively watches for any suggestive manifestations such as skin discoloration, black tissue or pain around the foot. The earliest sign of a diabetic foot ulcer is drainage from the foot of a patient. The discharge might stain the socks or even leak out of the shoes of the patient. The patient also experiences unusual swelling, irritation, and redness at the affected foot(Singh, Pai&Yuhhui, 2013). Odors may also emanate from the injured foot or feet which worsens the situation by impairing with the comfort of the patient.
A diabetic foot ulcer is characterized by a black tissue known as eschar surrounding the sore, and it is a severe problem. The tissue forms as a result of impaired blood flow into the area which causes the tissues to die and become black. Tissue death due to infections causes a complete or a partial gangrene around the diabetic foot ulcer. The formation of necrosis causes a discharge with a powerful odor which is characterized by severe pain and numbness. The patient may have a noticeable lump that is not always painful(Singh, Pai&Yuhhui, 2013). A diabetic patient has dry feet most of the times which are prone to cracking and may, therefore, have calluses, corns, and bleeding wounds.
Focused Assessment
The assessment of a diabetic foot ulcer is comprised of a comprehensive health history followed by physical examination. The healthcare professional should take the history of a previous foot ulcer and also the past amputation. Peripheral neuropathy, foot deformity, and peripheral vascular disease are also other elements of health history that should be taken by the patients. The healthcare practitioner should also take the history of visual impairment and diabetic nephropathy especially for the patients on dialysis(Damir, 2011). The glucose control and cigarette smoking history should also be considered since they are predisposing factors to a diabetic foot ulcer.
A focused assessment for a patient with a diabetic foot ulcer begins with general inspection where the patient is asked to remove his or her shoes and socks. The medical professional should inspect the shoe wear and ask the patient about its suitability given that inappropriate footwear and foot deformities may contribute to the development of diabetic foot ulcers(Damir, 2011). Excessively worn off or too small shoes could predispose to diabetic foot ulcer as they cause rubbing, erythema, blister or callus. A medical person should, therefore, inspect for the signs of inappropriate footwear.
Dermatological assessment should begin with global and inter-digital inspection for ulceration or areas which have abnormal erythema. The person conducting the evaluation should check for the presence of callus, nail dystrophy, ingrown toenail/paronychia. It is also important to note the focal or global skin temperature differences between the two feet which could indicate a vascular disease or cellulitis. Assessment for foot deformities should also be done and specifically Charcot arthropathy(Damir, 2011). Neurological evaluation should also be done given that peripheral neuropathy is the primary cause of diabetic foot ulcer. 10-G monofilaments are used to screen for sensory loss in the patient.
Pinprick sensation can also be done whereby a disposable pin is applied to the toenail and determine the ability to feel the pinprick. Neurological assessment can also be done by performing ankle reflex test, tuning fork test and even vibration perception threshold testing. Circulatory assessment should also be done to rule out peripheral arterial disease which contributes to the development of diabetic foot ulcers. Pedal pulses should be assessed to determine vascularization but should not be the only basis for intervention (Damir, 2011). The posterior tibia and dorsalispedis pulses should also be identified. Patients who demonstrate signs of vascular disease should be prescribed for advanced tests such as brachial ankle index which gives a better picture of the circulatory function.
Nursing Interventions for Diagnosis
The primary role of the nurse in the diagnosis of a diabetic foot ulcer is the recognition of risk factors for the condition. The nurses should carry out a comprehensive health assessment to determine the risk as well as identity health problems of a given patient. The nurses should conduct a physical examination of the foot based on general inspection, circulation, and neurological assessment. The nurse should identify the signs and systems of a diabetic foot ulcer including gangrene, odorous discharge from the foot, eschar and loss of sensation (Singh, Pai&Yuhhui, 2013). The nurse should also make recommendations for further tests such as the brachial-ankle index to aid in making a thorough diagnosis.
Cultural Considerations
Cultural considerations related to the management of the patient population with foot ulcers may need special considerations. The fact that the client is Hispanic raises the concern that diabetes mellitus is a disease of high interest among that population which necessitates serious interventions for handling the condition. Diabetes mellitus is highly prevalent among the Hispanics and is the fifth cause of death among this population (Rice et al, 2014). Around 2.5 million Hispanics in the United States aged above 20 years are living with diabetes.
Conclusion
Diabetes mellitus possess an excellent health and healthcare burden for individuals not just in the United States but also globally. One of the significant complications of the disease is diabetic foot ulcer characterized by an eschar, gangrene and odorous discharge. The key to the control of this condition is proper foot care to prevent it and vigilant watching for any early signs of the disease. Diabetic foot ulcers are mostly caused by improper glucose control, poor blood circulation and impaired neurological supply. The symptoms of diabetic foot ulcers are not obvious, and it is important to be watchful on any pain, loss of sensation and darkening of some parts of the foot. Nurses should also conduct a comprehensive health assessment through history taking to determine risk factors and physical examination to identify the signs of the condition.
References
Alavi, A., Sibbald, R. G., Mayer, D., Goodman, L., Botros, M., Armstrong, D. G., …&Kirsner, R. S. (2014). Diabetic foot ulcers: Part I. Pathophysiology and prevention. Journal of the American Academy of Dermatology, 70(1), 1-e1.
Damir, A. (2011). Clinical assessment of diabetic foot patient. JIMSA, 24, 199-203.
Rice, J. B., Desai, U., Cummings, A. K. G., Birnbaum, H. G., Skornicki, M., & Parsons, N. B. (2014). Burden of diabetic foot ulcers for medicare and private insurers. Diabetes care, 37(3), 651-658.
Singh, S., Pai, D. R., &Yuhhui, C. (2013).Diabetic foot ulcer–diagnosis and management. Clin Res Foot Ankle, 1(3), 120.
