DIABETIC FOOT ULCER. (DFU)

Diabetic patients are more prone to foot problems due to skin irritation, infection and ulcers. If adequate care is not taken in the treatment of the diabetes, it will lead to poor blood circulation to the feet resulting in diabetic foot ulcer.

Diabetic foot ulcer is defined as an open sore or wound that usually occurs in about 15% to 17% of patients with diabetes. These foot ulcer are commonly located on the bottom of the foot. The early signs of these will be swelling, irritation, redness,there is definitely very bad smell. It could be from one foot or both feet .The smell is very peculiar. When diabetes mellitus is not properly managed through balanced nutrition, exercise and insulin the complications of diabetes will erupt. And when it starts it is difficult to control. Some other co-morbidities include leg trauma, leg compartment syndrome, a spinal cord injury, hemiparesis,CHF,Malnutrition, Stroke etc.This ulcer is under the great toe (big toe)and it will slowly affect the bone and the other toes. DFU develop due to increased or repeated trauma to areas with severe peripheral neuropathy. So for healing process to take place, pressure redistribution and minimizing pressure in the affected areas is very important in achieving healing. PICTURES BELOW ARE DIABETIC FOOT ULCER.

HOW DO YOU OFFLOAD PRESSURE?.

• Therapeutic shoes.
• Foot inserts.
• Cast.
• Surgical intervention.
• TOTAL-CONTACT CAST is often considered the GOLD STANDARD for the management of Plantaur DFU according to literature books. .It has the highest success rate of healing in comparison to other forms of offloading. From my experience over twenty years the major problem is COMPLIANCE with the treatment regimen. Most of these patients are not willing to follow the right nutritional guidelines for their treatment. And also not willing to settle down for offloading.You talk to patient about offloading put him in bed with his feet off the matress ,and you come back 3ominutes later,he has borrowed a wheelchair and gone downstairs to smoke cigarettes and come back to his room with soda and chips. So poor compliance adherence hinders the effectiveness of treatment.DEBRIDEMENT is another form of treatment. Debridement including removal of necrotizing tissue, excessive calluses, removing unresponsive tissues from the wound bed.There are various types of debridement and these include.
• 1. SURGICAL debridement which is done by the Physician or a trained physical therapist. Nurses are not allowed to do surgical debridement unless they are trained. Surgical debridement involves the use of sharp instrument to remove devitalized tissue and debris living viable tissues for granulation and healing process to begin.
• 2.ENZYMATIC debridement: Nurses are allowed to do enzymatic debridement. The enzymes are applied to the wound and it helps to eat up all the dead tissues. In enzymatic debridement Santyl ointment is use to treat the wound. If infection develops apply a topical antibiotic powder before the application of Santyl ointment. But if infection continues stop Santyl until infection is resolved. Santyl will be discontinued when all the necrotic is removed. And the process of granulation tissue is established.
• 3.AUTOLYTIC debridement. “This is the process of the removal of necrotic debris and devitalized tissues from a wound through a moist environment that will facilitate the body’s own endogenous enzymes. Native enzymes that are normally present in wound fluid such as Proteolytic and Collagenolytic( matrix metalloproteinasis) disrupts the protein that is binding the dead tissue to the body”.( Sanara MedTech- Evidence Based Practice)The problem with Autolytic debridement is that it is very slow. It will take few days for the necrotic tissue to be separated from the viable tissues before the healing process begins. It is effective and convenient allowing the body to heal itself. Other forms of debridement can be used if Autolytic debridement did not begin within 14days.
• 4.MECHANICAL debridement is very common. It is commonly known as wet to dry dressing. It is a nonselective type of debridement ,that means that it will remove devitalized tissue,debris and also some viable tissues because it uses mechanical force.I usually wet the dressing first before removaal to minimize pain. Some wound will bleed when mecchanical force is used.Some hospitals often transition from wet to dry dressing to woundvac when they think that the wound bed is clean and woundvac will be beneficial to the patients. Please comply with your facility policy and procedures.
• 5.BIOLOGICAL debridement is also known as Larval therapy. The use of maggots that are grown in a sterile environment, digest dead tissue and pathogens. These maggots are applied into the wound and is covered with dressing to keep the maggots in place. The first time that I experienced it.I had goosebumps but with time I got comfortable with it.(ARROWHEAD Medical Center 2011)You will see maggots alive moving around in a sterile container. It is use in large wounds where painless necrotic debris removal is severely needed. (Uses sterile larvae of lucilia.Sericata species of the green bottle fly)
• WHAT ARE THE PRINCIPLES OF DRESSING CHANGE.
• The Principles of dressing change are adequate moisture in the wound, infection under control, minimal inflammation which will lead to angiogenesis, connective tissue synthesis, and epithelial cells migration and allow wound healing.
• Assess patients wounds based on the characteristics of the wound, necrotic tissue, depth of the wound ,the drainage level that is the amount of the exudate and the size of the wound. So the characteristics of the wound will determine the type of dressing. Determine the appropriate primary and secondary dressing needed for the wound. For example a shallow dry wound will only need a duoderm dressing as primary dressing and does not need secondary dressings.Whereas a deep heavy exudate drainage wound will need primary and secondary dressing and needs to be changed frequently.
• Major Factors Associated with the development of diabetic foot ulcer include mechanical changes in conformity of the bony architecture of the foot, atherosclerosis, peripheral artery disease and peripheral neuropathy.
• The questions that need to be addressed are?.
• High blood sugar control.
• Nutrition consultant and education on balance nutrition.
• peripheral neuropathy,
• Peripheral artery disease,
• Diabetic ulcer and bone infection. It is very important to treat wound holistically that is not just the wound but the patient with the wound. Mortality rates of people with diabetes foot ulcers are 2.5 higher of death in five years when you compare to those without foot ulcers. Also those with foot amputations with 70% of mortality rate in five years.
• PREVENTION IS BETTER THAN CURE.
• Can the complications from diabetes mellitus be prevented. Diabetes is often associated with poor circulation.
• Bath the feet very well with soap in a basin cleaning in between digital areas and rinse.Soak in warm water to soften the feet ,bring out and dry.
• Keep feet clean and warm.If nails need to be trim for diabetic patient. YOU NEED DOCTOR ORDERS .
• In most hospitals Physician order is needed to trim the nails. After you obtain the order when trimming avoid digging or probably cutting into the toenail at the lateral corners because patient can get injured. A Podiatrist or Physician should be consulted if patient develops calluses and corn.Do not do it yourself by using advertise objects as this may cause infection, ulcer or irritation.No heating pads, hot water or hot bottle. Patient should not wear any object that will cut off circulation in affected areas. Apply powder in between digital areas of the foot.If skin is too dry apply lanolin cream. Recently there are so many recommended lotion.Follow the doctor orders and hospital policy and procedures.Encourage patient to wear socks or shoes with plenty of room to avoid irritation.
• Discourage barefoot.,not good for diabetes because they can easily burn their foot without knowing it.Shoes with great support is often recommended. And 3/4 space in the shoe in front beyond the great toe.Feet kept in warm stocking and shoe with surplus room.Looking for and inspecting the feet which include areas between the toes looking for skin breakdown or blisters, redness and some abnormalities and irritability. You can use mirror to see the button of your feet.
• DIAGNOSTIC STUDIES ON WOUND CARE.
• Ankle Brachial index( ABI)Used to rule out arterial disease. Comparison is made between the ankle systolic blood pressure to the arm(brachial)Test is performed in hospitals and clinics. It is a reliable test.
• Transcutaneous oxygen. It is done to Measure the oxygenation of lower extremities.
• Prognosis will determine if patient will need hyperbaric treatment. TPCO2 check the level of oxygen at the lower extremities. It takes 45minutes. From my experience if the oxygenation is less than 40% the affected Extremity cannot be salvaged. Amputation will be most likely.
• Other test are Skin perfusion pressure, Angiogram, Color index scanning, Dropper wave analysis and Segmental Pressure.

WOUND MEASUREMENTS.

Wound should be measured accurately.

Measure in centimeters for better accuracy.

Place patient in same anatomical position. It should be away from the sleep surface.

Measurements are taken from wound edge to wound edge. LENGTH × WIDTH ×DEPTH. Is there a Tunneling or Undermining?.

Establish landmarks. So the wound must be looked at as the face of a clock. Head is 12oclock and patient feet is 6oclock.While the length is head to toe and Width is side to side.

• ASSESSMENT OF LOWER EXTREMITIES.
• Asses for history of ulcer. Does patient has history of previous ulcers.
• Any traumatic event irritating the ulcer?.
• History of smoking.
• History of vascular disease, diabetes or surgeries.
• GRADING OF PULSES OF LOWER EXTREMITIES.
• O= Absent.
• 1+= Barely palpable.
• 2+ = Palpable but diminished.
• 3+ = Normal.
• 4+ = Prominent,suggestive of aneurysm.
• pedal pulse is located on top (dorsal pedis) of the foot.
• Posterior tibial pulse ( Inside the ankle)
• CAPILLARY REFILL .
• Apply gently pressure to the distal part of the digit for 5 seconds.
• Release,then start counting the seconds until the blanched skin resolves and the vessels have refilled.
• Normal =10 – 15seconds .
• Moderate Ischemia 15- 25seconds.
• Severe Ischemia 25 – 40seconds.
• And very severe Ischemia = 40+seconds.
• IMPORTANT NUTRIENTS NECESSARY FOR WOUND HEALING.
• Protein for wound repair .
• Albumin for control of osmotic equilibrium.
• Ccarbohydrates for cellular energy.
• Fats supplies fatty acids .
• And also vitamins A,C,K ,copper,iron,Zinc, Pyridoxine,riboflavin and thiamine.
• CONCLUSIVELY, the best practice of wound care will be:
• 1. Interdisciplinary team approach, doctors, Podiatrist, nurses ,dietitian and physical therapist.
• 2. Offloading.
• 3.Weekly wound assessment and reevaluation of treatment regimen.
• 4.Patients, caregivers and families education.
• 5.Compliance problems.
• 6.Debridement.
• Other Treatment modalities.
• Diagnostic Studies.
• NB: Dry stable eschar of the heel does not need debridement.
• REFERENCES.
• Expert Guide: Solutions Algorithms for skin and wound care.
• http://www.woundsource.com
• surgery.ucsf.edu/debridement.
• http://www.physio-pedia.com/wound
• Susan, MS,RN,CWS@ September 16/2020.(Sanara MedTech- Evidence Based healing)Autolytic Debridement.

Questions and Answers .

1.The nursing assistant is to give patient a bath,during the process she observed that patient has very dry skin. What will be the best action for the nurse to take?.

A. What action, no action is needed.

B.Give patient a frequent bath.

C. Use an emollient on dry skin

D.Use alcohol to message the dry skin.

Correct answer C.

Rationale: An emollient soothes dry skin.A,B,D are all wrong.

2.The nurse is giving her patient foot care .Her responsibility should be?.

A.Use scissors to correct an ingrown toenail situation.

B.Do not clean the feet.

C.Trim toenail as short as possible.

D.Bathing the feet atleast daily.

Correct answer D.

Rationale: Correction of an ingrown toenail should be done by the Podiatrist (Foot doctor) not the nurse. A diabetic and elderly patients should have foot care at least once a day.

3.Stable heel dry eschar should not be debride.

A. True.

B. False.

Correct answer A.

Rationale:Because the debridement of stable dry heel should be left alone.Debridement is not needed.

4.Ankle Brachial index is an indication of loss of perfusion in the lower extremities.

A.True.

B.False.

Correct answer A.

Rationale :Perfusion of the lower extremity is usually measured by the ABI.