A diabetic foot ulcer is one of the most common complications diagnosed in patients with uncontrolled diabetes mellitus. Anyone with diabetes mellitus can develop a foot ulcer resulting from poor glycemic control, peripheral vascular disease, underlying neuropathy, and poor foot care.
The development of a diabetic foot ulcer begins with a callus from neuropathy. The loss of sensation results in ongoing trauma, skin breakdown, and ulcer development. Patients with diabetes mellitus often experience poor circulation from atherosclerosis and vascular damage, which inhibits wound healing and can lead to tissue necrosis and gangrene.
60% of patients with diabetes will develop neuropathy, increasing the risk of foot ulcers. Ulcers most commonly occur on the plantar surface of the foot, including the heel and tips of hammer toes. Podiatrists and healthcare providers should examine the feet and legs of diabetic patients to evaluate the presence of calluses and areas of decreased sensation.
Tests performed that can diagnose and manage diabetic foot ulcers include fasting blood sugar, complete metabolic panel, erythrocyte sedimentation rate, glycated hemoglobin levels, and C-reactive protein. X-rays, bone scans, and arterial doppler with ankle brachial index may also be performed to determine and rule out underlying fractures, osteomyelitis, and peripheral vascular disease.
Nursing Process
The management of diabetic foot ulcers requires interdisciplinary support from podiatrists, endocrinologists, primary care providers, diabetes educators, nurses, and wound care specialists. Patient education is essential to prevent diabetic foot ulcers and delays in care that could contribute to complications like osteomyelitis and amputations.
Nursing Care Plans Related to Diabetic Foot Ulcer
Impaired Skin Integrity
A diabetic foot ulcer is an open sore that looks like a round crater with thick calluses as borders. It can become deep enough to expose tendons or bone.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Poor glycemic control
- Disease complications
- Neuropathy
- Inflammatory process
- Poor circulation
- Inadequate primary defenses
- Inadequate knowledge about protective skin integrity
As evidenced by:
Expected outcomes:
- Patient will demonstrate interventions, including proper skin care that promotes the healing of diabetic foot ulcers.
- Patient will demonstrate timely wound healing without complications.
Assessment:
1. Assess the patient’s wound.
The color, odor, visibility of bones, and the presence of necrosis must be assessed to determine an appropriate plan of care for the patient’s condition. The color of the skin and surrounding tissues can indicate the tissue’s vitality and oxygenation.
2. Assess the extent of skin impairment.
Pressure ulcers can be classified as partial thickness, stage 1-4, or unstageable. Inspect surrounding skin for maceration and erythema.
3. Assess the ulcer’s size weekly and compare it with baseline data.
The length, depth, and width of the ulcer must be measured and compared with baseline data to determine the progression of the ulcer and the effectiveness of the treatment regimen.
Interventions:
1. Remind the patient to inspect the feet daily.
Patients with neuropathy or peripheral vascular disease may not be able to feel when they have cut their skin. They must inspect their feet and lower legs daily for open areas. They can accomplish this by holding a mirror under their feet or having a family member assess them.
2. Advise the patient to avoid walking in bare feet.
The patient should wear footwear at all times. The patient can wear slippers indoors.
3. Assist with debridement.
Wounds with necrotic tissue or nonviable tissue must be removed to allow for treatment and healing.
4. Perform wound care.
Perform wound care per the physician’s orders. Depending on the type and thickness of the wound, this can include hydrocolloid dressings, absorptive dressings, alginate dressings, hydrogels, silver nitrate, and wound vacs.
5. Encourage the patient on skin care.
The patient should keep their skin moisturized, clean, and dry to prevent breakdown.
Risk for Infection
Patients with diabetic foot ulcers have a higher risk of developing infections. Foot ulcers are frequent sites of delayed healing and risk becoming infected. When the infection spreads to the soft tissues and bones, it can lead to lower-limb amputation.
Nursing Diagnosis: Risk for Infection
Related to:
- Open wound
- Disease process
- Delayed healing
- Inadequate primary defenses
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will exhibit no signs of infection.
- Patient will demonstrate interventions that promote wound healing and decrease the risk of infection.
Assessment:
1. Obtain a wound swab.
A wound can be cultured for the presence of bacteria such as staphylococcus, pseudomonas, etc., to allow for proper antibiotic treatment.
2. Assess the patient’s wound.
Wound characteristics like green or yellow drainage, foul odor, and erythema are signs of an infection.
3. Review imaging and lab results.
If there is a concern for osteomyelitis, MRI is useful for diagnosis. An elevated white blood count also signals an infection.
Interventions:
1. Use an aseptic technique in changing wound dressings.
Aseptic technique can reduce the risk of contamination and infection in the patient’s diabetic foot ulcer.
2. Administer antibiotics.
Severely infected diabetic foot ulcers may require inpatient hospitalization and IV antibiotics.
3. Ensure tight glycemic control.
Uncontrolled diabetes prevents wound healing from reducing oxygenation to tissues. Monitor the glucose level frequently and keep it within a tight range.
4. Refer to a wound care specialist.
Complicated, infected, or non-healing wounds require treatment at a wound care center with ongoing assessment from a wound care team.
Impaired Physical Mobility
Patients with diabetic foot ulcers may experience impaired physical mobility from their wound or amputation.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Discomfort
- Pain
- Pressure offloading
- Peripheral neuropathy
- Open wound
- Reluctance to move
- Amputation
As evidenced by:
- Limited range of motion
- Expresses discomfort when moving
- Use of prosthetic devices
- Use of assistive devices
- Inability to bear weight
Expected outcomes:
- Patient will demonstrate interventions that promote increased mobility.
- Patient will effectively use assistive devices and perform activities independently.
Assessment:
1. Assess the patient’s extent of immobility.
Understanding the patient’s functional mobility and level of dependence can help plan interventions and offer resources.
2. Assess the cause of immobility.
Causes of impaired mobility can be physical, psychological, and motivational. Some patients with diabetic foot ulcers do not move due to pain, fear of failing, or depression.
Interventions:
1. Encourage the patient to perform range of motion exercises.
Exercise can help prevent muscle stiffness and improves blood circulation in the affected area.
2. Assist the patient in using assistive devices.
Pressure offloading is essential in the management and healing of diabetic foot ulcers. Patients can use assistive devices like wheelchairs, crutches, cancer, and trapeze bars to reposition themselves. Use pillows and wedges to elevate extremities.
3. Encourage the patient and family members to participate in care.
Motivation and assistance by family members may be necessary to assist the patient with movement and repositioning expectations.
4. Consult with a prosthetist.
In the event that the patient requires amputation, they may be fitted with a prosthetic. A prosthetist is trained to work with those with disabilities and instruct on the wear and use of the prosthetic for optimal mobility.
References
- Diabetic Foot Ulcers. UCSF Department of Surgery. 2023. From: https://surgery.ucsf.edu/conditions–procedures/diabetic-foot-ulcers.aspx
- Diabetic Foot Ulcer. Oliver TI, Mutluoglu M. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537328/
- Foot and Toe Ulcers. Cleveland Clinic. Reviewed: April 27, 2022. From: https://my.clevelandclinic.org/health/diseases/17169-foot-and-toe-ulcers
- Diabetic Ulcers: Causes and Treatment. Healthline. Updated: February 4, 2021. From: https://www.healthline.com/health/diabetic-foot-pain-and-ulcers-causes-treatments
