nurse should report what abnormal finding on a patient with a infected diabetic foot ulcer

Assess feet for callus. Ulcer may be embedded under thickened callus. A qualified professional (physician, podiatrist/chiropodist, foot care nurse) must pare down the callus Assess feet for swelling. Swelling predisposes the patient to diabetic foot ulcers, impedes healing, has implications for footwear PREVENTION AND TREATMENT

Full Answer

What is the nursing diagnosis for diabetic foot ulcer?

Nursing Diagnosis for Diabetic Foot Ulcer Impaired tissue perfusion related to the weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels. Impaired tissue integrity related to the presence of gangrene in the extremities. Impaired sense of comfort (pain) related to ischemic tissue.

What tests should be performed on diabetic patients with foot infections?

Additional tests that need to be performed on diabetic patients with foot infections include full blood count, erythrocyte sedimentation rate, electrolytes, HbA1c, plus renal and liver function tests. Weekly measurement of the C-reactive protein titre during treatment of a foot infection may help determine progress.

Who should be trained to treat diabetic foot ulcers?

The authors believe that it may be useful to primary care physicians, nurses, podiatrists, diabetologists, and vascular surgeons, as well as all healthcare providers involved in the prevention or management of diabetic foot ulcers.

What is the pathophysiology of diabetic foot ulcers?

Structural foot deformities and abnormalities, such as flatfoot, hallux valgus, claw toes, Charcot neuroarthropathy, and hammer foot, play an important role in the pathway of diabetic foot ulcers since they contribute to abnormal plantar pressures and therefore predispose to ulceration.

Why should the patient's health literacy level be catered to?

The patient’s health literacy level should be catered to because interventions that patients do not fully comprehend are far less likely to be followed. The patient should be counseled regarding resources if any gaps in care are encountered (e.g., if the patient does not have running water, referral to case management to seek assistance programs for utilities, etc., may be warranted).

What is the importance of a physical exam?

A thorough physical examination will reveal an abundance of useful clinical information. The information garnered will allow for appropriate grading and classification of the DFU, by providing prognostic value and guiding treatment. Some information in the examination may even reveal undiagnosed conditions impeding the healing process (e.g., lower extremity swelling despite adequate elevation and compression may indicate the need for a cardiology referral).

What is a DFU?

Diabetic foot ulcers (DFUs) are ostensibly the most challenging types of chronic ulcerations to manage, given their multifactorial nature. Thorough, systematic assessment of a patient with a DFU is essential to developing a comprehensive plan of care. To implement the treatment plan successfully, clinicians and patients must work together to address each factor contributing to ulcer development and perpetuation.

What are the three subclassifications of DFU?

At present, subclassification of DFUs can be divided into three categories: neuropathic, ischemic, and neuroischemic. The most prevalent of the three is the neuroischemic DFU, which comprises approximately 50% of such ulcerations. 2 Organization and reproducibility of the assessment process are crucial to success.

Why is it important to note the history of a corrective procedure?

Moreover, if a patient has a corrective procedure that resulted in resolution of an ulceration, and the same phenomenon occurs on the contralateral limb, it is of great clinical importance to note this in the history because the patient may benefit from repeating the procedure on the affected side.

Is depression a diagnosis of DFU?

Depression is commonly associated with a diagnosis of DFU, especially the primary episode. 5

Does insulin help wound healing?

Patients taking insulin have higher rates of wound healing overall. 3 Most other medications to be cognizant of are those that delay healing such as anti-inflammatory drugs; their use on a short-term basis can be beneficial, but in the long term they can be a barrier to healing.

How to determine if a diabetic foot is neuropathic?

Neuropathic deficits in the feet can be determined using the Neuropathy Disability Score (NDS), which is derived from the inability to detect pinprick sensation (using a neurological examination pin), vibration (using a 128-Hz tuning fork), or differences in temperature sensation (using warm and cool rods), and loss or reduction of the Achilles reflex (using a tendon hammer) [1] (Table 1). According to the American Diabetes Association, a foot that has lost its protective sensation is considered to be a “foot at risk” for ulceration. The diagnosis of a foot at risk is confirmed by a positive 5.07/10-g monofilament test, plus one of the following tests: vibration test (using 128-Hz tuning fork or a biothesiometer), pinprick sensation, or ankle reflexes [25].

What is the physical examination of diabetic feet?

Physical examination of the diabetic foot is based on assessment of the skin and of the vascular, neurological, and musculoskeletal systems.

How to know if you have diabetic neuropathy?

The presence of diabetic neuropathy can be established from an abbreviated medical history and physical examination. Symptoms such as a burning sensation; pins and needles; shooting, sharp, or stabbing pains; and muscle cramps, which are distributed symmetrically in both limbs (“stocking and glove distribution”), and often worse at night, are usually present in peripheral neuropathy. Diabetic peripheral neuropathy may also be evaluated using the Neuropathy Symptom Score (NSS), which is a validated symptom score with a high predictive value to screen for peripheral neuropathy in diabetes [23, 24] (Table 1).

What are the risk factors for foot ulceration?

Other risk factors for foot ulceration include a previous history of foot ulceration or amputation, visual impairment, diabetic nephropathy, poor glycemic control, and cigarette smoking. Some studies have shown that foot ulceration is more common in men with diabetes than in women [14, 16]. Social factors, such as low socioeconomic status, poor access to healthcare services, and poor education are also proven to be related to more frequent foot ulceration [14, 16].

What are the most common causes of foot ulcers?

Pathogenesis. The most significant risk factors for foot ulceration are diabetic neuropathy, peripheral arterial disease, and consequent traumas of the foot. Diabetic neuropathy is the common factor in almost 90% of diabetic foot ulcers [9, 10]. Nerve damage in diabetes affects the motor, sensory, and autonomic fibers.

What is the most significant and devastating complications of diabetes?

Introduction. Diabetic foot is one of the most significant and devastating complications of diabetes, and is defined as a foot affected by ulceration that is associated with neuropathy and/or peripheral arterial disease of the lower limb in a patient with diabetes. The prevalence of diabetic foot ulceration in the diabetic population is 4–10%;

How long does it take for a foot ulcer to heal?

The majority (60–80%) of foot ulcers will heal, while 10–15% of them will remain active, and 5–24% of them will finally lead to limb amputation within a period of 6–18 months after the first evaluation.

What is the importance of nursing care for diabetic foot ulcers?

Therefore, nursing care plan for individuals with diabetes with foot ulcers must focus on these important physical and emotional care issues. The dearth of specialized care in parts of the developing world compounds the lack ...

What is the nursing diagnosis of diabetic foot gangrene?

Nursing diagnosis that appear in diabetic foot gangrene patients are as follows: Impaired tissue perfusion related to the weakening / decreased blood flow to the area of gangrene due to obstruction of blood vessels. Maintain peripheral circulation remain normal.

What is the role of a diabetic nurse?

Diabetes Nurses play their educating role in the field of prevention of diabetic foot, foot care and preventing from foot injury.

How to treat diabetic foot ulcers?

The management of diabetic foot ulcers requires offloading the wound by using appropriate therapeutic footwear, [ 8 , 9 ] daily saline or similar dressings to provide a moist wound environment , [ 10 ] debridement when necessary, antibiotic therapy if osteomyelitis or cellulitis is present, [ 11 , 12 ] optimal control of blood glucose, and evaluation and correction of peripheral arterial insufficiency. [ 61 ] Wound coverage by cultured human cells [ 29 , 30 ] or heterogeneic dressings/grafts, application of recombinant growth factors, [ 31 , 32 , 33 , 34 ] and hyperbaric oxygen treatments also may be beneficial at times, but only if arterial insufficiency is not present. Physicians of diabetic patients with ulcers must decide between the sometimes conflicting options of (1) performing invasive procedures (eg, angiography, bypass surgery) for limb salvage and (2) avoiding the risks of unnecessarily aggressive management in these patients, who may have significant cardiac risk. In general, the greatest legal risks are associated with delay in diagnosis of ischemia associated with diabetic ulceration, failure to aggressively debride and treat infection, and failure to treat the wound carefully. If a patient presents with a new diabetic foot ulcer, he or she should receive care from physicians, surgeons, podiatrists, and pedorthotists who have an active interest in this complex problem. Treatment of diabetic foot ulcers requires management of a number of systemic and local factors. [ 35 , 36 , 37 , 38 ] Precise diabetic control is, of course, vital, not only in achieving resolution of the current wound, but also in minimizing the risk of recurrence. Management of contributing systemic factors, such as hypertension, hyperlipidemia, atherosclerotic heart disease, obesity, or Continue reading >>

What causes red dots on the skin?

Streptococci and Staphylococci can enter the skin to cause cellulitis infection through scrapes, cuts, wounds, blisters, insect bites and ulcers and find their way into the dermal and subcutaneous layers of the skin. Typical symptoms that indicate a cellulitis infection include sudden reddish swelling of the skin, headache, nausea,fever along with multiple small reddish colored dots appearing on the surface of the skin. Cellulitis caused by the Group A beta-hemolytic streptococci is rapid spreading because of the enzymes produced by the bacteria that breaks down the cellular components responsible for localized infection. 1. Acute pain related to irritation of the skin, impaired skin integrity, ischemic tissue. 2. Impaired Skin Integrity related to the presence of gangrene in the extremities. 3. Anxiety related to lack of knowledge about the disease. 4. Imbalanced Nutrition Less Than Body Requirements related to poor food intake. 5. Disturbed Body Image related to changes in the form of one limb. 6. Sleep Pattern Disturbance related to pain in a leg wound. Continue reading >>

What is a nursing care plan for diabetic gangrene?

Diabetic Gangrene , Nursing Care Plan , Nursing Care Plan for Diabetic Gangrene Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies (necrosis). This may occur after an injury or infection, or in people suffering from any chronic health ...

Why does gangrene cause cell death?

The primary cause of gangrene is reduced blood supply to the affected tissues, which results in cell death. Diabetes and long-term smoking increase the risk of suffering from gangrene.

What is the diagnosis of diabetic foot ulcer?

The diagnosis of a diabetic foot ulcer requires careful examination of the patients feet. This includes the top (dorsum), sole (planta) and sides of both feet, areas between the toes (interdigital), around the nails and the back of heels.

What should nurses ask patients to do during foot examination?

During foot examination, nurses should ask patients to remove their shoes and socks and then examine their feet in order to screen patients at high risk and report to other members of the multidisciplinary diabetic foot team. After the wound assessment, perform a complete body assessment.

What is the sore on the foot of a diabetic?

Diabetic ulcers are sores, or pain that occurs at the foot of the person who has suffered from diabetes mellitus. Meanwhile, according to Askandar (2001) Diabetic Ulcers are sores on the feet of red-black and foul smelling due to the blockage that occurred in medium or large vessels in the legs.

What is diabetes mellitus?

Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid metabolism. The primary feature of this disorder is elevation in blood glucose levels (hyperglycemia), resulting from either a defect in insulin secretion from the pancreas, a change in insulin action, or both. Sustained hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels. Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria. Assessment Nursing Planning Nursing Rationale Evaluation Diagnosis Interventions Subjective: (none) Deficient Short Establish Friendly Short Term:After 3° rapport Take relationship Term:After 3° Fluid Objective: Volume r/t of NI, patient and record vital with patient of NI, patient intracellular shall have signs and to be able will have y elevated verbalized to each temperature DHN 2° the verbalized understanding Monitor the understanding DM II other¶s of of causative concern To of causative 38.4°C/axilla temperature factors and factors and obtain y increased purpose of baseline data purpose of urine output. Assess skin individual individual y sweating of turgor and therapeutic the skin To monitor therapeutic mucous interventions interventions y thirst membranes for changes in and y exhaustion temperature and signs of medications. medications. y weight loss dehydration y dry skin or Long Term: Dry skin and Long Term: mucous Encourage the mucous membrane After 2 days Continue reading >>

What is ineffective perfusion for diabetic foot ulcers?

Ineffective Tissue perfusion related to Diabetic Foot Ulcers Nursing Care Plan for Diabetic Foot Ulcers Ulcers are open sores on the skin or mucous membrane surface and the ulcer is extensive tissue death and accompanied invasive saprophyte bacteria. The existence of the saprophyte bacteria cause ulcers smelling, diabetic ulcers is also one of the symptoms and the clinical course of the disease diabetes mellitus with peripheral neuropathy. (Andyagreeni, 2010). Diabetic ulcers are chronic complications of diabetes mellitus as a major cause of morbidity, mortality and disability in patients with diabetes. High LDL levels play an important role for the occurrence of diabetic ulcers through the formation of atherosclerotic plaque in the walls of blood vessels, (zaidah 2005). Diabetic foot ulcers are the complications associated with morbidity from diabetes mellitus. Diabetic foot ulcers are serious complications due to diabetes. (Andyagreeni, 2010). Nursing Care Plan for Diabetic Foot Ulcers Nursing Diagnosis : Ineffective Tissue perfusion related to weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels. Goal: maintain peripheral circulation remained normal. Palpable peripheral pulses were strong and regular. The color of the skin around the wound; not pale / cyanosis. Edema does not occur and the wound is not getting worse. Rational: the mobilization improves blood circulation. 2. Teach about the factors that can increase blood flow: Elevate the patient's leg is slightly lower than the heart (elevation position at rest), avoid crossing legs, avoid tight bandage, avoid the use of cushions, behind the knees and so on. Rational: increase blood flow back so there is no edema. 3. Teach about the modification of risk factors such as: Avo Continue reading >>

What are the factors that influence the occurrence of diabetic ulcers?

Factors that influence the occurrence of diabetic ulcers are divided into endogenous factors and ekstrogen. Nursing Diagnosis for Diabetic Foot Ulcer Impaired tissue perfusion related to the weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels.

How many people with diabetes have ulcers on their legs?

It is estimated that 5-10% of people with diabetes found any ulceration of the legs, and about 1% of them will undergo amputation. Four of the five non-traumatic amputation in adults caused by diabetic foot. Besides being a problem for people, also be costs for patients or the government.

What tests are needed for diabetic foot infection?

Additional tests that need to be performed on diabetic patients with foot infections include full blood count, erythrocyte sedimentation rate, electrolytes, HbA1c, plus renal and liver function tests. Weekly measurement of the C-reactive protein titre during treatment of a foot infection may help determine progress.

What causes diabetes in the foot?

Microbiology. In diabetes, infections that threaten the foot are usually caused by bacteria. Infected ulcers commonly have staphylococcal, streptococcal or facultative anaerobes such as Bacteroides species or faecal coliforms present. 1,2 Single or multiple pathogens may be identified.

What is the best antibiotic for a wound?

The initial choice of outpatient-administered antibiotic therapy will be empirical. 1 Where minimal inflammation is evident and the ulcer is both shallow and odourless a suitable wound dressing should suffice. If the ulcer is also malodorous an oral antibiotic can be trialled. Amoxycillin with clavulanic acid is a reasonable first choice. Dicloxacillin or flucloxacillin should be used when the clinical findings of localised erythema, swelling and heat without significant accompanying odour suggest that staphylococcal or streptococcal infection is likely. Clindamycin can be used in place of a penicillin if the patient has a history of penicillin hypersensitivity. Metronidazole combined with either dicloxacillin or flucloxacillin provides a reasonable oral antibiotic combination to use in systemically well patients, where an inflamed wound or ulcer appears localised with no necrosis but is malodorous, implying that the infection may be caused by a faecal organism or Bacteroides species. Occasionally, superficial pseudomonas infection is present, sometimes evident as a greenish hue over the surface of the ulcer. Application of a dilute acetic acid solution will often destroy this.

What is callus in a podiatrist?

The presence of callus is often a marker for future ulceration. Callus should be pared back regularly by a suitably-trained podiatrist, nurse or medical practitioner. 1. When ischaemia predominates, ulceration may often be initiated by ill-fitting footwear.

What to use for a dry ulcer?

If the ulcer is dry use a moisturising dressing such as a gel and avoid thin film dressings. If the wound is moist use an absorptive dressing such as foam or alginate. If the ulcer is superficially infected use a dressing that incorporates a bacteriocidal agent such as nanocrystalline silver.

Can diabetes cause amputation?

Foot infections are a significant cause of morbidity for patients with diabetes and if left untreated can lead to amputation. Patients need to be instructed to wash, dry and examine their feet daily and are encouraged to seek medical attention promptly if they see signs of foot infection or new ulcer formation. Empirical use of antibiotics will often be necessary while awaiting the results of bacteriological and imaging investigations. When in doubt about the severity of infection urgent referral to a surgeon or specialist foot service for a second opinion is advised. Hospitalisation for observation, parenteral antibiotic therapy and possible surgical intervention may also be necessary. Diabetic arthropathy needs to be considered when signs mimicking infection are present in the absence of ulceration. Osteomyelitis or plantar space infection should be excluded as complicating factors if there is not rapid clinical improvement after starting antibiotic therapy.

Can a diabetic foot be oedema?

Diabetic osteoarthropathy (Charcot's arthropathy) can often mimic a cellulitic process of the mid-foot or forefoot. Although a non-infective process in its pure form, it may sometimes present with sudden onset of oedema, redness, increased heat and sometimes pain . Elevation of the foot overnight can often help in making the diagnosis if X-ray signs are absent, as any oedema will often subside in the absence of infection. However, radionucleotide scanning must be performed if diabetic arthropathy is suspected, as increased isotope uptake in affected joints may be an early finding with this condition. Again, it is best to consult the nuclear medicine physician beforehand to ensure that the appropriate isotopes are used. MRI can also be used if available, as it may detect the bone oedema that can accompany diabetic arthropathy. Early diagnosis is important as appropriate treatment will prevent progressive foot deformity and subsequent disability.

Classification of Diabetic Foot Ulcers

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Patient's History

Physical Examination

Diagnostic Tests

Conclusions