Abstract
Diabetic foot ulcers are the most devastating and costly complication of diabetes mellitus. It affects approximately 15% of diabetic patients at whatever period in their life. Studies have indicated effective management of diabetic foot ulcer may lead towards decreased severity of the complications such as having preventable foot amputations. And possible a reduction of mortality in diabetic patients. The quality of life improves in patients experiencing effective treatment of diabetic foot ulcers. Managing diabetic foot ulcer requires a comprehensive multi-disciplinary health care team which shall apply a holistic approach in managing this complication. Studies have shown that having wound debridement, blood sugar control, offloading modalities as well as advanced dressing are a crucial part in the management of diabetic foot ulcer. In cases whereby diabetic foot ulcer is responding poorly towards management, surgical interventions are considered so as to prevent recurrence of diabetic foot ulcer. This paper examines a 60-year-old diabetes mellitus patient with a chronic history of diabetic foot ulcer. The paper examines the existing literature review on the management of diabetic foot ulcer, the current interventions as well as the best practices that will be employed towards the management of this patient.
Introduction
The increased prevalence of Diabetes Mellitus has resulted in the rise of concomitant illness which are associated with it. Among the hyperglycemic complications and critical effects that are known to be caused by diabetes mellitus include micro-vascular complications such as retinopathy, neuropathy and nephropathy. The macro-vascular complications are peripheral arterial disease, stroke and coronary artery disease. Diabetes mellitus is regarded as the main cause of lower limb amputations which are often presided over by non-healing ulcers. Individuals with diabetes mellitus have a lifetime risk of 15-20% of developing foot ulceration. More than 15% of patients with foot ulceration end up having lower limb amputation of one or both limbs. Population based have indicated an annual collective incidence of 0.5-3% of diabetic individuals developing foot ulcers (Yazdanpanah, Nasri & Adarvishi, 2015). It is estimated that 45-60% of all diabetic patients with foot ulcerations are mostly neuropathic while another 45% entail ischemic and neuropathic components. An estimate of 15-27% have been noted to require lower limb amputations with at least 50% of them being due to infections.
Theoretical Framework
Social cognitive theory of primary constructs of knowledge, theory, goals, perceived self-efficacy as well as outcome analysis and the perceived impediments and facilitators are observed to interact in way of formulating control in the individual over their illness and also the influences of human action and motivation. This theory does propose having inadequate confidence in an individual lead to an underperforming or total non-performing of individuals in the in the required activities as well as failing to reach their goals. Actions of self-care will also not be performed by the individuals. This precept has been repeated a number of times and has lead researchers concluding that in the application of the diabetic foot, there is the need of having self-care in a sense whereby one knows that the necessary care towards their feet should be done thoroughly. This ensures that the patients are confident in the activities they are performing in their legs and that self-care will be highly achieved (Kavitha et al., 2014). The assumptions that are made in this paper are centered on the essence of having regular practice towards foot care and that higher levels of self-efficacy are achieved in the patients compared to those that do not exercise regular foot self-care. A comparison of patients that have had previous ulceration against those that have never had in order to establish the relationship between the degree of self-efficacy, frequency of self-care practices of the foot and lastly having their influence towards preventing amputation and ulceration. Having such as understanding would lead towards practitioners being able to target specifically the intervention strategies that will be able to prevent the initial or subsequent diabetic foot occurrence by emphasizing on educational as well as on other supportive needs.
Literature Review of Diabetic Foot Ulcer
Diabetes Mellitus is considered as one of the main problems that is in the health care system as well as in global health. Studies on patients with diabetes mellitus have indicated these patients being prone to multiple complications such as diabetic foot ulcer. Diabetic foot ulcer is the most common complication in diabetic mellitus patients and its considered as being the main source of morbidity as well as the leading cause of hospitalization. At least 20% of admissions in patients with diabetic mellitus can be attributed to diabetic foot ulcer. Diabetic foot ulcer may lead to amputation, gangrene, amputation and even death in patients in situations where the necessary care has not been undertaken (Kahle, Hermanns & Gallenkemper, 2011). Alternatively, once diabetic foot ulcer has developed, there is likely probability of it progressing and ultimately leading into amputation.
The overall statistics of lower limb amputations in patients with diabetes mellitus is increased 15 fold than in patients with no diabetes. Several studies have implicated a number of risk factors being associated with the progression of diabetic foot ulcer. The main risk factors are male gender, advanced age, duration with diabetes mellitus being more than 10 years, high body mass index, comorbidities like diabetic peripheral neuropathy, retinopathy, glycated hemoglobin levels, peripheral vascular disease, high plantar pressure, foot deformity, inappropriate foot self-care habits and lastly infections. A number of literature review studies have identified the risk factors which contribute towards lower extremity amputation ulceration and amputation as being caused by neuro-ischemic abnormalities.
Incidences of neuro-ischemic problems are known to lead into increased neuro-ischemic ulcers (Kaur & Naser, 2014). The usual pathway for the development of foot problems in diabetic patients is having peripheral autonomic and sensorimotor neuropathy which are observed leasing to high foot pressure, gait instability as well as foot deformities that in turn increase the chances of developing foot ulcers. A number of investigations have demonstrated elevated plantar pressures are aligned with foot ulceration. Foot deformities as well as gait instability are also noted to increase plantar pressure that leads to foot ulceration.It is unfortunate that a number of patients often are often in denial of the disease they are ailing from. This denial leads to the patients forfeiting undertaking the necessary precautions which will ensure they are able to prevent the complications that may arise. Diabetic patients who neglect care of their health may be faced with the complications of diabetic foot ulcer and this often compounds the challenge of finding the right management of dealing with diabetic foot ulcer.
Proper management of diabetic foot ulcer as evidenced from numerous studies has depicted a greater reduction in the delay and prevention of complications such as gangrene, amputation and infection. The major goals of management of diabetic foot ulcer are supposed to ensure wound closure is done as fast as possible (Thulasikumar & Vijayasarathy, 2017). Since diabetes is regarded as a multi-organ systemic disease, the comorbidities which affect healing of the wound should be managed through a multi-disciplinary team so as to obtain optimal outcomes in managing diabetic foot ulcers. Managing diabetic foot ulcer should have the following healthcare personnel being managing it, general practitioner, orthotic specialist, nurse, educator, podiatrist, other specialists such as infectious disease specialists, vascular surgeons, dieticians, dermatologists, orthopedic specialists and endocrinologists.
Having a multi-disciplinary team managing patients with diabetes leads towards having reduced rates of amputation, better quality of life and lower costs. There is however the need of having a preventive care team which is supposed to aid the multi-disciplinary team in reducing risks which are associated with diabetic foot as well as have amputations decrease by a margin of 50-85%. By applying such an approach towards the management of diabetic foot ulcer, there will be consequently a reduction in the severity of the complications and an improved overall quality of life and increased expectancy in the patients (Yazdanpanah, Nasri & Adarvishi, 2015). There are various strategies that have been endorsed as having positive impact in managing diabetic foot ulcer, these strategies include the following.
Education
Studies have proved that up to 50% of diabetic foot ulcers can be prevented in cases whereby there is effective education. Educating patients with diabetic foot ulcers is regarded as being a cornerstone in the prevention of further complications. The education programs of diabetic patients should emphasize on having patient responsibility on their well-being and own health. The ultimate goal of having foot care should be to ensure education for individuals with diabetes will be one which will ensure prevention of the foot ulcers as well as amputation. A wide range of the combinations of patient education intervention are being evaluated towards ensuring prevention of diabetic foot ulcer. These interventions vary from one another and from having brief education sessions to intensive education sessions. The education sessions include demonstrations as well as hands-on-teaching (Thebati et al., 2016). The patients should be educated in regards to the risk factors that are involved in having diabetic foot ulcers. Emphasis on elements such as foot care, monitoring of foot temperature, self-inspection, blood sugar control, appropriate daily foot hygiene and use of proper foot wear. The education should however be incorporated with other treatment strategies since the preview on previous patient education method had suggested that whenever the methods are combined together, the chances of having a reduced morbidity and frequency of limb threatening complications that are caused by diabetic for ulcer are reduced.
Blood Sugar Control
Patients with diabetic foot ulcer require glucose control as being their fundamental metabolic factor that should be regulated. Having inadequate blood sugar control is considered as the primary causa of diabetic foot ulcer. HbA1C levels are considered as the best indicator of indicating the level of glucose control. This diagnostic test measures the average concentration of blood glucose in a more than 90-day span of red blood cells that are in the peripheral blood. Having a higher score of this test means that there is more glycosylation of the hemoglobin in the red blood cells occurring. Glucose levels that are higher than 11.1mmol or have an HbA1C that is greater than 12 means that there is a decreased neutrophil function which does include the leukocyte chemotaxis (Smith-Strom et al., 2017). Having a greater elevation of the blood glucose means that there is a high probability of having suppressed inflammatory response as well as a decreased host response towards infections. Patients with single blood-glucose levels of that was more than 220mg/dl in the first day of post-operation was in itself a sensitive predictor of 87.5% for postoperative infection. Authors in this report also found out that the patients with blood glucose values of more than 220mg/dl were considered to have infection rates amounting to triple than in the patients with lower blood glucose values.
Social-Cultural determinants of health in diabetic foot ulcer patients-related Quality of life
In order to have successful healing of the diabetic foot ulcers in patients, there is the need of long treatment periods as well as limitations towards the daily life activities of the patients. The burden on the quality of life on the patients is often adversely affected by the heath related quality of life. Understanding these determinants leads towards having the determinants of diabetic foot ulcer of the health related quality of life helping the health professionals towards having better clinical decision making skills which will enable them to be conduct screening as well as the prediction of quality of life in the diabetic patients. In regards to the soci0-cultural activities, it has been determined that diet does have an effect on the health related quality of life in the patients treatment plan (Singh et al., 2016).
This is primarily due to the fact that diet composes as a non-pharmacological intervention which when considered carefully will promote the empowerment of diabetic foot ulcer patients and thus having them being subjectively assessed. Various authors have proved that a number of reasons are given by patients currently. Patients are seen as being at the forefront of determining and preferring how to control their own lives by understanding how to prevent as well as treat the diabetic disease. There is need to understand that the working status of the individuals in instances whereby the unemployment status is observed as having adverse effects in influencing the health related quality of life of the patients. Employment is regarded as factor whereby there is wealth production and this in turn influences the level and quality health services that the patients will receive.
In respect to the size of the ulcer, diabetic foot ulcers that are beyond 5cm were observed as having a positive impact on the patients health related quality of life. This was due to factors such as the patients having inappropriate foot wear. This kind of instances requires that the patients to have therapeutic equipment which shall result in having better everyday functionality. The other aspect on the socio-cultural health determinant that was determined was the marital status of the individuals. Diabetic patients who were single were observed as having an affirmative influence on the health related quality of life. Married individuals on the other hand were observed as having better scores in terms of quality of life indicators (Macioch et al., 2017).
These measurements can be explained through the cases of diabetic foot ulcer being primarily affecting the physical wellbeing of the patients thus it’s the obligation of their families of ensuring that the burden of disease the diabetic individuals are experiencing is shared among family members. In regards to single people however, a study indicate that single women had higher quality of life than single men. Lastly, an analysis of the duration of diabetic ulcers revealed that ulcers which were less than a week and or greater than a week up to three months did affect the health related quality of life. Ulcers with a duration of more than three weeks affected adversely the quality of life and that they could be considered through the inclusion of the crisis phase of diabetic foot ulcers whereby the burden in the individual is greater (Kavitha et al., 2014). In a three-month duration, the diabetic foot ulcers are observed as having healed and cured.
Physical Examination
The patient discussed in this paper is a 60-year-old African-American male on controlled diabetic mellitus type two with neuropathy and as well as renal failure on HD. The patient had left below knee amputation done on him 7 years ago and currently presented with right leg and foot wounds which had occurred spontaneously two weeks prior. The patient complained of swelling and drainage. The patient had no signs and symptoms of fever, nausea, chills, chest pains, diarrhea, vomiting and or shortness of breath. The patient has no known drug and food allergies (Kahle, Hermanns & Gallenkemper, 2011). The last review of the patient indicated that the patient was able to tolerate ACE wrap as well as aquacel AG dressings The past medical history of the patient indicates the patient has medical history of end stage renal disease. The patient attends dialysis sessions on every Tuesdays, Thursdays and Saturdays. The surgical history of the patient reveals that the patient had a left below knee amputation and cholestectomy.
A review of the systems of this patient reveals that the patient complained of the following. On the musculoskeletal system, the patient was using assistive devices of wheelchair. The patient did not have any constitutional signs and symptoms on the gastro-intestinal, respiratory and cardio-vascular systems. The systemic review of the patient reveals that he is well, chronically ill and does not have sign of acute distress. The vitals of the patient are within the normal range. The important indicator in the systemic review of the patient is the integumentary system whereby its noted the patient has wound on the right lateral lower limb. The wound is a venous ulcer and non-healed. Day one of the past measurements of the wound were 16cm length by 10cm width with the depth of 0.1 cm. The area of the wound is approximately 160sq cm with the volume being 16 cubic cm. Of note is that the patient has a small amount of sero-sanguineous drainage with no odor.
There are no reports of wound pain with the wound being categorized as insensate. The margins of the wound are flat and intact. Overly, the wound is noted to be improving with the peri-wound skin color being normal, edematous and moist. The subsequent recordings of the right foot wound indicates the changes the wound underwent with the salient points being that the wound had been improving gradually. Day seven of wound care the patient had wagner grade diabetic ulcer (Kaur & Naser, 2014). The other parameters such as periwound skin color, wound pain, moisture and edema had remained relatively constant over the period of monitoring on the patient. The other physical examination findings on the patient reveals that the right leg ulcers had showed signs of granulation that were mixed with some sloughy tissue. There was some slight serous drainage and the edges were macerated with signs of drainage. There were no signs of cellulitis or odor. Hyperpigmentation was noted on the patient in the gaiter and was distributed like that of a pattern of chronic venous hypertension. Differential Diagnosis The following are the differential diagnosis for diabetic foot ulcer. Firstly, there is he venous leg ulcer. It generally takes place in the gutter area of a patient’s leg.
In addition, it may have surrounding lipodermatosclerosis, which is the discoloration and thickening of the skin as a result of hemosiderin deposition, scarring and inflammation. The various differentiating tests used in this case are the venous plethysmography or ultrasound. They have the ability of confirming venous incompetence making the diagnosis most likely (Yazdanpanah, Nasri & Adarvishi, 2015). Nonetheless, the venous leg ulcer may occasionally take place in the setting up of competent superficial venous system. Secondly, there is gout. This can be associated with swelling, erythema and pain. However, it is not commonly adjacent to the foot ulcer. It instead may take place in a setting with previous history of gout. The differential test in this case is use of plain x-ray of the patient’s foot. It tends to reveal the radiographic signs of gout such as scattered bony erosions, joint space narrowing and tophaceous arthritis. Lastly, there is acute charcot arthropathy. Th differential signs and symptoms are that it may cause swelling, erythema and pain. However, it may not be associated with the patient’s foot ulcer. Normally, it tends to occur in the mid foot between the proximal matatarsals all the way to calcaneus. The differential test for this case is MRI foot. It tends to reveal mid foot edema of the subchondral bone marrow. Typically, the subcutaneous tissues are usually not involved.
Management Practices for Diabetic foot ulcer
Debridement Debridement refers to the removal of senescent and necrotic tissues and other kinds of foreign as well as infected materials from any wound. This is usually regarded as the first as well as most significant step that leads to wound closure. In addition, this step tends to decrease the chances of limb amputation in individuals suffering from diabetes foot ulcer (DFU). This is because debridement tends to decrease the bacterial counts. In addition, it engages in the stimulation of production of various growth factors. Moreover, this particular method tends to reduce pressure, facilitates the drainage of the wound as well as evaluates the specific wound bed. There are specific kinds of debridement which include: autolytic mechanical, surgical enzymatic and biological (Thulasikumar & Vijayasarathy, 2017).
Among these methods, research shows that surgical debridement tends to be increasing effective in the treatment of DFU when compared to the others. Sharp or surgical debridement tends to involve cutting away of infected and dead tissues which is usually accompanied by every day application of the cotton gauze that is saline moistened. Normally, the main purpose for this kind of debridement is turning a chronic ulcer into one that is acute. Therefore, surgical debridement must be repeated as often as possible if new necrotic tissues continue to form. Research reveals that regular sharp debridement is mainly associated with rapid healing of ulcers when compared to less frequent method of debridement. A cohort study conducted by Wilcox et al reveals that frequent debridement is responsible for healing more wounds in a short period. Moreover, the study revealed that increased debridement leads to better healing of the wound.
Offloading
The most significant component for managing neuropathic ulcers particularly in individuals suffering from diabetes is offloading. Research tends to reveal that conducting of proper offloading tends to have the ability of promoting the healing of DFU (Singh et al., 2016). Despite the fact that numerous offloading modalities are presently in use, the choice of these approaches is mostly determined by the physical characteristics of patients as well as the abilities to comply with method of treatment. In addition, it also depends on the severity and location of the ulcers. Total contact casts in short TCC is regarded as the most effective form of offloading technique used in treating of neuropathic DFU. Normally, TCC is usually minimally padded as well as molded in a careful manner with the intention of shaping the specific foot using a heel for purposes of walking. The particular cast is usually designed for purposes of relieving pressure from the foot ulcer as well as distributing pressure over the whole foot surface. This in turn protects the wound site. Therefore, the efficiency of TCC in treating foot ulcer is mostly due to redistribution of the pressure as well as offloading from that specific ulcer area. As a result, the patient is often unable to remove the specific cast. This reduces the levels of activity and consequently improves the healing of the wound.
Advanced Dressing
The choice of wound dressing is greatly determined by the various causes of DFU, depth, the location of the wound, exudates, amount of slough or scar, the specific condition of the wound margins, presence of pain and infection as well as the need for conformability and adhesiveness of the particular dressing. Research reveals that wound dressing may be categorized as active, interactive or passive. Normally, passive dressings are usually used as protective functions (Thebati et al., 2016). In addition, they are also used for acute wounds due to the fact that they absorb sensible amounts of exudates as well as ensure good protection. Moreover, interactive and active dressings have the capability of modifying the wound psychology. This is by stimulation of cellular growth and activity factors release. Moreover, they are often used on the chronic wounds due to the fact that they tend to easily adapt to wounds, as well as maintain a moist environment that has the ability of stimulating the process of healing.
Surgery
Research shows that diabetic foot surgery tends to play a crucial and essential role in the prevention as well as management of DFU. Despite the fact that surgical interventions for patients suffering from DFU tend to be without risk, the discriminatory rectification of persistent foot ulcers may improve patient outcomes. Generally, surgery for healing DFU includes vascular foot surgery, non-vascular surgery of the foot, and in extreme cases amputation. The non-vascular surgery of the foot is usually divided into curative, prophylactic, elective as well as emergent surgeries that aim at correcting deformities which increase the pressure of plantar (Yazdanpanah, Nasri & Adarvishi, 2015). On the other hand, vascular foot surgery including bypass grafts particularly from the femoral all the way to the peripheral angioplasty and pedal arteries tend to improve the flow of blood. Further research reveals that these procedures help in healing of ischemic ulcers. However, despite the fact that the main goal of DFU is to manage the foot, in specific cases amputation tends to offer a better outcome that is deemed functional. In most cases, this decision tends to be multifactorial and individualized with the aim of matching the patient’s lifestyle, psychological, physical and medical comorbidities. Generally, amputation is usually considered as a curative and urgent surgery although it must be the last resort after all other kinds of salvage methods have been exhausted (Kavitha et al., 2014). In addition, the patient should also be in agreement. The various indicators for amputation include: removal of gangrenous or infected tissues, control of the specific infection, as well as creation of a functional stump or foot that tends to have the ability of accommodating prosthesis or footwear.
Advanced Therapies
he first one is identified as hyperbaric oxygen therapy, and tends to show the promise of treating severe cases of DFU that are deemed chronic and non-healing, which tends to be resistant to other forms of therapeutic methods. HBOT often involves the intermittent administration of pure oxygen mostly in every day sessions. Therefore, during every session, the patient must breath pure oxygen of 1.4-3.0 absolute atmosphere. This is during 3 different periods of 30 minutes intercalated by a period of 5-minute interval in the hyperbaric chamber. However, despite the fact that HBOT tends to be used in the treatment of DFU, it does not substitute for local humid therapy, antibiotic therapy or even surgical wound debridement. Moreover, it is usually available in very small communities because it is very expensive (Kaur & Naser, 2014). The second form of advanced therapy is identified as electrical stimulation.
Research shows that electrical stimulation has the ability of improving common deficiencies that are usually associated with the faulty healing of the wound in DFU. This includes: infection, poor blood flow as well as deficient cellular responses. In addition, this particular therapy is considered a safe, simple and inexpensive intervention aimed at improving the healing of wound in a patient with DFU. The third form is identified as negative pressure wound therapy. It is a non-invasive wound closure system which tends to use localized, controlled negative pressure with the aim of helping in healing of acute and chronic wounds. Normally, this system tends to use latex free, as well as polyvinyl or sterile polyurethane alcohol form dressing which is fitted at patient’s bedside to the appropriate size of the wound (Thulasikumar & Vijayasarathy, 2017). It is eventually covered with adhesive drape creating what is considered as an airtight seal.
Therefore, an 80-125 mmHg specifically of negative pressure is used, either in cycles or continuously. The fluid that is sanctioned from the wound is then collected inside a container that is found in the control unit. The last form of advanced therapy is known as bio-engineered skin (BES). It has the ability of providing the molecular components and cellular substrates necessary to accelerate the healing of the wound and angiogenesis. They usually act as a form of biologic dressing as well as delivery systems for the different growth factors and ECM elements. This is through the activity of the live human fibroblasts which are contained in the various dermal elements.
Role of Nursing Practitioner impact on Future Advanced nursing practice and policies.
Management of diabetes mellitus and its associated complications such as diabetic for ulcers is observed as a multi-disciplinary intervention which requires the input for various health care professionals. Nurses play a critical role in the management of patients with diabetic foot ulcer. The main goals apart from the improvement of patient care as well as health care services as observed in the patients is the accomplishment of major goals by the nurses (Kaur & Naser, 2014). These goals are, health promotion, patient care, prevention of diseases and lastly simplify the compliance of patients. In order to achieve these goals, the nurses undertake various roles such as, educator, care connector, providing health, researcher, leader, consultant and lastly supporting patients rights. The increasing prevalence of diabetes as well as its complications has in turn caused the undeniable necessity of training nurses specialists.
These nurses specialists will in turn ensure that diabetic foot incidences of foot ulceration as well as amputation is minimized to greater lengths. Achieving this goal will lead to an overall decline of amputations by 25% and that it will increase the incidence of foot examination by up to 75% in diabetic patients. In order to achieve the above the prevalence rates. The roles of nurses in the management of diabetes and its complication of diabetic foot ulcer will require the nurses participate in a number of activities. The first role that should be undertaken by the nurses will be participating effectively in the prevention of foot ulcers as well as lower limb amputations by employing educational interventions, providing health care and screening of high risk-individuals. Nurses will play the role of teaching the patients the ways of performing physical examination and how they will be able to take care of their feet in a daily basis (Singh et al., 2016).
The nurses will for instance encourage the individuals to participate in simple activities such as keeping their feet clean, checking their shoes before wearing them, cleaning and grooming of toes and the skin. Recognition of the current diabetic foot care education programs that are current propose having detailed educational programs which are expounded on table 1. The role of nurses in this incidence will be ensuring that the patients are able meet the requirements of diabetic foot ulcer hygiene as well as their families are able to participate in the management of their kin. This can be achieved through the family members understanding the importance of having regular visits as well as have blood tests conducted on them on specified regular intervals.
Role of Nurse care Screening and Examination
Patients with diabetic foot ulcer present with peripheral neuropathy, infection and peripheral vascular disease. These three presentations if not managed well may lead toward the patient developing gangrene and later amputation. Nurses should in turn be able to examine neurological examinations as being the first criteria of screening the patients that are at risk of developing foot ulcers (Yazdanpanah, Nasri & Adarvishi, 2015). The nurses should hence be able to perform diabetic foot examination by using monofilament and partner with fellow health care professionals.