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.
Pathophysiology
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 Assessment
Diabetic foot ulcers are a common and serious complication of diabetes mellitus, often leading to significant morbidity and mortality. Effective nursing assessment and management are critical in preventing infection, promoting healing, and improving patient outcomes. This document outlines a comprehensive approach to nursing assessment on diabetic foot ulcers, covering key areas such as patient history, physical examination, risk factor assessment, and the use of standardized assessment tools.
Nursing Interventions
Diabetic foot ulcers are a common and serious complication of diabetes, often leading to infection, hospitalization, and even amputation if not properly managed. Nurses play a crucial role in the prevention and treatment of these ulcers, employing a range of interventions to promote healing and prevent recurrence. This document outlines essential nursing interventions for diabetic foot ulcers, focusing on assessment, wound care, patient education, and collaboration with multidisciplinary teams.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a diabetic foot ulcer, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for a diabetic foot ulcer.
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.
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:
- Abscess formation
- Pain
- Bleeding
- Open wound
- Disrupted epidermis/dermis
- Dry skin
- Altered skin turgor
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.
Ineffective Tissue Perfusion
Elevation of blood glucose levels causes endothelial damage that leads to impaired oxygenation and perfusion of the tissues of the feet at the capillary level.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Elevated blood glucose level
- Impaired oxygen transport
- Interruption in blood flow
- Nerve damage
- Insufficient knowledge of diabetes mellitus and its management
As evidenced by:
- Foot ulceration
- Weak or absent peripheral pulses
- Cool, clammy skin
- Prolonged capillary refill time
- Numbness, burning, or tingling in the feet
- Delayed wound healing
- Altered sensation
Expected outcomes:
- Patient will maintain optimal peripheral tissue perfusion as evidenced by the following:
- Strong, palpable pulses
- Warm and dry extremities
- Capillary Refill Time of <2 secs
- Observed healing of the wound
- Patient will not experience complications of ineffective perfusion, such as infection, gangrene, or amputation.
Assessment:
1. Monitor peripheral pulses and their symmetry.
Diminished or absent peripheral pulses may indicate arterial insufficiency due to ischemia. This finding requires urgent investigation and intervention.
2. Assess skin color and temperature.
Cool, pale skin indicates arterial obstruction. Reddish blue discoloration indicates damaged vessels, while brownish discoloration correlates with venous insufficiency.
3. Assess for discomfort or reduced sensations in the lower extremities.
High glucose levels damage nerves causing reduced sensations or numbness and the feeling of pin-pricks or burning to the feet.
4. Assess chronic disease history.
Diabetes is a major risk factor for peripheral artery disease (PAD). Hypertension and hypercholesterolemia are also risk factors for PAD.
Interventions:
1. Instruct on an optimal hemoglobin A1c.
Educate the patient on maintaining a HbA1c of < 7% to ensure glycemic control and reduce the risk of vascular complications.
2. Perform bedside Duplex ultrasonography.
If palpating a pulse is difficult, the nurse can use a portable Doppler device to assess for alterations in blood flow and detect venous insufficiency.
3. Assess ankle-brachial index.
This test is recommended to screen for PAD in patients with diabetes over age 50. A result of < 0.9 indicates PAD.
4. Consider hyperbaric oxygen therapy.
Wounds that fail to heal after 30 days may need hyperbaric oxygen therapy to speed the rate of healing and reduce complications.
5. Inform on lifestyle factors that can promote improved tissue perfusion.
These measures decrease venous compression/stasis and arterial vasoconstriction:
- Avoiding crossed legs when sitting
- Exercising
- Maintaining a healthy weight
- Not smoking
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.
Risk For Unstable Blood Glucose Level
The patient experiencing hyperglycemia or labile glucose levels is at risk for diabetic foot ulcers.
Nursing Diagnosis: Risk For Unstable Blood Glucose Level
Related to:
- Insufficient adherence to diabetes management
- Inadequate blood glucose monitoring
- Excessive stress
- Weight gain/loss
- Improper diet
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will maintain a preprandial glucose level of <130 mg/dL.
- Patient will demonstrate a hemoglobin A1c of less than 7%.
- Patient will verbalize understanding of their glucose monitoring regimen and antidiabetic medication administration.
Assessment:
1. Monitor for signs and symptoms of hypoglycemia.
Signs of hypoglycemia include shakiness, dizziness, sweating, hunger, and confusion.
2. Monitor for signs and symptoms of hyperglycemia.
Signs and symptoms of hyperglycemia include polyuria, polydipsia, blurred vision, and headache.
Interventions:
1. Review glucose logs.
Review glucose trends through the patient’s glucose monitoring device or written logs. Unstable glucose levels or uncontrolled hyperglycemia will require modifications to the treatment plan.
2. Request return verbalization of the treatment plan.
Ensure the patient truly understands their diabetes treatment plan by having them verbalize their glucose goals, when and how to administer insulin, foods that increase glucose levels, and what to do when experiencing hypo or hyperglycemia.
3. Consider continuous glucose monitoring (CGM) devices.
Patients who struggle with monitoring their glucose levels may benefit from a CGM that tracks their current glucose levels to understand patterns and better manage their diabetes.
4. Discuss barriers to proper glucose control.
Educate the patient on barriers to normoglycemia, such as elevated stress levels, intense exercise, diet choices, and medication use. Let the patient consider their specific barriers so the nurse and healthcare team can offer appropriate interventions.
Nursing Diagnosis and Rationale for Diabetic Foot Ulcer
1. Risk for Infection
Rationale: Diabetic foot ulcers are highly susceptible to infections due to the impaired immune response and poor blood circulation in diabetic patients. These infections can progress rapidly and may lead to osteomyelitis or amputation if not promptly addressed. Nurses should maintain strict aseptic techniques when handling wounds and provide appropriate wound care to prevent infection. This includes cleaning the ulcer with sterile saline, applying prescribed topical antimicrobials, and covering the wound with appropriate dressings. Monitoring for signs of infection such as increased redness, warmth, swelling, purulent discharge, and fever is essential. Administering prescribed antibiotics and educating patients on proper foot hygiene and care can significantly reduce the risk of infection.
2. Impaired Skin Integrity
Rationale: The presence of a diabetic foot ulcer inherently indicates impaired skin integrity. Factors contributing to this condition include peripheral neuropathy, which reduces sensation and awareness of injury, and peripheral arterial disease, which impairs blood flow and healing. Regular assessment of the ulcer size, depth, and condition, along with the periwound skin, is crucial. Nurses should implement measures to protect the skin, such as using pressure-relieving devices, ensuring proper footwear, and avoiding trauma. Educating patients on the importance of daily foot inspections and skin care is also vital in preventing further deterioration.
3. Risk for Deficient Fluid Volume
Rationale: Diabetic foot ulcers can lead to exudate production and fluid loss, which may contribute to dehydration and electrolyte imbalances. Assessing the patient’s hydration status through monitoring intake and output, skin turgor, and mucous membrane moisture is important. Ensuring adequate fluid intake, both orally and intravenously if necessary, helps maintain hydration and supports the healing process. Nurses should be vigilant for signs of dehydration, such as decreased urine output, dry mouth, and hypotension, and respond promptly to restore fluid balance.
4. Chronic Pain
Rationale: Diabetic foot ulcers can cause significant pain due to tissue damage and infection. Chronic pain management is essential to improve the patient’s quality of life and promote adherence to the care plan. Regular pain assessments using appropriate pain scales should be conducted. Nurses should administer prescribed analgesics and consider complementary therapies, such as relaxation techniques, to manage pain. Educating patients on pain management strategies and the importance of reporting changes in pain levels is also crucial.
5. Impaired Physical Mobility
Rationale: Diabetic foot ulcers can limit a patient’s ability to ambulate due to pain, reduced sensation, and the need to offload pressure from the affected foot. This can lead to decreased physical activity and muscle atrophy. Nurses should assess the patient’s mobility and provide assistive devices, such as crutches or walkers, to facilitate safe movement. Encouraging a tailored exercise program that enhances circulation and overall fitness while protecting the ulcer is beneficial. Educating patients on the importance of offloading pressure and adhering to mobility recommendations is essential.
6. Ineffective Peripheral Tissue Perfusion
Rationale: Poor blood flow to the extremities is a common issue in diabetic patients, contributing to delayed healing of foot ulcers. Assessing the patient’s peripheral pulses, capillary refill, and skin temperature can help determine the extent of perfusion issues. Nurses should implement strategies to improve blood flow, such as encouraging regular exercise, using warm compresses, and avoiding constrictive clothing. Educating patients on lifestyle modifications, including smoking cessation and blood glucose control, can also enhance tissue perfusion.
7. Risk for Sensory/Perceptual Alterations
Rationale: Peripheral neuropathy in diabetic patients can lead to altered sensation and proprioception, increasing the risk of undetected injuries and subsequent ulcers. Regular neurological assessments, including monofilament tests, are important for detecting sensory deficits. Nurses should educate patients on the importance of protecting their feet, using proper footwear, and avoiding extreme temperatures. Providing resources for regular podiatric care can also help in early identification and management of sensory alterations.
8. Deficient Knowledge
Rationale: Effective management of diabetic foot ulcers requires patients to be knowledgeable about their condition, wound care practices, and preventive measures. Assessing the patient’s understanding and gaps in knowledge is the first step. Nurses should provide comprehensive education on diabetes management, foot care, recognizing signs of infection, and the importance of regular follow-ups. Utilizing visual aids, pamphlets, and interactive sessions can enhance understanding and retention of information. Encouraging patients to ask questions and actively participate in their care plan fosters a sense of empowerment and adherence to recommendations.
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