CASE ANALYSIS (WOUND DEBRIDEMENT; DIABETIC FOOT)

Submitted by: Guinto, Hazel Jean Ilagan, Conradito Ileto, Lyzet Kae Isunza, Ma. Cristina Jacoba, Jully Jantakun, Nicole Jimenez, Theresa Submitted to: Mr. Cisette Ricardo, RN MAN

Diabetic foot ulcers are deep wounds that occur on the foot of a person with diabetes. Diabetes is a chronic (long term) illness that occurs when your body does

not make enough insulin. Diabetes also occurs if your body does not use the insulin it makes properly. Insulin is a hormone that allows your cells to use the sugar in your blood for energy. Lack of working insulin leads to high blood sugar levels. Increased blood sugar levels may damage your blood vessels or nerves leading to skin and tissue breakdown. A diabetic foot ulcer usually starts as a small wound or break in the skin of your foot. With diabetes, your body may not be able to heal itself normally. You may also have an increased risk for infection. Diabetic foot ulcers may cause the tissues in your foot or leg to die. A foot ulcer may make it hard for you to do your normal daily activities. Having your diabetic foot ulcer treated may decrease your symptoms such as pain and trouble walking. Treatment may help you return to your usual activities. Treatment may allow your foot ulcer to heal and decrease your risk for losing your foot. These are the common problems that may lead to a diabetic foot ulcer:

Animal or insect bites. Blisters and scratches. Burns. Calluses or corns (thick layers of dead, dry skin on your feet). Shoes that are too tight or do not fit well and rub against your feet. Stepping on a sharp object.

Signs and symptoms of a diabetic foot ulcer:

Bad odor or pus coming from your ulcer. Changes in the look and feel of your skin. The skin on your foot may look shiny or tight. It may turn dark red, brown, or black in color. Your foot may also feel cold and look pale (colorless). Fever (high body temperature) and chills. Foot weakness or trouble moving your foot. Increased size or deepness of your ulcer. Muscle pain or cramping that occurs with walking or exercising, and goes away with rest. Over time, you may feel pain at rest. Pain in your foot that had little or no feeling before. Redness and warmth, or swelling in your foot. Thick, yellow toenails.

Description of Surgery Debridement may be considered one of the most important aspects of diabetic foot ulcer care, along with offloading and infection control. Debridement is the removal of necrotic tissue to decrease the risk of infection and to promote wound closure. Debridement should remove all necrotic tissue, callus, and foreign bodies down to the level of viable bleeding tissue. Wounds should be thoroughly flushed with sterile saline or a noncytotoxic cleanser following debridement. Hydrotherapy is not recommended for diabetic patients. Debridement is essential for the removal of nonviable cells and for healing. Periwound callus must also be removed, as it may contribute to periwound pressure and incomplete wound contraction. Ulcers may also be obscured by the presence of callus. Purpose An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter is removed. Wounds that contain necrotic and ischemic (low oxygen content) tissue take longer to close and heal. This is because necrotic tissue provides an ideal growth medium for bacteria, especially for Bacteroides spp. and Clostridium perfringens that causes the gas gangrene so feared in military medical practice. Though a wound may not necessarily be infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Debridement is also used to treat pockets of pus called abscesses. Abscesses can develop into a general infection that may invade the bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissue exposed to corrosive substances tends to form a hard black crust, called an eschar, while deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars may also require debridement to promote healing.

Diagnosis/Preparation The physician or nurse will begin by assessing the need for debridement. The wound will be examined, frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs, bone, or important body features. The assessment addresses the following points: the nature of the necrotic or ischaemic tissue and the best debridement procedure to follow the risk of spreading infection and the use of antibiotics the presence of underlying medical conditions causing the wound the extent of

ischaemia in the wound tissues the location of the wound in the body the type of pain management to be used during the procedure Aftercare After surgical debridement, the wound is usually packed with a dry dressing for a day to control bleeding. Afterward, moist dressings are applied to promote wound healing. Moist dressings are also used after mechanical, chemical, and autolytic debridement.... Risks It is possible that underlying tendons, blood vessels or other structures may be damaged during the examination of the wound and during surgical debridement. Surface bacteria may also be introduced deeper into the body, causing infection. Anatomy and Physiology of the Feet

The important structures of the foot can be divided into several categories. These include: bones and joints, ligaments and tendons, muscles, nerves, circulatory system, and skin. Physiology of the foot will be discussed as each category of anatomical structure is addressed. Bones and Joints The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint.

The mortise and tenon structure is well known to carpenters and craftsmen who use this joint in the construction of everything from furniture to large buildings. The arrangement is very stable. The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heelbone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. The subtalar joint allows the foot to rock from side to side. Just down the foot from the ankle is a set of five bones called tarsal bones that work together as a group. These bones are unique in the way they fit together. There are multiple joints between the tarsal bones. When the foot is twisted in one direction by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting. The tarsal bones are connected to the five long bones of the foot called the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at the joints. Finally, there are the bones of the toes, the phalanges. The joints between the metatarsals and the first phalanx is called the metatarsophalangeal joint (MTP). These joints form the ball of the foot, and movement in these joints is very important for a normal walking pattern. Not much motion occurs at the joints between the bones of the toes. The big toe, or hallux, is the most important toe for walking, and the first MTP joint is a common area for problems in the foot. Anatomy of the Foot Bones of the Feet The foot contains 26 bones. These 26 bones are divided into 3 groups; tarsal, metatarsal, and the phalangeal Bones. Following is a more in-depth discussion of these bones and their functions.

Tarsal Bones The tarsal area of the foot contains a total of 7 bones. Tarsal bones are also the largest bones found in the foot. 1. Talus: AKA the ankle bone, it is the second largest bone in the foot. It connects the foot to the leg. 2. Calcaneous: The heel bone is the largest of the tarsal bones. 3. Navicular or scaphoid bone: Located in the middle of the foot. It can be found between the talus bone and first, second and third cuneiforms. 4. Cuboid: This bone can be found on the outer side of the foot (the side with the pinkie toe).

5. Medial Cuneiform or Internal Cuneiform: Rests between the navicular, first and second metatarsal. 6. Intermediate Cuneiform: Is found between the medial and lateral cuneiform bones. 7. Lateral Cuneiform: Located between the intermediate cuneiform and the cuboid, and the second and third metatarsal. Metatarsal Bones The Metatarsal bones connect the tarsal bones to the toes. The metatarsal are identified as number 1-5. 1. The first metatarsal extends from the big toe to the heel and is the shortest and thickest of the metatarsal bones. Two additional small bones can be found underneath the first metatarsal they have small muscles attached to them that aid in stabilization. 2. The second metatarsal the longest of the metatarsal bones. 3. Third metatarsal, connects to the middle toe; it is usually slightly shorter than the second metatarsal. 4. The fourth metatarsal is slightly shorter than the third. 5. Fifth metatarsal attaches to the pinkie toe and is the shortest. It also differs because it has a bump that can be seen on the outer side of the foot. Phalangeal Bones There are 14 phalangeal bones which make up the toes. They are identified by number just like the metatarsal bones. The first phalangeal is the big toe and the fifth is the little toe. The big toe has only 2 bones, which are much larger than those in the other toes. The second through fifth toes have 3 bones each. 33 joints can found in the foot and each joint is surrounded with fluid. This fluid is contained in a sack which keeps the joint lubricated. Some customers experience pain from arthritis, which is directly linked to lubrication (lack of) and inflammation of the joints Ligaments and Tendons Ligaments are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure. Ligaments and tendons come in many different sizes, and like rope, are made up of many smaller fibers. The thicker the ligament (or tendon) the stronger the ligament (or tendon) is. The large is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the heel bone to allow us to raise up on our toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. The

toes have tendons attached that bend the toes down (on the bottom of the toes) and straighten the toes (on the top of the toes). The anterior tibial tendon allows us to raise the foot. Two tendons run behind the outer bump of the ankle (called the lateral malleolus) and help turn the foot outward. Many small ligaments hold the bones of the foot together. Most of these ligaments form part of the joint capsule around each of the joints of the foot. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac. Ligaments There are 107 Ligaments holding your bones in place in a foot. Ligaments are like rubber bands, meaning that they can stretch and return. When you sprain your ankle it is the ligaments that have been stretched too far or have torn, thus causing pain and injury. Arches Most people refer to the longitudinal arch as the arch of the foot. It extends from the big toe to the heel. Muscles Muscles in the feet help stabilize the toes, which effect the way we walk. Of the 20 muscles located in a foot, 19 of them can be found on the bottom. Weak or damaged muscles can cause many disorders. Most of the motion of the foot is caused by the stronger muscles in the lower leg whose tendons connect in the foot. Contraction of the muscles in the leg is the main way that we move our feet to stand, walk, run, and jump.Joints of the feet There are numerous small muscles in the foot. While these muscles are not nearly as important as the small muscles in the hand, they do affect the way that the toes work. Damage to some of these muscles can cause problems. Most of the muscles of the foot are arranged in layers on the sole of the foot (the plantar surface). There they connect to and move the toes as well as provide padding underneath the sole of the foot. Nerves The main nerve to the foot, the tibial nerve, enters the sole of the foot by running behind the inside bump on the ankle, the medial malleolus. This nerve supplies sensation to the toes and sole of the foot and controls the muscles of the sole of the foot. Several other nerves run into the foot on the outside of the foot and down the top of the foot. These nerves primarily provide sensation to different areas on the top and outside edge of the foot.

PATHOPHYSIOLOGY Hyperglycemia

stimulate polyol pathway

accumulation sorbitol + fructose in Schwann cells Increase IC osmolality

influx of water ( osmotic cell injury )

damage schwann cell (demyelination )

axon degeneration irreversibly

disrupt neural function

Diabetic neuropathys

LABORATORY TEST

I Infection tests: Blood tests: You may need to have blood taken for tests. The blood can be taken from a blood vessel in your hand, arm, or the bend in your elbow. Blood tests can give your caregivers information about your health condition. Blood tests may be used to check your blood sugar level and to check for an infection. You may need to h have blood drawn more than once. Bone biopsy: During a bone biopsy, your caregiver takes a sample of bone from y your ulcer area. The sample will be sent to a lab to test for infection. Drainage or tissue sample: Your caregiver may take a sample of drainage or skin from your ulcer. The sample will be sent to a lab for tests to check for infection. If you have an infection, the test may show what germ is causing it. The test may also show what medicines will kill the germs. N Nerve damage and blood flow tests: Ankle brachial index: Ankle brachial index (ABI) is a test to check how well your blood is flowing to your feet. During an ABI, your caregiver will measure the blood

pressure in your ankles and arms. Differences in pressure between your ankles and a arms may be a sign of blood vessel damage. Arterial Doppler: An arterial Doppler is done to check the blood flow through your arteries. An artery is a blood vessel that brings blood from your heart to other parts o of your body. Monofilament: Your caregiver will press a small wire against the bottoms of your feet until the wire bends. If you cannot feel the wire, you may have nerve damage. Ask your caregiver for more information about this and other tests he may use to c check for nerve damage. Urine test: Check a sample of your urine for microalbumin. The urine test may tell your caregiver if you have diabetic neuropathy.

Imaging tests: Certain tests may use a special dye to help the pictures show up better. People who are allergic to shellfish (lobster, crab, or shrimp) may be allergic to some dyes. Tell your caregiver if you are allergic to shellfish, or have other a allergies. Bone scan: A bone scan is done to look at the bones in your ulcered foot and leg. You are given a small amount of radioactive dye through an IV. An IV is a tube put in a blood vessel to give medicine and fluid. Pictures are then taken of your bones. Y Your caregiver may use this test to look for a bone infection. Computed tomography scan: A computed tomography (CT) scan uses a special machine with a computer to take pictures of your foot. A CT scan may be done to c check for a bone infection or deep abscess (pus pocket). Magnetic resonance imaging: During magnetic resonance imaging (MRI), pictures are taken of your foot. An MRI may be done to check for a bone infection or deep abscess (pus pocket). An MRI may also be used to plan your treatment. A special kind of MRI, called a magnetic resonance angiogram (MRA) , may also be done to c check for blood flow problems. Positron emission tomography: During positron emission tomography (PET) p pictures are taken of your foot to check for a bone infection. Ultrasound: An ultrasound uses sound waves to show pictures of your foot on a TVl like screen. This test may be done to check for a bone infection. X-ray: During an x-ray, pictures of the bones in your foot are taken. The pictures will help your caregiver check for infection, bone loss, and fractures (bone breaks). The pictures may show if your foot has a deformity (abnormal shape). X-rays may also show swelling in your joints or gas in your tissues that may lead to tissue death. MEDICAL MANAGEMENT

Check your blood sugar levels: Make sure you check your blood sugar levels as often as your caregiver tells you to. Your caregiver will tell you what your blood sugar level should be. Keeping your blood sugar normal decreases your risk for health problems, including foot ulcers. Keep a diary of your blood sugar levels with the date

and time that you checked them. The diary will show how well you are managing y your diabetes. Check your blood pressure: Have your blood pressure checked regularly. Keeping your blood pressure at the level your caregiver suggests may prevent damage to y your blood vessels. Eat healthy foods: Eat a variety of healthy foods every day. Choose foods lower in sugar, fat, and cholesterol. Your caregiver can help you plan a diet. Eating healthy f foods may help you feel better and have more energy. Drink enough liquid: Drinking enough liquid may help improve the oxygen in your tissues and decrease your risk for foot ulcers. Talk to your caregiver about how m much liquid you should drink each day. Keep a healthy weight: Maintaining a healthy weight decreases the amount of force and pressure you put on your feet. Talk to your caregiver if you need help losing w weight. Quit smoking: Quitting smoking may improve the blood flow to your legs and feet. If you smoke, you are also more likely to have a heart attack, lung disease, and cancer. You will help yourself and those around you by not smoking. Ask your caregiver for more information about how to stop smoking if you are having trouble q quitting. Take your medicine as directed by caregivers: Your caregiver may give you medicine to keep your blood sugar levels normal. You may also have medicine to help treat your nerve damage, or other health problems. Keep a written list of the medicines you take, the amounts, and why you take them. Do not stop taking your m medicines unless you discuss it with your caregiver. Wear proper fitting shoes: Wear shoes that do not rub against any area of your feet. Ask your caregiver for help in choosing shoes that fit you best. If your caregiver orders you special shoes, make sure you wear them.

M Medicines: Antibiotics: This medicine is given to fight or prevent an infection caused by b bacteria. Anti-platelets: Antiplatelet medicines may be needed to prevent clots from forming i in your blood. Growth factors: Growth factors are chemicals that help your body heal itself. They improve the action of the cells in your body used for healing. Growth factor may be p put directly on your ulcer as a gel. Cholesterol medicine: Cholesterol medicine is given to decrease the amount of c cholesterol (fat) in your blood. Cholesterol may weaken or block your arteries. Vasodilators: Vasodilators are given to widen your blood vessels and improve blood flow.

SURGICAL MANAGEMENT Surgery may be done to remove infected and dead tissue from your ulcer. Surgery may help improve blood flow and wound healing. You may need any of the following: Achilles tendon lengthening: Achilles tendon lengthening is done to improve the movement of your ankle. Your Achilles tendon connects your heel to your lower leg muscle. With better movement, your ulcer may heal faster, and your risk for another ulcer may decrease. Angioplasty: Angioplasty is done to open up a blocked or narrowed artery in your leg or foot. The blocked artery may be opened with a stent (hollow object) or a balloon. Bypass: During bypass surgery, a blocked blood vessel is replaced with another blood vessel. The new blood vessel may be taken from another area in your body. Reconstruction: Reconstructive surgery is commonly done for non-healing ulcers. Your caregiver may need to cut out your infected ulcer and the area around it. If your ulcer is large, your caregiver may also need to close it during surgery. He may use a muscle or skin flap near your ulcer to cover the open area. Your caregiver may also use a skin graft to cover the area. A skin graft is skin from another area of your body or from a donor (another person). Amputation: Amputation is surgery done to remove all or part of your foot. A part of your leg may also need to be removed. Amputation may be needed if you have a non-healing ulcer that is getting worse. You may also need an amputation if you get an infection in your skin or bone that does not go away.

ASSESMENT

DIAGNOSTI C

PLANNING

INTERVENTI ON

RATIONAL E

EVALUATIO N

OBJECTIVE DATA: >bloated feet >redness >desquamat ion >inflamed foot >skin warm to touch >pain

Alteration in comfort ,pain related to destruction of skin and tissues secondary to DM

>after 1 -2 hrs of nursing interventio n, patient will experience comfort and free from pain.

>Obtain a baseline data(speciall y vital signs).

>fever may sign of infection.

The patient experience comfortabl e and free of pain.

>Position client in comfortable position.

>

>Apply warm and cold sterile water.

>

>Maintain sterility during and after wound debridment.

>to be free of infection.

>Administer medication as prescribe.

>to help reduction of pain.

>conduct health teaching.

>To provide adequate knowledg e to the patient

ASSESME NT

DIAGNOSTI C

PLANNING

INTERVENTION

RATIONALE

EVALUATI ON

OBJECTIV E: >redness >warmth >inflame d foot >skin warm to touch

Risk for infection r/t tissue destruction and increased environme ntal exposure

>after 8 hrs of nursing interventi on, patient will be free from infection.

>observe for localized signs of infection

>stress proper hygiene

>to prevent microorgani sms

The patient was able to be free from infection

>maintain sterile technique

>change wound dressing as indicated

>to prevent cross contaminati on

>Administer/mo nitor medication regimen

>to reduce the spread of infection