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Discuss about the Scenario Of Fraser A Patient With Foot Ulcer.

For patients with diabetes, the diagnosis of foot ulcer is a complex and challenging issue for patient. Recognition of signs of deterioration and early treatment of wounds can help to prevent infection and provide a high quality of life to such patients. This report reviews the scenario of Fraser, a patient with foot ulcer in the left leg and conducts a wound assessment process to develop a wound management plan for patient.

Fraser is a 50 year old Maori, who was diagnosed with type one diabetes when he was 8 years old. The reason for his current admission to hospital is an infected left foot and hyperglycaemia. Due to poor circulation of blood to his feet, he has developed infected ulcer on his left foot. Diabetic foot ulcer is a major complication found in almost 15-20 of patients with diabetic foot ulcer. It is caused due to diabetic neuropathy, a condition leading to nerve damage and lack of sensation in the feet and lungs. Hence, any kind of cut or bruises to the foot results goes unnoticed in such patient and loss of sensation leads to delay in treatment. This often leads to serious consequences such as ulcer, infection and joint pain (Noor, Zubair & Ahmad, 2015). Fraser also developed foot ulcer because of diabetic polyneuropathy. As diabetic ulcer takes time to heal, strict wound care regimen and adequate treatment is needed for Fraser. Apart from poorly controlled diabetes, there are no other medical issues for the patient.

Diabetic foot ulcers are complex wounds that have adverse impact on the mortality and morbidity of patients like Fraser. To prevent the foot ulcer from deteriorating and increasing chances of amputation, proper evaluation and assessment of wound is necessary. The process of assessment starts from the analyzing detailed history of the presenting illness and past medical history in patient (Hinchliff et al., 2015). Ulcer is the presenting illness for Fraser and poor management of diabetes and history of smoking are past medical history details of Fraser. This can help to identify whether the patient is at risk of amputation or not. Furthermore, physical examination of the ulcer may help to determine the size, depth and location of wounds, assess the status of wound bed, identify signs and evaluate consistency of exudates. This process can help to appropriately document ulcer characteristics and develop a baseline for planning treatment and proper intervention for patient. The following are the details regarding wound assessment process for Mr. Fraser:

Assessment Process

On wound assessment, the area around the ulcer has been found to be red and swollen. Red and swollen foot is a sign of life threatening complication in the foot. Unusual swelling and redness are early sign and symptoms of diabetic foot ulcer. According to Gardner, Hillis & Frantz (2009), erythema or redness is the sign of inflammation. The wound was also found to be granulated indicating the contribution of peripheral neuropathy to ulceration. This type of signs are specific to secondary wound. As redness and swelling has been observed in Fraser even after initiating treatment for foot ulcer, this is a negative sign which suggest the need to change antibiotic to control infection.

The wound assessment process also measures the length, depth and width of ulcers. Engaging in accurate measurement of length and width can help a nurse to track progress in outcome and determine the effectiveness of treatment process. In addition, measurement of depth is necessary to evaluate wound healing process. The wound measurement with relevant tools revealed extensive erythema deeper than the skin (Brownrigg et al., 2016). This revealed signs of serious infection in Fraser’s foot ulcer. The severity of the infection was determined by the PEDIS scales and grade III revealed extensive and severe ulcer. The depth of ulcer also revealed deterioration of ulcer as Fraser’s foot ulcer had almost reached subsequent layers of foot. The advantage of using PEDIS scale in the wound assessment process is that it is a standardized and efficient tool and it helped to correctly identify degree of risk for complications in patients with diabetic foot ulcers (Chuan et al. 2015).

Another step during the wound assessment process was to observe the condition of the surrounding skin near the lesion. The surrounding skin assessment was done to measure skin colour and temperature, identify signs of callus formation and induration and edema in Fraser. The skin around the ulcer was found to be slightly warm and red in colour. Redness indicates prolonged inflammation and increase in temperature near the ulcer shows signs of infection in the wound (Sibbald et al., 2012). Presence of the symptom of edema and abnormal firmness of the tissue surrounding the ulcer also revealed severe infection in the wound.

Characterising the type of exudates coming out from wound is also necessary to check the status of wounds and identify signs of infection. The colour, type and odour of wound exudates is checked to check for changes in bacterial balance. Healthy wound has no odour and necrotic wounds have offensive odours. In case of Fraser, there was no discharge from wounds and pain, swelling and redness was the main issue for him.

Ulcer Characteristics

The above assessment of Fraser’s wound and its characteristic reveals poor healing process and presence of infection. Healing process might have been hampered despite treatment because of poorly controlled diabetes, age of the resident or the location of wound. The physiological process of wound healing traditionally consists of four phases namely homeostasis, inflammation, proliferation and maturation. It involves the process of vasoconstriction, the inflammation phase to prevent bacterial contamination, the process of angiogenesis and replacement of wound matrix. This form of normal healing process is however disrupted in patients with diabetes (Tsourdi et al., 2013). Since Fraser has been diagnosed with diabetes since a long time and he has struggled to manage his diabetes. This might have disrupted the normal wound healing process.

The main issue for Fraser is poorly controlled diabetes. It has influenced the normal wound healing process and contributed to deterioration of diabetic foot ulcer for patient. Wound healing is slowed in diabetic patient because of poor circulation of red blood cells to the wound tissue and poor efficiency of white blood cells in fighting infection. Fraser also suffered from diabetic polyneuropathy which further damaged his nerves and lead to loss of sensation. Inability to feel the change in wound status further increases severity of foot ulcers and complicates wound healing process (Baron et al., 2017). The duration of ulcer might also be a reason for poor wound healing process. Smith-Strøm et al. (2017) proved that duration of ulcer before starting specialist health care treatment can be regarded can influence healing time significantly. Hence, long duration of ulcer before specialist health care treatment decreased the rate of wound healing. Ageing also influences wound healing process, however age is not a factor for Fraser currently.

Based on wound assessment of Fraser, it has been found that infection in the foot ulcer is the major issue for patient. To prevent infection and promote wound healing process, developing an effective wound management plan is necessary. The wound management plan for quick healing of Fraser’s ulcer is as follows:

  • Proper dressing and regular dressing changes will be vital in preventing infection and changing the status of wounds. While choosing a dressing for an infected diabetic foot ulcer, the main consideration is to ensure that the dressing is comfortable and acceptable for patient. The dressing should help in the management of infection and it should not worsen pain. As a moist wound environment is optimal for wound healing, it is planned to use a dressing that controls growth of micro-organisms, allows gaseous exchange and thermally insulate wounds. The dressing should not interfere with the observation of wounds from time to time and the material should be such that dressing can be changes frequently and easily. As Fraser’s ulcer has been infected, it is planned to change his dressing everyday in the morning. Frequent daily dressing change, wound inspection and antibiotic therapy is the key to treat diabetic foot ulcer (Yazdanpanah, Nasiri & Adarvishi, 2015).
  • During dressing changes, it is planned to cleanse wound at each instant and clean the wound with saline and antiseptic wound cleansing agent. Repeated process of debridement and rigorous wound cleansing can reduce the biofilm burden found in foot ulcer and promote wound healing. It is an ideal step to prepare the wound bed for healing.
  • Documentation at regular interval will be necessary to track progress of Fraser. The improvement in healing process will be observed by digitally photographing the foot ulcers and it can help to prevent progression of the infection to a more severe form such as necrosis and gangrene (Chadwick et al., 2013).

Health education is also a priority to support Fraser in managing his foot ulcer. Patient must be made aware about risk factors that can complicate healing process. Nutritional and diet information will be given to patient so that he can control his blood sugar. All instruction related to foot care and use of appropriate footwear will be provided to manage. As Fraser has been smoking ten cigarettes a day, smoking cessation education will also be provided to reduce risk of recurrence (Chadwick et al., 2013).

Wound Assessment Results

To reduce pain in Fraser due to foot ulcer, it will be necessary to provide a comfortable and good dressing to Fraser. To minimize pain during dressing changes, it is convenient to use soft silicone dressings (Schaper et al., 2016).  

Wound care assessment Chart:

Wound type: Diabetic ulcer

Dimensions:   Width- 2cm , Depth-  2cm and Length- 2cm

Photograph (Consent obtained): No

Wound swabs: yes

Result of wound swab: No exudate from wound

Exudate: No

Odour: Offensive

Colour of wound and surrounds: Granulating

Surrounding skin: Other

Suture line: Suture Insitu

Present on admission: Yes

Pain on dressing change: Intermittent (Score-5)

Wound Care assessment plan:

Wound location: Left foot

Frequency of dressing change: Every day in the morning

Cleansing agent: Saline

Primary dressing: Hydrogels

Secondary dressing: CarboFLEX

References:

Baron, R., Maier, C., Attal, N., Binder, A., Bouhassira, D., Cruccu, G., ... & Jensen, T. S. (2017). Peripheral neuropathic pain. Pain.

Brownrigg, J. R. W., Hinchliffe, R. J., Apelqvist, J., Boyko, E. J., Fitridge, R., Mills, J. L., ... & On behalf International Working Group on the Diabetic Foot (IWGDF). (2016). Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review. Diabetes/metabolism research and reviews, 32, 128-135.

Chadwick, P., Edmonds, M., McCardle, J., & Armstrong, D. (2013). Best practice guidelines: Wound management in diabetic foot ulcers. Wounds International.

Chuan, F., Tang, K., Jiang, P., Zhou, B., & He, X. (2015). Reliability and Validity of the Perfusion, Extent, Depth, Infection and Sensation (PEDIS) Classification System and Score in Patients with Diabetic Foot Ulcer. PLoS ONE, 10(4), e0124739. https://doi.org/10.1371/journal.pone.0124739

Gardner, S. E., Hillis, S. L., & Frantz, R. A. (2009). Clinical Signs of Infection in Diabetic Foot Ulcers with High Microbial Load. Biological Research for Nursing, 11(2), 119–128.

Hinchliffe, R. J., Brownrigg, J. R. W., Apelqvist, J., Boyko, E. J., Fitridge, R., Mills, J. L., ... & International Working Group on the Diabetic Foot (IWGDF). (2016). IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes/metabolism research and reviews, 32, 37-44.

Noor, S., Zubair, M., & Ahmad, J. (2015). Diabetic foot ulcer—a review on pathophysiology, classification and microbial etiology. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 9(3), 192-199.

Schaper, N. C., Van Netten, J. J., Apelqvist, J., Lipsky, B. A., Bakker, K., & International Working Group on the Diabetic Foot (IWGDF). (2016). Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes/metabolism research and reviews, 32, 7-15.

Sibbald, R., Goodman, L., Woo, K. Y., Krasner, D. L., Smart, H., Tariq, G., ... & Norton, L. (2012). Special considerations in wound bed preparation 2011: An update. World Council of Enterostomal Therapists Journal, 32(2), 10.

Smith-Strøm, H., Iversen, M. M., Igland, J., Østbye, T., Graue, M., Skeie, S., … Rokne, B. (2017). Severity and duration of diabetic foot ulcer (DFU) before seeking care as predictors of healing time: A retrospective cohort study. PLoS ONE, 12(5), e0177176.

Tsourdi, E., Barthel, A., Rietzsch, H., Reichel, A., & Bornstein, S. R. (2013). Current aspects in the pathophysiology and treatment of chronic wounds in diabetes mellitus. BioMed research international, 2013.

Yazdanpanah, L., Nasiri, M., & Adarvishi, S. (2015). Literature review on the management of diabetic foot ulcer. World journal of diabetes and Nursing, 6(1), 37.

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