In this article, we will discuss a case scenario related to diabetic mellitus patient. After understanding the case, we will state what is our main concern in this scenario and why will we focus on this aspect rather other aspect. Also we will introduce some tools to do an assessment in order to predict the outcome. If we understand the possible outcome, we may anticipate the outcome of this patient and understand the possible worse situation too. In this scenario, foot assessment will be focused on.
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Ms Wong, 47 years old woman who was a housewife, arrived at hospital due to get dizzy, fatigue and fall in the floor at home with little bleeding. After she arrived at emergency department, nurse discovered she got a wound in the left heel but she didn’t feel pain, nurses suspected she got the wound during she fell in the floor. Her vital sign was normal; body temperature was37.5C, pulse 70/min, blood pressure 126/80 mmHg, respiration 18/min. After having a blood glucose test, we knew that she was suffering from hypoglycemia and her blood glucose index was 2 mmol/d. As nurse provided glucose water and wound dressing to her, she recovered and transferred to ward for continuing observation. Her past history was that she was suffering diabetic mellitus for 7 years and having regular oral diabetic mellitus medication without daily blood glucose test by herself and her BMI was over 25, she was overweighed. Her parents had diabetic mellitus too but they passed away.
After tackling her emergency problem which is lower blood glucose level, we will focus on the further investigation in order to find out the reason why she don’t get any feeling of her wound as well as to investigate how the sensation change and what is the possible outcome so as to give some recommendations to her and prevent the serious consequences. As early detection and treatment of diabetic foot complication could reduce the prevalence of negative outcome. (Prakash, 2011) In the following part, we will focus on the foot assessment.
For foot assessment
Foot assessments include the following aspects such as demographics, musculoskeletal system, neurologic system, peripheral vascular system and skin. Assessments will though inspection, palpation, sensation and using tools so as to obtain the result.
To obtain data from interview, it includes regarding type of diabetes, gender, any smoking habit, presence of hypertension, retinopathy, nephropathy and suitability of footwear. (Thompson, Nester, Stuart & Wiles, 2004)
For musculoskeletal system
Assessment includes postures, gait, strength, flexibility, endurance and range of motion. It includes evaluation for any deformity because imbalance of foot muscles frequently. (Khanolkar, Bain & Stephens, 2008) Other muscles problems like claw toes, hammer toes, heel spurs, calluses, cracks and corns. (Chan, Yeung, Chow, Ko, Cockram & Chan, 2005) The website shows how to have the musculoskeletal assessment to the patient. (BJSM, 2008)
Inspection and palpation can be applied into this assessment, note the size and contour of the joint which is including knee and ankle, inspect the skin and tissue of the foot for color, swelling and any masses, any lesion or deformity, pay attention of the skin integrity.
Palpation is including skin for temperature, muscles, bony articulations and area of joint capsule, notice any heat, tenderness, swelling. The most important is to palpate radial and brachial pulse. If the peripheral pulse is weak, we need to have a further assessment.
Assessment should include asking neuropathic symptoms such as burning, tingling, numbness and nocturnal leg pains. Assessment related to sensory assessment, pressure assessment, and vibration sensation too.
Pinprick sensation test is used to test pain. Lightly apply the sharp point or dull end to the foot skin randomly, unpredictable order and ask the patient to say sharp or dull depending on the sensation felt. If the result of pinprick sensation test is abnormal, temperature sensation test will be applied. Fill two test tubes, one with hot water and one with cold water and apply the bottom ends to the patient’s skin randomly and ask them to say which temperature is felt. Another method to test sensation is light touch. Apply a wisp of cotton to the skin, stretch a cotton ball to make a long end and brush it over the skin in a random order and irregular intervals and ask the patient to say yes when touch is felt. (Jarvis, 2004) Pressure sensation is usually assessed by using the10gnylon Semmes-Weinstein monofilament. (Khanolkar, Bain & Stephens, 2008)
Tuning fork can be used to test vibrations over bony prominences. Strike the tuning fork on the heel of your hand and hold the base on a bony surface of the fingers and great toe and ask the patient to indicate when the vibration starts and stops. If no vibrations are felt, move proximally and test ulnar processes and ankles, patellae. Also compare the vibration of both sides. (Jarvis, 2004)
For peripheral vascular system
The Doppler ultrasonic stethoscope is a device to detect a weak peripheral pulse and to measure a low blood pressure or blood pressure in a lower extremity. The Doppler stethoscope magnifies pulsatile sounds from the heart and blood vessels. Place a drop of coupling gel on the end of the handheld transducer. Place the transducer over a pulse site, swiveled at a 45-degree angle. Apply very light pressure and locate the pulse site by the swishing, whooshing sound. (Jarvis, 2004)
Nurses should apply both Doppler ultrasonic stethoscope and ankle-brachial index. The Ankle-brachial Index is to apply a regular arm blood pressure cuff above the ankle and determine the systolic pressure in either the posterior tibial or dorsalis pedis artery. Then divide that figure by the systolic pressure of the brachial artery. The normal ankle pressure is slightly greater than or equal to the brachial pressure. However, the ankle-brachial index may be less reliable because of calcification which makes their arteries non-compressible and may give a falsely high measurement. (Jarvis, 2004)
If patient have wound or skin impair, nurses should do wound assessment to record the size and the characteristic such as redness, edema, pain and heat. It is used to follow the wound healing progress. If necessary, nurses may have a bacteria test to confirm either the wound have microbe or not. (Worley, 2006)
The outcome of having foot assessment
The assessment findings can be used to indicate or predict the problems of their diabetic foot. The most positive outcome is no diagnostic findings. It is including integrated skin with normal sensation. However, other possible findings are neuropathy, ischemia, ulceration, infection and necrosis. The most serious alive consequence is amputation.
Outcome of musculoskeletal syste
The possible finding of musculoskeletal system is foot deformity. Deformity should be recognized early and accommodated in properly fitting shoes before ulceration occurs. If nurses assess the footwear, the chance of foot deformity will be reduced. Deformities include the Charcot foot which refers to bone and joint destruction that occurs in the neuropathic foot. Early diagnosis is important to prevent severe deformity. The foot presents with unilateral erythema, warmth and edema. (Edmonds, 2008)
Outcome of neurologic assessment
The outcome of neurologic assessment is either absent of sensory neuropathy or not. If patient loss of sensory neuropathy, they cannot sense pain or pressure and has a lack of identity with their feet. Also, motor neuropathy where muscular loss results in the clawed toes, high arch, foot drop and an absent ankle reflex. Due to absence of sweat and sebum production of autonomic neuropathy, the skin is dry and inelastic. In addition, pressure sensation test can be further confirmed their pain sensation is true or not. If patient can feel the pressure from the filament, the protective pain sensation is present. It is important to avoid areas of callus when carrying out this procedure as applying the filament to a plaque of callus may lead to a false diagnosis of neuropathy being recorded. (American Diabetes Association, 2010)
Outcome of peripheral vascular assessment
The outcome of Doppler ultrasonic stethoscope is to indicate the presence of peripheral vascular disease though listen the pulse qualities. The normal range of ankle-brachial index is 1.0 to 1.2. If the ankle-brachial index is of 90% or less, it indicates the presence of peripheral vascular disease. If the index is 0.9 to 0.7, it indicates a mild claudication, 0.7 to 0.4 indicates moderate to severe claudication, and 0.4-0.3 indicates severe claudication usually with rest pain except in the presence of diabetic neuropathy. The most serious outcome of this assessment is the index less than 0.3; it is diagnosing ischemia with impending loss of tissue. (Jarvis, 2004)
Ischemia or peripheral arterial occlusive disease is the possible outcome too. It eventually will reduce in arterial perfusion severely and result in vascular compromise of the skin, often precipitated by a major trauma. Also ischemia is always associated with neuropathy. (Wilson, 2003)
Infection process is the main reason for major amputation following ulceration. It can complicate the neuropathic and the neuro-ischemia foot ulcer. As infection originate from skin trauma or ulceration, often spreading to soft tissue then bone. Associated with neuropathy or ischemia, mean infection is often missed because of an absence of pain or loss of ability to mount an inflammatory response. Also there is no increase in temperature, white blood cell count and C – reactive protein. (Wilson, 2003)
Outcome of skin assessment
The most positive skin assessment outcome is integrated skin and no wound. However, if diabetic patient have wound, healing is usually protracted. It is because patients with neuropathy continually traumatize their foot wounds by walking freely upon them. It is difficult to tell patient to take rest when they don’t feel pain during walking. Also patients with ischemia cannot mount an adequate inflammatory response to fight infection and achieve healing. Another reason is related to the healing process. Macrophages and neutrophils are important agents in wound healing, particularly at the inflammatory stage which is fundamental to all ensuing stages. However, the above function of diabetic is impaired. Thus the wound will hard to heal. If the wound decay, it will become foot ulceration. (Bentley & Foster, 2007)
Necrosis is a grave implication that diagnosis necrotic foot, threatening the loss of the lumbs, and is caused by infection or ischemia or both. It is classified as either wet or dry, each with its specific management. If it is in the neuropathic foot, necrosis is invariably wet initially and is nearly always due to a septic arteritis secondary to soft tissue infection complicating a digital or metatarsal ulcer. The arterial lumen is often occluded by a septic thrombus. Both wet and dry necrosis can occur in the neuroischemic foot. The common cause of a black toe is again septic arteritis, exacerbated by large vessel disease in the leg. Dry necrosis can also develop in the neuroischemic foot and is secondary to a severe reduction in arterial perfusion. (Edmonds, 2008)
The combined impact of neuropathy, ischemia and infection are so great that is amputation. It is preceded by foot ulceration and infection. It is because diabetic related to an artery disease which reduces blood flow to the feet. If the blood flow reduces, the healing process will be slowly. Even with preventative care and prompt treatment of infection and complications, there are instances when amputation is necessary to remove infected tissue in order to save a limb or even save a life. (Wilson, 2003)
If missing the above assessment, nurses cannot diagnosis the problem of this patient. The most serious consequence will be happened.
Diabetic foot assessment indicates lots of different outcomes. Patient with diabetic should not look down upon their wound; it will be have a serious consequence which is amputation. In order to have a quality of life, an impaired skin’ diabetic patient must need the further foot assessment so as to prevent the negative outcome.
- American Diabetes Association. (2010). Foot Complications. Retrieved Mar 23, 2011, from http:// www.diabetes.org/living-with-diabetes/complications/foot- complications.html
- Bentley, J., & Foster, Ali. (2007). Multidisciplinary management of the diabetic foot ulcer. Wound Care, S6, S8, S10, S12.
- BJSM. (2008). Knee Exam (5 of 27): Neurovascular evaluation: supine. Retrieved Mar 23, 2011, from http://www.youtube.com/user/BJSMVideos#p/u/38/xe W7dwcBZCI
- Chan, C. N. J., Yeung, T. F. V., Chow, C. C., Ko, T. C. G., Cockram, C. S., & Chan, N. N. (2005). A manual for management of diabetes mellitus a Hong Kong Chinese perspective (revised ed.). Hong Kong: TheChineseUniversity ofHong Kong.
- Edmonds, M. (2008). A natural history and framework for managing diabetic foot ulcers. British Journal of Nursing, 17(11), S20, S22, S24, S25-S29.
- Jarvis, C. (2004). Physical Examination & Health Assessment (4th ed.).Philadelphia:Elsevier
- Khanolkar, M. P., Bain, S. C., & Stephens, J. W. (2008). The diabetic foot. Q J Med, 101, 685-695.
- Prakash, S. (2011). Early Screening to Cure from Type 2 Diabetes. Retrieved March 23, 2011, from http://topnews.us/content/237118-early-screening-cure-type-2 -diabetes
- Thompson, L., Nester, C., Stuart, L., & Wiles, P. (2004). Interclinician variation in diabetes foot assessment- a national lottery?. Diabetic Medicine, 22, 196-199.
- Wilson, D. J. (2003). Amputation and the diabetic foot: learning from a case study. Wound Care, S18, S20, S22, S24.
- Worley, C. A. (2006). Neuropathic Ulcers: Diabetes and Wounds, PartI.Etiology and Assessment. Dermatology Nursing, 18(1), 52-53.
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