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The assessment and treatment of a diabetic ulcer with be discussed.

Essay Topic: ,

Introduction

For this tissue viability assignment the assessment and treatment of a diabetic ulcer with be discussed. Wound healing and it properties will also be mentioned in regards to holistic factors affecting the chosen patient (pt). In accordance with the Health Professional Council (HPC) a standard of conduct, performance and ethics, a pseudonym has been used to protect the identity of the pt discussed (HPC 2008).

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I certify that confidentiality has been maintained, for the purpose of this assignment the patient will be called Mr Sim.An ulcer is a defect effecting loss of epidermis and all or part of the dermis (Lookingbill & Marks 1993). The skin comprises of three layers, and is the largest organ in the body. The average adult has 21 square feet of skin (2 sq m) weighing up to 3.2 Kg (Benbow 2007).

The three layers of the skin are, the Epidermis this consists of dead skin cells which shed continuously and it protects against certain bacteria. The epidermis also acts as a barrier to prevent evaporation and absorption of water. The Dermal Layer consists of capillaries, sebaceous (oil) glands, sensory receptors which transmit sensations such as itch, pain and temperature, and hair follicles all held together by elastin and collagen. The Subcutaneous layer contains fat and connective tissue that houses larger blood vessels and nerves. This layer is important in the regulation of temperature of the skin itself and the body. The size of this layer varies throughout the body and from person to person (Brannon 2007).

The skin is a complicated structure with many functions. If any of the structures in the skin are compromised through poor blood supply, trauma, surgery etc. a wound may develop.

“A wound is a loss of continuity to the skin “states Dealey & Cameron (2008)

The phases of normal wound healing

• Inflammation – a reaction to tissue damage / infection

• Reconstruction – granulation tissue starts to form.

• Epithelialisation – the wound becomes covered with epithelial cells.

• Maturation – scar tissue starts to fade and blend in with the normal tissue

Case Study

The subject of this study is a male patient aged 69 years, for the purpose of this case study the patient will be referred to as Mr Sim. Mr Sim attended as a new patient to the podiatry department at his local clinic complaining “something has been catching on my socks”. On examination of Mr Sim’s foot a large area of callus was observed on the plantar aspect of his right fifth toe (ball of foot under little toe) there was some brown discolouration due to extravasation (leakage of blood into the skin) indicating that there could be an ulcer under the callus. It was explained to Mr Sim that further assessment and treatment would be necessary to determine what and why the problem was occurring.

The podiatry assessment tool was used to provide a holistic approach to assessment of medical history and social factors that may affect the foot health of the patient. The tool has a systematic problem based approach to undertaking clinical assessment and a detailed history; it is similar in outlay to a Patient Orientated Medical Review (POMR). Both the POMR and the podiatry assessment tool include a description of the presenting complaint which is an important part as it determines what the patient considers to be important and can be used to establish agreed expectations. Both models include previous and current medical history including any operations, illnesses or injuries which is of high importance in wound healing as systemic disorders or medication can have a large impact on wound healing. Both assessment tools include a detail of any known allergies, any family traits and social factors such as smoking or drug taking. The factors assessed in the above tools are recognised as being significant factors in wound healing. Rainey (2005) lists medication, illness, smoking, alcohol consumption and mobility as factors that affect wound healing. In addition to the POMR the podiatry assessment tool focuses on the factors that may affect the patients foot health for example previous or current occupations, an appraisal of the patient’s footwear and assessment of patients gait, vascular assessment, condition of skin, skin colour, skin temperature as well as palpating pedal pluses. A neurological assessment using a 10 gram monofilament, which is the standard neuropathy test in primary and community care in the united kingdom since National Institute for Clinical Excellence (NICE) guidelines for the management of the diabetic foot were published in 2004 (Boulton et al 2006). However the podiatry assessment tool does not include an assessment of the nutritional status of a patient which has been regarded as a key factor affecting wound healing (Dealey 2005, Rainey 2005), and malnutrition is a very important cause in delaying the healing process (Morrison 1992).

Using the podiatry assessment tool it was found that Mr Sim was diagnosed with Type 2 diabetes nine years ago and had recently moved to the area from abroad after losing his wife of to whom he was married to for forty four years, he now lives in the same road as his nephew. Mr Sims has good control of his diabetes taking metformin 500m mg twice daily, his recent HBA1C was 7.3 % this is regarded as tight glycaemic control (Lee et al 2006) His nutritional status adequate, he reports no strong family history of diabetes or heart disease, he occasionally has a glass of red wine. Mr Sims also takes medication to control hypertension (high blood pressure), bendroflumethiazide and aspirin, a cholesterol tablet as a precautionary method, and painkillers and antiflammatory treatment for osteoarthritis. He also mentioned that the pain in his back was increasing, and was taking a course of antibiotics for an infected cut on his hand obtained whilst gardening. For some time now he had been experiencing bouts of tingling in both his hands and feet. He expressed that he takes good care of himself never smoked, eats well and keeps active, and he states he has “an awareness of the importance of good footwear as I was in the army”.

All patients with diabetes should receive an annual foot check by a trained health care professional (NICE 2004), this includes the application of a 10g monofilament to five points on each foot, to assess the protective sensation in the feet and the extent of any sensory neuropathy. Peripheral sensory neuropathy is thought to affect 20 – 40% of the population (McIntosh et al 2004) and is a major factor in the development of diabetic foot ulceration.

Both feet were tested using the 10g monofilament this resulted in 0/5 probes being detected on both feet indicating peripheral neuropathy, however the dorsalis pedis and posterior tibialis were palpable in both feet, skin colour, texture and temperature and capillary refill was 2 seconds indicating good blood supply (Dealey 2005). Baker, Murali and Fowler (2005) state that the palpation of foot pulses is not a good indicator for a good blood supply. A Doppler gives a more accurate result when assessing vascular status it assists the diagnosis by determining the presence or absence of a compromised arterial flow in the lower limb (Dughil 2006)

Jeng et al (2000) concluded that if a person cannot identify the pressure from a 10g monofilament on their skin approximately 98% of the sensory ability has been lost. When the 10g monofilament is applied to the foot it buckles at a given force of 10g, inability to feel this is a significant indication that neuropathy is present and protective pain sensation is lost (Edmonds and Foster 2000).

Neuropathy presents itself in various ways; motor, sensory and autonomic nerves are affected and there is no conclusive proof as to what causes neuropathy. Factors such as high glucose levels can cause chemical changes, harming blood vessels, which supply oxygen, to tissue. Motor neuropathy, causes abnormal foot pressures, the structure of the foot can change, giving abnormal pressure areas. Sensory neuropathy can give reduced sensation, masking pain, allowing for callus build up, and leading to ulceration. Autonomic neuropathy, which leads to dehydration of the skin, is commonly known as arteriovenous shunting (A.V). Neuropathy is detected by using a 10g monofilament. This is used on high pressure areas to detect if the patient can feel pain or not. These results, however, may not always be reliable, as they rely on patient feedback, therefore clinical judgement, must always be upheld at all times.

Diabetes affects the vascular supply to the foot, leading to reduce or absent pulses, causing poor tissue viability, decreasing healing time. Excess glucose and cholesterol deposits in the lumen of blood vessels, reducing the diameter, which in turn, increases heart activity causing hypertension. Aspirin is used as a prevention, it is classed as an anti-platelet drug which reduces platelet aggregation. Aspirin inhibits enzyme COX, which reduces platelet production of TXA2, which is a powerful vasoconstrictor. Mr Johnson* is currently taking Atenolol, hypertensive drug as well as Aspirin to reduce the chances of thrombosis or MI.

It was explained in detail to Mr Sim about the complications of diabetes and how it may affect the feet, during the discussion Mr Sim became upset about the loss of his wife, “she always looked after my feet particularly because of the diabetes”. It was important to establish a good rapour with Mr Sim, as the lesion was causing him no discomfort apart from catching on his socks. The recent loss of his wife, his back pain and hand infection had put a lot of stress on Mr Sim. Depression is twice as likely to occur in people with diabetes and this can have a link to fluctuating blood sugar levels. Mr Sim is also experiencing pain from his back and is still grieving about the death of his wife and coming to terms with living alone. Stress is recognised as a factor in delaying wound healing (Dealey 2005; Glasser et al 1999; Kiecolt-Glasser et al 1995). Cole-king and Harding (2001) found a statistically significant relationship between anxiety and depression and delayed in chronic wounds. Communicating with patients can reduce anxiety and promote the natural healing process, conversely lack of communication may impair healing (Collier 1994)

It was then explained to Mr Sim extenslevily about the lesion of his foot in regards to his general health without adding to his stress levels. Education has proven to be vital in the management of diabetes (NICE) . It was suggested that on debridement of the callus that there could possibly be foot ulcer, with Mr Sim’s consent the callus was removed using sharp debridement an ulcer was revealed. The ulcer measured 1cm x 1cm and probed to a depth of 5mm to tendon but not to bone, the base of the was ulcer was sloughy and yellow and appearance showed no sign of infection, sharp debridement was used very carefully to remove slough. Slough in the base of an ulcer is an ideal breeding ground for bacteria which increases the risk of infection and delays healing (Rainey 2005).If infection was noted healing will be delayed and may spread to surrounding tissue or bone. At the time of assessment Mr Sim’s ulcer showed no signs of infection, although he was taking a course of antibiotics for the infection in the wound on his hand. Diabetic problems such as peripheral ischemia or neuropathy can mask signs of infection this was considered on assessment. The wound following sharp debridement was flat and pink, this was significant as rolled edges would indicate infection. The condition of the skin was dry and showed no signs of maceration. The use of tool to grade the ulcer can provide objectivity and help with communication between health professionals. The tool used in this study was EPUAP European Pressure Ulcer Advisory System 1998, in this case the ulcer was caused by excess pressure over an area affected by peripheral sensory neuropathy. There are many wound classification systems including SAD, SINBAD and PEDIS, however the EPUAP grading system was protocol for this particular community trust. The ulcer was classified as a grade four pressure ulcer which is described as extensive destruction tissue necrosis, or damage to muscle, bone or supporting structure with or without full thickness loss.

The choice of dressing being “Activon Honey Tulle” produced by Advancis medical the gauze is impregnated with pure Manuka honey, this was used firstly to complete the debridement autolyticly. Secondly for the antimicrobial purposes and its aid to deslough and control odour in the wound. Benbow (2008) states a mosit environment is essential for optimal wound healing. Other dressings are considered also for their topical antimicrobial agents, such as Iodine and Silver. Iodine was an option although none where available in Clinic. Iodine is a popular choice for the use in Podiatry. Silver dressings are more expensive than the honey and also should only be used when there is clinical sighs of infection (British national Formulary: BNF, Nov 2009), so, as in Mr Sim’s case there was no signs. The secondary dressing was a foam dressing designed to absorb and retain any wound exudate to stop the wound from becoming macerated and inhibiting wound healing. ‘Biatain’ was the dressing choice as this is one of the foam dressings used in the clinics. This was needed as the Activion Tulle does not have any absorption properties. These dressing were held in place with ‘Mefix’ an adherent tape. Mr Sim was given instructions to keep the dressing clean and dry until his next appointment

Holistically the treatment plan was to contact Mr Sim’s, G.P regarding his depression over the loss of his wife, and referral to the local diabetes centre. A lengthy discussion was held on the importance of good footwear and changing shoes regularly, as although Mr Sim’s shoes where good shoes they were very old and the innersole had worn out penetrating to the outer sole (hole in bottom of shoe). A total contact insole referral was made to relieve the pressure long term. Temporally a pad was mad to deflect pressure away from the ulcer overlying the dressing in situ. Effective reduction in pressure relief is essential to heal a diabetic foot ulcer and to prevent reoccurrence (Armstrong et al 2001). A education booklet was supplied titled Diabetic foot Ulcer, if a patient has the knowledge and understanding of their treatment plan they are More likely to comply (Dowsett 2004).

Mr Sim was as asked to return to clinic in five days as part of his dressing regime, he reported he had an appointment with the G.P the following day to discuss his depression. He had also received a letter from the diabetes centre with an appointment for the following week. The NSF (National Service Framework) and NICE the National Institute for Clinical Excellence set standards and put polices in place for every health care professional to follow, all patients with diabetes present with an ulcer must be referred on to a multidisciplinary team to receive the best care possible. The multidisciplinary team consists highly trained podiatrist, diabetologist, consultant, nurses, orthotists all of which specialises in complications of the foot and lower limb (NICE 2004).

The dressing was removed the wound measured a reduction in depth and circumference 7mm x 6mm depth 3mm, exudate levels where low, there were no clinical signs of infection, no maceration or further callus formation, the same dressing was applied and along with padding. A further appointment was made for seven day’s time , ideally the dressing change should be five days but due to staff sickness this was not possible. At this appointment Mr Sim had seen the G.P who had referred him to a bereavement councillor. The diabetes Centre had furthermore made a referral to the orthopaedic department who are fitting Mr Sim for orthopaedic footwear for pressure relief in accordance with NICE guidelines (2008). On conclusion the outcome for this case study was a positive one, the patient was assessed holistically to identify and factors which may hinder the healing process, this not only includes the factors directly affecting the wound but also indirectly by affecting the patients quality of life including dealing with bereavement, housing issues etc. The Department of Health (DH 2008) stated “Delivering improvements for people with long term conditions is not just about treating illness, it is about delivering personalised, responsive, holistic care in the full context of how people live their lives. Our journey to achieve this has started, our challenge is to continue to take it forward and the evidence compels us to do this”.

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