I remember a man that came to our facility to see his wife every day. We noticed each day there was a smell about him that reminded you of a dead animal or rotten meat.
His wife finally asked him if he had been showering. He replied, “yes, every day”.
I knew he was diabetic, so I asked if I could see his feet, and it turned out he had a nail in the bottom of his boot that had been re-puncturing his foot day after day. He had no feeling and his foot had turned black.
He had not been inspecting his feet and by the time we saw in him in the Emergency room that day, his foot was not salvageable. It was spreading almost before our eyes, and the surgeon had to amputate.
This patient had neuropathy involved from the ankle down.
Neuropathic ulcer is synonymous with diabetic ulcer.
Sensory neuropathy is the loss of protective sensation, pain and temperature as displayed by the afore mentioned gentleman.
Motor neuropathy affects the muscles needed for foot movement and the foot becomes stiff causing hammer toes and claw toes thus transferring pressure to the metatarsals. This leads to the ulcers noted on the plantar surface of the metatarsal heads.
Autonomic neuropathy is decreased sweating and oil production, loss of temperature regulation, and poor blood flow to the soles of the feet. This will cause fissures, cracks, calluses and ulcer formations. Abnormalities in the bone formations of the feet cause fat pad loss and repetitive damage to the boney areas of the foot causing ulcerations.
Educate patients to inspect their feet daily for any redness or skin breaks
Stress the importance of checking shoes for any foreign objects
Ensure patients are fitted for proper shoes, insoles or orthotics, as needed
Educate regarding blood glucose control and push the need for strict adherence to their prescriptions
Teach patients that any foot injury or breaks in the skin must be reported to their provider as soon as they are noted.
Attempt to instill in the patient the importance of removing their socks and shoes when seeing provider.
Ask patients to make it a rule for themselves that they will not trim their own toenails but rather have a provider or certified nurse complete routine foot care for nail trimming and callous paring.
Stress the need to moisturize feet but never put lotions or creams between the toes as this can cause an increase of moisture and skin break-down
If problems arise with compliance, patients should be referred to a foot and ankle specialist and have their feet checked every 90 days.
Characteristics of the Diabetic Ulcer
The ulcer can take on the shape of a foreign object in the shoe or may be caused by trauma.
The ulcer may look like a laceration, puncture, or blister.
The wound base may be pink, pale, or necrotic with defined edges.
Exudate amounts are usually small to moderate in nature and clear.
The peri-wound is usually calloused with a white macerated appearance.
Offloading the diabetic ulcer is the gold standard in treatment of the ulceration.
Choosing a dressing to place over the wound inside the Total Contact Cast or Rocker Boot is usually the clinician’s choice. Healing or deterioration is noted with dressing changes. I routinely like to use a barrier cream around the wound to protect the wound from maceration and desiccation.
I favor debridement of the wound base followed by application of the dressings and the Total Contact Cast. I try not to use anything too thick over the wound as this destroys the purpose of offloading the wound.
Also - be sure to address hydration and nutrition.
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Meet the Author
Janis Harrison, RN, BSN, C.W.O.C.N & C.F.C.N. is the owner of Harrison WOC Services, L.L.C. in Thurston, Nebraska. A graduate of Morningside College, Janis works as an independent contractor of Wound, Ostomy, Continence, and Foot and Nail Care services for medical entities throughout Northeast Nebraska. With over 30 years of experience as a nurse and 12 years as a CWOCN and CFCN, she found her passion for wound care when her spouse was afflicted with many complications from four consecutively failed surgeries that involved his ostomy. Through this experience, it became obvious that rural Northeast Nebraska was in need of wound and ostomy nursing care. After her husband survived an nine additional surgeries, Janis enrolled and graduated from the WOC Nursing program. Along with writing case studies, poster abstracts, newsletters, consulting with KCI and in-services, Janis has also helped to write and is the Chief Clinical Consultant of WoundRight, which is a documentation app available for tablets.