Adult Medical-Surgical Nursing Endocrine Module: DM Footcare and Patient Teaching Plan

“Diabetic Foot”: Definition  “Diabetic Foot” is a term given to the condition where chronic infection and progressive gangrene affects the foot and leg of a person with DM  This is a chronic but preventable complication of DM  It may lead to amputation of toes or even a limb, therefore prevention must be taken very seriously

“Diabetic Foot”: Aetiology and Contributing Factors  Neuropathy: loss of sensation to injury and break in skin  Macrovascular disease: Atherosclerosis causing occlusion of large vessels and reduced blood flow to extremities ( ↓ O2 and nutrients to tissues)  Hyperglycaemia:  An ideal medium for bacterial growth  Increases osmolality/ sluggish circulation

“Diabetic Foot”: Incidence  Risk increased with:  DM >10 years  Age >40 years  Smoking  Bunions and callouses  Reduced peripheral pulses  Reduced sensation

“Diabetic Foot”: Pathophysiology  Soft tissue injury occurs when sensation is deficient (often blister, stone in shoe, cut)  Infection arises and cellulitis, enhanced by hyperglycaemia  Poor circulation therefore poor healing: (lack of nutrients, O2 and inflammatory response to fight infection)  Gradual death of tissue: gangrene spreading proximally from toes to leg

“Diabetic Foot”: Prevention  Foot care: daily inspection for blisters, redness, cracks. Regular podiatrist care  Daily bathing, drying and lubrication of feet (to avoid cracked dry skin)  Protect from hot or cold  Check shoes for fit, and rough spots inside  Avoid walking barefoot; elevate when sit  Monitor blood glucose, ↓ lipids, ↓ smoking

“Diabetic Foot”: Clinical Manifestations  Cool, discoloured extremity (such as toe or heel) or wound which fails to heal ( ↓ pulse)  Gangrene (discoloured, blackened, necrotic tissue, maybe wet or dry)  May be no sensation or painful, burning  *Special advice: Inform physician if cut or blister is not starting to heal after a day*

“Diabetic Foot”: Diagnostic Investigations  Physical examination to assess circulation to extremities: includes peripheral pulses, temperature of limbs and blanching of skin on pressure  Doppler assessment of circulation  Neurological assessment  Blood glucose and lipid profile  Wound or skin swab for bacterial culture

“Diabetic Foot”: Management  Bedrest  Control blood glucose (may require increased insulin because of infection)  Debridement/ sterile dressings  Antibiotics: systemic and topical, antifungal agents if necessary  If gangrene spreads, amputation may be indicated to control

Nursing Care Plan for Teaching a Patient with Diabetes Mellitus  Diet: controlled CHO, ↓ lipids, ↑ fibre  Exercise  Regular glucocheck or urinalysis  Medication/ insulin (storage, dosage, sites)  Awareness of “ hypo ” ; “ Sick Day Rules ”  Foot care, hygiene, inspection  Keep clinic appointments (HbA 1 C)  Regular eye tests, ECG

Notes on Insulin  Types of insulin:  Regular: immediate and short-acting  Intermediate-acting  Long-acting  Insulin pen; Insulin implant  Insulin pump s/c  Storage in fridge/ Subcutaneous inj  Injection sites

Oral Hypoglycaemics  *Sulphonureas: stimulate ↑ secretion  *Beguinides: facilitate cell membrane receptors (not used if renal disorder)  May use the above together  Alpha-Glucosidase Inhibitors: delay absorption of glucose in intestine  Thiazolinediones  Meglinides*most common