Pathophysiology, Nursing Priorities and Management of Diabetic Foot Ulcer: A Case Study

This case study discusses the pathophysiology, nursing priorities and management of diabetic foot ulcer through a case study of Mrs. Bacci, a 49 year-old Italian lady with type 2 diabetes. It covers the underlying causes of diabetic foot ulcer, nursing priorities of care and their justification, and safe and appropriate nursing management practices.

Nursing
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Introduction
This is a case study of Mrs. Bacci, a 49 year-old Italian lady. She was admitted to the hospital
two weeks ago after developing a complication from the foot ulcer. She had a partial limp
amputation of the foot including the great toes and first toes under general anesthesia. Mrs. Bacci
is a known type 2 diabetic. She was discharged a week ago from the hospital nut has now
presented to the outpatient department for further assessment of her wound status. This essay
will discuss the underlying pathophysiology of her wound and the status. Nursing priorities of
care will also be addressed and a clear rationale provided. Finally, the safe and appropriate
nursing management at the moment will be discussed
Underlying pathophysiology and causes of Mrs Bacci post-operative wound status
Diabetes is a metabolic disorder that occurs when the blood glucose cannot be controlled
effectively. Majority of diabetic patients usually develop a diabetic foot especially after a
previous lower extremity amputation, anatomic foot deformity, peripheral vascular disease and
history of a foot ulcer. It is mail y caused by loss of glycemic control, peripheral vascular
disease, immunosuppression, and peripheral neuropathy. According to Bakker et.al (2016), a
diabetic foot ulcer develops when there is a combination of different components which show a
base relationship with the hyperglycemic state of diabetes. Some of these components are;
vascular, neuropathic and immune system components. According to Volmer and Lobmann
(2016), neuropathy is caused by the oxidative stress on the nerves by the effects of
hyperglycemia. In addition, further glycosylation of nerve cell proteins leads to ischemia. This
contributes to further nerve dysfunction and therefore its function is impaired too. If this occurs,
there is cellular changer and this can be observed from, sensory, motor and autonomic

components of the diabetic foot. The normal functioning of these reflexes are affected and it can
be clearly seen.
If the autonomic nerves are damaged, then the organs innervated by the nerve cannot
function properly. For example, organs such as sweat glands which are innervated by the
autonomic nerves will fail to produce sweat and therefore decreased the ability to moisturize the
skin. This can be clearly seen as the epidermis may crack or skin breakdown may occur. The
leading causes of diabetic wound or ulcers are high blood sugar levels which stiffen the body’s
arteries and narrow blood vessels reducing blood supply to the tissues, poor blood circulation
due to peripheral arterial disease and nerve damage which can lead to the development of ulcer
without the sensation of pain. Others are immune system issues and infections can also lead to
the development or worsening of a diabetic ulcer.
Moreover, if motor neurons innervating the foot muscles are damaged, then the various
ranges of movements are affected. Muscles’ ability to extend and flex is affected. Skin
ulcerations can also result due to impaired innervation. Moreover, the patient’s peripheral
sensation is decreased. This can make the patient not be able to notice wound development until
it worsens. Lastly, the amount of blood required to heal a diabetic wound is higher than the
amount required by any other wound. From the case study, Mrs. Bacci has a history of peripheral
vascular disease. This disease causes narrowing of arteries especially those supplying the lower
extremities. Since amputation creates a wound that needs to heal, it requires increased blood
supply as the patient is already diabetic. This has greatly contributed to the serious nature of the
wound dehiscence and inflammation of the surgical site. This clearly indicates impaired wound
healing and it can even lead to a chronic diabetic ulcer. Other factors such as endothelial cell
dysfunction causing decreased vasodilation and elevated plasma thromboxane A2 which causes

vasoconstriction further decreases blood supply to the peripheral tissue for wound healing.
Finally, immune changes which cause a decreased response to wound healing further contribute
to chronic diabetic ulcers. Some patients may have increased T lymphocyte levels and increased
rate of apoptosis which further promote wound healing delay (Walton and Minton 2018).
Nursing priorities of care and their justification
Nurses play a vital role in the management of a patient with a diabetic ulcer or wound (Hicks
et al 2018). The first priority of care on Mrs. Bacci is wound care. Diabetic wounds are very
difficult to heal and have a tendency to get worse if appropriate care is not adhered to. Main
causes of delayed wound healing are reduced blood supply required for skin healing and repair
and damage to the nerves causing neuropathy. Another contributing factor is an infection and
further injury. Diabetic wounds also tend to take a very long time to heal therefore close
supervision on wound progress should be considered as the patient may stay in the ward for quite
a long period of time. The patient can easily contract infections within the hospital surrounding
hence the nurse should take good care of the wound. Monitoring blood sugar level is also vital in
the management of a diabetic foot (Lipsky et al, 2016). Research shows that patients with high
blood sugar levels before surgery and even after surgery are at a higher risk of wound reopen
through dehiscence. These delays wound healing and can also be a route for microorganism’s
entry hence infections. Long-term pressure on the diabetic foot should also be avoided to
increase blood supply to the wound site.
The second priority nursing care is the patient’s nutritional status and physical activity (Gau
et al, 2016). Since Mrs. Bacci has an amputated leg, it is very difficult for her to engage in
physical exercises and most activities of daily living. The patient is already overweight and the

best way to reduce weight gain is through physical exercises. Since it is hard for the patient to
perform these exercises on her own, a nurse can help the patient achieve as many objectives as
possible. The nurse can also encourage the patient on food to be taken which should be balanced
in dietary needs and necessary for both wound healing process and management of obesity. Self-
image should also be put into consideration. Amputation can bring many changes to an
individual's life both physically and emotionally. This care is a priority as it can even affect the
patients healing process especially when the patient has emotional stress. Nurses should,
therefore, take into consideration as emotional satisfaction is an important factor in any healing
process.
Safe and appropriate nursing management practices
Even though Mrs. Bacci already has a diabetic wound, effective management can help to
prevent the wound from advancing into a chronic phase which can be very hard to manage. The
nurse focuses on caring for the foot and surgical site, preventing further skin breakdown and
keeping blood sugar within the normal range. Appropriate wound and foot care can be achieved
through the use of an aseptic technique while cleaning the wound. The wound should be cleaned
at least once in a day especially when it is still producing serous exudate. Antibiotics can also be
used during wound cleaning and dressing for example metronidazole can be used (Tone et al,
2015). When cleaning this type of wound debridement should be done but it should be done
carefully to avoid further injuries. The principle of cleaning the wound from inside to the outside
should also be followed to avoid transferring micro-organisms from the edges of the wound to
the inside. The wound should also be cleaned within a minimal time of exposure to avoid
bacteria and viruses from infecting the wound. A dressing should be used to cover the wound site
but the type used should be easily removable to avoid further wound injury and if they stick to

the wound, normal saline can be used. In cases of full-thickness wounds, a dressing that hydrates
the site such as hydrogel can be used. This allows granulation tissue to form over tendon or bone,
therefore, promoting healing. The skin around the wound or surgical site should be kept clean
and dry to avoid further inflammation.
Blood sugar can be maintained within normal levers in different ways. According to
Imamura et al (2016), insulin is the most commonly used method. Insulin facilitates the
movement of glucose from the blood into the cells to be used. It can be broken down into energy
or it can be stored in the adipose tissues in the form of glycogen for later use. The nurse should
ensure that insulin injection is given in time to prevent hyperglycemia. The patient should also be
thought on the importance of using her medication which includes insulin and the consequences
that will arise if the regimen is not adhered to. Other drugs such as oral antidiabetics can be used
to lower the blood sugar levels. For example, metformin can be used to enhance cells sensitivity
to insulin especially in patients with insulin resistance. This will help maintain the random blood
sugar within the normal range (11mmol/l). The patient should take small frequent meals in
between to avoid the risk of hypoglycemia as it commonly occurs when using insulin. Exercises
should also be included. The patient should perform exercises she is able to perform and can also
be helped by the nurse.
Since Mrs. Bacci’s mobility is already compromised, constant pressure relieving practices
should be emphasized to increase blood supply to the extremities as much as possible. The
patient should be provided with a pressure reducing chair cushion and mattress system (Bus et al,
2016). She should also be encouraged to participate in physical activities, for example, using
hands and body parts that can be mobile. Sitting for more than two hours should be discouraged
but she can walk using walking aids if she can to improve blood flow to the feet. To control her

obesity the patient can take food which is more in proteins than carbohydrates. This will help
lower blood glucose as much as possible. According to Amalraj and Viswanathan (2017), the
majority of patients who have undergone amputation of any part of the body requires a
multidisciplinary approach in their care. The counselors should be involved to counsel the patient
on ways in which their lives will change after the surgery. This should always be done before the
surgery is done but it can sometimes be done after amputation especially in emergency cases.
Patient’s self-image after amputation of a body part is important in the healing process.
Therefore enough information on what the patient should expect after the surgery is very
important in the healing process. The patient should also be taught on how to manage the wound
at home in order to avoid further infections and injury. The patient should understand clearly
their risk of developing diabetic wounds even with minimal injuries as small as a scratch. They
should also avoid situations that can induce stress as stress leads to increased blood sugar levels
which if it happens constantly it can lead to the development of insulin resistance which makes it
very hard to manage blood sugar within normal levels.
Conclusion
Diabetes is a chronic disease which can lead to many complications. Therefore any patient
with diabetes mellitus disease should be managed closely to detect the onset of any complication,
for example, diabetic ulcers. If these complications are managed at early stages they can be
managed and the patient is able to live a comfortable life. Every healthcare giver especially
nurses should majorly focus on preventing complications rather than treating them.

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