Pathophysiology of Diabetic Foot Ulcer

This document discusses the pathophysiology of diabetic foot ulcers in patients with type 2 diabetes, including the causes and contributing factors such as peripheral neuropathy, vasculopathy, and immunopathy. It also covers the management and nursing priorities for diabetic foot ulcers.

Running header: RIGHT FOOT ULCER 1
Right foot ulcer
Student name
Student ID number
Specialty area

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Pathophysiology of diabetic foot ulcer
Mrs. Gina has a history of type two diabetes, peripheral vascular disease and obesity which
led to a right foot ulcer. Her blood glucose level was 12.6mmol/L and surrounding skin was wet
from exudate, dark pink and painful to touch. Factors that caused the growth of diabetic foot
ulcer in diabetic patients are divided into two. This includes causative factors and contributing
factors. Causative factors include peripheral neuropathy, vasculopathy, and immunopathy.
Contributing factors include atherosclerosis, and diabetes (Obaid & Eljedi, 2014).
a. Neuropathy
Peripheral neuropathy also called loss sensation is the impairment of nerves throughout the
body. An increased hyperglycemic condition in the blood causes the secretion of sorbitol
dehydrogenase and aldolase reductase. This enzyme causes the conversion of glucose to fructose
and sorbitol. The accumulation of these sugar products leads to a decreased production of nerve
cell myoinositol hence affecting nerve conduction. This causes a decreased peripheral sensation,
vasomotor control of the pedal circulation and lastly, it damages the nerves of the little muscles
in the foot (Merza & Tesfaye, 2018). When the normal functioning of the nerves is impaired it
may expose an individual to minor injuries without recognizing it until it makes an ulcer. High
sugar levels in the blood cause dryness and fissuring of the skin predisposing it to infection. The
autonomic nervous system controls the microcirculation of the skin. Damage of the autonomic
nervous system lead to the enlargement of ulcers, gangrene and lastly limb loss.
b. Vasculopathy

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Uncontrolled glucose level causes endothelial cell damage and smooth cell abnormalities.
Endothelial cells damage leads to rapid growth of endothelial cells, reduced production of nitric
oxide, increased blood viscosity, thickening of the basement membrane and reduced blood flow.
Endothelial cells synthesize nitric oxide which causes vasodilation of blood vessels. Reduced
nitric oxide production leads to a propensity for atherosclerosis, vasoconstriction of blood
vessels and finally leading to ischemia. Hyperglycemia cause overproduction of thromboxane A2
causing plasma hypercoagulability. Clients with this condition manifest with rest pain, absent
peripheral pulse and lastly thinning of the skin (Merza & Tesfaye, 2018).
c. Immunopathy
The immune system of a diabetic patient is much weaker than healthy people. The
hyperglycemic condition causes overproduction of pro-inflammatory cytokines and damage of
polymorphonuclear function like chemotaxis and phagocytosis. The immune system is weakened
due to decreased leukocyte activity, wrong inflammatory response and lastly disturbance of
cellular immunity (Merza & Tesfaye, 2018). Diminished chemotaxis of cytokines and growth
factors impended wound healing by extending the inflammatory state. The presence of an open
wound in a fasting state creates a catabolic state. Negative nitrogen balance results caused by
protein break down. This impairment of metabolic function affects the synthesis of proteins,
collagen, and fibroblast. Lack of these factors in the blood will result in prolonged healing of the
wound. High blood glucose creates a favorable condition for the growth of bacteria mainly the S.
Aureus and B- hemolytic streptococci (Robelledo, Soto, & Pena, 2015).
Causes of the patient post-operative wound status

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Mrs. Gina blood glucose level was 12.6mmol/L. She was unable to manage her high glucose
level since she was noncompliant to medication prescribed on discharge. Her wound was wet
from serous exudate output. The surrounding skin was warm, dark pink and painful to touch
which was an indication of an infection. The major cause of this infection was a peripheral
vascular disease caused by high blood glucose level in the blood. This condition resulted in
arterial insufficiency when blood flow to the legs is reduced (Rohfling, Weidmeyer, & Little,
2017). A decrease in blood flow to the tissue may lead to tissue decay, creating a favorable
environment for bacterial growth. Reduced blood flow also leads to reduced oxygen levels,
nutrition, and healing rate. Lack of oxygen in the tissues prevents the neutrophils from
phagocytizing bacteria and prevents the macrophages from reaching the site of infection. When
the blood sugar level is out of control, there is the production of harmful molecules known as
dicarbonyls. This molecule changes the structure of human beta-defensin-2 which is an
infection-fighting peptide. Destruction of this peptides reduces the ability of the body to fight off
bacteria and infection (Sacks, Bruns, & Macdonald, 2016).
Nursing priorities and rationale
Type two diabetes occurs when the glucose levels in the blood are too high. Hyperglycemia
may occur for several reasons such as not taking enough insulin or eating too much. Mrs. Bail
blood glucose level is 12.6mmol/L which was higher than normal. If the hypoglycemia was is
untreated it would lead to diabetic ketoacidosis which may later cause unconsciousness or even
death. The two main priorities of care include the following;
a. Administer glucose-lowering medication.

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Since the client was not compliant to medication prescribed which resulted in a high blood
glucose level of 12.6mmol/L the best treatment to rapidly lower the blood glucose level is insulin
pump therapy. The pump is attached to the client with a thin tubing with a needle at the end
which is introduced under the skin. This pump allows insulin to flow in a rate that one can
control. This means that the client can no longer give herself medication. Insulin acts by
lowering blood glucose. It stimulates glucose uptake by the skeletal muscles, prevents hepatic
glucose production, and lastly prevents proteolysis and lipolysis (Schetz, Wouterz, & Weekers,
2017).
Metformin is administered as the first medicine. It acts by decreasing the level of glucose that
the liver produces into the blood. This helps the body cells to be responsive to insulin. It’s also
prescribed for clients who are obese.
Sulphonylureas example glibenclamide is administered to the client to increase the amount of
insulin produced by the pancreas (Buchanan, Xiang, & Ochoa, 2016).
b. Monitor the foot and educate the client on the importance of foot monitoring
Having diabetes means that you are at risk of developing feet problems due to damage to the
nerves of the foot. This means that small cuts are not easily noticed leading to the development
of foot ulcer. Close monitoring and proper foot care are important because reduced blood flow to
the feet may result in decreased sensation also called neuropathy. Reduced blood flow may result
in slow wound healing. This can be avoided by encouraging daily foot care this includes sterile
cleaning of the wound, looking for any small cuts at the feet and lastly trimming toenails
(Pendsey, 2014).
Management of diabetic patients

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Diabetes is a chronic illness that calls –for continuing medical care and client’s self-
management education so as to prevent acute complication and decrease the chance of getting a
long term complication. Safe nursing management of the patient include the following;
1. Management of diabetic foot ulcer
The main objective in the management of diabetic ulcer is the closing of the wound to prevent
further infection. The basis of diabetic wound treatment include debridement, decreasing
pressure on the injured area, administering adequate antibiotics, wound treatment using a clean
and moist dressing and lastly managing the bacteria by diagnosing the type of infection.
a. Debridement
Debridement is the process of removing nonliving material, unhealthy tissue and foreign
bodies from the injured area. Debridement plays an important role in wound healing through the
production of granulation tissue. The major purpose of this process is to convert a chronic wound
healing environment into acute wound healing (Jupiter, Buckley, & Shibuya, 2016). Mechanical
debridement is carried out by dry-wet dressing pressure irrigation and hydrotherapy.
Debridement can also be done biologically by the use of sterile larvae of sericata fly which
produces a proteolytic enzyme that dissolves the necrotic tissue.
b. Offloading
Offloading is the act of decreasing pressure on the ulcer. The major purpose of offloading is
to reduce tissue trauma and enhance wound healing. Ulceration takes place on an area of the foot
that gets high pressure. In addition bed, rest is a method of choice so as to decrease pressure.

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Total contact casting is also used as an offloading method. This is done by letting the client take
a walk during therapy. It is important in controlling edema that can hinder wound healing
(Pataky & Conne, 2016).
c. Management of infection
Bacterial wounds allow bacterial entry leading to infection. Signs and symptoms of infection
include pain, edema, softness, and pus. Infections are treated by oral administration of antibiotics
example clindamycin. In severe infection, intravenous antibiotics are given examples include
ampicillin and imipenem-cilastatin.
d. Dressing
A dressing is a material used to cover a wound protecting it from infections. Several types of
dressing include the hydrocolloid and hydrogel. The advantages of a closed clean wound are that
it creates a humid healing environment to enhance cell migration and keep away dry sores.
Negative pressure wound treatment is also used to eliminate any possibility of edema formation.
It acts by removing lymph in interstitial hence elevating the movement of interstitial oxygen into
the cell.
2. Glycemic control
Glycemic control is very important in the management of the diabetic client. High glucose
levels in the blood can be controlled through the following ways;
a. Stress management

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Physiologic stress that may be caused by surgery or infection may contribute to high glucose
level and may trigger diabetic ketoacidosis. During stress, epinephrine is produced which causes
an elevation in glucose levels. In addition, during this time of emotional stress, a client with
diabetes may change the time of medication, exercise, and meals. This contributes to
hyperglycemia. Diabetic clients are encouraged to comply with the medication despite the
emotional stress. They are also taught on methods of minimizing stress such as exercise or
expressing their feelings to someone they trust (Tumilehto, Erikson, & Laakso, 2013).
b. Exercise program
Exercise is crucial in the management of diabetes. This is because it decreases blood glucose
levels and cardiovascular risk factors. Exerting your muscles results in increased uptake glucose
by skeletal muscles and also utilizes insulin (Schneider & Ruderman, 2017). Weight lifting can
increase muscle tone enhancing resting metabolic rate. Since the client is obese, exercise helps in
losing weight. Moreover, it reduces stress and maintains a feeling of well-being. Exercise also
increases the high-density lipoprotein and reduces the low-density lipoproteins. This is important
in diabetic patient because of increased risk of cardiovascular diseases (Haffner, 2014).
c. Nutritional management
Diet, nutrition and weight control are the basis for diabetes management. The important
process in nutritional management is the control of total caloric intake so as to maintain a normal
blood glucose level and maintain sensible body weight. The client is first educated on the
relationship between food and insulin. Food high in fiber is recommended for diabetic patients
since fiber lowers cholesterol levels in the blood. Fiber also reduces the demand for exogenous
insulin by slowing down the absorption of glucose in the blood (Pan, Wang, Lin, & Jiang, 2015).

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The client is also advised on eating a whole fruit rather than drinking juice. The fiber in the fruits
slows down the absorption process. Starchy food is also advised to be taken with protein so as to
slow down the absorption process lowering the glycemic index. Generally taking foods which
are whole and raw will lead to lower glycemic response than chopped or cooked foods (Pan,
Wang, Lin, & Jiang, 2015).
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