Wound Assessment and Management Plan for Diabetic Foot Ulcer Patient

This report reviews the scenario of Fraser, a patient with foot ulcer in the left leg and conducts a wound assessment process to develop a wound management plan for patient. The report includes details regarding wound assessment process, wound measurements, condition of surrounding skin, wound exudates, physiology of the healing process, evaluation of the wound management plan, health education, and pain management.

Running head: NURSING ASSIGNMENT
Nursing assignment
Name of the student:
Name of the University:
Author’s note

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Introduction:
For patients with diabetes, the diagnosis of foot ulcer is a complex and
challenging issue for patient. Recognition of signs of deterioration and early treatment of
wounds can help to prevent infection and provide a high quality of life to such patients.
This report reviews the scenario of Fraser, a patient with foot ulcer in the left leg and
conducts a wound assessment process to develop a wound management plan for
patient.
Diagnosis of the chosen resident:
Fraser is a 50 year old Maori, who was diagnosed with type one diabetes when
he was 8 years old. The reason for his current admission to hospital is an infected left
foot and hyperglycaemia. Due to poor circulation of blood to his feet, he has developed
infected ulcer on his left foot. Diabetic foot ulcer is a major complication found in almost
15-20 of patients with diabetic foot ulcer. It is caused due to diabetic neuropathy, a
condition leading to nerve damage and lack of sensation in the feet and lungs. Hence,
any kind of cut or bruises to the foot results goes unnoticed in such patient and loss of
sensation leads to delay in treatment. This often leads to serious consequences such as
ulcer, infection and joint pain (Noor, Zubair & Ahmad, 2015). Fraser also developed foot
ulcer because of diabetic polyneuropathy. As diabetic ulcer takes time to heal, strict
wound care regimen and adequate treatment is needed for Fraser. Apart from poorly
controlled diabetes, there are no other medical issues for the patient.
Evaluation of the wound:
Diabetic foot ulcers are complex wounds that have adverse impact on the
mortality and morbidity of patients like Fraser. To prevent the foot ulcer from
deteriorating and increasing chances of amputation, proper evaluation and assessment
of wound is necessary. The process of assessment starts from the analyzing detailed
history of the presenting illness and past medical history in patient (Hinchliff et al.,
2015). Ulcer is the presenting illness for Fraser and poor management of diabetes and
history of smoking are past medical history details of Fraser. This can help to identify
whether the patient is at risk of amputation or not. Furthermore, physical examination of
the ulcer may help to determine the size, depth and location of wounds, assess the
status of wound bed, identify signs and evaluate consistency of exudates. This process
can help to appropriately document ulcer characteristics and develop a baseline for
planning treatment and proper intervention for patient. The following are the details
regarding wound assessment process for Mr. Fraser:
Wound bed status:

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On wound assessment, the area around the ulcer has been found to be red and
swollen. Red and swollen foot is a sign of life threatening complication in the foot.
Unusual swelling and redness are early sign and symptoms of diabetic foot ulcer.
According to Gardner, Hillis & Frantz (2009), erythema or redness is the sign of
inflammation. The wound was also found to be granulated indicating the contribution of
peripheral neuropathy to ulceration. This type of signs are specific to secondary wound.
As redness and swelling has been observed in Fraser even after initiating treatment for
foot ulcer, this is a negative sign which suggest the need to change antibiotic to control
infection.
Wound measurements:
The wound assessment process also measures the length, depth and width of
ulcers. Engaging in accurate measurement of length and width can help a nurse to track
progress in outcome and determine the effectiveness of treatment process. In addition,
measurement of depth is necessary to evaluate wound healing process. The wound
measurement with relevant tools revealed extensive erythema deeper than the skin
(Brownrigg et al., 2016). This revealed signs of serious infection in Fraser’s foot ulcer.
The severity of the infection was determined by the PEDIS scales and grade III revealed
extensive and severe ulcer. The depth of ulcer also revealed deterioration of ulcer as
Fraser’s foot ulcer had almost reached subsequent layers of foot. The advantage of
using PEDIS scale in the wound assessment process is that it is a standardized and
efficient tool and it helped to correctly identify degree of risk for complications in patients
with diabetic foot ulcers (Chuan et al. 2015).
Condition of surrounding skin:
Another step during the wound assessment process was to observe the condition
of the surrounding skin near the lesion. The surrounding skin assessment was done to
measure skin colour and temperature, identify signs of callus formation and induration
and edema in Fraser. The skin around the ulcer was found to be slightly warm and red
in colour. Redness indicates prolonged inflammation and increase in temperature near
the ulcer shows signs of infection in the wound (Sibbald et al., 2012). Presence of the
symptom of edema and abnormal firmness of the tissue surrounding the ulcer also
revealed severe infection in the wound.
Wound exudates:
Characterising the type of exudates coming out from wound is also necessary to
check the status of wounds and identify signs of infection. The colour, type and odour of
wound exudates is checked to check for changes in bacterial balance. Healthy wound
has no odour and necrotic wounds have offensive odours. In case of Fraser, there was
no discharge from wounds and pain, swelling and redness was the main issue for him.
Physiology of the healing process:
The above assessment of Fraser’s wound and its characteristic reveals poor
healing process and presence of infection. Healing process might have been hampered
despite treatment because of poorly controlled diabetes, age of the resident or the

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location of wound. The physiological process of wound healing traditionally consists of
four phases namely homeostasis, inflammation, proliferation and maturation. It involves
the process of vasoconstriction, the inflammation phase to prevent bacterial
contamination, the process of angiogenesis and replacement of wound matrix. This
form of normal healing process is however disrupted in patients with diabetes (Tsourdi
et al., 2013). Since Fraser has been diagnosed with diabetes since a long time and he
has struggled to manage his diabetes. This might have disrupted the normal wound
healing process.
The main issue for Fraser is poorly controlled diabetes. It has influenced the
normal wound healing process and contributed to deterioration of diabetic foot ulcer for
patient. Wound healing is slowed in diabetic patient because of poor circulation of red
blood cells to the wound tissue and poor efficiency of white blood cells in fighting
infection. Fraser also suffered from diabetic polyneuropathy which further damaged his
nerves and lead to loss of sensation. Inability to feel the change in wound status further
increases severity of foot ulcers and complicates wound healing process (Baron et al.,
2017). The duration of ulcer might also be a reason for poor wound healing process.
Smith-Strøm et al. (2017) proved that duration of ulcer before starting specialist health
care treatment can be regarded can influence healing time significantly. Hence, long
duration of ulcer before specialist health care treatment decreased the rate of wound
healing. Ageing also influences wound healing process, however age is not a factor for
Fraser currently.
Evaluation of the wound management plan:
Based on wound assessment of Fraser, it has been found that infection in the
foot ulcer is the major issue for patient. To prevent infection and promote wound healing
process, developing an effective wound management plan is necessary. The wound
management plan for quick healing of Fraser’s ulcer is as follows:
 Proper dressing and regular dressing changes will be vital in preventing infection
and changing the status of wounds. While choosing a dressing for an infected
diabetic foot ulcer, the main consideration is to ensure that the dressing is
comfortable and acceptable for patient. The dressing should help in the
management of infection and it should not worsen pain. As a moist wound
environment is optimal for wound healing, it is planned to use a dressing that
controls growth of micro-organisms, allows gaseous exchange and thermally
insulate wounds. The dressing should not interfere with the observation of
wounds from time to time and the material should be such that dressing can be
changes frequently and easily. As Fraser’s ulcer has been infected, it is planned
to change his dressing everyday in the morning. Frequent daily dressing change,
wound inspection and antibiotic therapy is the key to treat diabetic foot ulcer
(Yazdanpanah, Nasiri & Adarvishi, 2015).
 During dressing changes, it is planned to cleanse wound at each instant and
clean the wound with saline and antiseptic wound cleansing agent. Repeated
process of debridement and rigorous wound cleansing can reduce the biofilm
burden found in foot ulcer and promote wound healing. It is an ideal step to
prepare the wound bed for healing.

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 Documentation at regular interval will be necessary to track progress of Fraser.
The improvement in healing process will be observed by digitally photographing
the foot ulcers and it can help to prevent progression of the infection to a more
severe form such as necrosis and gangrene (Chadwick et al., 2013).
Health education:
Health education is also a priority to support Fraser in managing his foot ulcer.
Patient must be made aware about risk factors that can complicate healing process.
Nutritional and diet information will be given to patient so that he can control his blood
sugar. All instruction related to foot care and use of appropriate footwear will be
provided to manage. As Fraser has been smoking ten cigarettes a day, smoking
cessation education will also be provided to reduce risk of recurrence (Chadwick et al.,
2013).
Pain management:
To reduce pain in Fraser due to foot ulcer, it will be necessary to provide a
comfortable and good dressing to Fraser. To minimize pain during dressing changes, it
is convenient to use soft silicone dressings (Schaper et al., 2016).
Wound care assessment Chart:
Wound type: Diabetic ulcer
Dimensions: Width- 2cm , Depth- 2cm and Length- 2cm
Photograph (Consent obtained): No
Wound swabs: yes
Result of wound swab: No exudate from wound
Exudate: No
Odour: Offensive
Colour of wound and surrounds: Granulating
Surrounding skin: Other

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Suture line: Suture Insitu
Present on admission: Yes
Pain on dressing change: Intermittent (Score-5)
Wound Care assessment plan:
Wound location: Left foot
Frequency of dressing change: Every day in the morning
Cleansing agent: Saline
Primary dressing: Hydrogels
Secondary dressing: CarboFLEX

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