Wound Care: Pathophysiology of Neuropathic Foot Ulcer and Strategies for Management

The case study of Mrs. Lowe has demonstrated that she has been diagnosed with diabetes 10 years ago and currently she has been presented with foot ulcer in the right medial bunion area. The ulcer has been developed before 12 weeks but she did not realized, however, due to aching she has understood the requirement for treatment.

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Introduction:
The case study of Mrs. Lowe has demonstrated that she has been diagnosed with diabetes
10 years ago and currently she has been presented with foot ulcer in the right medial bunion area.
The ulcer has been developed before 12 weeks but she did not realized, however, due to aching
she has understood the requirement for treatment. Symptoms such as redness, pain, formation of
callus and excessive fluid coming out of the infected area have been found. She has experienced
such foot problem before and administering antibiotics recommended by the GP has helped her.
However, her arterial flow has been found to be normal, but poor glycaemic control is also
noted. The purpose of the assignment is to discuss the pathophysiology of neuropathic foot ulcer,
impact of poor glycaemic control and local pressure on healing and strategies for managing the
poor health condition of Mrs. Lowe. The following paper will focus on the hypothesis that
diabetic people are more prone to foot ulcer due to poor glycaemic control and effective home
based care for diabetes management, treatment of foot ulcer and patient education is helpful to
recover from foot ulcer.
Discussion of the pathophysiology of the diabetes related neuropathic foot
ulcer:
One of the significant complications for the patient with diabetes mellitus or type 2
diabetes is the development of foot ulcers. Various foot disorder such as gangrene, infection and
ulceration have been found to be the major contributing to the hospitalization of the patients with
type 2 diabetes. According to the research of (Amin & Doupis, 2016) neuropathic ulcers
develops as a result of peripheral neuropathy, especially for the patients with diabetes. It mainly
occurs due to the lack of balance between damage of nerve fiber and repair. Such damage of
nerve affects the distal and autonomic sensory fiber and leads to the consequence of lack of

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sensation. The lack of sensation of the pressure points of foot could lead to increased
microtrauma and breakdown of overlying tissues that gradually causes ulceration (Naves, C.
2016). Thus, in case of Mrs Lowe who has been suffering from foot ulcer in right bunion area,
poor diabetes management of can be considered as the risk factor of her foot ulcer. It has been
indicated that symptoms of diabetic neuropathic foot ulcer varies according to the affected
nerves (Volmer-Thole & Lobmann, 2016). The symptoms may include lack of sensation or
numbness or reduction in the ability to feel pain, burning sensation, cramps, lack of reflexes, lack
of coordination or balance and finally some severe foot problems such as foot ulcer (Chammas,
Hill & Edmonds, 2016). The color of the neuropathic foot ulcer may range from red to brown or
black based on the blood circulation of the patient. As found in case of Mrs Lowe, redder ulcer
has indicated normal circulation or arterial flow. In addition, symptoms such as callused skin,
fluid secretion, punched outlook are common. Furthermore, the untreated neuropathic foot ulcer
may lead to the consequence of osteomyelitis (Armstrong, Boulton & Bus, 2017).
Impact of poor glycaemic control on healing and susceptibility to
infection:
In case of diabetes, beside the focus on blood glucose management, diet, medication and
exercise it is necessary to increase awareness regarding infection as well as poor glycaemic
control could affect the immune system and influence slow healing and chronic infection. The
immune system consists of innate immunity and adaptive immunity (Lipsky, Silverman &
Joseph, 2017). Innate immunity is responsible for the first line defense. It alerts the immune
system regarding the invasion of specific foreign element and activates the adaptive immunity
for better response. The adaptive immunity serves to provide protection from infection. The
response of adaptive immunity activates the lymphocytes that contain B cells, T cells and natural

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killer and establish immunologic memory (Chammas, Hill & Edmonds, 2016). In case of poor
management of gycemia (hyperglycemia) or uncontrolled diabetes, the patient is considered as
immunosuppressed due to the negative effect of high blood glucose on immune system. The
consequence of hyperglycemia affects the immune system in different ways, for example, it
could lead to the consequence of acidosis that restricts the activity of immune system, thus slow
down the process of healing (Lipsky, Silverman & Joseph, 2017). This is because chronic
hyperglycemia slows the blood perfusion and could lead to damage of nerves as well. The skin
become less competent to provide protection against inflammation and trauma due to damaged
nerves and increases the risk of infection (Amin & Doupis, 2016). Hence in case of Mrs. Lowe
proper glycaemic control is important in order to facilitate the healing of leg ulcer and reduce the
risk of severe infection that may cause osteomyletis.
Impact of local pressure on healing:
Diabetic patients have been found to develop various foot complications similar to the
case of Mrs.Lowe. It has been found that an ordinary problem may lead to severe complication if
remain untreated. The main reason of foot problems is the damage of nerve due to high blood
glucose. As a result, pain, tingling, inflammation and weakness could be experienced by the
patient. Even it may lead to the consequence of lack of sensitivity (Armstrong, Boulton & Bus,
2017). In addition, poor blood flow has been found to change the shape of the feet. Among
different foot problems one of the common problems is the formation of calluses. There are high
pressure areas in the foot that lead to the development of callus and it has the potentiality to build
up faster in case of people with diabetes (Amin & Doupis, 2016). Untrimmed calluses become
thick and may turn into severe ulcer and affect the healing process effectively. Furthermore,
inappropriate foot wear also affects the healing of ulcer, however, adequate evidence is not

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provided by study for this. Thus it is important to cut the calluses by health professionals in case
of Mrs. Lowe and any chemical should not be used to remove it as it may burn the skin
(Grigoropoulou et al., 2017).
Possible management strategies:
According to the health condition of Mrs. Lowe, it is required to implement effective
nursing strategies in order to heal the leg ulcer on the right medial bunion area and proper focus
need to be provided to the diabetes management as diabetes has contributed to the current health
condition of the patient and according the above discussed factors it is clear that in order to
improve the healing process and reduce the risk of severe ulcer it is necessary to control the
blood glucose in an effective manner. In this regards, it is required to introduce multidisciplinary
approach to facilitate the recovery of Mrs. Lowe (Grigoropoulou et al., 2017). Hence the
following strategy could be helpful for Mrs. Lowe-
Firstly, the patient needs to diagnose for diabetes in order to identify the severity of
diabetes. It could help to introduce effective diabetes management plan in home based care.
Next, effective diet chart and adequate physical exercise needs to be recommended to the patient
(Alavi et al 2014). Appropriate anti-diabetic medications such as sulfonylurea, metformin and
alpha-glucosidase inhibitors could be provided. In this regards it has been found that
combination of sulfonylurea and metformin is more effective to control blood sugar. (Garber et
al., 2016).
Second, it has been found that tropical dressing is not a superior choice for leg ulcer, thus
primary dressing need to be selected for the dressing of leg ulcer for Mrs. Lowe. In this regards

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availability, cost, wound assessment and preference of patient need to be considered
(Grigoropoulou et al., 2017).
Third, adequate antibiotic needs to be prescribed based on the infection and its severity to
progress the healing. In this regards it is important to consider the history of previous infection,
histology reports and previous antibiotics that have been provided by the GP (Hingorani et al.,
2016). In addition surgical intervention such as surgical excision could be introduced in
combination with shorter dosage of antibiotics. Furthermore advance therapies such as negative
pressure wound therapy or tissue based products could be recommended if needed
(Grigoropoulou et al., 2017).
Fourth, she could be recommended to use custom-made foot wear to avoid the recurrence
of foot ulcer (Premkumar et al., 2017).
Lastly, patient education is one of the most essential part of treatment as it helps to
develop knowledge of the patient regarding the illness and treatment and facilitate self-
management as well (Alavi et al., 2014). Thus, Mrs. Lowe should be educated on diabetes
management and infection management in order to help her to learn about self-management and
foster the recovery in an effective management in an effective manner.
Conclusion:
The above discussion has informed that, development of foot ulcers is one of the
significant complications for the patient with diabetes. In addition, poor glycaemic control also
affect the immune system and leads to slow healing that may cause chronic infection. The
damage of nerve due to high blood glucose has been identified as the main reason of foot
problems. Furthermore, formation of callus is a common factor of foot problem for the diabetic

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patients and such calluses could leads to the condition of foot ulcer if remain untreated.
Additionally inappropriate foot wears also contributed to foot ulcer in some cases. In this case,
effective home based care for diabetes management, proper dressing of wound, effective
antibiotics, custom-made foot wear and adequate patient education could help to recover from
foot ulcer and help to reduce the risk of recurrence.

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