Diabetic Foot Ulcers:

Transcription

1 TREATMENT Diabetic Foot Ulcers: How to Assess, Treat, and Prevent Them General public awareness of diabetes has grown in recent years, thanks in part to the warnings about childhood obesity and its relationship to diabetes. Caregivers involved with long-term-care residents are already familiar with diabetes mellitus and its consequences. Unless lifestyle changes occur, it is likely we will continue to see an increase in diabetes in our elderly patients. Janet L. Jones, RN, BSN, PHN, ET, CWOCN, DAPWCA 36 HEALTHY SKIN

2 Let s look at the statistics Foot complications are one of the most common reasons for hospital admissions among patients with diabetes mellitus. The incidence of diabetic ulceration is as high as 4.1% annually, and the lifetime risk for foot ulcers in persons with diabetes is estimated at 15%. 1 Nonhealing diabetic ulcers are the most common cause of lower extremity amputations in the industrialized world. 2 Research has shown that early diagnosis and treatment can prevent a majority of these amputations. Costs associated with ulcer care Diabetic ulcers account for 25% to 50% of the cost of inpatient diabetic care, recurring at a rate of greater than 50% over a two- to five-year period. 3 It is clearly evident that treating neuropathic/diabetic ulcers has a huge financial impact on health care. Several studies have examined the direct treatment costs. One study determined that the average cost to heal an ulcer is $6,664; the cost rises to $44,790 following an amputation. 4 Pathophysiology of diabetic ulcers The pathophysiology of neuropathic diabetic ulcers includes a triad of events angiopathy, neuropathy, and infection sometimes related to minor trauma. Angiopathy: Occlusion begins distally with smaller vessels in areas (multisegmental) along the leg. Both limbs may be affected. The patient can present with dry gangrene. Auto-amputation of the digits or limb is not uncommon. Sensory neuropathy: Hyperesthesia or an exaggerated sensation of pain may occur. Alternatively, the patient can have hypoesthesia or a lack of sensation. Having no sensation poses greater concern. For example, if a patient steps on a nail and the nail becomes embedded in the tissue, the patient with hypoesthesia will be unaware of its presence. This situation can lead to infection and threatened loss of limb. Motor neuropathy: Approximately 10% of residents with neuropathy experience a progressive deformity, dislocation, and destruction of the bones of the foot called Charcot foot. If hammertoes or crunched-up toes are present and the patient is wearing inappropriate footwear, ulcers can occur on the tops of the toes from the skin rubbing (friction) on the shoe. When severe foot deformity occurs, custom footwear is essential. Calluses can form over bony prominences such as under the metatarsal heads or on the plantar surface of the foot. These calluses become thick, acting as a foreign object that can lead to ulceration. To avoid these problems, routine foot care, with debridement of the callus, and appropriate footwear are essential. Autonomic neuropathy: The patient can also experience anhydrosis or a lack of perspiring or sweating, which can promote bacterial invasion and lead to infection. Keeping the feet clean and dry helps prevent bacterial invasion. The toenails of the diabetic often become infected with fungus, which can lead to severe nail deformity. 37

3 Diabetic Foot Ulcers: How to Assess, Treat, and Prevent Them continued Assessing residents with diabetic neuropathy A comprehensive medical history is vital to the assessment and treatment of residents with neuropathic/diabetic ulcerations. Many components contribute to poor or slow healing; these include increasing age, increasing duration of the diabetes, smoking, hypertension, hypercholesterolemia, and abnormal blood sugar levels. Neuropathic/diabetic ulcers usually occur below the ankle at any site of pressure, friction, shear, or trauma. The wound margins are often characterized by a periwound callus, and the wound is likely to be round. The presence of diabetes increases the risk for infection. Diabetic wounds heal at approximately half the rate of venous ulcers. Expect them to make slow progress. 5 If it has been determined that the arterial perfusion is adequate to support wound healing, then treatment of the wound should be based on optimal moisture. If the wound is dry, apply a product that creates moisture or supports what moisture is already present. If the wound is moderately to heavily draining, choose a dressing that absorbs excess drainage, thereby bringing the moisture level back into balance. Because a person with diabetes experiences reduced blood flow to the skin, consider improving circulation through vascular bypass, percutaneous angioplasty, laser treatment, and hemorrhagic agents like Trental. Vascular assessment includes arteriography to assess the level of blood flow and determine if vascular reconstruction is appropriate. Results compare favorably with those achieved in nondiabetics. The results include increased healing, elimination of pain, improved function, and overall increased well-being. A decrease in amputation rates has also been demonstrated. Managing infection is crucial in the treatment of a diabetic ulcer in order to preserve the limb. Treating neuropathic/diabetic ulcers The treatment plan for the neuropathic/diabetic ulcer is complex and involves the following: The primary treatment is removing the pressure from the foot (off-loading). This can be accomplished in multiple ways, e.g., contact casting, therapeutic boots, specialty footwear, or off-loading devices. Radical local debridement of the callus, tissue, and bone should be performed as appropriate. Evidence does not support soaking, whirlpool, or other hydrotherapies, which can lead to maceration, mild burns, or infection. General skin care of the extremity includes keeping the foot clean and dry. Emolliating the leg to the wound margin is essential in regaining and maintaining skin integrity and skin health. Adjunctive medical therapies are important in the treatment of neuropathic/diabetic ulcers and should not be overlooked. Such modalities as normalizing blood glucose (macrophages perform less efficiently if blood glucose is greater than 180), treating edema, providing for nutritional therapy, and controlling comorbid conditions have been proven beneficial. 38 HEALTHY SKIN

4 Infection and antibiotic therapy Managing infection is crucial in the treatment of a neuropathic/diabetic ulcer in order to preserve the limb. All of these wounds are colonized with bacteria, and most have a high surface overgrowth of bacteria or bioburden. An infection diagnosis that would require systemic antibiotics includes the presence of purulent secretions (pus) and two or more signs of inflammation (erythema, pain, warmth, and edema). Literature suggests that osteomyelitis is present in 89% of infected neuropathic/diabetic ulcers that probe to the bone. 6 When should antibiotic therapy be considered? If assessment reveals a nonlimb-threatening infection, begin antibiotic therapy on the day the infection is diagnosed. If assessment reveals a limbthreatening infection, the patient requires hospitalization and parenteral antibiotic therapy should be initiated. Amputation: the last resort Limb loss is a common event associated with neuropathic/diabetic ulcers. Its pathophysiology follows a fairly predictable course. The baseline neuropathy, when combined with a minor trauma, may result in ulceration. This can lead to poor healing, gangrene, infection, and cellular failure. These events can lead to amputation. 7 Preventing ulcer recurrence Ultimately, preventing ulcer recurrence is the key to longterm success, and patient education tops the list of strategies. Educating your residents should include demonstrating how to inspect the feet, explaining the difference between improper and proper nail care, and discussing the importance of never walking barefoot. Patients with foot deformities or those wearing customized footwear or orthotics also need to be educated in observing any changes in foot condition. There are no conclusive studies to support prophylactic foot surgery, although some patients have experienced improvement. It is certain, however, that diabetics do benefit from regular foot care by specialists. Regular exercise, proper diet, controlling blood sugar, and being alert to changes in the skin before an ulcer develops are key components to managing diabetes. If the resident smokes, it is essential for him or her to stop smoking and to understand the reasons why this is so important. These issues are all part of diabetic education. It is obvious that responding to a neuropathic/diabetic ulcer is not merely treating the wound; rather, the treatment is complex and multidisciplinary and involves making the resident a participating member of the care team. Amputation should be considered when perfusion is below the threshold necessary for healing. Amputation may be preferred for patients who have endured an unsuccessful course of therapy, or for patients who are not candidates for revascularization. References: 1. Warriner III, R. Chief Medical Officer, Wound Care Group Medical Director, Southeast Texas Center for Wound Care and Hyperbaric Medicine Moss S, Klein R, Klein B. The 14-year incidence of lower-extremity amputations in a diabetic population: the Wisconsin epidemiologic study of diabetic retinopathy. Diabetes Care, 22(6): , Harris, M.I., Cowie, C., Stern, M., Boydo, E., Reiber, G., & Bennett, P. (Eds). (1995). Diabetes in America. Bethesda, MD: U.S. Department of Health and Human Services. 4. Appelqvist J. Wound healing in diabetes. Outcome and costs. Clin Podiatric Med Surg 1998; 15: Kantor J, Margolis D. Expected Healing Rates for Chronic Wounds. Wounds 12 (6): , Wound, Ostomy, and Continence Nurses Society (2004). Guideline for management in patients with lower-extremity neuropathic disease. Glenview, IL. 7. Reiber G, et al. Causal pathway for incident lower extremity ulcers in patients with diabetes from two settings. Diabetes Care,

5 TREATMENT COMPRESSION: HOW MUCH IS NEEDED TO BE THERAPEUTIC? Elizabeth O Connell-Gifford and Jackie Young Mrs. PJ enters your facility with a family-reported vague diagnosis of poor circulation and a lot of swelling in both of her legs. You note a small shallow wound in the gaiter area of her left lower extremity. She is 76 years old and obese; she has stress incontinence that is managed by panty liner; she has dementia; and she is no longer able to perform her ADLs. After the initial assessment, you realize that more information is needed to initiate appropriate treatment.you call the primary care physician s office and learn that Mrs. PJ has been diagnosed with venous hypertension or lower extremity venous disease (LEVD). Her arterial perfusion is adequate. Let s discuss the treatment for LEVD and the best plan for Mrs. PJ. 41

6 TREATMENT COMPRESSION: HOW MUCH IS NEEDED TO BE THERAPEUTIC The gold standard of treatment for LEVD is to use adequate compression. Before any form of compression is applied, the arterial perfusion status must be evaluated. If the lower extremity has either arterial or mixed (arterial and venous) disease, applying compression is usually contraindicated and could lead to negative results. A fairly simple diagnostic test, the ABI or ankle-brachial index, is often all that is needed to decide if compression is appropriate or not. (1) This article focuses on compression, but it is important to realize that the wound itself may also need to be dressed. The dressing is chosen based on multiple factors including wound characteristics, frequency of dressing change (a daily dressing is not the best choice with a seven-day compression wrap, for example), the ability of the patient or caregiver to apply the dressing, as well as reimbursement and availability issues. There are no studies showing that one type of dressing or specific frequency of dressing change is appropriate for all LEVD wounds. A short course (approximately two weeks) of a topical antimicrobial may be considered if the ulcer has a high level of bacteria. (1) About the ankle-brachial index (ABI): ABI = ankle blood pressure divided by brachial (arm) blood pressure.the result will be close to 1 (meaning they are about the same) in a normal person. Results of 0.8 to 1 are within the normal range. Residents with an ABI of less than 0.8 may have peripheral arterial disease, in which case compression would be contraindicated. In a diabetic, because of small vessel calcification, this test is not as reliable. Applying compression in any form to a patient with venous hypertension can be challenging! One of the most common complaints from clinicians is, My patients are noncompliant; they won t leave their compression system in place because they say it hurts. Realize that edema associated with LEVD can be very painful. The challenge is to get the patient to leave the product on until the edema is reduced. Once that happens, it is likely the pain will lessen or be nonexistent. Discuss with the patient that this pain is not uncommon and usually lessens over time with treatment. Talk with the physician about prescribing appropriate analgesics for the first several weeks of therapy. There is research that supports therapeutic compression as an effective means of treatment. But how much compression is enough? It is documented that some compression therapy is more effective than no compression therapy for the treatment of LEVD wounds. High compression (30 50 mmhg) is more effective than low compression, but there are no differences in the effectiveness of the different types of products available for high compression. (1) The most commonly used products for compression are wraps or stocking-like products. Application of wraps should not be performed by an inexperienced person. Proper technique is crucial and requires training. Wraps that are applied incorrectly can create too much compression, leading to limb loss or damage, or too little compression, causing a delay in healing or even a decline in condition. There are several different ways to address wounds on the lower extremity. As with Mrs. PJ, the initial assessment leads to further investigation and some detective work on the part of the nurse. Obtaining all the information from the family as well as the primary care physician s office allowed Mrs. PJ to receive the best treatment for her LEVD. The wound was small and had some drainage that needed to be managed. Because there was a concern about bioburden, a silver alginate dressing and a four-layer compression wrap was the dressing of choice. The entire dressing was changed every five days. 42 HEALTHY SKIN

7 Easy Guide to Compression Therapy Type of Amount of Application of Performance Compression Examples Compression Compression Characteristics Long stretch elastic bandages *Matrix, *Swift-Wrap, *Sure-Wrap, Ace, Curity 17 mmhg pressure Applied in a figureof-eight from toe to knee with a 50% overlap on an ankle circumference of cm (3) Not washable or reusable, loses stretch after first application Zinc paste bandages (inelastic compression) *Primer Boot, Unna Boot, Dome Paste Bandage Applies initial pressure of 29.8 mmhg at the ankle but falls to 10.4 mmhg at 24 hours (2) Applied in an overlap fashion from the toe to the knee with a 50% overlap Not reusable Light compression, support *Medigrip, Tubigrip If the product is shaped, it applies mmhg pressure in a single layer (3) Cannot apply graduated compression because it does not conform to the leg. May fit at the calf but be too loose at the ankle. Washable (not dryersafe) for up to 6 months Multilayer *FourFlex, Profore, Dynaflex, Four-Press Can maintain 40 mmhg pressure on an ankle circumference of cm for up to (2, 4) one week Various layers are applied differently. Please refer to package insert for instructions. High compression. Cut off entire dressing at change. Cohesive or selfadherent bandage *Co-Flex, Coban, *PowerFlex, Flex-Wrap 23 mmhg pressure Applied at mid stretch with a 50% overlap in a spiral from toe to knee on an ankle circumference (3, 4) of cm Used with other products to produce therapeutic compression. Not washable or reusable. High elastic compression Setopress, Surepress Can apply up to 40 (3, 4) mmhg pressure Please refer to individual package Therapeutic compression to treat LEVD * These products are available through Medline. References: 1. Johnson J and Paustian C. Guideline for Management of Wounds in Patients with Lower Extremity Venous Disease. Number four in WOCN Clinical Practice Guideline Series. Wound Ostomy and Continence Nurses Society, 2005, Glenview IL, p Blair SD, Wright DDI, Backhouse CM et al. Sustained compression and healing of chronic venous ulcers. British Medical Journal 1988:297: Moffatt CJ. Compression bandaging the state of the art. Journal of Wound Care 1992:1:1: Moffatt CJ, Dickson D. The Charing Cross high compression four-layer bandage system. Journal of Wound Care 1992:2:2: