Nursing Case Study for Diabetic Foot Ulcer
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Outline
Michael is a 15-yr-old male diagnosed with type I diabetes mellitus (DM) last year. He presents to the acute care clinic with a “sore that will not heal” on the bottom of his right foot. He states that he sees an endocrinologist for his DM but has no other health issues to report at this time. He also says that he exercises frequently under the guidance of a dietician and personal trainer consulted through endocrinology and still wrestles for his high school team
His mother is with him and gives consent for treatment. She says, “The pad of his foot has not even been hurting him but when he was pushing off the wrestling mat in practice, he noticed something there.”
What does the nurse suspect may be going on with Michael today? Why?
- A diabetic foot ulcer.
- He is at high risk for foot ulcers (“The lifetime risk of a foot ulcer in patients with diabetes [type 1 or 2] may be as high as 34 percent”)
- He seems to have neuropathy because he does not feel the wound
- He says it will not heal (could be due to many factors especially high blood glucose)
What does the nurse suspect may be going on with Michael today? Why?
- Assessment should include evaluating and documenting the following:
- Size and depth of the wound
- Color of wound (area and base)
- Look for drainage (exudate)
- Check for loss of sensation (pinprick, touch, pressure) in the lower extremities
- Vascular status (pulse, claudication) in the lower extremities
The nurse notices she cannot feel pedal pulses and the feet seem cool, but not cold. However, the area around the wound is warmer and red. Both feet are WNL in regard to color. Michael denies any cramping or pain in his legs.
What should the nurse do now? How would she document this finding?
- She should get a doppler device prior to proceeding. The pulse may only be weak, not absent. Care should be taken not to document “absent pulse” without first attempting a doppler pulse. Documentation should include whether pulses are palpable or doppler only.
The wound has a slightly foul odor and has a circular “punched out” shape almost like a red based crater. Michael’s mother asks how this could happen.
How should the nurse explain Michael’s risks for this condition?
- Foot problems are a common complication in people with diabetes. Poor glucose control can lead to vascular problems (poor circulation), neuropathy, higher risk for infection (impeding white blood cells from doing their job).
- “Risk factors that can lead to foot wounds in patients with diabetes include loss of protective sensation due to neuropathy, prior ulcers or amputations, foot deformity leading to excess pressure, external trauma, infection, and the effects of chronic ischemia, typically due to peripheral artery disease. Patients with diabetes also have an increased risk for non-healing related to mechanical and cytogenetic factors, as well as a high prevalence of peripheral artery disease”
The provider assesses the patient and advises the staff he has put in orders. He also asks for a set of vital signs (which had not yet been taken).
Why would the provider want vital signs when the patient only has a wound on his foot?
- This is a basic part of an assessment and should never be skipped even if the patient seems healthy. If the patient were to have a change, and no vital signs were taken early on, there would be nothing to compare VS to. Also, if he has an infection, his VS could be the first clue if he were to become septic (signs of septic shock).
BP 110/68 SpO2 98% on Room Air
HR 92 bpm and regular Pain 0/10 on 1-10 scale with 10 being highest
RR 16 bpm at rest
Temp 37.9°C
Michael’s mother asks why the acute care clinic cannot just take care of her son’s foot. She says, “Can’t we just get some antibiotics and go?”
How should the nurse address this issue?
- Foot ulcers in diabetics can be complicated to treat. To prevent complications like worsening infection, possible surgery and/or amputation coordinated care is recommended. A culture of the wound may guide the provider’s choice of antibiotic. Especially since Michael does not seem to feel this wound, it should be addressed more carefully than just a “wound.”
Both patient and mother agree to the prescribed treatments. Before they leave, the provider indicates he wants to talk to them about when to seek a higher level of care.
What does the nurse expect the provider to discuss?
- “Management of diabetic foot infections requires attentive wound management, good nutrition, appropriate antimicrobial therapy, glycemic control, and fluid and electrolyte balance. Although severe infections warrant hospitalization for urgent surgical consultation, antimicrobial administration, and medical stabilization, most mild infections and many moderate infections can be managed in the outpatient setting with close follow-up.
- Several studies have reported improved outcomes with a multidisciplinary approach to diabetic foot infections. This includes involvement of specialists in wound care, infectious diseases, endocrinology, and surgery”
What should the nurse ensure she does in regard to discharge teaching?
- If antibiotics are prescribed, whether now or pending wound culture, the full course must be taken even if everything seems to be improving.
- “It is important to examine your feet every day. This should include looking carefully at all parts of your feet, especially the area between the toes. Look for broken skin, ulcers, blisters, areas of increased warmth or redness, or changes in callus formation; let your health care provider know if you notice any of these changes or have any concerns.”
- Take note of any unusual sensations in the feet and legs, including pain, burning, tingling, or numbness. If you notice these symptoms, keep track of when they happen; whether your feet, ankles, and/or calves are affected; and what measures relieve the symptoms.
Michael says he will follow the prescriptions and follow up as instructed. He also wants to know how to keep this from happening again.
What are some tips the nurse can provide regarding prevention? What about resources to provide?
- Avoid smoking
- Avoid going barefoot, even at home, and especially on hot decks and hot sand
- Test water temperature before stepping into a bath
- Trim toenails to the shape of the toe, and remove sharp edges with a nail file; do not cut cuticles
- Wash in lukewarm water, dry thoroughly (including between the toes), and check feet daily
- Shoes should be snug, but not tight, and customized if feet are misshapen or have ulcers
- Socks should fit and be changed daily
- Resources – for this particular patient, he may like audio-visual education resources. There may also be resources available through his endocrinologist’s office.
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Transcript
Hi, everyone. We’re going to go through a case study for a diabetic foot ulcer together. Let’s get started. In this scenario, Michael is a 15-year-old male diagnosed last year with diabetes type one. He presents to the acute care unit with a sore that will not heal on the bottom of his right foot. He states that he sees an endocrinologist for his diabetes type one, but has no other health issues to report at this time. He also says that he exercises frequently under the guidance of a dietician and personal trainer consulted through his endocrinologist and still he wrestles for his high school team. His mother is with him and gives consent for treatment. She says, “The pad of his foot has not even been hurting him but when he was pushing off the wrestling mat in practice, he noticed something there.” Now that we have this information, let’s take a look at critical thinking checks number one and number two below.
Great job. The nurse notices that she cannot feel pedal pulses and the feet seem cool, but not cold. However, the area around the wound is warmer and red. Both feet are within normal limits in regards to color. Michael denies any cramping or pain in his legs. Now that we have these results, let’s take a look at critical thinking check number three below.
Excellent work. The wound has a slightly foul odor and has a circular punched out shape. Almost like a red based crater. Michael’s mother asks how this could happen. Let’s take a look at critical thinking check number four below.
Great job. The provider assesses the patient and advises the staff that he has put in orders. He also asks for a set of vital signs, which weren’t taken before. With all of this in mind, let’s take a look at critical thinking check number five below.
Great job. Let’s take a look at those vitals. His blood pressure came back at 110/68 mmHg, on room air he’s saturating at 98%, looks good. His heart rate is 92 beats per minute with a regular rhythm and a respiratory rate of 16 breaths per minute at rest. Temperature running at 37.9 degree Celsius and he isn’t complaining of any pain. 0 to 10 on the 1 to 10 scale with 10 being a medical emergency. With all of this information, Michael’s mother asks why the acute care clinic cannot just take care of her son’s foot. She says, “can’t we just get some antibiotics and go?” With these results in mind, let’s take a look at critical thinking check number six below.
Excellent work, both the patient and the mother agree to the prescribed treatments. Before they leave, the provider indicates he wants to talk to them about when to seek a higher level of care. With this in mind, let’s take a look at critical thinking checks number seven and number eight below.
Well done. Michael says he will follow the prescriptions and follow up as instructed. He also wants to know how to keep this from happening again. With this in mind, let’s take a look at our last critical thinking check number nine below.
Great work, everyone. This wraps up our case study on the diabetic foot foot ulcer. Please take a look at the attached study tools and test your knowledge with a practice quiz. And as always, we love you guys, now go out and be your best self today and happy nursing!
References:
Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities
Authors:Amy C Weintrob, MDDaniel J Sexton, MD, updated Jan, 2021; Evaluation of the diabetic foot
Author:Deborah J Wexler, MD, MSc updated Sept 2021; Patient education: Foot care for people with diabetes (Beyond the Basics)
Author:Deborah J Wexler, MD, MSc, updated Feb, 2021
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