Diabetic Foot Ulcer Nursing Diagnosis and Nursing Care Plan

Diabetic Foot Ulcer Nursing Care Plans Diagnosis and Interventions

Diabetic Foot Ulcer NCLEX Review and Nursing Care Plans

Diabetic foot ulcer is a complication of diabetes that may be aggravated by poor diet, exercise, and insulin therapy. Skin tissue deteriorating and exposing the layers beneath causes ulcers to form. They can damage the bones of the feet and are most frequently found under the big toes and on the balls of the feet.

Diabetic foot ulcers can possibly occur in all diabetic patients, regular foot hygiene can help avoid them. Depending on their etiology, diabetic foot ulcers require different treatments.

If there are any foot concerns, an immediate consultation is advised. If left untreated, infected ulcers can lead to amputation.

Signs and Symptoms of Diabetic Foot Ulcer

  • drainage from the foot
  • unusual swelling
  • foot irritation
  • redness around the wound
  • foul-smelling odor from one or both feet
  • eschar or black tissue surrounding the ulcer
  • odorous wound discharge
  • pain around the wound
  • numbness
  • increased warmth
  • fever
  • chills
  • dry and scaly skin
  • any changes to the toenails and skin which include cuts, blisters, calluses or sores.

Causes of Diabetic Foot Ulcer

  • Diabetes. The nerves and blood vessels can become damaged by excessive blood sugar levels. That reduces blood flow, which makes it more difficult for cuts and sores to heal particularly in the hands, feet, and limbs.
    • Poor circulation. It causes an inefficient blood flow to the feet and ulcers may be more difficult to heal if there is poor circulation.
    • High blood sugar level or hyperglycemia. Blood sugar control is essential because high glucose levels might hinder the healing of an infected foot ulcer. People with type 2 diabetes and other illnesses frequently struggle to combat ulcer-related infections.
    • Nerve damage. The long-term impact of nerve damage is a lack of sensation in the feet. Nerve damage can cause tingling and pain, it also causes painless ulcer-causing sores and lowers the sensitivity to foot pain.
    • Irritated or wounded feet. Drainage from the affected area and occasionally a pronounced bulge that is not necessarily painful are indications of an ulcer.
    • Obesity. Obese people with diabetes may be especially at risk for developing peripheral neuropathy, peripheral arterial disease, and becoming unable to care for themselves.
    • Flat foot. Diabetic patients with flat foot impose uneven tension on the foot which causes tissue inflammation in high-risk foot areas.

Risk Factors to Diabetic Foot Ulcer

  • Neuropathy. The occurrence of any type of diabetic neuropathy, particularly polyneuropathy, which is characterized by altered vibration, position, temperature sensations, numbness or pain, and other symptoms, increases the risk of developing diabetic foot ulcers.
  • Peripheral vascular disease. Insufficient blood flow is caused by peripheral vascular disease, especially in the lower limbs. The likelihood of infection and necrosis can rise as a result of the resultant ischemia.
  • Presence of pre-ulcerative lesions. In order to prevent foot ulcers in diabetic individuals, it is essential to recognize new lesions. Ulcers typically develop in places that are prone to recurrent shear or stress, particularly if the calluses are hemorrhagic.
  • Hypertension. More than half of diabetic people who develop foot ulcers also have hypertension. This illness can be managed with a mix of oral medications and insulin treatment.
  • Age and Sex. Male individuals with diabetes are more likely than female patients to develop foot ulcers. Additionally, the majority of them are between the ages of 40 and 70.
  • Smoking. Smoking has been linked to additional comorbid conditions such arterial and vascular disease and chronic obstructive pulmonary disease, as well as the onset of foot ulcers and gangrene. These circumstances have a detrimental effect on healing and may lead to the persistence of lesions that may develop into ulcers.
  • Charcot joint. When bones, joints, and the soft tissue of the foot and ankle become inflamed as a result of neuropathy, a Charcot joint forms. The emergence of this illness raises the possibility of getting a diabetic foot ulcer.

Complications of Diabetic Foot Ulcer

  • Skin infection. Skin infections from diabetic foot ulcers can cause swelling around the wound site, foul-smelling discharge, fever, and chills. Amputation risk increases if the infection travels from the incision to the bone.
  • Abscess formation. A painful collection of pus beneath the skin’s surface, may develop from an infected diabetic foot ulcer.
  • Sepsis. Sepsis may result from an infection that has spread far enough to infiltrate the bloodstream. When the body’s immune system overreacts to an infection and starts to harm tissues and organs, this illness could be fatal.
  • Foot deformities. Deformities in the feet can develop from weakening of the muscles and bones of the feet caused by long-term uncontrolled diabetes and diabetic foot infections. They might potentially result in Charcot foot. As the bones age, they become brittle and begin to fracture or dislocate in response to light pressures, like walking.
  • Gangrene. The term used to describe when body tissue dies due to a bacterial infection or a reduction in blood supply. The skin tissues surrounding a diabetic foot ulcer that is not immediately treated risk losing blood and oxygen due to lack of supply. As a result, ischemia, a dark tissue that is one of the early warning symptoms of gangrene, may emerge.
  • Foot amputation. Peripheral artery disease and neuropathy make it simpler to develop infections and ulcers. Severe infections that are resistant to therapy run the risk of entering the bloodstream. The diseased foot might need to be removed in order to prevent this from happening.

Diagnosis of Diabetic Foot Ulcer

  • Medical History. The healthcare provider will determine when the foot ulcer has been noticed and if there are any additional illnesses that could raise the chance of developing foot ulcers, such as peripheral neuropathy or lower extremity arterial disease.
  • Physical Assessment. The foot, toes, and toenails will be checked by the healthcare provider to look for any blisters, wounds, scratches, or ingrown toenails that could cause more ulcers. By sensing the pulse, the healthcare provider also gauges the rate of blood flow in the foot.
    • Wagner Ulcer Classification System. The healthcare provider will most likely rate the ulcer’s severity from 0 to 5 using this system

0: no exposed sores

1: a surface ulcer that has not reached deeper levels

2: deeper ulcer reaching tendons, bones and joint capsule

3: deeper tissues affected with abscess, tendonitis and osteomyelitis

4: gangrene in the heel

5: widespread involvement of the entire foot in gangrene

  • Imaging
    • X-ray. To check changes in the alignment of the bones in the foot, which might contribute to an ulcer, the healthcare provider will order an X-ray imaging. X-rays can also show a reduction in bone mass, which may be brought on by hormonal disturbances caused by diabetes.
    • MRI. If the healthcare provider requires further information about the degree of ulcer damage, this test is suggested. Inflammation, which can be an indication of an infection, can also be seen on MRI images.
  • Blood test. The healthcare provider can advise a blood test to screen for infection if the affected foot exhibits symptoms of infection like redness, swelling, and warmth.

Treatment for Diabetic Foot Ulcer

  • Infection prevention. To prevent an ulcer from becoming infected, there are numerous important factors to consider including:
    • Maintaining a clean and bandaged ulcer.
    • Using a bandage or wound dressing to clean the wound every day.
    • Avoid going barefoot.
    • Keeping the blood glucose under strict control.
  • Off-Loading. Patients may be instructed to wear specialized footgear, or a brace, or use a wheelchair or crutches in order to “off-load” the patient’s foot ulcer, which is especially important for those on the bottom of the foot. With the help of these devices, the ulcer area will experience less pressure and inflammation, hastening the healing process.
  • Medications. If the infection persists despite preventive or anti-pressure therapy, the healthcare provider may advise antibiotics, antiplatelet, or anticlotting drugs to treat the ulcer.
    • Medicated dressings. Dressings and medications used topically are part of proper wound treatment. These range from common solutions like saline to cutting-edge products like growth factors, bandages for ulcers, and skin replacements that have been proven to be incredibly successful in treating foot ulcers.
  • Surgical procedures. The healthcare provider might advise the patient to get surgical treatment for the ulcers. By correcting foot abnormalities like bunions or hammertoes, a surgeon may be able to reduce pressure around the ulcer. Surgery can stop the ulcer from getting worse or resulting to an amputation if no other form of treatment can help it heal.
  • Debridement. A debridement, or the removal of dead skin or foreign objects that may have contributed to the ulcer, is one method healthcare providers use to treat foot ulcers.
  • Blood glucose management. When treating a diabetic foot ulcer, strict blood glucose management is of the utmost significance. To do this, working closely with a medical professional or endocrinologist will speed healing and lower the chance of problems.

Nursing Diagnosis for Diabetic Foot Ulcer

Nursing Care Plan for Diabetic Foot Ulcer 1

Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity related to decreased circulation and sensation caused due to peripheral neuropathy secondary to diabetic foot ulcer, as evidenced by destruction of skin layers and disruption of skin surfaces.

Desired Outcomes:

  • The patient will experience healing of foot ulcers.
  • The patient will demonstrate proper foot care.
  • The patient will prevent further ulcer formation.
Nursing Interventions for Diabetic Foot UlcerRationale
Determine the patient’s wound or wound bed condition including the color, presence of necrosis, odor and visibility of joints or bones.        The color of tissue is a sign of the tissue’s vitality and oxygenation; necrotic tissue is dead tissue that must be removed in order for healing to take place. Odor may be a sign of a wound infection or it could be caused by necrotic tissue. Multiple stages or characteristics of a wound can be seen in a single wound.
Measure the ulcer’s size and take note of any undermining.  The length, width, and depth of the ulcer are all measured. In the innermost tissue layers, an ulcer develops before the skin degrades. As a result, the ulcer’s full size might not be shown by the skin’s surface opening.
Assess the patient’s wound for exudates.      Exudate, a typical component of wound physiology, needs to be distinguished from pus, which is a sign of infection. Exudate can be clear, hazy, or have a bloody tint, and it can contain serum, blood, and white blood cells.
Advise the patient to use warm water and mild soap to wash the feet every day. Remind the patient to check the temperature before putting the feet in the water.Burns and other skin injuries are more likely to occur when sensation is reduced.  
Instruct the patient to change the socks and stockings every day and encourage the patient to wear white cotton socks.To avoid infection caused by moisture. The white fabric makes it simple to see any blood or exudates.
Instruct the patient to avoid walking in bare feet.  There is a considerable danger of trauma from this, which could lead to infection and ulceration.
Advise the patient to use moderate moisturizers on the feet.Skin cracking is prevented by moisturizers’ ability to lubricate and soften dry skin.
Examine the tissue surrounding the patient’s wound and its edges for damage.  The surrounding tissue may be in good health or may be impaired to varying degrees. To employ local wound care treatments that adhere to the skin, healthy tissue is required.

Nursing Care Plan for Diabetic Foot Ulcer 2

Risk for Infection

Nursing Diagnosis: Risk for Infection related to open wound secondary to diabetic foot ulcer.

Desired Outcomes:

  • The patient will identify methods to prevent the risk of infection.
  • The patient will demonstrate techniques and lifestyle changes to prevent the development of infection.
Nursing Interventions for Diabetic Foot UlcerRationale
Assess the patient’s wound including the drainage, tissue color, and odor of the foot ulcer.      A foot ulcer that smells bad may be infected; infected tissue typically looks gray-yellow and lacks pink granulation tissue; and discharge that is clear to straw-colored is typical. While excessive purulent green or yellow drainage suggests an infection.
Monitor the patient’s body temperature.  A temperature of more than 37.7° (99.8° F) may be an indication of an infection, and a very high temperature with chills and sweating may be an indication of septicemia.
Provide precise foot care to the patient by gently massaging bony areas and keeping the skin dry.The risk factors for skin deterioration and infection development include impaired or inadequate peripheral circulation.
Provide local wound care to the patient as prescribed.  The ulcer’s stage and the type of infection present determine the type and intensity of the wound treatment.
Ensure that all the patient’s blisters and cuts are cleaned and treated with an antiseptic solution.  Quick wound care reduces the risk of infection. Encourage the patient to contact the main healthcare provider immediately if the wound seems infected.
Ensure strict aseptic technique for dressing changes, wound care, intravenous therapy, and catheter handling.  Pathogens are less likely to be transferred to or spread among patients when using aseptic method. It is possible to stop the transmission of infection by breaking the chain of infection.
Promote nail care by instructing the patient to cut toenails straight across when soft after a bath.Proper nail care ensures that ingrown toenails are avoided, which reduces the risk of infection.  

Nursing Care Plan for Diabetic Foot Ulcer 3

Risk for Ineffective Health Maintenance

Nursing Diagnosis: Risk for Ineffective Health Maintenance related to impaired functional status related to diabetic foot ulcer.

Desired Outcomes:

  • The patient and family will express the ability to cope effectively with the current situation, provide support and monitoring as indicated.
  • The patient will demonstrate knowledge on self-care measures related to diabetic foot ulcer.
Nursing Interventions for Diabetic Foot UlcerRationale
Assess the patient and the family’s knowledge and skills on wound care.    Patients are no longer held in hospitals until their ulcers have healed. However, they may still require home wound care for several weeks or months.
Assess the patient and family’s understanding of the prevention of further foot ulcer development.patients who are immobile will need to be repositioned or move their feet frequently to reduce the chance of breakdown in the intact parts.
Teach the patient and the family to report any of the following symptoms of wound infection: fever, malaise, chills, an offensive odor, and purulent drainage.Early detection will result to rapid intervention.  
Educate the patient and family about local wound care and requirements for a return demonstration.  This will enable the patient to apply new knowledge right away, improving retention. The patient/ family can make adjustments as soon as they receive feedback, as opposed to practicing the skill incorrectly.
Provide the patient with written instructions for wound care.  Specific written plans are necessary for long-term management in order to improve treatment adherence.
Determine whether the patient and the family are aware of the long-term nature of wound healing.    Even in the best cases, a foot ulcer may take weeks or months to heal. Ulcers heal from their edges toward their centers and from their bases up. Clean, persistent wounds that are not healing may be appropriate for palliative wound care.

Nursing Care Plan for Diabetic Foot Ulcer 4

  Acute Pain

Nursing Diagnosis: Acute Pain related to skin disruption secondary to diabetic foot ulcer, as evidenced by guarding behavior, facial grimace, and patient’s expression of pain with a rate of 8 on a scale of 1-10.

Desired Outcomes:

  • The patient will report pain reduced to a 4/10 or less.
  • The patient will demonstrate the use of appropriate diversional activities and relaxation skills.
  • The patient will use pharmacological and nonpharmacological pain-relief methods.
  • The patient will display an improvement in mood and coping.
Nursing Interventions for Diabetic Foot UlcerRationale
Conduct a thorough evaluation of the patient’s pain. Assess the location, characteristics, onset, duration, frequency, quality, and intensity.  The most trustworthy source of knowledge on a person’s pain is the person who is actually experiencing it. Their ability to characterize the location, intensity, and duration of their pain makes their self-report the gold standard in pain evaluation. Thus, assessing pain through an interview aids the nurse in creating the best pain treatment plans.
Determine the signs and symptoms related to the patient’s pain.        An accurate pain evaluation is essential for creating a personalized care plan. Bringing up related symptoms and indicators may aid the nurse in assessing the discomfort. In some cases, the patient ignores the fact that they are in pain.
Determine the patient’s anticipation for pain relief.While some people may be content when their pain is less severe, others may demand that their suffering be completely gone. This affects how well the treatment modality is seen to work and how motivated is the patient to try new treatments.
Determine how comfortable the patient is using non-pharmacological pain management.Some patients are not aware that analgesic medications can be used in conjunction with non-pharmacological techniques. Combining these therapies can result in a pain reduction that is more potent.
Offer cognitive behavioral therapy (CBT) to the patient including distraction, guided imagery, meditation and relaxation techniques.These techniques modify psychological reactions to pain in order to provide comfort.  

Nursing Care Plan for Diabetic Foot Ulcer 5

 Impaired Physical Mobility

Nursing Diagnosis: Impaired Physical Mobility related to pain and discomfort secondary to diabetic foot ulcer, as evidenced by expression of pain when mobilizing, refusal to move and limited range of motion.

Desired Outcomes:

  • The patient will perform physical activities independently.
  • The patient will demonstrate measures to increase mobility.
Nursing Interventions for Diabetic Foot UlcerRationale
Assess the patient’s skin integrity for symptoms of ischemia and redness especially over the heels, ankles, and toes.Foot ulcers can be prevented or detected and treated early by routine skin inspection, especially over bony prominences.  
Encourage the patient to perform passive or active range of motion exercises.Exercise helps preserve muscle strength and endurance, avoids stiffness, and increases venous return. Additionally, it prevents contracture deformation.
Offer the patient diversional activities.      Observe the patient for behavioral or emotional responses to immobility. Forced immobility may intensify agitation and restlessness. Diversional activity aids in refocusing attention and promotes coping.
Assess the patient’s strength and range of motion.Patients who are weak may not have the power to perform ADLs or move around, whether they are deconditioned from lack of exercise or illness.
Administer the patient’s pain medication as required.  Before conducting exercises or scheduled ADLs, the nurse can administer analgesics if pain and discomfort constitute a barrier.
Instruct the patient or family on how to keep the home secure and hazard-free.    A secure environment will lessen the chance of injury from falls. Home modifications can lessen activity fatigue and help the patient retain the desired level of functional independence.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

Nursing Stat Facts
Nursing Stat Facts

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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