Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Diabetic Foot Ulcer and Wound Care

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In one line

·Lost feeling plus poor blood flow plus repeated rubbing equals a wound that does not heal.

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Normal physiology

·Three shields keep your feet safe: nerve signals that make you feel pain and shift away from pressure, blood flow that feeds skin with oxygen and nutrients, and tough skin that locks germs out.

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What goes wrong

·High blood sugar over months and years poisons the nerves so they stop sending pain signals, clogs and stiffens the blood vessels so less blood reaches the foot, and makes skin dry and fragile. Without pain to warn you, without blood to heal, and without tough skin to protect, even a small bump or rub turns into a wound that will not close.

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Hallmark signs

·Open sore on the foot that won't heal
·Loss of feeling in the feet (numbness or can't feel light touch)
·Skin around the ulcer looks red, swollen, or feels warm
·Foul-smelling drainage or pus coming from the sore
·Foot feels cold or has weak pulses
·Blackened or dead-looking tissue at the edges of the wound
·Probe-to-bone test is positive (a sterile metal probe touches bone at the bottom of the ulcer)
·Ankle-brachial index (ABI) is low (less than 0.9)

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Red flags · escalate now

·Fever, chills, or feeling very sick all over (suggests the infection is spreading into the bloodstream)
·Red streaks running up the leg from the wound (sign that infection is traveling through the lymph vessels)
·Black or gray dead tissue, or a foul smell (means gangrene or deep infection that can lead to losing part of the foot)
·Sudden severe pain in a foot that used to feel numb (can mean a blood clot just blocked an artery or infection hit a nerve)

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Workup

·Plain X-ray of the foot (anteroposterior, lateral, and oblique views)
·Red blood cell (Erythrocyte) sedimentation rate (ESR) and C-reactive protein (CRP)
·Ankle-brachial index (ABI)
·Wound culture (deep tissue or bone sample, NOT swab of surface)
·Hemoglobin A1c (HbA1c)
·MRI of the foot (with and without contrast)

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Treatment

·Offload pressure with a total contact cast, removable cast walker (if adherent), or custom orthotic
·Sharp debridement (surgical removal of dead tissue, callus, and infected material)
·Revascularization (angioplasty or bypass surgery) if ABI is below 0.50 or toe pressure is below 30 mmHg
·Antibiotics: oral (e.g., amoxicillin-clavulanate, doxycycline, or trimethoprim-sulfamethoxazole) for mild infection; IV (e.g., vancomycin plus piperacillin-tazobactam or ceftriaxone plus metronidazole) for moderate-to-severe or bone infection
·Tight blood sugar control: target HbA1c below 7% (ADA) with medication adjustment, insulin if needed, and diabetes education
·Daily foot inspection and patient education on proper footwear, moisturizing (not between toes), and when to call for help

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NCLEX trap

·Most diabetic foot ulcers do not hurt because the nerves are damaged (neuropathy means the nerves cannot send pain signals anymore). Pain medicine will not help. The real fix is to take pressure off the ulcer (offloading), cut away dead tissue (debridement), control blood sugar, and treat any infection.
·A tiny hole on the skin can hide a deep infection underneath. Even a small ulcer can reach bone (osteomyelitis, which is infection of the bone) or spread bacteria into the blood. Always probe the ulcer gently with a sterile tool; if the tool touches bone, infection has gone deep and needs weeks of IV antibiotics.
·Antibiotics kill bacteria, but they do not fix the three things that caused the ulcer: broken nerves (so the patient cannot feel pressure), poor blood flow (so oxygen and nutrients do not reach the wound), and constant pressure (which keeps reopening the wound). You must offload the foot with a special boot or cast, control blood sugar, improve blood flow if needed, and cut out dead tissue. Antibiotics alone will fail.
·Diabetic foot ulcers are a medical emergency. They can lead to amputation (losing part of the foot or leg), sepsis (infection spreading through the whole body), and death. They signal that three body systems have broken down: nerves, blood vessels, and skin. Treat every diabetic foot ulcer seriously and start care right away.
·Patients with diabetic neuropathy cannot feel pain, heat, or pressure in their feet. They will not complain until the problem is very bad. You must screen every diabetic patient at every visit with a monofilament test (a soft thread that tests if they can feel light touch) and a full foot exam, even if they have no complaints.
·Dead tissue (also called dead (necrotic) tissue or eschar, which is black or yellow crusty stuff) traps bacteria and blocks healing. Sharp debridement (using a scalpel or special tool to cut away the dead parts) is a core part of treating diabetic foot ulcers. You must clean out the dead tissue before putting on any bandage or cream, or the wound will never heal.

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