Introduction
Wound care and diabetic foot care are critical skills for nurses to master. With the rising rates of diabetes and obesity, nurses today are caring for more patients with complex wounds that require comprehensive assessment and evidence-based interventions to promote healing.
Wound Healing Process
To properly care for wounds, nurses must first understand the physiology of normal wound healing which occurs in four overlapping phases.
- Hemostasis – Bleeding is stopped through vasoconstriction and a fibrin clot is formed
- Inflammation – White blood cells clean the wound by removing debris and bacteria while cytokines and growth factors initiate the proliferation stage
- Proliferation – Fibroblasts and endothelial cells proliferate, reforming the extracellular matrix and blood vessels
- Remodeling – Collagen strengthens tissue tensile strength over months to years
Factors that can delay wound healing include poor circulation and oxygenation, infection, foreign bodies, necrosis, age, stress, hormones, obesity, medications, radiation, and systemic illness like diabetes.
Diabetes and Wound Healing
Several factors related to diabetes contribute to poor wound healing:
- Neuropathy – Nerve damage leads to altered sensation and injuries going unnoticed
- Peripheral Artery Disease (PAD) – Reduced blood flow limits oxygen and nutrients to wounds
- Hyperglycemia – Impairs leukocyte function and angiogenesis
These issues make comprehensive foot exams and patient education about foot care and signs of complications extremely important nursing interventions.
Comprehensive Foot Assessment
Nurses should conduct a vascular, dermatologic, musculoskeletal, and neurological exam of both feet for all diabetic patients at least annually.
Vascular
- Assess pedal pulses with Doppler if needed
- Inspect for hair loss, skin discoloration, temperature changes
Dermatologic
- Skin – dryness, calluses, blisters, cracks, ulcers
- Nails – thickening, ingrown, fungus
Musculoskeletal
- Deformities like bunions, hammertoes, Charcot foot
- Limitations in joint mobility
Neurological
- 10-g monofilament testing
- Vibration perception
- Protective sensation
Risk Factors Requiring Referral
High risk foot conditions requiring specialty referral include.
- History of previous ulceration or amputation
- Peripheral neuropathy with loss of protective sensation
- Absent pedal pulses
- Severe foot deformities
- Pre-ulcerative signs like calluses, blisters, swelling, redness
Patient Education
Nurses play a key role in patient education to promote foot self-care. Education should include.
- Signs of foot complications to report immediately
- Proper nail and skin care
- Proper footwear fit, features, and break-in
- Daily foot inspections
- Blood glucose monitoring
- Instruction on special footwear, braces, custom inserts if needed
Diabetic Foot Ulcers
Presentation Diabetic foot ulcers commonly occur over areas of bony prominences and pressure. Patients may report pain, but numbness due to neuropathy can lead to wounds going unnoticed.
Assessment
- Measure wound dimensions and characteristics
- Probe wounds for depth and tunnels
- Assess for infection – redness, purulent drainage, odor
- Palpate pedal pulses and capillary refill
- Assess sensation and offloading needs
Principles of Care
- Offload pressure from wound
- Control blood glucose
- Promote a moist wound environment
- Manage infection
- Improve circulation and oxygenation
- Maintain nutrition
- Educate on self-care
Debridement, advanced dressings and topical therapies, and adjunctive measures like hyperbaric oxygen may also be utilized.
Moist Wound Healing
Maintenance of a moist wound environment has been shown to improve healing times compared to allowing wounds to dry out and form scabs. Moist wound healing principles include:
- Keeps growth factors and cells in contact with wound
- Reduces pain
- Promotes granulation and epithelialization
- Reduces scarring
Many advanced dressings and wound fillers promote a moist environment through moisture donation, retention, or occlusion.
Wound Dressings
There are hundreds of wound care dressings and topical products available to manage various wound types and stages of healing. Dressing categories include:
Passive Dressings
- Gauze
- Non-adherent pads
- Petrolatum gauze
Interactive Dressings
- Films
- Foams
- Hydrogels
- Hydrocolloids
- Alginates
- Collagen
Dressing selection is based on properties of the wound (size, depth, tunnels, undermining, drainage), stage of healing, presence of infection, and dressing characteristics like absorbency, moisture donation/retention, debriding capabilities, frequency of desired dressing changes, action against infection, and cost.
Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT) uses subatmospheric pressure to help promote wound healing by:
- Removing exudate
- Reducing edema
- Promoting perfusion
- Removing bacteria
- Promoting granulation tissue
The systems consist of an open cell foam or gauze dressing placed into the wound, sealed with an adhesive film, and connected to a pump that applies negative pressure.
Debridement
Debridement involves removal of dead, damaged, or infected tissue to improve wound healing. Methods include:
- Autolytic debridement – Application of occlusive or semi-occlusive dressings allows endogenous enzymes and moisture to slowly break down necrotic tissue.
- Enzymatic debridement – Topical enzymes like collagenase and papain directly digest nonviable tissue.
- Mechanical debridement – Wet-to-dry dressings adhere to nonviable tissue which is pulled away when dressings are removed. Irrigation under pressure can also debride.
- Surgical/sharp debridement – Quick and selective removal of necrotic tissue using a scalpel, scissors and forceps. Considered most effective method.
- Maggot debridement therapy – Sterile medicinal maggots secrete enzymes to break down necrotic tissue and bacteria.
- Biosurgical debridement – Loosened necrotic tissue is removed using sterile larvae.
Regular debridement helps properly stage wounds, remove biofilm and nonviable tissue, and promote healing.
Infection Control
Due to high bacterial burden, critically colonized and locally infected wounds may benefit from antimicrobial dressings containing silver, iodine, polyhexamethylene biguanide (PHMB), honey, and other antimicrobials which can help reduce bioburden.
Systemic antibiotics and wound culture should be considered for spreading cellulitis or patients who are immunocompromised. Signs of wound infection include:
- Increased pain
- Erythema
- Local warmth
- Purulent drainage
- Friable granulation tissue
- Pocketing at base of wound
- Delayed healing
Treating underlying factors like malnutrition, immunosuppression, and peripheral artery disease is also important.
Biofilms
Biofilms are communities of microorganisms that attach to surfaces and secrete a protective extracellular polymeric substance matrix. Within biofilms, organisms become 10-1000 times more resistant to antimicrobials. Biofilms are often present in chronic, stalled wounds and can severely delay healing.
Strategies to disrupt wound biofilm:
- Frequent debridement
- Wound cleansing
- Rotating topical antimicrobials
- Applying dressings that disrupt biofilm
- Using antiseptics
- Administering antibiotics based on culture and sensitivity results
Adjunctive Care
Hyperbaric Oxygen Therapy involves delivery of pure oxygen at increased atmospheric pressures to help improve wound oxygenation. It is used to treat diabetic ulcers, radiation tissue damage, graft/flaps with compromised circulation, necrotizing infections, and refractory osteomyelitis.
Electrical Stimulation may enhance wound healing through attraction of epithelial cells and fibroblasts, increased blood flow, and antibacterial effects.
Ultrasound transmits high-frequency acoustic pressure waves that stimulate cellular activity to help clean wounds, deliver blood flow, and promote healing. It can help loosen thick eschar for debridement.
Negative Pressure Wound Therapy also provides adjunctive therapy to help remove exudate and infectious materials and prepare the wound for closure.
Conclusion
The fundamentals of proper wound and diabetic foot care include risk assessment, structured examinations, patient education, maintaining a moist wound environment, strategic debridement, advanced dressings, infection control, biofilm disruption, adjunctive therapies, and addressing underlying patient factors.
With the aging population and rising incidence of obesity and diabetes, nurses must be fully prepared to care for complex wounds and help prevent lower extremity amputations through evidence-based interventions. Ongoing nursing education is imperative for optimal patient outcomes.
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