National Nursing Review : Nursing Study Resources & Health Tips

Definition
Diagram 1
The foot wounds “do not come only because we are diabetic. A precipitating cause is found in over half the cases, and this cause is very often avoidable through prevention understood.

Diagram 2: The plantar perforating ulcer appears as a small crater in the emerging center of an area of hyperkeratosis on the skin that has no tendency to heal. It can begin simply by a light bulb or a crack.

Contrary to what its name suggests, this lesion is not painful, but she has a chronic course.

Diagrams 5a, 5b, 5c: It is important to know the initial mechanism by which develops perforating disease because it is the beginning (hypertension => callus) it must intervene to stop the evolution.

The perforating disease occurs most commonly at the foot (plantar perforating disease) but the same mechanism may occur in other parts of the foot where there is excessive pressure or friction exaggerated in practice, anywhere can develop corns, calluses, “eye of partridge, horns or other calluses.

The wounds of the so-called heel decubitus are also common and often occur after a hospitalization and / or an operation facilitated by support extended over an area of skin surface limited.

The trouble penetrating the shape of a cone whose tip is in the skin and the base is deep.

Diagram 11: It often seems very small but exploration permits to assess the depth and extent of damage. It does not look at the wounds, it is also necessary to touch them!

The appearance of foot wounds in diabetics is favored by the presence of arteritis in approximately 15% of cases of neuropathy have enabled the development of a painless sore in 60% of cases and an attack mixed (arterial and neurological) in 25% of cases.
Fundamental point: a foot wound in a diabetic signs a multisystem disease. Comorbidities should be taken into account.
Heading the list of precipitating factors include problems with shoes. They can be compressed (pressure) or Dia assaulting the 24 foot by repeated internal friction (friction). The shoes are too narrow, “too new” or too worn, due to the rough seams or leather, areas of delamination within the footwear and foreign bodies (small stone, piece of glass, …) are main causes of aggression foot.

Shoes too big cause excessive friction and can also be traumatic. The soles may be involved if the leather is deformed and hardened by perspiration or are cracked or Plicata; also the socks when the seam at the toes is particularly heavy, especially when they are plastic.
If alterations in static foot, shoes and soles are not the direct cause of plantar perforating ulcer and can nevertheless consider that there is a “problem of inappropriate footwear, by wearing an inch discharge to better distribute the weight of the body here could prevent the occurrence of the wound.

Ulcer
Above all: remember the importance of the management of comorbidities.
Treatment involves a multidisciplinary approach:
The arterial circulation must be evaluated and improved where possible.
Diagram 32: Infection must be tracked at any time and effectively treated.

The general condition is maximized: cardiovascular status, renal function, nutritional status.
The update of the anti-tetanus vaccination will be verified.
The wound will be closed following example, the classification of the Texas University used more frequently today than that of Wagner.
Wounds in diabetic patients should be handled very quickly. Before a wound that does not improve within 48 hours, this will require the care of a specialized team.
Otherwise, treatment of the wound is that of any other wound, provided the following rules:
Diagram 38: After eliminating superficial or deep infection (osteitis), the wound healing in diabetic patients is based on two major points: the discharge and treatment locally adapted.

1) Discharge
The landfill is to subtract the wound pressure that impedes the healing process including the removal of body weight, this can be done in different ways:
* Strict rest in bed
* Port of a device “ambulatory” discharge.
There are 2 main versions: the removable devices like the boot of total contact (Total Contact Cast) (Chart 42) resin made by an experienced and considered the “gold standard”, although not all patients can not walk without bearing the risk (balance problems … etc).

It must be broken and remade every week to ensure proper development of the wound.

Diagram 43: The boot fenestrated resin has the advantage of a first household on the wound which can see its status and perform care without having to break the plaster.

Diagram 45: The removable devices such as Aircast, the DHWalker, etc..

Diagram 46: The Scotch Cast Boot

Diagram 47: Ransart boot … have the advantage of allowing care to make every day after temporarily removing the plaster.

Chart 48: Other devices exist such as the half-shoe (shoe Barouk) …
Whatever the device used, the discharge must actually achieve zero pressure at the ulcer healing to hope. Thus, the discharge device must be worn at all times even for very short trips.
The sayings “a wound is not discharged untreated wound” and “take care of a wound in a diabetic, is the discharge” are essential for healing wounds in diabetics.

2) The local treatment

Its implementation requires the understanding of processes that are causing the wound and contribute to its maintenance, which involves exposed tissues provide the best environment possible to promote healing, that is to say clean and cover them properly.
The healing process is a very complex phenomenon that involves several steps:

* The bleeding stops.
* Inflammation with invasion of the wound from various types of cells and release of growth factors.
* The growth of new capillaries.
* The proliferation of specialized cells, fibroblasts, which form the connective tissue and collagen which are the framework of support for healing (extracellular matrix).
* The epithelialization leading to the closure of the wound.
* The organization of the scar.

In diabetics, the healing process is not proceeding normally as long as the wound is often misunderstood by the patient as by the caregiver due to the insensitivity due to neuropathy.
To be effective, care of the wound must be achieved carefully and in order the following steps:

Diagram 60: debridement (or cleansing): It is to be removed from the wound all dead or infected tissue to prevent secondary infection and provide the healthy tissue remains the best basement to promote healing from the tissue under underlying healthy.

Diagram 62: The elimination of fibrin and necrotic tissue, by methods more or less aggressive, can bring healing ulcers even those aspects of the most despairing.

Cleaning: The wound after being unbridled be cleaned to remove extraneous microscopic organic debris and potentially pathogenic bacteria. It is not necessary to keep the entire surface of the wound completely sterile and try to eliminate all the bacteria will probably increase the risk of colonization by more pathogenic organisms yet.
Cleaning should be smooth and practiced with saline.
Application of topical local: The antibiotic ointments and ointment touteautre called “healing” have not shown up so far in the treatment of diabetic foot ulcers.
Remember that all disinfectants are toxic to cells and, if used should rinse the wound after applying saline solution before applying the dressing selected.
Cover the wound: the wound must be covered with a bandage adapted to his condition. The use of products other than “current dressings” currently has no scientific justification.