Diabetic foot ulcers are a significant and frequent complication in individuals with poorly managed diabetes mellitus. These ulcers can arise from a combination of factors, including inadequate glycemic control, peripheral vascular disease, neuropathy, and insufficient foot care. Calluses play a crucial role in the development of these ulcers, often acting as the initial point of pressure and skin breakdown. This article delves into the critical aspects of nursing diagnosis and foot care for calluses, particularly in the context of preventing diabetic foot ulcers and promoting overall foot health in at-risk populations.
Understanding the Pathophysiology of Calluses and Diabetic Foot Ulcers
The formation of a diabetic foot ulcer often begins with a seemingly minor issue: a callus. In individuals with diabetic neuropathy, the loss of protective sensation means that repetitive pressure and friction on the feet may go unnoticed. This sustained trauma leads to the development of calluses as the skin thickens in response to the pressure. However, beneath the surface of a callus, the continued pressure can cause skin breakdown, leading to ulceration.
Patients with diabetes frequently suffer from compromised circulation due to atherosclerosis and vascular damage. This poor circulation significantly impairs wound healing. When a callus progresses to an ulcer, the reduced blood flow hinders the body’s natural repair processes, increasing the risk of tissue necrosis and gangrene.
Neuropathy, affecting approximately 60% of diabetic patients, further elevates the risk of foot ulcers. These ulcers commonly appear on the plantar surface of the foot, especially the heel and the tips of hammer toes – areas subjected to high pressure during weight-bearing activities. Regular foot examinations by podiatrists and healthcare providers are vital for diabetic patients to identify calluses and areas of diminished sensation proactively.
Diagnostic and management strategies for diabetic foot ulcers include monitoring fasting blood sugar, comprehensive metabolic panels, erythrocyte sedimentation rate, glycated hemoglobin levels, and C-reactive protein. Imaging techniques like X-rays and bone scans, along with arterial Doppler studies using the ankle-brachial index, may be employed to rule out underlying fractures, osteomyelitis, and peripheral vascular disease.
Alt text: Detailed foot examination by a healthcare professional to identify calluses and potential ulcer development in a diabetic patient, emphasizing preventative foot care.
The Nursing Process and Collaborative Care for Diabetic Foot Ulcers
Managing diabetic foot ulcers requires a multidisciplinary approach, integrating the expertise of podiatrists, endocrinologists, primary care physicians, diabetes educators, nurses, and wound care specialists. Patient education is the cornerstone of prevention, aiming to reduce the incidence of diabetic foot ulcers and avoid delays in seeking care that can lead to severe complications such as osteomyelitis and amputations. Nurses play a pivotal role in this collaborative care model, from initial assessment to patient education and ongoing management.
Nursing Care Plans: Addressing Key Nursing Diagnoses
Once a nursing diagnosis is established for a patient with a diabetic foot ulcer, nursing care plans become essential tools for structuring assessments and interventions. These plans prioritize both immediate and long-term goals of care. Here are examples of nursing care plans tailored to common nursing diagnoses associated with diabetic foot ulcers, emphasizing foot care related to calluses:
Impaired Physical Mobility
Diabetic foot ulcers, particularly when severe or following amputation, can significantly impair a patient’s physical mobility.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Discomfort and pain from the ulcer
- Pressure offloading requirements
- Peripheral neuropathy affecting balance and coordination
- Presence of an open wound restricting movement
- Reluctance to move due to fear of injury or pain
- Amputation of a lower extremity
As evidenced by:
- Limited range of motion in the affected limb
- Reports of discomfort or pain upon movement
- Use of prosthetic devices
- Use of assistive devices for ambulation (crutches, wheelchair)
- Inability to bear weight on the affected foot
Expected Outcomes:
- The patient will demonstrate strategies to enhance mobility within their limitations.
- The patient will effectively utilize assistive devices and perform activities of daily living as independently as possible.
Assessments:
- Assess the patient’s current level of mobility and dependence. Understanding the extent of immobility is crucial for tailoring interventions and allocating appropriate resources.
- Determine the underlying causes of impaired mobility. Immobility can stem from physical discomfort, psychological factors like fear of falling, or motivational issues such as depression. Addressing these root causes is vital for effective intervention.
Interventions:
- Encourage range of motion exercises. Regular exercise helps prevent muscle stiffness, improves circulation, and promotes overall mobility. Focus on exercises suitable for patients with foot ulcers, avoiding weight-bearing on the affected foot if necessary.
- Provide and train on the use of assistive devices. Pressure offloading is paramount in diabetic foot ulcer management. Assistive devices like wheelchairs, crutches, walkers, and specialized footwear are crucial for reducing pressure on the ulcerated foot and promoting healing. Educate patients on proper use and safety precautions. Pillows and wedges can also be used for extremity elevation when resting.
- Involve the patient and family in care planning and execution. Family support and encouragement are essential for patient motivation and adherence to mobility plans. Educate family members on how they can safely assist with mobility and repositioning.
- Consult with a prosthetist if amputation is necessary. For patients requiring amputation, early consultation with a prosthetist is crucial. A prosthetist can provide guidance on prosthetic fitting, use, and rehabilitation to optimize mobility and independence post-amputation.
Impaired Skin Integrity
A diabetic foot ulcer represents a significant disruption in skin integrity, often characterized by a deep, crater-like wound surrounded by thickened callus tissue.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Poor glycemic control contributing to delayed healing
- Complications of diabetes such as neuropathy and vascular disease
- Inflammatory processes within the wound
- Poor circulation hindering tissue repair
- Inadequate primary defenses against infection
- Lack of knowledge regarding preventative skin care and foot care practices
As evidenced by:
- Abscess formation within or around the ulcer
- Pain and tenderness at the ulcer site
- Bleeding from the wound
- Open wound with visible disruption of epidermis and dermis
- Dry, cracked skin surrounding the ulcer
- Altered skin turgor indicating dehydration or poor circulation
Expected Outcomes:
- The patient will demonstrate proper skin care techniques to promote diabetic foot ulcer healing.
- The patient will achieve timely wound healing without developing further complications.
Assessments:
- Thoroughly assess the wound characteristics. Document the color, odor, depth, presence of necrotic tissue, and any exposed bone or tendon. These characteristics guide the wound care plan. Assess the color of surrounding skin and tissues to gauge vitality and oxygenation.
- Evaluate the extent of skin impairment. Classify the ulcer according to established staging systems (e.g., Wagner scale, Texas Diabetic Foot Ulcer Classification system). Inspect the periwound skin for maceration, erythema, and signs of infection.
- Measure and document ulcer size weekly. Accurate measurements of length, width, and depth, compared to baseline data, are essential for monitoring healing progress and adjusting treatment as needed.
Interventions:
- Educate the patient on daily foot inspection. Emphasize the importance of daily self-examination, especially for those with neuropathy who may not feel injuries. Teach patients to use a mirror to visualize all surfaces of their feet and lower legs. Family members may need to assist if the patient has visual impairments or difficulty reaching their feet.
- Advise on appropriate footwear and to avoid bare feet. Stress the need to wear protective footwear at all times, even indoors (slippers are recommended). Properly fitting shoes and avoiding walking barefoot minimize trauma and prevent new injuries.
- Assist with wound debridement as ordered. Removal of necrotic or nonviable tissue is crucial for promoting wound healing. Debridement may be sharp, mechanical, enzymatic, or autolytic, depending on the wound characteristics and physician orders.
- Perform prescribed wound care. Implement wound care protocols as directed by the physician. This may involve various dressings (hydrocolloid, absorptive, alginate, hydrogels, silver-containing dressings), topical agents (silver nitrate), and advanced therapies like wound vacuum-assisted closure (VAC).
- Educate on comprehensive skin care. Instruct patients on maintaining skin moisture, cleanliness, and dryness to prevent further breakdown. Recommend gentle cleansing with mild soap and water, patting skin dry, and applying appropriate moisturizers, avoiding areas between toes to prevent maceration.
Alt text: A nurse providing meticulous wound care to a diabetic foot ulcer, highlighting the importance of sterile technique and proper dressing application for infection prevention and healing.
Ineffective Tissue Perfusion
Elevated blood glucose levels in diabetes contribute to endothelial damage, leading to impaired oxygenation and perfusion of tissues in the feet at the capillary level.
Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral)
Related to:
- Elevated blood glucose levels causing microvascular damage
- Impaired oxygen transport due to reduced blood flow
- Interruption of arterial and venous blood flow
- Nerve damage (neuropathy) affecting vascular regulation
- Insufficient knowledge about diabetes mellitus and its management, including the importance of glycemic control for vascular health
As evidenced by:
- Presence of foot ulceration
- Weak or absent peripheral pulses (dorsalis pedis, posterior tibial)
- Cool, clammy skin temperature in the lower extremities
- Prolonged capillary refill time (>3 seconds) in toes
- Reports of numbness, burning, or tingling sensations in the feet (neuropathy)
- Delayed wound healing
- Altered sensation in the feet, diminished response to touch or temperature
Expected Outcomes:
- The patient will maintain optimal peripheral tissue perfusion, indicated by:
- Strong, palpable peripheral pulses
- Warm and dry extremities
- Capillary refill time within normal limits (<3 seconds)
- Observable wound healing progression
- The patient will avoid complications associated with ineffective perfusion, such as infection, gangrene, or amputation.
Assessments:
- Monitor peripheral pulses and symmetry. Diminished or absent pulses may indicate arterial insufficiency due to ischemia, requiring immediate medical attention. Compare pulses bilaterally to assess for unilateral reduction.
- Assess skin color and temperature of lower extremities. Pale, cool skin suggests arterial obstruction. Reddish-blue discoloration may indicate damaged vessels, while brownish discoloration can be associated with venous insufficiency.
- Assess for discomfort and sensory changes in lower extremities. Neuropathy caused by high glucose levels can lead to reduced sensation, numbness, and neuropathic pain (burning, tingling, shooting pain).
- Review chronic disease history, particularly diabetes, hypertension, and hyperlipidemia. These conditions are major risk factors for peripheral artery disease (PAD), which significantly impairs tissue perfusion in the lower extremities.
Interventions:
- Educate on the importance of optimal hemoglobin A1c (HbA1c) levels. Emphasize the link between tight glycemic control and improved tissue perfusion. Educate the patient on target HbA1c goals as recommended by their healthcare provider.
- Utilize bedside Doppler ultrasonography if pulses are difficult to palpate. A portable Doppler device can help assess blood flow when pulses are not easily palpable, aiding in the detection of peripheral artery disease.
- Assess ankle-brachial index (ABI) as recommended. ABI is a screening test for PAD, particularly recommended for diabetic patients over 50 years old. An ABI < 0.9 is indicative of PAD and warrants further investigation.
- Consider hyperbaric oxygen therapy for non-healing wounds. For ulcers that fail to show significant healing after 30 days of standard treatment, hyperbaric oxygen therapy may be considered to enhance oxygen delivery to tissues and promote healing.
- Educate on lifestyle modifications to improve tissue perfusion. Advise on measures to reduce venous compression and arterial vasoconstriction:
- Avoid crossing legs when sitting to prevent circulatory restriction.
- Engage in regular exercise, as tolerated, to improve circulation.
- Maintain a healthy weight to reduce strain on the circulatory system.
- Abstain from smoking, as nicotine is a potent vasoconstrictor.
Risk for Infection
Diabetic foot ulcers inherently carry a high risk of infection due to compromised immune response, poor circulation, and open wounds.
Nursing Diagnosis: Risk for Infection
Related to:
- Presence of an open wound providing a portal of entry for pathogens
- Underlying disease process of diabetes compromising immune function
- Delayed wound healing prolonging the period of vulnerability
- Inadequate primary defenses due to impaired skin integrity and reduced immune response
As evidenced by:
A risk diagnosis is not evidenced by existing signs and symptoms but by risk factors.
Expected Outcomes:
- The patient will remain free from infection.
- The patient will demonstrate techniques to promote wound healing and minimize infection risk.
Assessments:
- Obtain wound cultures if signs of infection are present or suspected. Wound swabs can identify bacterial pathogens (e.g., Staphylococcus, Pseudomonas) to guide appropriate antibiotic therapy.
- Assess the wound for signs of infection during each dressing change. Monitor for local signs of infection: purulent drainage (green, yellow, or cloudy), foul odor, increased erythema, warmth, tenderness, and increased pain.
- Review relevant imaging and laboratory results if osteomyelitis is suspected. MRI is highly sensitive for diagnosing osteomyelitis. Elevated white blood cell count and inflammatory markers (ESR, CRP) can also indicate infection.
Interventions:
- Employ aseptic technique during wound dressing changes. Strict aseptic technique minimizes the introduction of bacteria into the wound, reducing infection risk.
- Administer antibiotics as prescribed. Severely infected diabetic foot ulcers may require inpatient hospitalization and intravenous antibiotics. Ensure timely administration and monitor for therapeutic effectiveness and adverse effects.
- Emphasize tight glycemic control. Maintaining stable blood glucose levels is crucial for immune function and wound healing. Monitor glucose levels frequently and work with the healthcare team to achieve optimal glycemic control.
- Refer to a wound care specialist for complex or non-healing wounds. Infected, complex, or non-healing wounds often require specialized care in a wound care center with a multidisciplinary team. Early referral can improve outcomes and prevent complications.
Risk For Unstable Blood Glucose Level
Patients with diabetes are at risk for fluctuations in blood glucose levels, which can impede wound healing and increase the risk of foot ulcer complications.
Nursing Diagnosis: Risk For Unstable Blood Glucose Level
Related to:
- Inconsistent adherence to prescribed diabetes management plan
- Inadequate blood glucose monitoring practices
- Excessive stress impacting glucose regulation
- Weight fluctuations (gain or loss) affecting insulin sensitivity
- Improper dietary choices and meal timing
As evidenced by:
A risk diagnosis is not evidenced by existing signs and symptoms but by risk factors.
Expected Outcomes:
- The patient will maintain preprandial glucose levels within the target range specified by their healthcare provider.
- The patient will achieve a hemoglobin A1c (HbA1c) level below 7% or as individualized by their provider.
- The patient will verbalize understanding of their glucose monitoring regimen and proper administration of antidiabetic medications.
Assessments:
- Monitor for signs and symptoms of hypoglycemia. Educate the patient and family to recognize and report symptoms such as shakiness, dizziness, sweating, hunger, confusion, and palpitations.
- Monitor for signs and symptoms of hyperglycemia. Educate the patient and family to recognize and report symptoms such as polyuria, polydipsia, blurred vision, headache, fatigue, and increased thirst.
Interventions:
- Review glucose logs and trends. Analyze glucose monitoring records (devices or written logs) to identify patterns and trends in glucose levels. Unstable glucose levels or persistent hyperglycemia necessitate adjustments to the treatment plan.
- Assess patient understanding of the diabetes treatment plan. Request the patient to verbally explain their glucose goals, medication administration (timing, dosage, technique), dietary guidelines, and actions to take in case of hypo- or hyperglycemia. Clarify any misunderstandings and reinforce key aspects of self-management.
- Consider continuous glucose monitoring (CGM) devices. For patients struggling with glucose control or frequent hypo/hyperglycemia, CGM devices can provide real-time glucose data, improve awareness of glucose patterns, and facilitate better diabetes management.
- Explore barriers to optimal glucose control. Discuss potential barriers such as stress, exercise patterns, dietary habits, medication adherence, and socioeconomic factors. Identify patient-specific barriers to tailor interventions and provide appropriate support and resources.
Conclusion: Prioritizing Foot Care and Nursing Diagnosis for Calluses
Effective nursing diagnosis and meticulous foot care are paramount in preventing and managing diabetic foot ulcers, with callus management being a critical component. By implementing comprehensive nursing care plans, educating patients on self-care practices, and fostering interdisciplinary collaboration, healthcare professionals can significantly improve outcomes, reduce complications, and enhance the quality of life for individuals at risk of or affected by diabetic foot ulcers. Focusing on early identification and management of calluses, combined with rigorous attention to glycemic control and overall foot health, can substantially decrease the burden of diabetic foot ulcers and their devastating consequences.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Centers for Disease Control and Prevention. (2022). Diabetes and your feet. https://www.cdc.gov/diabetes/library/features/healthy-feet.html
- Diabetic Foot Ulcer. Oliver TI, Mutluoglu M. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537328/
- Diabetic Foot Ulcers. UCSF Department of Surgery. 2023. From: https://surgery.ucsf.edu/conditions–procedures/diabetic-foot-ulcers.aspx
- Diabetic Ulcers: Causes and Treatment. Healthline. Updated: February 4, 2021. From: https://www.healthline.com/health/diabetic-foot-pain-and-ulcers-causes-treatments
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Dumville, J. C., Lipsky, B. A., Hoey, C., Cruciani, M., Fiscon, M., & Xia, J. (2017). Topical antimicrobial agents for treating foot ulcers in people with diabetes. The Cochrane Database of Systematic Reviews, 2017(6). https://doi.org/10.1002/14651858.CD011038.pub2
- Foot and Toe Ulcers. Cleveland Clinic. Reviewed: April 27, 2022. From: https://my.clevelandclinic.org/health/diseases/17169-foot-and-toe-ulcers
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and Outcomes (8th ed.). Elsevier.
- Mouri, M.I.& Badireddy, M. Hyperglycemia. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430900/
- Oliver, T.I.& Mutluoglu, M. (2022). Diabetic foot ulcer. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK537328/
