Diabetes Mellitus
Drainage from infected wounds is often higher in amount, thicker in consistency and malodorous, with drainage color that may be green, blue, yellow or white, as opposed to the normal serous or sanguineous drainage associated with uninfected wounds.
Describe the characteristics of drainage from an infected wound?
The metabolic abnormalities that lead T2DM include insulin resistance, unbalanced secretion of the beta cells in the pancreatic cells and increased glucose prodction by the liver. Insulin resistance usually stimulates an increase in insulin secretion often to a level of mild hyperinsulinemia (levels of excess insulin in the blood) as the beta cells attempt to maintain a normal blood glucose level, in time the increased demand for insulin secretion leads to beta cell exhaustion and failure. This results in elevated post prandial blood glucose levels and an eventual increased of glucose by the liver.
Explain why T2DM has a slow onset
Types of insulin used are based on the patients blood sugar levels • Rapid acting - this type of insulin takes effect within 15 mins and you take it right before a meal. It's the insulin that is used to help process and use the carbohydrates in food. • Regular or short acting - regular - also called short acting insulin takes effect within 30 mins to an hour. It is also taken before a meal but the effects lasts longer than rapid acting insulin. It is injected 30-60 mins before a meal regular insulin also imitates the bolus secretion. o A bolus dose is insulin that is specifically taken at meal times to keep blood glucose levels under control following a meal. Bolus insulin needs to act quickly and so short acting insulin or rapid acting insulin will be used. • Intermediate acting - This type of insulin lasts 10-15 hours, its generally taken twice a day and its used to imitate your basal secretion. The basal secretion is a small amount if insulin that is always in your blood. In order to function efficently the body needs the basal secretion so people with T1DM must take insulin that replicates it • Long acting - Similar to intermediate-acting insulin long acting insulin replicates the basal secretion. Long acting insulin lasts from 20-24 hours so its usually taken once a day. Some patients may take this twice a day for better control of their blood sugar. • Pre-mixed - a premixed insulin combines two other types of insulin, for example a repid acting and an intermediate acting insulin. This makes sure you have enough insulin to cover the basel and bolus secretions
Explore the type of insulin that Jeff (Case Study 8) may be prescribed once the GIK infusion has been discontinued. Understand the rationale for the types he could be prescribed.
• Education of patients to ensure health literacy levels and understanding of treatment and management requirements and an understanding if these management requirements can and will be undertaken by my patient • Completion of all relevance nursing assesments and generation of a care plan relevant to my patient • Attention to the holistic model of health, taking into account social and emotional aspects of their diabetes as well as pathophysiological issues associated with diabetes • Helping to establish a care plan my patient is able to adhere to and is relevant to their lifestyle, assisting with implementation of small and significant health changes that could potentially keep my paitent healther for longer.
How can you as a nurse make a difference to support a patient with Type 2 DM?
• Macrovascular changes/complications o Affect larger vessel and take their toll on the heart and brain o Long standing hyperglycaemia can cause damage to the blood vessels, decreasing blood flow to the feet o Poor circulation will will weaken the skin and lead to formation of ulcers and also impair wound healing o Some bacteria and fungi thrive in high glucose levels in the bloodstream and fungal and bacterial infections will break down the skin and complicate ulcers o Serious complications can include deep skin and bone infections, gangrene is a serious complication that can include infection. Widespread gangrene can lead to amputation • Microvascular changes and complications that impact on development of pressure and leg ulcers o Affect small blood vessels o Creating problems in nerves, eyes and kidneys o The risk of developing microvascular complications of diabetes depends on duration and severity of hyperglyceamia and hypertension o High glucose levels can stimulate free radical production and reactive oxygen species formation o The most common cause that interact to result in diabetic foot are nueropathy, (loss of pain and position sensation), deformity (most commonly prominence of the metatarsal heads and clawing of toes) and trauma (most commonly ill fitting shoes) o Elevated blood sugar levels over time lead to nerve damage in the foot decreasing a persons ability to feel pain and pressure in the foot. Without these sensations its easy to develop callused pressure spots and accidently injure the skin, soft tissue bones and joints. o Overtime bone and joint damage can dramatically alter the shape of the foot o Nerve damage - also called neuropathy can weaken certain foot muscles
How do the macro (large) and micro (small) complications impact on the development of leg and foot ulcers?
• Blood and glucose levels o Elevated blood sugar levels can stiffen the arteries and narrow the blood vessels, the effects are far reaching and include the origin of the would as well as risk factors for proper wound healing • Poor circulation o Narrowed blood vessels and decreased blood flow and oxygen to a wound. Elevated blood sugar decreased oxygen and other nutrients getting to skin, tissues and muscles slowing wound healing, it also lessens white blood cells getting to the wound again slowing the healing process • Diabetic neuropathy o When blood sugar levels in the body remain uncontrolled nerves in the body are affected and can cause a loss of sensation, patients can not feel a blister, infection or surgical wound issue - because diabetic patients might not be able to feel a change to the status of the wound or the actual wound the severity might progress unchecked and there might be complications when healing • Immune system dificency o Diabetes lowers the efficency of the immune system, the bodies defence against infection, high glucose casues the immune system to function ineffectively which raises risk of an infection. Studies indicate that certain enzymes and hormones the body produce in respose to high blood sugar are responsible for negitively impacting the immune system • Infection o With a poorly fucntion immune system diabetics are at higher risk of developing an infection, infections raises many health concerns and slows the overall healing process. Left unchecked infection can lead to gangrene, sepsis or a bone infection such as osteomylitis
How does T2DM change wound healing?
• Regular exercise • Controlled diet • Medications to further control blood glucose levels • Attention to skin care and wound management • Regular podiatry visits • Education of patients to ensure health literacy levels and understanding of treatment and management requirements and an understanding if these management requirements can and will be undertaken by my patient
How is T2DM regulated effectively to prevent complications?
The two main causes for metabolic syndrome are obesity and insulin resistance. Insulin resistance is strongly associated with obesity and physical inactivity increasing the risk of patients not only have T2DM but also developing cardiovascular disease. Insulin resistance is a physiological condition in which cells fail to respond to the normal actions of the hormone insulin. The body produces insulin, but the cells in the body are unable to use this effectivley leading to high blood sugar. Beta cells in the pancreas increase levels of insulin further contributing further still to high blood insulin levels.
How is metabolic syndrome related to T2DM?
The time mnemonic • T - tissue viability of the tissue on the wound, if the tissue is not viable it will have black eschar and slough and may require debridement or removal • I stands for inflammation and will show signs of redness, pain, swelling, and heat, if there are signs of infection treatment is required • M - stands for moisture imbalance, as a nurse I would view the scab, if the wound is to dry wound contracture might occur and healing would be delayed, conversley if the wound is too wet maseration will occur because of the exudate. Moisture balance is important for healing as it acts as a medium to transport growth factors and enhances the natural debridement process) • E - stands for the edges of the wound, attention needs to be paid to if the edges of the wound are non advancing (non healign wounds) or becoming undermined - non-advancing and underminded wounds can my signs of infection
How would you identify if a wound was infected?
• Don't skip or delay meals or snacks. If you take insulin or oral diabetes medication, be consistent about the amount you eat and the timing of your meals and snacks. • Monitor your blood sugar. Depending on your treatment plan, you may check and record your blood sugar level several times a week or several times a day. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range. • Measure medication carefully, and take it on time. Take your medication as recommended by your doctor. • Adjust your medication or eat additional snacks if you increase your physical activity. The adjustment depends on the blood sugar test results and on the type and length of the activity. • Eat a meal or snack with alcohol, if you choose to drink. Drinking alcohol on an empty stomach can cause hypoglycemia. • Record your low glucose reactions. This can help you and your health care team see patterns contributing to hypoglycemia and find ways to prevent them. • Carry some form of diabetes identification so that in an emergency others will know that you have diabetes. Use a medical identification necklace or bracelet and wallet card.
Identify the information you would discuss with Jeff (Case Study 8) to ensure he understands how to prevent hypoglycaemia.
• Anne's high carbohydrate diet • Wounds are metabolically active, to promote healing a balanced combination of energy, macro nutrients (carbohdrate, protien and fat) and micronutrients (minerals, vitamins and trace elements) • Alcohol increases susceptability for infection by lowering the bodies natural immunities • Growth of micro-organisms is stimulated by increased glucose levels • Impaired blood supply hinders healing because there are lower levels of oxygen, white blood cells and vital nutrients getting to the tissues • Decreases collagen synthesis, retards capillary growth impairs phagocytosis
In Case Study 7, what impairs the healing of Anne's wounds?
The glucose insulin potassium (GIK) drip is a single solution infusion that includes 500ml of D5W, 10mmol of potassium chloride and 15 units of short acting insulin. The solution is infused at an initial rate of 100ml/hr. The solution can be altered depending on the blood glucose measured every two hours by adding or subtracting 5 units of insulin. The regimen is safe because the insulin and glucose are given together but may require frequent changes in intravenous solution. The blood glucose should be monitiored frequently at least every two hours. The issue with this course of treatment is that if glucose levels run low based upon the target levles and the infusion is stopped patients with type 1 diabetes can become ketotic.
In Case Study 8, Jeff's blood glucose level has had wide fluctuations in his first 24 hours of admission. He has been commenced on Glucose Insulin Potassium (GIK) infusion with sliding scale insulin management. How will this stabilise his blood sugar levels?
As a result of T1DM, the beta cells in the Islets of Langerhans in Jeff's pancreas are no longer able to produce insulin due to the previously mentioned autoimmune disorder. Without administration of daily insulin, Jeff's body would be unable to manage it's blood glucose levels resulting eventually in a life-threatening medical situation. That is because: • Inside cells glucose is stored and used later for energy • As beta cell mass declines insulin production decreases until the amount of insulin is no longer able to maintain normal blood sugar levels • Without insulin, glucose builds up in the blood stream instead of going into cells • After 80-90% of beta cells are destoyed, hyperglyceamia develops and diabetes may be diagnosed. • As there is no insulin available the glucose can not enter the cell and there is no glucose available for cell metabolism • In reponse fat lipolysis occurs in the body tissue • If no insulin is administered to patients, fats continue to get broken down into fatty acids and conversly these fatty acids are broken down into ketones in the liver • By promoting protein synthesis, insulin enhances the activity of cellular mechanisms. Glucose comsumption increases and blood sugar decreases. Insulin is the only hormone capable of down regulating blood sugar, so patients suffering from T1DM experience acute periods of hyperglycaemia • Insulin has important functions in the metabolism of carbohydrates, fatty acids and amino acids when the molecules enter the blood stream in their absorptive stat insulin catalyses their cellular uptake and synthesis into glycogen, triglycerides and proteins • With regards to glucose regulation, insulin has 4 main functions depending on glucose levels and cellular needs o Insulin opens the glucose transport protiens (GLUT 1-5) allowing passive diffusion of glucose into cells o Insulin stimulates formation of glycogen from glucose for the purpose of storing energy in cells o Insulin inhibits the breakdown of glycogen to glucose favouring the glycogen state reducing output of glucose by the liver o Glucose prevents the breakdown of glucose from amino acids by reducing the amount of amino acids available to the liver as well as blocking the hepatic glucogenic enzymes
In Case Study 8, why does Jeff require insulin for the rest of his life? (ie. What is the pathophysiology of T1DM?)
If possible, check blood glucose on your meter. It may be something else making you feel unwell. If in doubt, or if you are feeling very unwell, treat your low blood glucose anyway. Remember, "if in doubt, treat." Step 1 Eat or drink one serving of a quick acting carbohydrate. Choose one serving from (4-5 dextro-energy tablets, 4-5 glucotabs, 7-8 jellybeans, 3 teaspoons of glucose powder or sugar in water, a small glass of fruit juice or sugar-sweetened soft drink non-diet (100-150mls), 3 teaspoons of honey or jam.) Step 2 After 10 minutes, test your blood glucose level again. If it is still less that 4 mmol/L, eat another serving of quick-acting carbohydrate (list above). Step 3 Once your blood sugar is above 4 mmol/L, follow up with more substantial carbohydrate food. If it is your mealtime, eat your meal. Otherwise, have a snack, such as: 1 glass (250ml) of low-fat mik. 1 medium raw fruit 1 small tub of low-fat, diet yogurt. 3-4 crackers 1 slice of wholegrain bread as a small sandwich Make sure your family and friends know the signs of a hypo and how to help you. When you have treated your hypo, ask yourself why it happened and what you need to do to stop it happening again. You should not have any more than 2 hypos per week. If you can't find a cause or they keep happening, contact your healthcare team.
Treating Hypoglycaemia (from diabetes.org.nz)
• This is a problem controlling blood sugars, meaning the panceas will compensate by producing larger levels of insulin • Insulin resistance is the primary cause of hyperinsulinaemia with the pancreas compensating by producing more insulin • Insulin resistance of this type can lead to development of T2DM which occurs when the pancreas cannot secrete the insulin required to maintain normal blood glucose levels. • Consequences are - higher triglyceride levels , high uric acid, hardening of the arteries, weight gain, hypertension, T2DM, intense hunger polyphagia, difficulty concentrating, feeling anxious and panicky, general malaise
What are the causes and consequences of hyperinsulinaemia?
Usually found on the lateral side of the ankles, feet, heels, toes but not always just lateral ankle Frequently painful, particularly at night in bed or when the legs are at rest and elevated. This pain is relieved when the legs are lowered with feet on the floor and it is postulated that gravity causes more blood to flow into the legs, but we do not really know. Sufferers may find they will hang their legs over the side of the bed at night, or sit or stand for relief. (Rest pain) The borders of the ulcer appear as though they have been 'punched out' and have a gray base Associated with cold white or bluish, shiny -skinned feet There may be cramp-like pains in the legs when walking, known as intermittent claudication, as the leg muscles do not receive enough oxygenated blood to function properly. Resting just a few minutes will relieve this pain. Doppler arterial testing by a vascular specialist to measure the ankle to brachial index and toe to brachial index. The level of severity can be determined by these pressures. Arterial ulcer treatments vary depending on the severity of the arterial disease.
What are the characteristics of arterial ulcers?
Diabetic ulcers have similar characteristics to arterial ulcers but are more notably located over pressure points such as heels or between toes or anywhere on the bottom of the feet where the bones may protrude and rub on wrinkles in socks or improper fitting shoes. In response to pressure, the skin increases in thickness (or forms a callus) but with a minor injury breaks down and thus an ulcer is formed. Infected ulcers may have surrounding tender redness, warmth and swelling (cellulitis).
What are the characteristics of diabetic (neuropathic) ulcers?
Located below the knee and most often on the inner part of the ankles but can be anywhere around the ankles • Relatively painless unless infected • Associated with aching, swollen lower legs that feel more comfortable when elevated • Surrounded by mottled brown or black staining and/or dry, itchy and reddened skin (eczema) • Usually associated with varicose veins due to incompetence of the superficial venous system • May be associated with lipodermatosclerosis, which is loss of tissue under the skin and in which the lower part of the leg is hardened. This skin is brown because of leakage of the capillaries of protein and red blood cells (hemosiderin) that stain the tissue brown. • Often associated with swelling, which may be caused by local inflammation. Chronic (constant or long lasting) inflammation destroys underlying lymphatic vessels, causing lymphedema and increased pressure in the lower leg. • Thickened skin, scaliness, tiny rough bumps on the lower legs and feet, fissuring, oozing
What are the characteristics of venous ulcers?
• Diabetic Cardio Myopathy o What is this? o Damage to the heart muscle leading to impaired relaxation and filling of the heart with blood - this is diastolic disfunction. And eventually heart failure, this condition can appear independantly of damage done to blood vessels overtime from high levels of blood sugar. • Diabetic nephropathy o What is this? o Damage to the kidney that can lead to chronic kidney failure, eventually requiring dialysis. Diabetes Mellitus is the leading cause of kidney failure in the developed world • Diabetic Neuropathy o Abnormal and decreased sensation, starting with the feet and potentially in other nerves, later often fingers and hands. Other forms of neuropathy may present as mononeuritis or autonomic neuropathy • Diabetic amotrophy o What is this? o Muscle weakness due to neuropathy • Diabetic retinopathy o What is this? o Growth of friable and poor quality new blood vessels in the retina as well as macular edema (swelling of the macular) which can lead to severe vision loss or blindness • Diabetic encephalopathy o What is this? o Is the cognitive decline and increased risk of alzhiemers (but not limited to) observed in diabetes. Various mechanisms are proposed including alterations to vascular systems in the brain and interaction with the brain itself • Macrovascular disease o This leads to cardiovascular disease to which accelerated atherosclerosis is a contributor • Diabetic myonecrosis - muscle waste • Peripheral vascular disease - which contributes to intermittent claudication - this is exertion related food and leg pain as well as diabetic foot • Stroke o Diabetes increases the risk of developing cardiovascular diasease. Althought the process of how diabetes increases the likelihood of athersclerotic plaque is not presciely known association between the two is profound. CVD is the primary cause of death with T1 and T2DM, CVD is accountable for the greatest component of health care expenditure in people with diabetes. Type 2 diabetes usually occurs in the setting of a metabolic syndrome which also includes obesity, hypertension, hyperlipidemia and increased coaguability Hyperlipidemia is high cholesterol
What are the macro (large) complications and micro (small) complications that lead to alteration in body functions for the patient with T2DM?
When wounds are infected, the classic signs of inflammation are disproportionate to the size and extent of tissue damage. It can be difficult to tell when a wound has crossed the line between normal inflammation and abnormal infection. You should suspect infection when the cardinal signs of inflammation are exaggerated: • Rubor (redness): an infected wound will have a poorly defined erythemal border, and redness will be obvious and disproportionate to the size and extent of the wound; there may also be proximal "streaking". • Calor (temperature): in infected wounds, the normal localized increase in skin temperature will be increased, and the warmth will extend farther from the wound borders; there may also be a systemic increase in temperature (fever). • Dolor (pain): wound infection often causes a very noticeable increase in the level of pain associated with the wound; in immunocompromised patients, an increase in pain may be the only sign that a wound has become infected, as the body's ability to mount an immune response will be dampened. • Functio Laesa (functional decline): an individual with an infected wound will often feel unwell, in addition to being unable to use the affected body part as usual; there may be fatigue or malaise, hypotension, tachycardia or other symptoms that contribute to functional decline.
What are the possible symptoms of an infected wound?
• Diabetes can cause nueropathy nerve damage that can lead to reduced sensation in the feet. Its important regular checks are untaken to ensure there is no injurt or hard skin that can calluse and ulcer. Decreased blood flow to the feet and therefore decreased nutrients reaching the feet can lead to ulceration, these wounds can potentially take longer periods of time to heal (or not heal at all) • Additionaly if you have lost sensation in your foot you might unwittingly damage your feed - podiatrist often help by cutting a diabetes toe nails to mitigate accidental self harm.
What are the reasons for regular podiatry checks?
Diabetes Smoking High blood fat/cholesterol Hypertension Renal failure Obesity Rheumatoid arthritis Clotting and circulation disorders History of heart disease, cerebrovascular disease or peripheral vascular disease
What are the risk factors for arterial ulcers?
Varicose viens History of leg swelling DVT - and DVT causing post thrombotic syndrome Stasis Hypertension Multiple pregnancies Previous surgery Fractures or injuries Increasing age and obesity, immobility
What are the risk factors for venous ulcers?
• Diabetetic Ketoacidosis o If hyperglycemia isnt treated a condition called diabetic ketoacidosis (diabetic coma) could occur. o Ketoacidosis develops when you body doesn't have enough insulin and is accompanied by counter regulatory hormones. Without insulin your body cant use glucose for fuel so your body breaks down its fats to use for energy o When your body breaks down fats waste products called ketones are produced. The body can not tolerate large levels ketones and will try to eleminate these through urine. Unfortunatly the body cant eliminate all these ketones and they build up in the blood causing ketoacidosis o This will cause signs and symptoms such as nausea, vomiting, and abdominal pain and can progress to cerebral odema and death
What are the risks of hyperglycaemia? What assessments do you need to complete to identify any risks occurring?
• Blood sugar monitoring Certain foods, activities and situations may impact their blood glucose levels. Data onbtained from testing blood sugar levels can help us evaluate how effective, or ineffective a new treatment routine or change of medication is. For people taking insulin it allows more accurate dosage adjustments
What assessments will you complete whilst caring for Jeff (Case Study 8)?
Diabetic ulcers are caused by a combination of arterial blockage and nerve damage, the nerve damage or sensory neuropathy reduces awareness of pressure, heat or injury. Rubbing and pressure on the foot goes unnoticed and caused damage to the skin and leads to neuropathic ulceration. Diabetic ulcers are more likely if diabetes is not well controlled by diet and medications.
What causes diabetic (neuropathic) ulcers?
Diabetic ulcers develop due to neuropathy - a type of nerve damage Neuropathy develops with persistant hyperglycaemia, this leads to the accumulation or sorbitol and fructose in the nerve, damage is then caused to the nerve resulting in reduced nerve conduction and demyelination
What causes neuropathy associated with diabetes?
A cluster of biochemical and physiological abnormalities/risk factors associated with the development of cardio vascular diasease, stroke and T2DM - these can include high blood pressure, increased blood sugars, fat stores around the waist
What is metabolic syndrome?
o Increased thirst and fluid intake o Diabetes causes blood sugar levels to rise o This causes the body to pull fluid from the blood stream delivering increased load to the kidneys by osmotic effect. This can cause production of more urine then normal and make the paitent dehydrated and thirsty, thirst is stimulated in the hypothalamus as a result of the instracellular dehydration o Glycosuria - water and electrolytes are lost in large levels in urine.
What is polydypsia?
o Increased hunger, depletion of cellular stores of carbohydrates fats and protein result in cellular starvation and corresponding increase in appetite o Weight loss and fatigue are due to loss of fluid in tissues, fat and protiens are used as an energy source
What is polyphagia?
o Frequent urination 3+ltrs o Condition where the body urinates more then usual and passes excessive or abnormally large amounts of urine each time you urinate. The amount of glucose filtered by the glomeruli of the kidney exceed what can be reaborded by the renal tubules, glycosuria results accompanied by large amounts of water lost in urine. o Each kidny contains about a million function units called nephrons. o The first step in the production of urine is a process called filtration, in filtration thee is bulk flow of water and small molecules from the plasma into the bowmans capsule. During filtration small useful molecules from the plasma such as glucose and amino acids and certain ions end up in the forming urine which flows into the kidney tubules. o To prevent loss of of these useful substances from the body the cells lining the tubule in the kidney transfer these out of the forming urine into the extracellular fluid. o This process is known as reaborption o Undernormal circumstances glucose is filtered in the nephron freely and reabsorbed. Glucose reabsorption involves transort protiens that require specific binding. In a patient with T1DM the filtered load of glucose can exceed the capacity of the renal tubules to absorb glucose because the transport protiens become saturated. This results in glucose being passed in the urine, due to high levels of glucose in the blood overwhelming the kidneys ability to absorb it. Since glucose is a solute that draws water into the urine by osmosis. o Hyperglycaemia causes a diabetic paitent to produce high levels of glucose containing urine. This is called glycosuria
What is polyuria?
Venous insufficiency refers to improper functioning of the one-way valves in the veins. Veins drain blood from the feet and lower legs uphill to the heart. Arterial insufficiency refers to poor blood circulation to the lower leg and foot and is most often due to atherosclerosis.
What is the difference between arterial and venous insufficiency?
• The inflammatory response is a sequential reaction to cell injury • It dilutes and nutrilises the inflammatory agent removes necrotic agents materials and establishes an enviroment for healing and repair • Inflammation is always present with infection but infection is not always present with inflammation • Infection involves invasion of tissues or cells by fungi, micro-organisims, bacteria and viruses • Inflammation can be cuased by heat, radiation, trauma, chemicals. Allergins and autoimmune complications • If patient is post op the infection might become evident 3-5 days post op.
What is the difference between inflammatory response and developing an infection?
Neuropathy is the gateway to development of foot ulceration in diabetic patients. Intensive treatment of blood glucose concentration has been shown to slow onset and progression of peripheral neuropathy. It is critical that patients at risk of foot ulceration receive appropriate blood sugar management from their primary care physician. Regular screening for development of neuropathy, intensive podiatric care and custom footware may all reduce the risk of ulceration. Once ulceration occurs treatment should focus on pressure relief, debridement and possible infection. Client should also be educated on foot health, exaiming feet and legs, ensuring they do not cut their own toenails with anything sharp and self management of exercise and healthy eating.
What is the necessary nursing intervention for leg and foot ulcers?
1 - damage to the tissue - histamines increase blood flow to the area - histamines are chemical messengers that increase blood flow to the area by causing capillaries to leak 2 - releasing phagocytes and clotting factors into the wound 3 - phagocytes engulf bacteria, dead cells and cellular debris 4 - platelets move out of the capillary to seal the wounded area
What is the pathology of inflammation?
• Warm saline stimulate healing because it promotes vasodilation (increased blood flow to an area). A mild saltwater solution irrigates, cleanses and allows cells to rejenerate. Saline soaks keep the cells well hydrated while flushing out fluid and cellular material that can accumlate in a wound. This reduces crusting and helps to prevent trapped matter which can create unsighlty and difficult to elimate bumps. If debris is not removed it can impede healing. The warm water opens capallieries, stimulating blood flow which transport blood flow to the region promoting healing • Moist dressings o Are soaking of a bulky dressing to aid in cleansing, drainage and debridement of a wound. It might be applied intermittantly or continously. As moisture evaporates it cools and dries the skin, softens dried blood and sera and stimulates drainage. Wounds cant heal if there is drainage and gunk in it and sets ups conditions for infections to form. • Holistic interventions o Wounds can cause sleep deprivation, be maloderous, restrict mobility and cause social hardship which can lead to depression and anxiety o Holistics interventions are important because they highlight priorities and effective treatment options to the patient. o It involves perception of an individual as an intergrated system rather that one or more separate parts. o This involves physical, mental, spiritual and emotional. o Holistic interventions prevent complications by understanding underlying causes of health issues, identify co-morbidities and complicatations that can lead to delayed wound healing. o It is important to consider and assess interventions that can reduce the effect the wound may have on a paitents everyday lives o Also we need to understand the patient's health literacy and if they are able to care for the wound and what support might be offered to improve chances of healing and better long term health outcomes.
What is the reasoning behind moist dressings and use of warmed saline irrigations?
• Weight - being overweight and obese (particularly carrying weight around the abdomin - beuase this adipose is highly vascular and interacts with the endocrine system). The more adipose tissue you have (anywhere) the higher your risk of developing diabetes. • The less active you are the higher your risk factors for getting diabetes • Genetics • Race - although its not clear why certain races inluding maori, pacific islanders, blacks hispanics and indians are more likely to develop diabetes • Age - risk increases as we age - especially after the age of 45, this could be because as we age we exercise less, lose muscle mass and gain weight. Type 2 DM is also increasing amongst children and adolescents as our populations become more obese this increases risks • Prediabetes - is a condition where blood sugar levels are higher then normal but not high enough to be classed as diabetes, left untreated it is likely to process to T2DM
Who is at risk of developing Type 2 DM?
The development of foot ulcers in diabetic patients has several parts: • Neuropathy, biomechanical pressure,and vascular supply • Perphieral neuropathy is a dominant factor in the pathogenesis of diabetic foot ulcers this is because people with diabetes have reduced blood circulation throughout the body especially in the parts furthest from the heart, such as legs and feet, this slows venus return • There might be reflux in the valves, obstruction in the viens and impaired calf pumping action resulting in pooling of blood around the bottom half of the leg to just below the ankle • Increased venous pressure causes fibrin deposits around capillaries which then act is a barrier to oxygen and nutrients making it to muscle and tissue. • The death of this tissue leads to ulceration • The sensory component of nueropathy results in decreased ability to perceive pain from foreign bodies, trauma or areas of increased pressure on the foot, loss of sensation and trauma on the foot lead to skin rbeakdown and are often accompanied by ulcer formation at the site of pressure • Open wounds lead to increased bacterial infection
Why are leg or foot ulcers a common health issue for someone with Type 2 Diabetes Mellitus?
T2 DM is primarily a vascular disease. Leg and foot ulcers result from a combination of microvascular and macrovascular diseases that place patients at risk injury or amputation Leg and foot ulcers in diabetic patients have three potential causes: venous insufficiency peripheral neuropathy (neurotrophic ulcers), or peripheral arterial occulsive disease (claudication) Claudication, which is defined as reproducible ischemic muscle pain, is one of the most common manifestations of peripheral arterial occlusive disease (PAOD) caused by atherosclerosis. Claudication occurs during physical activity and is relieved after a short rest. Pain develops because of inadequate blood flow. Venus ulcer risk factors o Varicose viens o History of leg swelling o DVT - and DVT causing post thrombotic syndrome o Stasis o Hypertension o Multiple pregnancys o Previous surgery o Fractures or injuries o Increasing age and obesity, immobility Risk factors for arterial ulcers o Diabetes o Smoking o High blood fat/cholesterol o Hypertension o Renal failure o Obesity o Rhuematiod arthritis o Clotting and circulation disorders o History of heart disease, cerebrovascular disease or peripheral vascular disease • Diabetic ulcers are caused by a combination of arterial blockage and nerve damage, the nerve damage or sensory nueopathy reduces awareness of pressure, heat or injury. Rubbing and pressure on the foot goes unnoticed and caused damage to the skin and leads to neuropathic ulceration. Diabetic ulcers are more likely if diabetes is not well controlled by diet and medications. • Diabetic ulcers develop due to neuropathy - a type of nerve damage • Develop with persistant hyperglycaemia, this leads to the accumulation or sorbitol and fructose in the nerve, damage is then caused to the nerve resulting in reduced nerve conduction and demylination • Ischemia in blood vessels due to chronic levels of high blood sugars - hyperglycaemia that supply the peripheral nerves is also implicated in the development if diabetic neuropath • Put more simply high blood sugar levels mean there is a very high level of glucose in the blood stream (hyperglycaemia), in T2DM glucose can not be absorbed into the target cells (or at lower then optimal levels) to reduce blood sugar levels to within normal ranges • This means there are lower levels of oxygen, white blood cells and vital nutrients getting to the tissues, damage to arteries and blood vessels can lead to ischemia which can lead to nerve and tissue damage and death • PVD peripheral vascular disease - in PVD, blood vessels become narrowed and blood flow decreases. This can be due to arteriosclerosis, or "hardening of the arteries," or it can be caused by blood vessel spasms. In arteriosclerosis, plaques build up in a vessel and limit the flow of blood and oxygen to your organs and limbs. • As plaque growth progresses, clots may develop and completely block the artery. This can lead to organ damage and loss of fingers, toes, or limbs, if left untreated. • High blood sugars, reduced oxygen, nutrients and white blood cells lead to arteriosclerosis, this is a hardening of the vessels caused by a plague build up from deposits of fatty acids (foam cells) arteriosclerosis (and it can take decades) leads to ischemia vessel narrowing and damage leading to infarction - tissue death
Why do people with T2DM develop leg ulcers?
T1DM is an autoimmune disorder characterized by the destruction of insulin-secreting beta cells in the islets of langerhans in the Pancrea. Pancreatic cells stop producing insulin in the levels required to maintain normal glucose levels. Insulin is needed to introduce blood sugar (glucose) into cells • The attack on the beta cells is initiated by activated cytotoxic T-lymphocytes that target specific islets for destruction • The CTL activity triggers the release to cytokines (immune hormone messengers) which inturn stimulate the proliferation of activated macrophages and autoantibodies that are attracted to the site of inflammation. The antibodies along with complement-mediated lysis as well as macrophages and CTL activity are responsible for the overall destruction of pancreatic tissue
Why is Type-1 Diabetes Mellitus considered an autoimmune disorder?
If you ignore the symptoms of hypoglycemia too long, you may lose consciousness. That's because your brain needs glucose to function properly. Recognize the signs and symptoms of hypoglycemia early because untreated hypoglycemia can lead to: • Seizure • Loss of consciousness • Death Hypoglycemia unawareness Over time, repeated episodes of hypoglycemia can lead to hypoglycemia unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats. When this happens, the risk of severe, life-threatening hypoglycemia is increased. Undertreated diabetes • If you have diabetes, episodes of low blood sugar are uncomfortable and can be frightening. Repeated episodes of hypoglycemia may cause you to take less insulin to ensure that your blood sugar level doesn't go too low. But long-term high blood sugar levels can be dangerous, too, possibly causing damage to your nerves, blood vessels and various organs.
Why is hypoglycaemia a risk for Jeff, in Case Study 8?