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REFERAT

Diabetic Ulcer

definition
Diabetic ulcer is an open lesion on
the surface of the skin due to
angiopathy complications resulting
in
vascular
insufficiency
and
neuropathy, which in further there
is a lesion in patients which is often
not perceived, and can progress to
an infection caused by aerobic and
anaerobic bacteria.

epidemiology
Indonesia 15% of diabetic
patient
Foot diabetic ulcer Most causes
of hospitalization by 80% to
diabetic patient
mortality rate 32%
amputation 30%
diabetic
patient
with
post
amputation 14,3% will be die

Etiology
The
etiologies
of
diabetic
ulceration include neuropathy,
arterial disease, pressure, and foot
deformity.
Diabetic
peripheral
neuropathy, present in 60% of
diabetic persons and 80% of
diabetic persons with foot ulcers,
confers the greatest risk of foot
ulceration; microvascular disease

classification

Risk factor
Risk factors that can not be changed:
1. age 60 years old
2. Diabetic periods 10 tahun
. The risk factors that can be changed
(including habits and lifestyle):
1. neuropathy (sensory, motor, peripheral)
2. Obesity
3. Hypertension
4. Uncontrolled Glycosylated hemoglobin
(HbA1C)
5. Uncontrolled blood glucose

6. Vascular insufficiency because of


Atherosclerosis that caused by:
a) Uncontrolled total cholesterol level
b) Uncontrolled HDL level
c) Uncontrolled triglycerides
7. Smoke
8. Disobedience Diabetic Diet

Pathogenesis

In patients with diabetes uncontrolled


blood glucose levels are not controlled
cancaus complications such as
neuropathy,
changes in nerve tissue is due to
accumulation of sorbitol and fructose
As a result axons started to dissapear,
decreasing the speed of induction,
paresthesia, decreased muscle reflex,
muscle atrophy, excessive sweating, dry
skin and numbness

Ischemia is a condition where there is a lack of


blood supply (oxygen deprivation) in the tissue.
This is due to the process of macroangiopathy in
blood vessels, decreased tissue circulation
characterized by missing or reduced pulse in the
dorsalis pedis artery, tibial and popliteal, foot
atrophy, and cold toe tip.
The disorder occurs subsequent to a tissue
necrosis causing ulcers that usually starts from
the foot or leg.

Atherosclerosis is a condition in
which the arteries thicken and
narrow due to the buildup of fat on
the inside of blood vessels.

Thickened arteries in the legs can


affect the muscles of the legs due to
reduced blood supply, resulting in
tingling, discomfort, and in the long
term can lead to tissue death which
will develop into a diabetic ulcer.

Angiopathy process in patients with


Diabetes mellitus is a narrowing and
blockage of peripheral blood vessels,
often occurs in the lower limbs,
especially legs, as a result of reduced
tissue perfusion to the distal part of
the legs that can give rise to diabetic
ulcers.

High blood glucose levels can lead to


thickening of the intima (hyperplasia
of the arterial basal membrane)
albumin could leak out of large blood
vessels and capillaries which can
disturb the distribution of blood to
tissues and lead to tissue necrosis
and diabetic ulcers.

Erythrocytes in patients with


uncontrolled diabetes will have an
increase in HbA1C which causes
erythrocyte deformability ineffective
oxygen release in tissues, resulting in
blockages that interfere with tissue
circulation and lack of oxygen resulting
in tissue death that subsequently give
rise to diabetic ulcers.

Increased levels of fibrinogen and


increased platelet reactivity
resulting in increased aggregation of
red blood cells blood circulation
becomes slow and facilitate the
formation of thrombi in the blood
vessel which would interfere with
blood circulation.

Inflammatory changes in the blood


vessels, accumulation of fat in the
lumen of blood vessels, as HDL
concentrations are usually low.
The existence other risk factor that
increases susceptibility to
atherosclerosis such as hypertension.
Atheroscrelosis can cause decreased
circulation to the foot tissue, causing
necrosis and ulcer

Signs and symptoms of diabetic ulcers


are:

Frequent tingling
Leg pain at rest
diminished sensoric perception
Tissue damage (necrosis)
Decreased pulse of the dorsalis
pedis, tibial and popliteal arteries
Leg atrophy
dry skin

Examination in Diabetic
Ulcer
Whean treating patient wit diabetic
ulcer, there are a few steps that can be
done to determine the wound status :
1. Wound Asessment
a) Determine the wound location : this is
useful as an indicator to what caused
the wound, therefore minimizes the
probability of the wound from occuring,
by eliminating the cause of the wound.

b) Evaluate the grade of the wound :


according to Wagner grading system
for diabetic foot ulcer.
c) Wound colour : If the colour at the
base of the wound is red, the thw
wound is clean and is rich in
vascularisation. If yellow, then the
wound is infected, if it is black or
dark coloured then the tissue is
necrotic and avacular.

d) Wound shape and size : evaluate the


wound size; length, width, and depth
e) Vascular status
i. Subjective : is patient still sensitive to pain
on the wound area.
ii. Objective : observe the skin colour, is it
pale or cyanotic distal to the wound.
iii. Palpation :
1. Any changes in temperature especially on toe
tip (becoming colder)
2. Palpate pulse beat distal to the wound,
whether it is still palpable, or not tekanan nadi.

b. Ankle Brachial Index (ABI)


The Ankle Brachial Index is a non invasive
vascular screening test, to identify enlargement
of blood vessels and peripheral vascular diseases,
by comparing the systolic pressure on the ankle
with brachial systolic pressure, in which central
systolic pressure can be estimated. ABI is
measured using continous wave Doppler, a
sphygmomanometer, and a pressure cuff to
measure the ankle and brachial systolic pressure.
ABI has a high sensitivity an specifity in
diagnosing arterial diseases of the lower
extremity. ABI of less than 0.9 indicates an
arterial disease of the lower extremity.

Indications of ABI
Intermittent claudication
Diagnosing a patient suspected of a lower
extremity arterial disease with wound on the
lower extremity
People over 70 years
People over 50 years with a history of smoking
and diabetes.
To evaluate the arterial flow of the lower
extremity, and to determine the process for
compression therapy, or wound debridement.
To determine the wound healing potential.

Contraindication of ABI
Severe pain on the leg
Deep vein thrombosis
Severe pain linked to wound of the
lower extremity.

ABI Procedure
Place the patient at a supine position for 20
minutes
Make sure the toe area is not blocked or
obstructed by clothing
Cover the wound with cuff
Place the measurement cuff above the ankle
Doppler probe is placed in the anterior tibial
and dorsalis pedis arteries (with connecting
gel) directions of probe is set to 450

Press cuff until until pulse sound dissapears


Press cuff again to lower pressure until pulse
sound appears, this point is the ankle systolic
pressure
Move cuff to arm of the same side
find the brachial pulse with doppler probe.
Press cuff until until pulse sound dissapears
Press cuff again to lower pressure until pulse
sound appears, this point is the brachial
systolic pressure
Count the ABI by dividing the ankle systolic
pressure with the brachial systolic pressure.

ABI score

Perfusion Status

>1.3

Elevated, incompressible
vessels

>1.0

Normal

<0.9

Lower Extremity Arterial


Disease

<0.6 to 0.8

Borderline

<0.5

Severe Ischemia

<0.4

Critical Ischemia, limb


threatened

Treatment
a. correction of vascular abnormalities
b. Improve circulation
c. Manage the problems that arises (infections,
necrosis)
d. Foot care education.
e. The provision of appropriate medications for
infections (according to laboratory results) and
eliminate symptoms and compklications of diabetes.
f. Regular excercise to maintain an ideal body weight
g. Stop smoking

h. Daily foot care


i. Using the right footwear
J. Avoid repeated trauma, whether it is
physical, chemical or thermal
k. Avoid the use of vasoconstrictors
l. Regular check up to the doctor even
after the foot ulcer have healed.

Debridement
One of the most important action in
wound care
Debridement is an action to dispose
the necrotic tissue, callus and fibrotic
tissue around 2-3 mm from the wound
edges. Debridement increases the
growth factors which helps the wound
to heal. Frequent debridement
methods are : Surgical, autolytic,
chemical, and mechanical

Debridement cont.
Surgical, autolytic, and chemical
debridement only removes the
necrotic tissues (selective
debridement), while mechanical
debridement removes both the
necrotic tissue and healthy tissue
around the wound (non-selective
debridement)

Offloading
Is a reduction in pressure on the ulcer,
diabetic ulcers usually occurs on
lacations receiving high pressure, bed
rest is the best way to reduce
pressure.