SILLIMAN UNIVERSITY

COLLEGE OF NURING
DUMAGUETE CITY

RESOURCE UNIT ON
THE CARE OF CLEINT WITH
DIABETIC FOOT
AND
PERIPHERAL VASCULAR DISEASE (PVD)

Date:

2016|06|10

Submitted to:

Asst. Prof. Maria Ellaine A. Adarna

Submitted by:

Kriemheld Kriel Straecy Grace Bubbles Bajar

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

Vision
A leading Christian institution committed to total human development for the well being of society
and environment.
Mission
Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ.
Provide an environment where Christian fellowship and relationship can be nurtured and
promoted.
Provide opportunities for growth ad excellence in every dimension of the University life in order
to strengthen character, competence and faith.
Instill in all members of the University community an enlightened social consciousness and a
deep sense of justice and compassion.

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

Placement: NCM 106A, 1st Semester, Level IV

Time allotment: 30 minutes
Topic description: This unit emphasizes on the care given to a surgical client having diabetic foot and peripheral vascular
disease. The concepts include pathophysiology, nursing diagnosis, and pain management of the diseases.
Central objective: At the end of the ward class, the learners shall acquire new knowledge, learn beginning skills, and develop a
positive attitude in the care of surgical client having diabetic foot and peripheral vascular disease.
SPECIFIC
OBJECTIVE

At the end of the

30-minute
discussion, the
learners shall:

1. Briefly
discuss the
description
of a diabetic
foot;
2. Describe

CONTENT

I.

Diabetic Foot

A. Definition
The development of diabetic foot is a multifactorial process.
They result from a combination of microvascular and macrovascular
diseases that place the patient at risk for injury and serious infection that
may lead to amputation.
B. Signs and Symptoms
A.
Cellulitis
Tender, erythematous, nonraised skin lesions are present,

T.A.

10
mins.

T-L
ACTIVITIE
S

Lecture
with
socialized
discussion
(slideshow
presentati
on)
Diagrams
/Illustratio
n

EVALUATION
METHOD

Question and
Answer (with
incentives if
able to answer)

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

and signs
and
symptoms
of a diabetic
foot;

sometimes with lymphangitis . Lymphangitis suggests group A

streptococcal infection. Bullae are typical of Staphylococcus aureus
infection, but occasionally occur with group A streptococci. No ulcer or
wound exudate is present.
B.
Deep-skin and soft tissue complication
The patient may be acutely ill, with painful induration of the soft
tissues in the extremity. Wound discharge is usually not present. In mixed
infections that may involve anaerobes, crepitation may be noted over
the afflicted area. Extreme pain and tenderness may indicate
compartment syndrome or clostridial infection (ie, gas gangrene). The
tissues are not tense, and bullae may be present. Discharge, if present,
is often foul.

C.
Acute osteomyelitis
Unless peripheral neuropathy is present, the patient has pain at
the site of the involved bone. Usually, fever and regional adenopathy are
absent.
D.
Chronic osteomyelitis
The patient's temperature is usually less than 102F. Discharge
is commonly foul. No lymphangitis is observed. Pain may or may not be
present, depending on the degree of peripheral neuropathy. Deep,
penetrating ulcers and deep sinus tracts (diagnostic of chronic
osteomyelitis) are usually located between the toes or on the plantar
surface of the foot. The medial malleoli, shins, or heels are not usually

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

sites of involvement .
3. Enumerate
at least 5
possible
complicatio
ns of a
diabetic
foot;

C. Possible Complications
1. Skin changes
Diabetes can cause changes in the skin of your foot. At times
your foot may become very dry. The skin may peel and crack. The
problem is that the nerves that control the oil and moisture in your foot
no longer work.
2. Neuropathy or nerve damage
Although it can hurt, diabetic nerve damage can also lessen
your ability to feel pain, heat, and cold. Loss of feeling often means you
may not feel a foot injury. You could have a tack or stone in your shoe
and walk on it all day without knowing. You could get a blister and not
feel it. You might not notice a foot injury until the skin breaks down and
becomes infected. Nerve damage can also lead to changes in the shape
of your feet and toes.
3. Calluses
Calluses occur more often and build up faster on the feet of
people with diabetes. This is because there are high-pressure areas
under the foot. Too much callus may mean that you will need therapeutic
shoes and inserts. Calluses, if not trimmed, get very thick, break down,
and turn into ulcers (open sores).
4. Foot ulcers

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

Ulcers occur most often on the ball of the foot or on the bottom
of the big toe. Ulcers on the sides of the foot are usually due to poorly
fitting shoes. Remember, even though some ulcers do not hurt, every
ulcer should be seen by your health care provider right away. Neglecting
ulcers can result in infections, which in turn can lead to loss of a limb.
5. Poor circulation
Poor circulation (blood flow) can make your foot less able to
fight infection and to heal. Diabetes causes blood vessels of the foot and
leg to narrow and harden. You can control some of the things that cause
poor blood flow. Don't smoke; smoking makes arteries harden faster.
Also, follow your health care provider's advice for keeping your blood
pressure and cholesterol under control.

4. Enumerate
at least 5
prevention
of foot
problems in
diabetes;

6. Deformities
The structure and appearance of the feet and foot joints can
indicate diabetic complications. Nerve damage can lead to joint and
other foot deformities. The toes may have a peculiar "claw toe"
appearance, and the foot arch and other bones may appear collapsed.
D. Prevention
1. Quit smoking
Smoking can worsen heart and vascular problems and reduce
circulation to the feet.
2. Avoid of activities that can injure the feet
Some activities increase the risk of foot injury and are not
recommended, including walking barefoot, using a heating pad or hot

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

5. Recite
treatment
and care
manageme
nt of a
diabetic
foot;

water bottle on the feet, and stepping into the bathtub before testing the
temperature.
3. Use care when trimming the nails
Trim the toe nails along the shape of the toe and file the nails to
remove any sharp edges. Never cut (or allow a manicurist to cut) the
cuticles. Do not open blisters, try to free ingrown toenails, or otherwise
break the skin on the feet. See a healthcare provider or podiatrist for
even minor procedures.
4. Wash and check the feet daily
Use lukewarm water and mild soap to clean the feet. Gently pat
your feet dry and apply a moisturizing cream or lotion. Check the entire
surface of both feet for skin breaks, blisters, swelling, or redness,
including between and underneath the toes where damage may be
hidden. Use a mirror if it is difficult to see all parts of the feet or ask a
family member or caregiver to help.
5. Choose socks and shoes carefully
Select cotton socks that fit loosely, and change the socks every
day. Select shoes that are snug but not tight, and break new shoes in
slowly to prevent any blisters. Ask about customized shoes if the feet are
misshapen or have ulcers; specialized shoes can reduce the chances of
developing foot ulcers in the future. Shoe inserts may also help cushion
the step and decrease pressure on the soles of the feet.
6. Ask for foot exams
Screening for foot complications should be a routine part of
most medical visits, but is sometimes overlooked. Don't hesitate to ask
the healthcare provider for a foot check at least once a year, and more
frequently if there are foot changes.

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

E. Treatment and Management

1. Debridement
The treatment of foot problems depends upon the presence and
severity of foot ulcers. Treatment of superficial ulcers (involving only the
top layers of skin) usually includes cleaning the ulcer and removing dead
skin and tissue (debridement) by a healthcare provider. There are a
number of debridement techniques available. If the foot is infected,
antibiotics are generally prescribed. The patient (or someone in his or
her household) should clean the ulcer and apply a clean dressing twice
daily. The patient should keep weight off the foot ulcer as much as
possible, meaning that they should not walk with the affected foot. The
foot should be elevated when sitting or lying down. The ulcer should be
checked by a healthcare provider at least once per week to make sure
that the ulcer is improving.

6. Contrast
peripheral
vascular
disease
(PVD) from
diabetic
foot;
7. Differentiate

2. Amputation
If part of the toes or foot become severely damaged, causing
areas of dead tissue (gangrene), partial or complete amputation may be
required. Amputation is reserved for patients who do not heal despite
aggressive treatment, or whose health is threatened by the gangrene.
Untreated gangrene can be life-threatening.

II.

Peripheral Vascular Disease (PVD)

15
mins.

Lecture
with
socialized
discussion
(slideshow
presentati
on)
Diagrams
/Illustratio
n

Question and
Answer (with
incentives if
able to answer)

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

the types of
PVD;

8. Enumerate
at least 3
causes of
PVD;

A. Definition
Refers to any disease or disorder of the circulatory system
outside of the brain and heart. Although the term peripheral vascular
disease can include any disorder that affects any of the blood vessels, it
often is used as a synonym for peripheral artery disease. Peripheral
vascular disease is the most common disease of the arteries. It is caused
by build-up of fatty material within the vessels, called atherosclerosis.
B. Types of PVD
There are two main types of PVD
1. Functional PVD
This does not involve physical problems in the blood vessels. It
causes incidental or short-term symptoms. Usually these spasms occur
erratically.
2. Organic PVD
This involves changes in blood vessel structure. This type of
PVD causes inflammation, tissue damage, and blockages.
C. Causes
1. Smoking
In a healthy blood vessel, the inner lining of the arteries, known
as the endothelium, constricts and dilates with blood flow. Smoking
damages the endothelium, making arteries prone to spasms and
deposits of diffuse plaque that diminish their ability to dilate properly.
This condition is known as atherosclerosis, often called "hardening of the
arteries." Atherosclerosis is a gradual process in which cholesterol and
scar tissue build up, forming a substance called plaque that clogs the

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

blood vessels and makes them less elastic.

Smokers are at increased risk for peripheral arterial disease,
clogged arteries in the legs that cause insufficient blood flow to get to
the leg muscles. This causes pain, especially when walking and, left
untreated, this insufficient blood flow can lead to limb amputation. While
this may require angioplasty and stenting to improve blood flow, many
people can avoid these procedures and alleviate their symptoms just by
quitting smoking and beginning a specific exercise regimen. Smoking
makes that big a difference in vascular disease.

9. Enumerate
at least 3
risk factors
of PVD;

2. Blood clot
A blood clot can block a blood vessel (thrombus/emboli).
3. Diabetes
Over the long term, the high blood sugar level of persons with
diabetes can damage blood vessels. This makes the blood vessels more
likely to become narrowed or weakened. Plus, people with diabetes
frequently also have high blood pressure and high fats in the blood,
which accelerates the development of atherosclerosis.
4. Inflammation of the arteries
This condition is called arteritis and can cause narrowing or
weakening of the arteries. Several autoimmune conditions can develop
vasculitis, and, besides the arteries, other organ systems are also
affected.
5. Infection
The inflammation and scarring caused by infection can block,
narrow, or weaken blood vessels. Both salmonellosis (infection with

Socialized
discussion
Use of
Slideshow
presentati
on using
Microsoft

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

10.
Trace
the
pathophysio
logy of PVD;

Salmonella bacteria) and syphilis have been two infections traditionally

known to infect and damage blood vessels.
6. Injury
Blood vessels can be injured in an accident such as a car wreck
or a bad fall.
D. Risk factors
There are numerous risk factors for PVD. Some are due to
underlying medical conditions, age, and gender while others are due to
lifestyle choices. You are at a higher risk for acquiring PVD if you are a
man over age 50 or a postmenopausal woman. A risk factor is anything
that may increase a person's chance of developing a disease. It may be
an activity, diet, family history, or many other things.
1. Hypertension
2. Diabetes mellitus
3. Familial predisposition
4. Lifestyle
E. Pathophysiology
Peripheral vascular disease (PVD), also known as arteriosclerosis
obliterans, is primarily the result of atherosclerosis. The atheroma
consists of a core of cholesterol joined to proteins with a fibrous
intravascular covering. The atherosclerotic process may gradually
progress to complete occlusion of medium and large arteries. The
disease typically is segmental, with significant variation from patient to
patient.
Vascular disease may manifest acutely when thrombi, emboli, or

Excel

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

acute trauma compromises perfusion. Thromboses are often of an

11.
Enum atheromatous nature and occur in the lower extremities more frequently
erate at
than in the upper extremities. Multiple factors predispose patients for
least 5 signs thrombosis. These factors include sepsis, hypotension, low cardiac
and
output, aneurysms, aortic dissection, bypass grafts, and underlying
symptoms
atherosclerotic narrowing of the arterial lumen.
of PVD;
Emboli, the most common cause of sudden ischemia, usually
are of cardiac origin (80%); they also can originate from proximal
atheroma, tumor, or foreign objects. Emboli tend to lodge at artery
bifurcations or in areas where vessels abruptly narrow. The femoral
artery bifurcation is the most common site (43%), followed by the iliac
arteries (18%), the aorta (15%), and the popliteal arteries (15%).
The site of occlusion, presence of collateral circulation, and
nature of the occlusion (thrombus or embolus) determine the severity of
the acute manifestation. Emboli tend to carry higher morbidity because
the extremity has not had time to develop collateral circulation. Whether
caused by embolus or thrombus, occlusion results in both proximal and
distal thrombus formation due to flow stagnation.
F. Signs and symptoms
Only about half of the individuals with peripheral vascular
disease have symptoms. Almost always, symptoms are caused by the
leg muscles not getting enough blood. Whether you have symptoms
depends partly on which artery is affected and to what extent blood flow
is restricted.
The most common symptom of peripheral vascular disease in
the legs is pain in one or both calves, thighs, or hips. The pain usually
occurs while you are walking or climbing stairs and stops when you rest.

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

This is because the muscles' demand for blood increases during walking
and other exercise. The narrowed or blocked arteries cannot supply more
blood, so the muscles are deprived of oxygen and other nutrients. This
pain is called intermittent (comes and goes) claudication. It is usually a
dull, cramping pain. It may also feel like a heaviness, tightness, or
tiredness in the muscles of the legs. Cramps in the legs have several
causes, but cramps that start with exercise and stop with rest most likely
12.
Recite are due to intermittent claudication. When the blood vessels in the legs
the
are completely blocked, leg pain at night is very typical, and the
complicatio individual almost always hangs his or her feet down to ease the pain.
ns of PVD;
Hanging the legs down allows for blood to passively flow into the distal
part of the legs.
Additional symptoms may occur as a result of reduced blood
supply. With PVD, you may have:
1. Skin changes on legs and feet
2. Weak pulses on legs and feet
3. Gangrene
4. Wounds and ulcers on les and feet
13.
Discus
5. Reduced hair growth on your legs
s the
6. Toes that turn blue
appropriate
7. Severe burning pain in your toes
diagnoses
8. Leg cramps and pain when you are lying in bed
9. Muscles that feel numb or heavy
used for
10.
Arms and legs that are reddish blue
determining
11. Toenails that are thick and opaque
PVD;
G. Complications
Complications from undiagnosed and untreated PVD can be

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

serious and even fatal. The restricted blood flow of PVD can be a warning
sign of other forms of vascular disease. When arteries leading to the
heart and brain become clogged with plaque, it can cause:
1. Heart attack
2. Stroke
3. Death
H. Diagnosis
1. Measuring the pulses in your legs and feet
Your physician can check the pulses in your legs and feet with a
stethoscope. A whooshing sound called a bruit indicates a narrowed area
in the vessel.
2. Doppler ultrasound
This test shows the blood flow in your vessels. Ultrasound is not
invasive. It uses sound waves to take images.
3. Ankle-brachial index (ABI)
This is the most common test used to diagnose PVD. A blood
pressure cuff and ultrasound assess blood pressure and flow. The blood
14.
Enum
pressure in your ankle is compared to the blood pressure in your arm. In
erate at
some cases, readings will be taken before and after you walk on a
least 5 ways
treadmill. This helps demonstrate how the arteries react to exercise.
of
4. Pulse volume recording (PVR)
preventing
This test checks the blood flow in your legs. Blood pressure cuffs
and caring
are wrapped around one arm and leg as you are lying down. The cuffs
PVD;
are inflated slightly. As blood flows through the arteries, a device records
the ability of the vessels to expand.
5. Angiography

Question and
Answer (with
incentives if
able to answer)

5
mins.
Lecture
with
socialized
discussion
(slideshow
presentati
on)

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

A catheter is guided through an artery in your groin. It is passed

to the targeted area. Contrast dye is injected. An X-ray can then
diagnose the clogged artery. By inflating a balloon at the end of the
catheter, the artery can be opened in the same procedure.
6. Magnetic resonance angiography (MRA) and computerized
tomography angiography (CTA)
These are noninvasive imaging techniques that allow doctors to
view blood flow and diagnose blockages.
I. Prevention and Care Management
These are noninvasive imaging techniques that allow doctors to
Discus
view blood flow and diagnose blockages.

15.
s
appropriate
nursing
diagnoses
wit
intervention
s related to
diabetic foot
problem
and PVD.

1. Stop smoking
2. Commit to a regular exercise program that includes
walking
3. Eat a balanced diet with proper nutrition
4. Stop smoking
5. Lose weight
6. Treat conditions such as diabetes, high blood pressure, or
high cholesterol
Smoking cessation is one of the most important ways to treat

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

PVD. Smoking directly causes reduced blood flow in vessels.

III.

Nursing Diagnosis and Interventions

A. Altered comfort: pain r/t psychological disability

Interventions:
1. Perform a comprehensive assessment of pain to include
location, characteristics, onset/duration, frequency,
quality, intensity or severity of pain, and precipitating
factors
2. Determine the needed frequency of assessing client
comfort and implement a monitoring plan.
3. Reduce or eliminate factors that precipitate or increase
the pain experience.
4. Select and implement a variety of measures to facilitate
pain relief, as appropriate.
B. Ineffective tissue perfusion mechanical reduction of venous
blood flow
Interventions:
1. Check peripheral pulses, edema, capillary refill, color, and
temperature.
2. Inspect skin for arterial ulcers or tissue breakdown.
3. Monitor degree of discomfort or pain.
4. Place the extremity in a dependent position, as
appropriate.

SILLIMAN UNIVERSITY
COLLEGE OF NURING
DUMAGUETE CITY

C. Risk for injury r/t broken skin

Intervention:
1. Monitor the environment for potential safety hazards.
2. Communicate information about the clients risk to other
nursing staff.
3. Retrieve and interpret laboratory data.
4. Compare the clients current status with his/her previous
status.
IV.

Open Forum

References:

Book sources
Black, J., Hawks, J. (2009) Medical-Surgical Nursing: Clinical Management for Positive outcomes, (8th Ed) Philippines: Elsevier Inc.
Brown, D., Edwards, H. (2005) Lewis Medical Surgical Nursing. Australia: Elsevier Inc.
McCance, K., Huether, S. (2015) Pathophysiology: The Biologic Basis for Disease in Adults and Children (7th Ed). USA: Mosby Inc.
Smeltzer, S., Bare, B., (2004) Medical-Surgical Nursing. (10th Ed). USA: Lippincott Williams and Wilkins
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever,K.H. (2008). Brunner and Suddarths Textbook of Medical and Surgical Nursing.( 11th ed).
USA: Lippincott Williams& Wilkins
Lewis, S. L. et. al. (2007). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. (7th ed.) (Vol.1.). Philippines:
Elsevier, Inc.

Internet sources:
Healthline Media. Retrieved from http://www.healthline.com/health/peripheral-vascular-disease#Overview1
eMedicineHealth. Retrieved from
http://www.emedicinehealth.com/peripheral_vascular_disease/article_em.htm#peripheral_vascular_disease_overview