Medical Surgical Nursing
[A CASE STUDY OF A PATIENT WITH DIABETES RIGHT FOOT ULCER]

With loss of elasticity and padding, wound are likely to occur with repetitive minimal stress or constant pressure.  However, they would not ordinary occur.  If the tissue were normal.  Most diabetes foot ulcer occur because of a combination of direct and indirect cause.  Direct cause make the sites more vulnerable to wound for formation and the indirect causes delay management and /or attenuate the healing /wound prevention processes
RECURRENT CONDITION
Deformity, peripheral artery disease, peripheral neuropathy, previous foot wound and or a prior amputation are risk factors prediative of new or recurrent diabetes foot ulcer.  The more risk factors that are present, the more likely diabetes foot ulcer will occur . within one year of wound healing following diabetes foot ulcer, upto 60% of patients with a previous diabete foot ulcer  history will develop a recurrent wound reasons for this include failure to implement preventive measures as well as the wound site being more vulnerable to reinjury due to less reisilency and elasticity of scar tisse, abnormal mechanics from tissue loss with amputation and debridment or combination of these.  Hence this healed ulcer group presents a dichotomy, it has the highest risk for developing new or recurrent ulcerations and conversely is the easiest group to recoignise the risk factors.

LIFESTYLE FACTOR
Other risk factors contributing to the development of diabetes foot ulcer include, smoking, diabetes, malnutrition, immobility, older age, deficiency in cognitive function, lack of insight and inability to follow optimal management(such as lower extremity elevation). Because of other significant factors like smoking is not to have effect on wound healing outcome essencially doubles decomplications rate for any surgery or wound healing intervention as compare to non smokers (Groner,C 2011).
Other condition contributing to diabetic foot ulcer are as follows
•    Obesity (including metabolic syndrome
•    Smoking
•    Diabetics mellitus(DM)
•    Malnutrition
•    Immobility
2.40    FOOT ULCER ASSESSMENT AND CLASSIFICATION
The evalution and classification of diabetic food ulcer are essential in other to organize the treatment plan and follow up. During the past year, several foot ulcer classification methods have been proposed however, none of the proposal have been universally accepted. The Wagner_Meggitt classification is based on wound debth and consist of six wounds grades this include,
    Grade O (intact skin)
    Grade 1 (supervicail ulcer)
    Grade 2 (deep ulcer to tendon, burn or joint)
    Grade 3 (deep ulcer with abscess or osteomyelitis)
    Grade 4 (four foot gangrene)
    Grade 5 (whole foot gangrene)
The university of texas system grade the ulcer by debth and then stages by the presence or absence of infection and ischemia. More especially, the grade 0 in the texas system classification represent a pre or post ulcerative site. Grade 1 ulcer are supervisial wound through either the epidermis or the dermis, but do not penetrate through the tendon capsule or born. Grade 2 wound penetrate to tendon or capsule but the born and joint are not involve. Grade 3 wound penetrate to born or into a born. Each wound grade is comprise of four(4) stage, clean wounds(A) nonischemic infected wound, (B) inschemic wound, (C) and effectedischemic wound. Grade 5 ulcer features (size, debth, sepsis, arteriopathy and denervaing).
Similarly, the international working group on diabetic foot has proposed the classification which grade the ulcer on five (5) feature bases, perfusion(artery supply) extend area, depth, infection, and sensation.
     Finally, according to infection disease society of American guidelines, the infected diabetic foot is sub classified into the categories of mild (restricted involvement of only skin and subcutaneous tissues)
Moderate (more extensive or affecting deeper tissues ) and severe (accompanied by systemic signs of infection or metabolic instability)
    Other important factors that must be considered are wound size and depth, the presence of sinus tracts or probing to bone, the amount of fibrotic or dysvascular tissue, the amount of hyperkeratotic tissue sounding the wound and signs of infection such as erythema, edema, odour or increase warmth
2.50      PATHOPHYSIOLOGY OF DIABETES FOOT ULCER
The pathophysiology of diabetes foot ulcer has neuropathic, vascular and immune system components, which all show a base relationship with the hyperglycemic state of diabetes.