1. A foot ulcer comes as a complication in diabetes. The main feature if an underlying diabetic foot is damage to nerves, leading to dilated blood vessels, blood supply is increased, and atherosclerosis leads to reduced blood flow causing pulses to disappear. The medial wall caisifies and arteriovenus shunting occur. Neuropathy is an underlying feature in the development of a foot ulcer. It comes about as a result of increased glucose levels. The hyperglycemia leads to increased action of the enzymes sorbitol dehydrogenase and aldose reductase. The increased action of the resulting enzymes leads to the accelerated conversion of the intracellular glucose, forming the enzymes. This leads to nerve damage, which is the underlying cause of the ulcer (Jack et al., 2013).
2. Proliferation of skin layer cells prevents damage by ensuring that dermis is intact always. Whenever the cells of the skin grow old, they are worn out and replaced with new ones. This assists in the maintenance of the integrity of the skin. When the integrity is maintained, micro-organisms that cause disease are not able to penetrate the skin.The process of desquamation ensures that dead cells are worn out. Retention of water by the skin, and also deposition of more skin content on some parts like palms
3. The ulcer in Cathy’s foot started with the integrity of the skin being compromised. This led to nerve damage through primary injury. Tissue damage and nerve damage led to reduced blood supply. The reduction in blood supply caused the cells to lose isotonic power. Physiological processes that maintain the integrity of the cells were compromised leading to loss of function. This caused the ulcer.
4. Inflammation is the pathological response behind reddening in a wound (Lara, Giovanni & Stefano, 2013). It is a primary immune response towards fighting micro-organisms. It involves an increase in flow of blood through arterioles. The hormones released cause the permeability of capillaries to increases. Blood proteins move from the capillaries to the interstitial spaces. Neutrophils also migrate out of capillaries to the interstitial spaces. They then release paracrines and cause excytocic activity. The exocytotic activities help in resisting infection of the wound by microorganisms.
5. The four factors that affect skin integrity in relation to this wound are:

Failure of inflammation leading to infection of the wound, damaged nerves that would lead to worsening of the wound; compromised blood supply leading to necrosis; inadequate nutrients that would lead to cell death.

PART II:

1. Cathy is more predisposed to infection because his immune system is compromised by the ailment’s process. This does not happen to a person without diabetes. The hyperglycemic environment characteristic of diabetic promotes immune dysfunction, and thus promotes infection. Immune dysfunction comes in that the cells of the immune system are not able to perform their function, as a result of weakening by high amounts of glucose. For example, it leads to damage to macrophages which prevent micro-organisms (Khardori, 2013).
2. The inflammatory phase of wound healing requires many cells of the immune system that facilitate exocytosis of microorganisms. Diabetes creates an environment of hyperglycemia. Immune cells that are involved in the inflammatory process do not survive in this environment. This leads to the depression of the antioxidant system. Neutrophils are damaged. The damage to neutrophils leads to failure of immune function.
3. Cathy waited for long before seeing her practitioner because the healing of the foot was being delayed by the reversal of healing processes. In diabetics, wound healing is delayed because of the interference of the process secondary to the disease process. The interruption of the inflammatory phase, for example, led to the prolongation of the healing of the ulcer (Jack et al., 2013).
4. The microbiological, bacteriological investigation of the wound at this stage should target both anaerobic bacteria, aerobic bacteria, with consideration of both gram-positive and gram-negative. This because, at this stage, a diabetic foot is attacked by mixed bacterial flora. Although the gram-positive bacteria are commonly isolated in diabetic wounds, the hyperglycemic environment of the wound attracts a variety of bacteria (Metreveli et al., 2010).
5. The wound is in secondary wound healing stage. A close look at the wound shows that the edges are not approximated.It has a reddish, punkish appearance. The wound also has some tannish necrotic tissue. The epithelial tissue is dry. The wound has not tunneled. It is irregular and macerated. It also has little serous exudate.

PART III:

1. A large section was removed from Cathy’s foot to promote healing. For wound healing process to be realized faster and effectively, necrotic material needs to be removed frequently. The section of tissue that was removed helped do away with foreign tissue, and that contaminated by bacteria. If the contaminated tissue is not removed from a wound, it would lead to infection, which delays wound healing. It also helped decrease scarring, and the maintenance of the wound bed.Scarring can delay wound healing by delaying approximation of the edges. In addition, maintenance of wound bed is vital for wound healing. Also, it reduces pressure and helps in inspection of the wound (Wounds International, 2013).
2. The enrolled nurse would monitor the wound by checking for dryness. A dry wound heals faster than a wet wound. To keep the wound dry, it has to be cleaned well to prevent infection. For this reason, the nurse also maintains the hygiene of the wound by frequently checking for signs of infection. For example, an oozing wound is an infected wound. The nurse also checks for tunnels and desiccation in the wound. This is to ensure that the wound does not lead to damaging of the underlying tissues. Infection to the underlying tissues can lead to migration of infection to other organs like the sensitive heart. Further, the nurse checks for the colour of the wound. The color of the wound helps the nurse determine the effectiveness of wound healing, through determining inflammation. The nurse also monitors the wound’s response to treatment, and the persistence of debridement tissue.
3. To decrease the chances of infection, the nurse has to observe thorough cleaning of the wound. This practice keeps the microorganisms away. Further, the patient has to be taught on the principles and procedures of caring for her wound. Empowering the patient to cooperate in their care improves clinical results in a great deal; hence, Cathy has to be taught on how to care for the wound. Debridement of the wound also helps to reduce infection. It helps in removing contaminated tissue. This leaves the wound free of a contaminant that can cause infection. The nurse also has to keep on re-examining the foot with the wound frequently. This will enable her identify any sign of infection at the earliest opportunity. The other intervention to reducing infection is dressing of the wound. It helps keep infection away, by protecting the area of the wound. Also, the nurse should keep on assessing vascular status and toe pressure. This may be an indication of infection (Aalaa, Malazy & Tehrani, 2012).
4. She should be taught to cooperate with the health care personnel in her care. This will in turn improve her health outcomes, towards the healing of the wound. Cathy also needs to be taught on how to keep the foot and the wound clean and also dry at all times. This will help keep infecting agents away. The patient should also be advised on eating a balanced diet. This will give enough nutrients to the body. She should report any sign of infection to the nurse.This will enable a quick response from the care team. She should also be ready to keep the area of the wound out of external pressure.
5. Community public health worker through the government programmes that support people with diabetes. Community health nurse responsible to community cases like the one for Cathy. Community diabetes clinic where people with diabetes are treated. Community health center through the diabetes clinic.

References

Aalaa, M., Malazy. T.O., & Tehrani, M. (2012). Nurse’s role in diabetic foot prevention and care: a review. Journal of Diabetes and Metabolic Disorders, Nov, 24: 2012

Jack, Y.C., Robert, D., Mohamad, M., Jacqueline, S., & Babak, B. (2013). An integrative approach towards chronic wounds in patients with diabetes: PPPM in action. Advances in Predictive, Preventive and Personalized Medicine. 3(2013): 283-321

Khardori, R. (2013). Infection in patients with diabetes mellitus. Retrieved online from Medspace at http://emedicine.medscape.com/article/2122072-overview

Lara, B., Giovanni, Z., & Stefano, V. (2013). Physical disability in the elderly diabetics: epidemiology and mechanisms. Current Diabetes Reports, 13(6): 824-830

Metreveli, D., Chikiviladze, D., Gachechiladze, K.H., & Avazashivili, D. (2010). Microbiological investigation of a diabetic foot infection. Georgian Medical News, 183: (22-26)

Wounds International. (2013). Best practice guidelines: wound and management in diabetic foot ulcers. London: Wounds International.

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