I need help! What is the nursing assessment for diabetic toe necrosis?

[Julie Reyes, DNP, RN]

Ugh! Please help me with this assignment! I have most of what i am looking for, but I need to know what assessment i should do for a 68 year old man who cut out his own ingrown toenail (5 days earlier) and now it is swollen and there is necrosis in the center of it. He lives alone - no family nearby.

I wrote this as my "temporary answer", but I just feel like I am missing .... something. Please let me know what it is I am not getting! Thanks! I may have put stuff in there that has nothing to do with anything too....my prof says i always "overkill" everything!

Assess for changes in the color of the skin on the feet (the toe is reddened with a necrotic center). Compare with the other foot. Assess changes in the skin temperature between the 2 feet as warm skin to the touch may indicate infection or cool indicates poor circulation. Assess for pain in his legs - both at rest and when walking. Assess for swelling in his foot and ankle (swelling is in that foot, but does it continue to the ankle?) Assess the rest of his toes for ingrown or fungus-infected toenails; corns or calluses that bleed within the skin and cracks in the skin especially around the heel area. The inflamed swollen areas with redness indicate infection. Check for read streaks because this can indicate an internal infection as well. Assess the color of the skin for paleness or blue skin which would indicate poor circulation.

[RochesterRN-BSN, BSN, RN]

Pulses, and patients temp--if febrile the toe infection could become systemic--sepsis. (Even if on ABX they sometimes have to change them if not working) Oh--just general CNS checks/assessment--that would be your color, pulses, movement and sensation. Drainage, + or - and if + describe. if there is actual opening of the skin--the actual measurment, describe the edges and wound bed. and current tx.

[RochesterRN-BSN, BSN, RN]

Oh--and forgot I would document how his BGs have been as BGs that continue to be high leave for poor wound healing conditions, and diet needs to be high in protein for healing.... Usually on MVI for healing too.....and pleanty of of fluids.

[lsyorke, RN]

Evaluate his sensation in his feet. Insensate feet are the biggest cause of diabetic foot ulcers.

[Beerim]

You need to also check the pulses in that foot and compare it with the pulses in the other foot and assign a grade to each pulse. Measure the area of redness and the area of necrosis, this will give you precise idea of the progression of the wound.Assess between each individual toe for breakdown or s/s of infection such as fungal.

[leslie :-D]

and this pt needs diabetic shoes!

leslie

[Magsulfate, BSN, RN]

Pulses, and patients temp--if febrile the toe infection could become systemic--sepsis. (Even if on ABX they sometimes have to change them if not working) Oh--just general CNS checks/assessment--that would be your color, pulses, movement and sensation. Drainage, + or - and if + describe. if there is actual opening of the skin--the actual measurment, describe the edges and wound bed. and current tx.

This is really good! What she said! lol

OH yes, and think about education while you're assessing him. Educate him on how NOT to be cutting his toenails... go to the podiatrist for that! Also, he needs to inspect his feet EVERYDAY, thoroughly. And make it a routine check, like when he gets out of the shower. Check for sores, scratches, tacks sticking in the bottom of his feet etc. I know that sounds funny, but some diabetics get neuropathy of their feet and can't feel a thing!

[SuesquatchRN, BSN, RN]

Measure size of necrotic wound. Assess toe for s/s infection. Assess patient's pain. Please Make Sure To Chart - pulse, movement, sensation, temperature, color (all of of toe, least distal pulse).

That's it, in a nutshell. The rest of the stuff you have is relevant to the entire assessment, not the toe.

:)

[Faeriewand, ASN, RN]

Great thread guys Learned a few things :)

[Daytonite, BSN, RN]

you have a lot of skin and wound assessment, but you are missing vascular, neuro and muscular assessments. your assessment needs to be more organized. assessment should be presented as strictly factual information. you do not include rationale for why something is the way it is unless your instructors are requiring that of you for the pathophysiology. there is a sticky thread on the nursing student assistance forum with weblinks to sites on how assessment should be done: https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html.

• skin: observe for color (note any brown skin pigmentation); look for eczema or stasis dermatitis; no hair; it is not unusual for people with circulation problems to have skin that feels leathery; warmth; describe and measure the wound size, depth, location, presence of any drainage and its amount and any odor detected.
  
• cardiovascular: observe nail beds; capillary refill; rate pulses on a scale of 0 to 4+ (they may be absent); look for edema of the tissue or joints; if tissue edema is present measure the involved and an uninvolved structure for comparison; look for dilated leg veins which you can see with your own eyes
  
• neuro: ask about numbness and/or tingling in the toes, feet and legs; test for sensation
  
• muscular: have patient perform rom, inversion and eversion of the foot, flexion and extension of the toes, pushing and pulling of the foot against pressure, dtrs
  
• assess for pain
  

[VivaLasViejas, ASN, RN]

When the toes look like raisins and fall off in your hands.........now THAT'S an easy assessment of necrosis.

Seriously, this happened to me when I was fresh out of nursing school. I was changing a dressing on this poor little elderly man's foot, and two of his toes dropped off right into my (thankfully gloved) hand. I was, to say the least, horrified..........but the patient never even noticed! He had NO feeling in his feet at all---brittle diabetic, missing half of his right foot, and then he'd got gangrene in the baby toe and its neighbor on the remaining foot. It was awful.........but he merely asked "Nurse, is everything all right?"

I had three CNAs standing next to me, watching to see what I would do, and to this day I think that was the only reason I didn't freak out right then and there. I knew I'd having trouble establishing myself as a supervisor if I flipped my cork in front of a patient, so I put the toes aside, told the gentleman I had everything under control, and re-dressed the foot, fighting both panic and nausea the whole time.

Of course, I've since seen much worse things than this, but it did make quite an impression on me, as well as the aides. It also served as cautionary tale, as I now have some neuropathy in my right foot and am very careful to check it daily for any foreign objects. I once found a thumbtack in the ball of that foot; now I don't go barefooted anymore. All I have to do is think about that poor man and those little shriveled up, black toes.........shudder~