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Clinical Practice to Assess and Manage Diabetic Foot Ulcers

Executive Summary

Diabetic foot ulcers are a result of complications of diabetes such as peripheral arterial disease (PAU) which is a circulation problem or neuropathy which results in loss of sensation. Ulcers and amputations cause a significant negative economic impact including lost wages, job loss, prolonged hospitalization, lengthy rehabilitation and an increased need for home care and social services. Diabetic foot infections may require debridement, antibiotics, resection, or amputation. The Registered Nurses Association of Ontario has released clinical best practice to address how to assess and manage people with an established diagnosis of diabetic foot ulcers.

For more information on wound care: Wound Care Overview

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Registered Nurses Association of Ontario Standards

The Registered Nurses Association of Ontario has released recommendations that serve as an evidence-based guide for nurses and other health-care professionals to identify and assess people in high-risk groups who would benefit from specialized wound care. 


Summary of Recommendations 

Assessment

1.1 Complete a comprehensive health history and perform a physical examination of the affected limb(s).

  • The comprehensive health history includes a history of presenting illness, past medical history (co-morbidities, previous ulcers, smoking), glycemic control, nutritional status, allergies, medications, family history, and psychological well-being

1.1 Identify the location and classification of foot ulcer(s) and measure length, width, and depth of wound bed.


1.2 Assess bed of foot ulcer(s) for exudate, odor, a condition of peri-ulcer skin and pain.

  • The amount and type of drainage are important to examine. The type of wound exudate is dependent on the exudate observed
  • Change in the odor can indicate an alteration in the bacterial balance 
  • For more information on pain assessment tools: Wound Care: Assessment Tools

1.3 Assess affected limb(s) for vascular supply and facilitate appropriate diagnostic testing, as indicated.


1.4 Assess foot ulcer(s) for infection using clinical assessment techniques, based on signs and symptoms and facilitate appropriate diagnostic testing if indicated.

  • Microbial load is often a critical factor in determining whether an infection will develop. 
  • Signs and symptoms of an infection are important to look out for including:


1.5 Assess affected limb(s) for sensory, autonomic and motor changes.

  • Components associated with sensory, autonomic and motor changes include associated pathophysiological involvement, considerations, and clinical indications

1.6 Assess affected limb(s) for elevated foot pressure, structural deformities, ability to exercise, gait abnormality, and ill-fitting footwear and offloading devices.

  • As the plantar surface of the forefoot is a common location for foot ulcer development pressure mapping can be a useful technique to detect the risk of foot ulcers
  • Offloading devices should include considerations regarding the ability to remove pressure, cost-effectiveness, the skill required for application of the device

1.7 Document characteristics of foot ulcer(s) after each assessment including location, classification, and any abnormal findings


Planning

2.0 Determine the potential of the foot ulcer(s) to heal and ensure interventions to optimize healing have been explored.


2.1 Develop a plan of care incorporating goals mutually agreed upon by the client and health-care professionals to manage diabetic foot ulcer(s).

Such goals should include:

  • Wound stabilization
  • Reduced pain
  • Reduced bacterial load
  • Decreasing dressing changing

2.2 Collaborate with the client/family and interprofessional team to explore other treatment options if healing has not occurred at the expected rate.


2.3 Collaborate with client/family and the interprofessional team to establish mutually agreed upon goals to improve quality of life if factors affecting poor healing have been addressed and complete wound closure is unlikely.


Implementation

3.0 Implement a plan of care to mitigate risk factors that can influence wound healing.


3.1 Provide wound care consisting of debridement, infection control and moisture balance where appropriate.

  • Common debridement methods include Autolytic, Mechanical, and Surgical
  • Methods for infection control should include considerations examining co-morbidities, glycemic control, nutritional needs and sleep-wake cycles
  • Moist wound dressing should include:
    • Assess the wound bed for bacterial balance, exudate level and the need for debridement
    • Select a dressing or combination of dressings that can manage and/or control the environment above the wound
    • Use a dressing that will keep the wound bed continuously moist and the peri-wound skin dry
    • Choose a dressing that controls exudate but does not dry the ulcer bed
    • Consider the amount of professional caregiver time needed to apply and change dressing(s)
    • Eliminate wound dead space by loosely filling all cavities with dressing material
    • Ensure that the dressing does not become a source of increased pressure to the affected area
    • Confirm that the person with a diabetic foot ulcer is aware of the need to reduce pressure to the affected area
    • Evaluate the wound as prescribed to determine the effectiveness of the treatment plan.

3.2 Redistribute pressure applied to foot ulcer(s) by the use of offloading devices.

  • Examples include total contact casting (TCC), fiberglass cast shoes, scotch-cast boots, window casts and custom splints

3.3 Provide health education to optimize diabetes management, foot care, and ulcer care.


3.4 Facilitate client-centered learning based on individual needs to prevent or reduce complications.


Evaluation

4.0 Monitor the progress of wound healing on an ongoing basis using a consistent tool and evaluate the percentage of wound closure at 4 weeks.

  • As wound care is a comprehensive process a treatment plan needs to be made and progress should be evaluated on an ongoing basis
  • Wound Care: Assessment Tools can be used to use help monitor and manage wound care

4.1 Reassess for additional correctable factors if healing does not occur at the expected rate.

  • Correctable factors include: infection, poor glycemic control, and inadequate pressure redistribution from prescribed devices
  • These correctable factors can delay wound healing in a diabetic foot ulcers

Education Recommendations

5.0 Health-care professionals participate in continuing education opportunities to enhance specific knowledge and skills to competently assess and manage clients with diabetic foot ulcers, based on the RNAO Nursing Best Practice Guideline, Assessment, and Management of Foot Ulcers for People with Diabetes (2nd ed.).


5.1 Educational institutions incorporate the RNAO Nursing Best Practice Guideline, Assessment, and Management of Foot Ulcers for People with Diabetes (2nd ed.), into a basic registered nurse, registered practical nurse, doctor of medicine and interprofessional curricula to promote a culture of evidence-based practice.

  • Interpersonal teams play a vital role in early detection and assessment 

Organization and policy recommendations

6.0 Use a systematic approach to implement the Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.) clinical practice guideline and provide resources and organizational and administrative support to facilitate clinician uptake.


6.1 Develop policies that acknowledge and designate human, material and fiscal resources to support the interprofessional team in diabetic foot ulcer management.


6.2 Establish and support an interprofessional, inter-agency team comprised of knowledgeable and interested persons to address and monitor quality improvement in the management of diabetic foot ulcers.


6.3 Develop processes to facilitate the referral of clients with diabetic foot ulcers to local diabetes resources and health-care professionals.

  • The role of organizations is to advocate for increased availability and accessibility of diabetic foot ulcers.
  • Interprofessional community-based teams can help to consider age, gender, cultural beliefs and socioeconomic dispositions. 

6.4 Advocate for strategies and ongoing funding to assist clients in obtaining appropriate pressure redistribution devices during and after ulcer closure. 

  • Costs of redistribution devices should be taken into relative consideration with the total cost of the care of foot ulcers

Additional quality standards that may be helpful include: