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Best Practice in the Assessment and Management of Diabetic Foot Ulcers
Diabetes is an increasingly serious health issue in the rehabilitation population. Foot ulcers develop in approximately 15% of people with diabetes and are a preceding factor in approximately 85% of lower limb amputations. Nurses have significant opportunity to positively influence client outcomes and quality of life by promoting maintenance of healthy feet, identifying emerging problems, and supporting evidence-based self-care and interdisciplinary intervention. Best practice guidelines (BPG), such as those developed by the Registered Nurses Association of Ontario, provide a framework to enhance nursing practice and promote excellence in client care. This article highlights key evidence from the BPG, “Assessment and Management of Foot Ulcers for People with Diabetes,” and other relevant diabetes literature. This information better equips rehabilitation nurses to promote ulcer prevention strategies; identifies key factors in ulcer risk; and utilizes current, best evidence for ulcer assessment, management, and evaluation.
Diabetes is a serious health issue worldwide. In the rehabilitation population, diabetes is a complicated comorbidity that significantly affects patient progress and rehabilitation outcomes. The complications of both Type 1 and Type 2 diabetes result from a failure to achieve adequate glycemic control. Foot ulcers develop in approximately l5% of people with diabetes and are a preceding factor in approximately 85% of lower limb amputations (Reiber et al., 1999). The resulting physical, psychosocial, and economic burdens are immense.
The literature on management of diabetic foot ulcers is dispersed widely across a large inventory of healthcare resources. To gather the best evidence provided by systematic reviews, existing guidelines, peer-reviewed research, and expert consensus is a complex process that must be guided by critical appraisal. The evidence obtained frequently informs the development of a best practice guideline (BPG), which provides a framework for healthcare practice and policy. To support nurses and other healthcare professionals, the Registered Nurses Association of Ontario (RNAO), with funding from the Ministry of Health and Long-Term Care (MOHLTC), has developed a BPG, “Assessment and Management of Foot Ulcers for People with Diabetes” (RNAO, 2005). In this article, selected evidence from this guideline and content from other relevant diabetes literature is summarized and presented to support and enhance rehabilitation nursing knowledge.
Risk Assessment and Prevention
Foot ulcers are complex wounds best treated by a systematic, interdisciplinary team approach (Apelqvist & Larsson, 2000). Nurses have significant opportunities to promote maintenance of healthy feet, identify emerging problems, advise clients of their risk status, and positively influence and support appropriate self-care practices. Five primary risk factors for diabetic foot ulcers and lower extremity amputation that can be quickly assessed and screened by nurses have been identified in the literature. These factors are previous history of foot ulcers, sensation, structural and biomechanical abnormalities, circulation, and self-care behavior and knowledge. The presence of one or more of these risk factors is consistent with increased risk for foot ulcers and lower extremity amputation. (RNAO, 2004). By identifying such factors and informing and providing appropriate referrals for clients at risk, nurses contribute a key element to prevention strategy.
Reasons for Risk
The development of diabetic foot ulcers is multifactoral; however three significant contributing factors have been identified. These include the presence of peripheral neuropathy, the presence of ischemia, and the exposure to a pivotal event or situation (Jeffcoate & Harding, 2003; Levin, 2001; Reiber et al., 1999).
Peripheral Neuropathy: The hyperglycemia associated with diabetes damages the myelin sheath and structure of the axon fibers of the nerves (Boulton, Malik, Arezzo, & Sosenko, 2004; Vinik, Maser, Mitchell, & Freeman, 2003). This leads to changes in the function and efficiency of the nerves of the sensory, autonomic, and motor systems. In the sensory system, there is a loss or reduction of sensory nerve function (the most significant change), and loss of proprioception. In the autonomic system, the changes influence peripheral circulation and microvascular skin blood flow. In the motor system, the intrinsic muscles of the foot are affected (Boulton et al., 2004; Jeffcoate & Harding, 2003). Evidence suggests that within 20 years of diagnosis, 50% of people with diabetes have developed neuropathy (Birke, Patout, & Foto, 2000).
Sensory neuropathy presents as a loss of protective sensation, commonly with a stocking-glove distribution. This is because the long fibers are affected first, and after the neuropathy reaches approximately the level of the knee distally, it can be expected to be experienced in the fingers and hands (Apfel, 2000). Loss of proprioception results in sensory ataxia, which increases the risk of falls (Sinacore & Mueller, 2000). Evidence shows that 4-point testing of specific sites on the feet with a Semmes-Weinstein monofilament is a good assessment tool for identifying loss of protective sensation (RNAO, 2004; Smieja et al., 1999). To identify changes in proprioception, assessment for an altered gait pattern should be conducted.
Autonomic neuropathy presents as a loss of peripheral sympathetic vascular tone with increased distal arterial flow and pressure. This increased pressure damages vessel walls, increasing the risk of plaque formation. The microvascular damage also promotes decreased production of the sweat and oil glands, resulting in anhydrosis, dry skin, and the appearance of premature aging (Vinik et al., 2003). Nurses should assess for this condition by checking the feet for dry, scaly skin and fissures (especially between the toes) and for thickened, waxy skin, which affects joint mobility (Zimny, Schatz, & Pfohl, 2004).
Motor neuropathy presents as damage to or altered function of the intrinsic muscles of the foot and leads to imbalance of the tendons, hyperextension of the toes, displacement of the fat pads, and splaying of the foot. Nurses may detect this condition by looking for foot deformities such as hammer or claw toes, hallux deformity or bunion, callus, pes cavus, pes planus, and Charcot arthropathy. Nurses should also assess patients for gait deviation and increased pressure over bony prominences (Shaw & Boulton, 1997).
Ischemia: In diabetes, hyperglycemia further alters cellular function, damaging the endothelium of the vessel walls. This predisposes patients to plaque build-up and narrowing (American Diabetes Association [ADA], 2003; Brownlee, 2005). Atherosclerosis of the lower limbs is two to three times higher in people with diabetes, and the vessels of the calf are most affected (Shaw & Boulton, 1997). Peripheral vascular disease leads to poor healing and increased risk for amputation (Adler, Boyko, Ahroni, & Smith, 1999; Boyko et al., 1999).
Ischemia presents as bilateral absent pedal pulses and claudication pain (Boyko et al., 1997). In assessment, nurses should palpate for posterior tibial and dorsalis pedis pulses and ask about a history of claudication pain (pain on exercise or walking that is relieved with rest). Color should also be assessed, which may be more difficult to do if a patient has dark skin. Pallor on elevation or rubor on dependency may indicate ischemia. Other characteristics of this condition include skin temperature (cool to touch); capillary refill (longer than 3 seconds); absence of hair growth; dystrophic toenails; dry and fissured skin; and the presence of edema, pain, or dry gangrene (ADA, 2003; Bowker & Pfeifer, 2001; Frykberg et al., 2000).
Pivotal Event: The pivotal injury proceeding the development of an ulcer may result from an acute episode such as banging a toe or stepping on a foreign object. Most often, however, it is the result of repeated trauma over time. The literature suggests that 55% of foot ulcers are related to pressure from footwear, which may cause trauma to the tissues of patients with reduced circulation and loss of protective sensation (Abbott et al., 2002). Assessment should include checking for callus, for structural abnormality, and footwear. Assessment of footwear will be discussed in greater detail later in this article.
One of the more serious structural abnormalities is the development of a Charcot arthropathy, in which joint instability results from muscle and ligament atrophy. Walking on a weakened, insensate joint causes structural damage and results in sprains and stress fractures to the foot. The acute stage presents as an inflammatory response (hot at the onset) with bone resorption and then proceeds to bone destruction. With destruction the arch may fall, the foot presents with a rocker-bottom sole, and the altered pressure distribution significantly increases the risk of ulceration (Bowker & Pfeifer, 2001; Frykberg et al., 2000).
When a person with diabetes has developed an ulcer, it is important to remember that the ulcer presents in the context of the patient. Information must be gathered or reviewed and appropriate tests conducted to determine the etiology and risk factors (see Figure 1). History of ulcer, comorbidities, and glucose control are all significant determinants of healing and complications (Australian Centre for Diabetes Strategies, 2001; Boyko et al., 1997; Falanga & Sabolinski, 2000). To develop a plan of care, it is also important to identify key features of the ulcer, such as ulcer type and characteristics, which may include the presence of infection or ischemia (Apelqvist & Larsson, 2000).
Ulcer Type and Characteristics: About 60% of diabetic ulcers are primarily neuropathic, about 20% ischemic, and 20% mixed (Krasner, 1998). This means that about 40% of diabetic ulcers have an ischemic component, which will affect the plan of care. On examination, the neuropathic foot usually appears as warm, dry, insensate, and painless. The ischemic foot is often cold, with atrophic skin, dystrophic nails, and absent pulses. Intermittent claudication may be present (Campbell et al., 2000). In order to monitor ulcer status and identify change over time, several important characteristics—including location, size, and presence or absence of infection—need to be assessed and documented.
Location: Location of an ulcer or ulcers should be identified. Neuropathic ulcers may be primarily found on the plantar aspect of the foot, at the base of the metatarsal heads, and at the base of the lst and 5th toes and ischemic ulcers may most often occur from distal lesions on the toes or back of the heel (ADA, 2003; Apelqvist et al., 2000; Krasner, 1998).
Size: Evidence suggests that a 20%–40% reduction in ulcer size at 2 weeks is a good predictor of healing at 12 weeks (Flanagan, 2003; Margolis, Kantor, & Berlin, 1999). In addition to size, depth should also be measured and recorded since an ulcer that can be probed to bone is significant for osteomyelitis (Greyson, Gibbons, Balogh, Levin, & Karchmer, 1995). It is also important to assess the ulcer bed. Is the tissue fibrous, necrotic, or have good granulation? What are the characteristics of the exudate? Is there an odor upon checking the wound that comes from the wound itself not the dressing materials (Vowden & Vowden, 2002)? Peri-ulcer skin must also be assessed for color, induration, maceration, and callus (Boulton, 1991; Cutting & Harding, 1994).
Infection: People with diabetes have a blunted inflammatory response, causing their immunity and resistance to infection to be compromised. Also, poorly controlled blood sugars reduce the efficiency of the neutrophils, the white blood cells that clean wounds (Apelqvist & Larsson, 2000; Calhoun et al., 2002; Frykberg et al., 2000). As a result, infection may be underestimated or the diagnosis delayed.
Because infection may be more difficult to diagnose in people with diabetes, the following wound characteristics and symptoms have been identified as significant: increased pain, wound breakdown, friable granulation, and foul odor (Boulton, Meneses, & Ennis, 1999; Gardner, Frantz, & Doebbling, 2001). Armstrong, Lavery, and Harkless (1998) found that poor wound outcomes are associated with infection, peripheral vascular disease, and increasing depth. These researchers developed and validated the University of Texas Health Science Center San Antonio Diabetic Wound Classification System (see Table 1), a grading scale to demonstrate that increased wound depth, infection, and ischemia is significant for increased risk of amputation.
After a comprehensive assessment, an ulcer management plan must be developed to direct the treatment goals (see Figure 2). It is important to first determine the potential of the ulcer to heal as wound healing and cellular function are significantly impaired in chronic wounds (Sibbald et al., 2003). Nurses must then identify and modify factors that affect or interfere with healing and determine actions to promote healing. All interventions should be based on clinical findings, patient preference, and best evidence. Treatment goals may include the following: obtain wound closure as soon as possible; eliminate or control infection; decrease risk of recurrence; maintain/stabilize the non-healable wound; maximize health status; and, improve function and quality of life.
Factors that May Affect Healing: In addressing factors that may affect healing, it is necessary to include the contextual wound environment. Assessment would include vascular status, signs of ischemia, and assessing pressure areas, as previously discussed. In assessing metabolic control, it would be necessary to monitor glycemic control and nutritional status (Stratton et al., 2000). Good glycemic control has been identified as A1C ≤7 (ADA, 2003; Canadian Diabetes Association [CDA], 2003). It is also necessary to be aware that comorbidities such as end-stage renal disease, hypertension, retinopathy, history of amputation, and certain medications are all implicated in blood glucose control and peripheral vascular disease (Eggers, Gohdes, & Pugh, 1999; Frykberg et al., 2000; Reiber et al., 1999; Royal Melbourne Hospital, 2002). In older adults, peripheral vascular disease, limb-threatening ischemia, and foot deformities are more prevalent. Many secondary aging factors also contribute to delayed wound healing (Sinacore & Mueller, 2000). In addition, patient education, physical environment, and compliance may affect wound management, healing potential, and quality of life (Hutchinson et al., 2000; Ribu & Wahl, 2004; Valk, Kriegsman, & Assendelft, 2004).
Actions to Promote Healing: Interventions to promote healing include tissue debridement, control of infection, provision of a moist wound environment as appropriate, selection of appropriate dressing, avoiding further trauma, examination of footwear and provision of education, and promotion of oxygenation and wound perfusion.
Tissue Debridement: The purpose of debridement is to remove dead or devitalized tissue. Common techniques for the management of diabetic ulcers are mechanical debridement (irrigation with saline solution, wet to dry dressings, hypertonic saline gauze dressing); autolytic debridement (hydrogels, hydrocolloids); and sharp or surgical debridement (scissors, scalpel). The latter is the method of choice for wounds with large amounts of devitalized tissue or infection. It must be noted, however, that sharp debridement must be performed only on tissue with adequate blood supply or circulation (Inlow, Orstead, & Sibbald, 2000; Leaper, 2002).
Infection Control: In controlling infection, the level or degree of intervention will be influenced by the nature of the infection (e.g., acute, chronic, and systemic). For all wounds, however, general interventions are used to promote healing. In addition to debriding, it is necessary to control bacterial balance, support host defenses (through glycemic control and stabilization of comorbidities), and support medical and pharmacological intervention (Calhoun et al., 2002).
Optimization of Wound Environment: Wound care and maintenance of the wound environment involves a number of components. These include assessing the wound bed for bacterial balance, exudates, and need for debridement; selecting a dressing that can manage or control the wound environment; maintaining a moist wound bed as appropriate while keeping the peri-wound skin dry; controlling exudates without desiccating the ulcer bed; eliminating dead space by loosely filling the cavity; and ensuring there is adequate pressure relief in the affected area (Jeffcoate & Harding, 2003; Sibbald et al., 2000).
It is important to note, however, that wound management must be based on wound healibility. If healing is not anticipated, nurses should employ conservative, supportive management that will prevent deterioration (Enoch & Price, 2004).
Selection of Appropriate Dressing: In choosing a dressing, it is important to recognize that no one dressing is appropriate for all diabetic wounds or the various stages of healing. Selection must be made on the basis of the clinical assessment of the ongoing wound status and healing potential. Wound-dressing categories include transparent or film; moisture retentive (adherent or non adherent); hydrating (hydrocolloids and hydrogels); absorbent (alginates, hydrofibers, hypertonic saline and foam); and antimicrobial (cadexomer iodine, and silver agents) (Calhoun et al., 2002; Jeffcoate & Harding, 2003).
Removal of Trauma or Pressure: Trauma and pressure are significant risk factors for ulcer development. It may be necessary to promote non-weight bearing strategies such as bed rest and/or use of a wheelchair, crutches, walker, or cane. Patients may also be advised to replace or modify their footwear. The lack of sensation associated with neuropathy can result in the tendency to buy shoes that are too small or too tight. It is necessary to accommodate any foot changes or deformities. Orthoses (custom-made shoe inserts) may be required for pressure reduction or redistribution. A total contact cast may also be prescribed for pressure offloading.
Selection of devices must take into consideration the ability of a device to remove or redistribute pressure, the ease of application, cost effectiveness, characteristics of the ulcer (note that ischemia and decreased sensation greatly increase risks from pressure), and ability to gain patient compliance (it is important that the patient realizes that pressure is the cause of the ulcer) (Armstrong & Lavery, 1998; Armstrong, Lavery, Kimbriel, Nixon, & Boulton, 2003; Armstrong, Nguyen, Lavery, van Schie, Boulton, & Harkless, 2001).
Examination of Footwear: Because 55% of pivotal traumatic events are the result of poorly fitting shoes, clients and healthcare providers must be able to assess the appropriateness of footwear. The type of shoe, fit, patterns of wear, linings, seams, insoles or orthoses, and presence of foreign bodies must all be assessed and appropriate intervention implemented. When choosing shoes, clients are advised to shop late in the day and have both feet measured. Shoes should be sufficiently wide with a deep toe-box to accommodate foot changes or deformities. Laces are preferred to accommodate swelling; natural fibers, such as soft leather, more readily conform to the foot, and non-skid soles and low heels reduce the risk of falls. New shoes should be broken in gradually with frequent inspection of the feet (Zangaro & Hull, 1999).
Promotion of Oxygenation/Perfusion: Adequate blood supply must be available for wound healing. Nursing interventions may include reducing pressure or constriction around the wound by, for example, choosing new dressing materials or advising against tight stockings; managing edema or inflammation through physical or pharmacological modalities; supporting activity to promote collateral circulation if indicated; encouraging smoking cessation; and providing care for surgical revascularization as appropriate.
Other treatment modalities or adjunct therapies that may be indicated in diabetes wound care but are not discussed here, include topical negative pressure, electrical stimulation, hyperbaric oxygen, growth factors, bioactive agents, and surgical procedures such as grafts.
Ongoing evaluation of patients is necessary to identify wound status and compatibility with treatment goals. The edge of the wound should be examined to determine the presence of cell migration and wound closure (Schultz, Barillo, Mozingo, Chin, & The Wound Bed Advisory Board Members, 2004). If healing is not occurring, the status of those factors that can be corrected—such as infection, pressure or trauma, glycemic control, management of comorbidities, and patient compliance—should be addressed.
When Healing Is Not a Goal
In certain situations, healing may not be a goal. Examples may be a chronic osteomyelitis or a dry, gangrenous toe that is expected to auto-amputate. In such cases the goals for palliative wound management would reflect a realistic outcome based on function and quality of life. Effective wound management should also support pain control, promote infection control (cytotoxic agents may be considered when risk of infection outweighs healing potential) (Sibbald et al., 2003), provide odor control, keep the wound bed dry, and manage exudates (Enoch & Price, 2004).
In the assessment and management of foot ulcers in people with diabetes, evidence supports a prevention strategy of risk assessment and appropriate referral. To help answer the question of why people with diabetes have a higher risk for ulcers, three predisposing factors and the influence of hyperglycemia have been identified. In addition the literature suggests key intervention strategies for ulcer assessment, management, and evaluation.
Rehabilitation nurses can facilitate and positively influence wound-healing outcomes for clients in this high-risk population by identifying the primary contributing factors of neuropathy, ischemia, and trauma; identifying the wound type; promoting healing and preventing infection; promoting good glycemic control and management of comorbidities; and supporting interdisciplinary management and intervention strategies. Guidelines, such as the RNAO’s Best Practice Guidelines, available at www.rnao.org, can be a useful resource to direct and achieve these goals.
In addition to contributing to nursing knowledge and best practice, the development panel identified several areas for future research and development. These prospective areas include the development of standardized assessment and documentation tools for diabetic foot ulcers; provision of more evidence-based dressing choices; validation of the effectiveness of adjunct therapies to promote wound healing; and assessment of the impact of education for healthcare providers on specific patient outcomes such as healing or ulcer re-occurrence. The author challenges rehabilitation nurses to contribute to these initiatives as a means of improving both nursing practice and patient outcomes.
The author wishes to acknowledge the Registered Nurses Association of Ontario Best Practice Guidelines Project for its work in advancing nursing knowledge and excellence and for inspiring me to contribute to this exciting challenge.
Also, thank you to ARN for inviting me to submit this manuscript.
About the Author
Lillian Delmas, BScN RN CRRN, is a nurse clinician at the Ottawa Hospital Rehabilitation Centre, ON. Address correspondence to her at 505 Smyth Road, Ottawa, ON K1H8M2 or firstname.lastname@example.org.
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