Wound Care of The DM Foot

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Objectives:
Wound Care:
The Patient with
Diabetic Foot
1. What is a diabetic foot ulcer.

2. Review the contributing factors causing a
diabetic foot ulcer.
3. Review the assessment and management
strategies for patients with diabetic feet based
on best practice documents.
4. Discuss the role of antimicrobial dressings to
assist in reducing the bacterial burden.
5. Discuss the role of the team in providing
support for the patients with diabetic ulcers
Sheila Moffatt RN BN IIWCC

Pressure Ulcer Prevention Coordinator
October 28, 2011

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Amputation
Diabetic foot ulcer
In industrialized countries, diabetes is the leading cause of

non-traumatic, lower extremity amputations (American
Diabetes Association (ADA), 1999; Foundation for
Accountability, 1996).
Approximately 15% of all persons with diabetes (PWD) will
develop a foot ulcer at some time during the course of their
disease (ADA, 1999).
Eighty-five percent of lower extremity amputations are
preceded by foot ulcers (Reiber, Boyko & Smith, 1995).
Of these, 14% to 24% will proceed to major amputation
(Ramsey, Newton, Blough, McCulloch, Sandhu, Reiber et al.,
1999).
A syndrome comprised of
neuropathy, peripheral arterial
disease and deformity. The end-stage
complications of this syndrome are
diabetic foot ulcerations.
Chronic Wound Care, 4th edition 2007, p549
RNAO. 2005

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Risk factors for vascular

disease
Diabetes
Smoking
Hyperlipidemia (above LDL below 2
mmol/L
Hypertension (BP more than 130/80)

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Pathway to Assessment/Treatment
Person with Diabetic Foot Ulcer
Treat the Cause
Vascular flow
Awareness of
neuropathic changes
Pressure redistribution
Glycemic control
Lipid control
Debridement
Local Wound
Care
Patient-centered
Concerns
Adherence to plan
of care
Quality of life
Caregiver/Family
Inflammation/Infection
Control
Moisture
Balance
Rule out/treat osteomylitis
Edge of the Wound

Active therapies
Biological agents
Adjunctive therapies
Adapted from Sibbald RG,

Orsted HL, Schultz GS, et
al, 2006

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RNAO Principles for

Assessment and Management
Cardiovascular disease
Comorbidities
Diabetes/Glycemic control
Smoker
Obesity
Medications (steriods)
Nutrition
Adherence and Behavioural Choices (QoL)
V VASCULAR INSUFFICIENCY
I INFECTION
P - PRESSURE

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Assessment of Patients
Physical presentation

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function, urinalysis, microalbumin, creatinine)
ECG, cardiac echo

Ankle Brachial Index (abnormal less than
0.8) , Transcutaneous oxygen levels
(abnormal less than 40mmHg, Systolic toe
pressures (abnormal less than 45mmHg)

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Dorsal Pedal Pulse
RNAO pictures
RNAO,
Posterior Pedal Pulse
(medial maleollus)
Assessment of Vascular
System
BP, Pedal pulses
Blood work (ESR, CRP, lytes, HbA1c, Cr, liver
visual vascular assessment (color,

temperature, edema)
sensation
structural deformities
pain (i.e. intermittent claudication)
footwear
infection
pressure

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Assessment of the
Patients History
Assessment of
Peripheral Neuropathy
Sensory- loss of first line of defense
against injury
Autonomic- improper vasoconstriction and
vasodilation (i.e.-the skin dries and
cracks and is more at risk for
trauma/damage)
Motor- nerve damage in muscle leads to
abnormal shape, bones are not held in
proper alignment

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Neuropathy (SAM)
Protective Sensation
Sensory
Autonomic
Motor
Heat intolerance
Mild edema
Excessive
moisture
or dry skin
Burning
Numbness
Tingling
Pain
Lack of
sensation

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DCPNS

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DCPNS
Perform a
ten point monofilament test
using a 10-gm Semmes-Weinstein Monofilament
Foot Drop
Tripping
Deformities
Changes in
gait

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DCPNS

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60 second assessment
The 60-second foot exam for people with diabetes
Questions
First 15 seconds Are your feet ever

numb?
Physical Exam
Look at the feet/shoes. Visually examine the
foot for skin condition, colour, calluses,
toenail condition and structure deformities.
Next 15
seconds
Do they ever tingle?
Palpate the foot for temperature and ROM in

general (but of the big toe specifically).
Final 30
seconds
Do they ever burn?

Do they ever feel like
insects are crawling on
them?
Check for sensory intactness, especially light

touch using a 10-gram monofilament,
The 60-second Foot Exam for People with

Diabetes, Wound Care Canada ( 2004, Inlow)

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Deformities/Mobility
Footwear Assessment
Callus
Hammer toes or claw toes
Arch deformity
Overlapping digits
Rigid digits (especially the great toe)
Bunion
Ingrown or fungal nails
Charcot foot
Gait changes

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Ensure footwear is part of your

assessment. Many times this is the
source of the trauma which leads to
the ulcer.

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Orthotics Consult
Infection
Appropriate fitting shoe

Adjustment to shoes for deformity
Brace or cast to offload (ie. Total cast or
pneumatic walker)
Half shoes
Healing sandals (ie. Rocker bottom
sandles)

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Bedside assessments:
Probe to bone ?
NERDS and STONES?
Eyes and nose!

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NERDS
Non-healing wounds
Exudative wound
Red and bleeding wound surface
granulation tissue
Debris (yellow or black necrotic tissue) on

the wound surface
Smell or unpleasant odor from the wound

Sibbald, Woo, Ayello
Wounds UK, 2007, Vol 3, No 2
For deep infection, think of

STONES:
Size is bigger
Temperature is increased
Os probe to or exposed bone
New or satellite areas of breakdown
Exudate, erythema, edema
Smell.
Sibbald, woo, Ayello
Wounds UK, 2007, Vol 3, No 2

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Diagnostic Tests

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Wound Cultures
C-Reative Protien
ESR
WBC
X-ray (cannot identify acute osteomylitis)
Bone/Gallium Scan
CT
Magnetic Resonance Imaging (MRI)
Dressings to fight
infection
Antimicrobials:
Silver (Ag)Cadexomer iodine-(Iodosrb)
Honey
AMD gauze or cling roll
Superior sensitivity and specificity

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Pressure
Most Common Ulcers

#1. Metatarsal head is the most common
site of ulceration (especially the first
and fifth)
#2. Midfoot collapse with loss of planter
arch
Intrinsic: Genetic / Structural

Extrinsic: Shoes / Trauma / Surgery
Behavioural: Poor choices of
footwear / walking patterns

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Self-care / Education
Check feet morning at night with a mirror
Moisturize dry and cracked skin (natural
oils decrease with age and disease)
Cut nails regularly straight across with
straight clippers
Ensure you check and dry between toes
Always wear footwear to protect your feet
Inspect your shoe prior to wearing
Buy sock that are not restricting circulation
or causing irritation from seams
Include the Team

Physician
Nurse
Foot Care Nurse
Diabetic Educator
Dietitian
Orthotics
Podiatrist
Endocrinologist
Vascular Surgeon
Smoking program
Vision screening
Daily Assistive Care

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Optimize the Patients

Status

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Pathway to Assessment/Treatment
Person with Diabetic Foot Ulcer
Ensure the patient has foot care ordered

by family doctor, if unable to perform by self
Ensure the patient is optimizing their
nutritional intake of protein
Encourage blood sugar control to optimize
healing
Involve orthotics to maintain foot structure
early, accommodate deformities and
offloading as ulcers develop.
Treat the Cause

Vascular flow
Awareness of
neuropathic changes
Pressure redistribution
Glycemic control
Lipid control
Debridement
Local Wound
Care
Patient-centered
Concerns
Adherence to plan
of care
Quality of life
Caregiver/Family
Inflammation/Infection
Control
Moisture
Balance
Rule out/treat osteomylitis
Edge of the Wound

Active therapies
Biological agents
Adjunctive therapies

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RNAO
Recommendation 6.2

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Biologics/Modulators
Promogran /Prisma
Oasis
Consider the use of biological agents, adjunctive

therapies and/or surgery if healing has not
occurred at the expected rate. Consider use of:
J Biological agents
J Adjunctive therapies- Electric Stimulation,
Hyperbaric Oxygen, and NPWT
J Surgery (e.g., skin graft, Achilles tendon
lengthening, bony reconstruction)

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Adapted from Sibbald RG,

Orsted HL, Schultz GS, et
al, 2006

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Adjunctive Therapy
Hyperbaric oxygen therapy
Electrical modalities
Gene therapy
Human growth factors
Human skin equivalents
Laser
Negative Pressure Wound Therapy
Resource Material
RNAO- www.rnao.org
Reducing Foot Complications for People with Diabetes
Assessment and Management of Foot Ulcers for
People with Diabetes
CAWC- www.cawc.net
Best Practice for the Prevention, Diagnosis, and
Treatment of Diabetic Foot Ulcers
Monofilaments
DCPNS- www.diabetescareprogram.ns.ca
Diabetes Foot Inspection Tool
CDA- www.diabetes.ca
Clinical Practice Guideline

Wound Care of The DM Foot

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1. What is a diabetic foot ulcer.

Sheila Moffatt RN BN IIWCC

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Diabetic foot ulcer

In industrialized countries, diabetes is the leading cause of

Chronic Wound Care, 4th edition 2007, p549

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Risk factors for vascular

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Rule out/treat osteomylitis

Edge of the Wound

Adapted from Sibbald RG,

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To help protect y our priv acy , PowerPoint

RNAO Principles for

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To help protect y our priv acy , PowerPoint

function, urinalysis, microalbumin, creatinine)

ECG, cardiac echo

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Dorsal Pedal Pulse

visual vascular assessment (color,

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To help protect y our priv acy , PowerPoint

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First 15 seconds Are your feet ever

Do they ever tingle?

Palpate the foot for temperature and ROM in

Do they ever burn?

Check for sensory intactness, especially light

The 60-second Foot Exam for People with

To help protect y our priv acy , PowerPoint

To help protect y our priv acy , PowerPoint

To help protect y our priv acy , PowerPoint

Ensure footwear is part of your

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Appropriate fitting shoe

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To help protect y our priv acy , PowerPoint

Debris (yellow or black necrotic tissue) on

Smell or unpleasant odor from the wound

For deep infection, think of

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To help protect y our priv acy , PowerPoint

Superior sensitivity and specificity

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Most Common Ulcers

Intrinsic: Genetic / Structural

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Include the Team

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Optimize the Patients

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