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Diabetic foot ulcers:Assessment andeducation

by Debra Clair, PhD, RN, APN, WOCN

" T ' T T ' T ' i t h 285 million people sufFer-\ yit / ing from diabetes worldwide,'

V V the disease has become a globalepidemic.^ Twenty million people sufferfrom diabetes in the United States' andmore than six million of them are un-aware that they have the disease. And theprevalence will increase as, according toan American Diabetes Association (ADA)forecast, an estimated 44 million people arelikely to develop the deadly disease in thenext 15 years.^

THE DIABETIC FOOTOne of the most significant complicationsof diabetes is the diabetic foot. Neuropathy,deformity, and/or repetitive trauma suchas inappropriate footwear, are the mostcommon causes of a diabetic foot ulcer.'*''Fifteen percent of people with diabetes areestimated to develop foot ulcers.'' In addi-tion to the economic costs, the emotionaland lifestyle impact of having a foot ulceror amputation is tremendous for the per-son experiencing this complication.*^

Neuropathy plays a large role in the

creation of an ulcer of the diabetic foot. Ifthe person with diabetes has no feeling inhis or her feet (loss of protec-tive sensation), he or she isunaware of any issues that maybe causing a foot ulcer. Due toobesity and/or vision problemscommonly associated with dia-betes, many diabetics cannotsee their feet to conduct a selfassessment. Often a diabeticfoot ulcer is not found untilit has been present for some

time.2.4

AMPUTATIONThere are a large number of lower extrem-ity amputations in people with diabetes.One third of them are at risk for amputa-tion. Seventy to ninety percent of lower-limb amputations in people with diabeteswere preceded by a foot ulcer." There were71,000 nontraumatic lower-limb amputa-tions performed on people with diabetesin 2004.' People with diabetes have beenidentified as having the largest number

Debra Clair, PhD, RN, APN,WOCN

ABOUT AALTCNThe American Association for Long Term Care Nursing(AALT'CN) unites all levels of nursing staff to advance excel-lence in the specialty of LTC nursing. The association encour-ages respect for LTC nursing staff by informing colleaguesand consumers about the complexities, competencies, andcommitment of the special caregivers who commit to this specialty. As the nationslargest network of caregivers, the mission of the AALTCN is to create community andteamwork, provide educational resources, support, and promote excellence in care, andadvocate for an improved status and voice for LTC nursing staff.

American Association forLONG TERM CARE

NURSING

of nontraumatic lower-limb amputationsin the world.' Every 30 seconds a lower

limb is amputated somewherein the world as a result ofdiabetes.

SHOESFootwear is the numberone cause of trauma to thediabetic foot.""^ The footshould be examined for anyabnormal structures such ashammertoes, bunions, or am-putations. Also, current shoesshould be evaluated, lookingfor uneven wear and any worn

areas inside the shoe that might indicatepressure areas. The shoe's toe box shouldbe deep," allowing no pressure on the toes,and wide enough to avoid causing pressureon either side of the foot.

ASSESSING DIABETIC FEETTake the time for a diabetic foot assess-ment. The person's history of ulcers and thecurrent presence of ulcers should be dis-cussed and become part of the diabetic footulcer care and prevention plan. Diabeticfoot ulcers can be located on the plantar(bottom) of the foot, over the metatarsal(bones proximal to the toes) heads, on theheel, tips of the toes, and areas exposed torepetitive trauma (e.g., hitting on a shoeor brace). Characteristics of diabetic footulcers include even wound margins, deepwound bed, callus around the wound pe-rimeter, the presence of granular tissue, andlow to moderate drainage.'

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CLINICALLY SPEAKING

Neuropathy contributes to the forma-tion of wounds and ulcers on the diabeticfoot. Limited blood flow, caused by poorcirculation, makes it difficult for sores andinfections to heal, and can ultimately leadto the amputation ofa toe, foot, or leg.Evaluating blood flow to the diabetic footincludes palpating the dorsalis pedis andthe posterior tibial arterial pulses and isa crucial part of the diabetic foot assess-

ment.3,4,8.11,13-15

EDUCATIONThe ADA and the American Associationof Wound Care identify the importanceof prevention in reducing amputationsof lower limbs in people with diabetes. Aprogram already in practice for preventingamputations in persons with Hanson's dis-ease has been adapted for the person withdiabetes. It consists of:

annual foot screening patient education daily self-inspection of the feet appropriate footwear selection management of simple foot problems.'

Diabetic education is the key to preven-tion. Many patients with diabetes are notadequately educated about how to care fortheir feet. They need to be aware of theirrisk factors and how to manage them (e.g.,once they buy the appropriate shoes, theyneed to break them in by wearing them forshort periods of time to avoid getting blis-ters). If patients are unable to see their feetbecause of obesity, they need to learn howto examine their feet using a mirror or havesomeone evaluate their feet for them.

PREVENTIONThe majority of amputations can beprevented by monitoring blood sugars andregular foot evaluations." Many peoplewith diabetes assume that foot ulcers arejust a way of life. With the appropriateeducation, they can realize that they don'thave to live with foot ulcers.

Preventing ulcers in diabetic feet involveseducation on how to perform the tasksnecessary for prevention. The person withdiabetes, along with a diabetic educator.

can decrease the incidence of diabetic footulcers and lower-limb amputations.

Research has shown that the develop-ment ofa foot ulcer is preventable. Eighty-five percent of lower extremity amputationscan be prevented through programs forpreventing and treating foot ulcers, andproper patient education including pre-venting ulcer reoccurrence.

BE PROACTIVENurses must be proactive with diabeticfoot assessment and education. Taking afew extra minutes to assess the feet and toeducate the individual or family memberduring this assessment ultimately couldsave a toe, foot, leg, or even a life. Nursesknow how to function as team leaders andcan educate stafl^ about diabetic foot assess-ment. Teaching caregivers to look for anysigns that may lead to a diabetic foot ulcerwhile giving patients a bath can make a dif-ference. Seeing the positive outcomes willreinforce the benefits of investing the timeto educate and assess, tn

Debra Clair, PhD, RN, APN, WOCN, is a clinicalwriter/educator, Wound Care Education institute.She can be reached at Debbie@wcei.net.

REFERENCES1. Diabetes Trends in 2010: Air Pollution,

Avandia, and Alzheimer's. Web site. Ac-cessed January 5, 2011. www.healthline.com/heaith-feature/diabetes-aware-ness-2010.

2. Daly M, Faul J, Steinberg J. Hyperbaricoxygen therapy as an adjunctive treatmentfor diabetic foot wounds: A comprehen-sive review with case studies. Wounds,Available at: www.woundsresearch.com/content/hyperbaric-oxygen-therapy-ad-junctive-treatment-diabetic-foot-wounds-a-comprehensive-review-w.

3. American Diabetic Associa-tion. Diabetic statistics. AccessedJanuary 7, 2011. Available at: www.diabetes.org/diabetes-basics/diabetes-statistics/?utm_source=WWW&utm_medium=DropDownDB&tm_content=Statistics&utm_campaign=CON.

4. Doupis J, Veves A. Classification, Diagno-sis, and Treatment of Diabetic Foot Ulcers.Wounds. Accessed January 5, 2011. www.woundsresearch.com/article/8706.

5. Williams-Bennett P. Cllnicai Advances inWound care for the Diabetic Patient. Ac-cessed January 5, 2011, www.nbna.org/conferences/2010/The_Diabetic_Foot.ppt.

6. Diabetes Health. (2008) Foot care fordiabetics. Accessed on January 5,2011, www.diabeteicshealth.com/read/2008/08/04/2115/foot-care-for-dia-betics/.

7. American Diabetes Association. Preven-tive foot care in diabetes. Diabetes Care2004; 1 (27). http://care.diabetesjournals,org/content/27/suppl_1/s63.full,pdf.

8. Dinh D, Pham H, Veves A. (2002). Emerg-ing teatments in dabetic wounds. Wounds.Accessed January 5, 2011, www.wound-sresearch.com/article/138.

9. King L. Impact of a preventative programon amputation rates in the diabetic popu-lation. Journal of Wound, Ostomy, andContinence Nursing 2008;35(5). AccessedJanuary 5, 2011.

10. Stults B, Clark S, Miller T (2006) Preven-tion of the diabetic foot, American Collegeof Physicians. Accessed January 5, 2011.diabetes.acponline.org/custom.resources/as06_wso523.ppt.

11. Registered Nurses Association of Ontario:Best Practice Guidelines. Reducing footcomplications for people with diabetes.Updated: 2004, Accessed: January 5,2011, www.rnao.org/Storage/16/1036_BPG_Foot_Diabetes_Workshop_Partici-pant.pdf.

12. Terrie Y, (2010) Diabetic foot care. Phar-macy Times. Accessed January 5, 2011.www.pharmacytimes.com/issue/pharma-cy/2010/October2010/OTCDiabetic_Foot_Care-1010.

13. Bergin MS. Assessment and Managementof the Diabetic Foot, Accessed: January 7,2011. www.dcgpa.com.au/_cms/CMSJm-ages/resources/Wounds%20Ulcers%20and%20Dressings%20Part%201%20Pre-sentation.69.ppt.

14. National Institute of Diabetes and Diges-tive and Kidney Disease. Diabetes relatedamputations on the rise; daily foot carecan help reverse trend. Updated April2010. Accessed January 5, 2011, http://www2.niddk.nih.gov/News/Search-News/11_01_2000.htm,

15. American Diabetes Association. Preven-tive foot care in diabetes. Diabetes Care2004; 1:27. Accessed January 5, 2010.http://care.diabetesjournals,org/con-tent/27/suppl_1/s63.full.pdf.

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