DIABETIC FOOT CARE & MANAGEMENT

DIABETIC FOOT ULCER

A diabetic foot ulcer is an open sore or wound that occurs in approximately 15 percent of
patients with diabetes and is commonly located on the bottom of the foot. Of those who
develop a foot ulcer, 6 percent will be hospitalized due to infection or other ulcer-related
complication.

Diabetes is the leading cause of non-traumatic lower extremity amputations in the United
States, and approximately 14-24 percent of patients with diabetes who develop a foot ulcer
will require an amputation. Foot ulceration precedes 85 percent of diabetes-related
amputations. Research has shown, however, that development of a foot ulcer is
preventable.

CAUSES

Anyone who has diabetes can develop a foot ulcer. Native Americans, African Americans,
Hispanics, and older men are more likely to develop ulcers. People who use insulin are at
higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and
heart disease. Being overweight and using alcohol and tobacco also play a role in the
development of foot ulcers.

Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor
circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as
duration of diabetes. Patients who have diabetes for many years can develop neuropathy, a
reduced or complete lack of ability to feel pain in the feet due to nerve damage caused by
elevated blood glucose levels over time. The nerve damage often can occur without pain,
and one may not even be aware of the problem. Your podiatrist can test feet for neuropathy
with a simple, painless tool called a monofilament.

Vascular disease can complicate a foot ulcer, reducing the body's ability to heal and
increasing the risk for an infection. Elevations in blood glucose can reduce the body's ability
to fight off a potential infection and also slow healing.

SYMPTOMS

Because many people who develop foot ulcers have lost the ability to feel pain, pain is not a
common symptom. Many times, the first thing you may notice is some drainage on your
socks. Redness and swelling may also be associated with the ulceration and, if it has
progressed significantly, odor may be present.

DIAGNOSIS AND TREATMENT

There are several key factors in the appropriate treatment of a diabetic foot ulcer:

• Prevention of infection
• Taking the pressure off the area, called “off-loading”

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• Removing dead skin and tissue, called “debridement”
• Applying medication or dressings to the ulcer

To keep an ulcer from becoming infected, it is important to:

• keep blood glucose levels under tight control;

• keep the ulcer clean and bandaged;
• cleanse the wound daily, using a wound dressing or bandage; and
• avoid walking barefoot.

The science of wound care has advanced significantly over the past ten years. The old
thought of “let the air get at it” is now known to be harmful to healing. We know that
wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and
moist. The use of full-strength betadine, hydrogen peroxide, whirlpools, and soaking are not
recommended, as these practices could lead to further complications.

Appropriate wound management includes the use of dressings and topically-applied

medications. Products range from normal saline to growth factors, ulcer dressings, and skin
substitutes that have been shown to be highly effective in healing foot ulcers.

Surgical Options: A majority of non-infected foot ulcers are treated without surgery;
however, if this treatment method fails, surgical management may be
appropriate. Examples of surgical care to remove pressure on the affected area include
shaving or excision of bone(s) and the correction of various deformities, such as
hammertoes, bunions, or bony “bumps.”

Healing time depends on a variety of factors, such as wound size and location, pressure on
the wound from walking or standing, swelling, circulation, blood glucose levels, wound care,
and what is being applied to the wound. Healing may occur within weeks or require several
months.

PREVENTION

The best way to treat a diabetic foot ulcer is to prevent its development in the first place.
Recommended guidelines include seeing a podiatrist on a regular basis. Your podiatrist can
determine if you are at high risk for developing a foot ulcer and implement strategies for
prevention.

You are at high risk if you have or do the following:

• Neuropathy
• Poor circulation
• A foot deformity (e.g., bunion, hammer toe)
• Wear inappropriate shoes
• Uncontrolled blood sugar
• History of a previous foot ulceration

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Reducing additional risk factors, such as smoking, drinking alcohol, high cholesterol, and
elevated blood glucose, are important in prevention and treatment of a diabetic foot ulcer.
Wearing the appropriate shoes and socks will go a long way in reducing risks. Your podiatrist
can provide guidance in selecting the proper shoes.

Learning how to check your feet is crucial so that you can find a potential problem as early
as possible. Inspect your feet every day—especially the sole and between the toes—for cuts,
bruises, cracks, blisters, redness, ulcers, and any sign of abnormality. Each time you visit a
health-care provider, remove your shoes and socks so your feet can be examined. Any
problems that are discovered should be reported to your podiatrist as soon as possible; no
matter how simple they may seem to you.

The key to successful wound healing is regular podiatric medical care to ensure the
following “gold standard” of care:

• Lowering blood sugar

• Appropriate debridement of wounds
• Treating any infection
• Reducing friction and pressure
• Restoring adequate blood flow

Wound debridement is an integral part of wound management. A clinician’s ability to

assess the wound and select the proper debridement technique is as critical as addressing
all aspects of wound management, including vascular assessment, offloading, infection
control and selecting the appropriate wound dressing regimen.

Debridement is necessary to remove necrotic tissue. Necrotic tissue serves as a medium

for bacterial growth and blocks normal wound healing.

Methods include:
• Mechanical
debridement: This
method includes
hydrotherapy (whirlpool
baths) and most
commonly wet-to-dry
dressings. Cleaning
wounds by irrigation at
sufficient pressures can
also accomplish mechanical debridement. Mechanical debridement removes
necrotic debris on the wound’s surface and should only be done on wounds with
very loose exudate. In wet-to-dry dressings, exudate and necrotic tissue adhere to a
gauze dressing as it dries so that removal of the gauze thus debrides the wound; this
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method must be used cautiously because dressing changes are painful and may
remove underlying healthy granulation tissue.

• Sharp (surgical) debridement: This method involves using a sterile scalpel or

scissors to remove eschar and thick necrosis. Modest amounts of eschar or tissue
can be debrided at the patient’s bedside, but extensive or deep areas (eg, if
underlying bone, tendon, or joints are exposed) should be debrided in the operating
room. Sharp debridement should be done urgently for advancing cellulitis or lesions
suspected of causing sepsis.

• Autolytic debridement: Synthetic

occlusive (hydrocolloids/hydrogels)
dressings or semi-occlusive (transparent
film) dressings are used to facilitate the
digestion of dead tissues by the enzymes
already normally present in the wound.
Autolytic debridement may be used for
smaller wounds with little exudate. This
method should not be used if a wound
infection is suspected.

• Enzymatic debridement: This technique (using collagenase, papain, fibrinolysin,

deoxyribonuclease, or streptokinase/streptodornase) can be used for patients with
mild fibrotic or necrotic tissue within the ulcer. It can also be used for patients
whose caretakers are not trained to do mechanical debridement or for patients
unable to tolerate surgery. It is most effective after careful and judicious cross-
hatching of the wound with a scalpel to improve penetration.

• Biosurgery/Bioligic Debridement Therapy: Medical maggot therapy is useful for

selectively removing dead necrotic tissue; maggots (fly larvae) eat only dead tissue.
This method is most helpful in patients who have exposed bone, tendons, and joints
in the wound where sharp debridement is contraindicated.

• Wound offloading
Offloading refers to minimizing or removing weight placed on the foot to help
prevent and heal ulcers, particularly those caused by poor circulation to the feet due
to diabetes. Offloading is an integral part of diabetic ulcer healing strategies. Of the
studies reviewed, 12 had offloading as a part of the protocol. The type of offloading
system use was highly variable ranging from a non-specific offloading device to total
contact casting. Based on the inconsistency of offloading systems, the authors could
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not conclude there was a debridement paired with offloading enhancing technique.
They suggest that all DFU care providers use standard of care as it relates to
offloading.

METHODS OF DEBRIDEMENT

Type Methods Comments

Mechanical Wet-to-dry irrigation, May remove both dead and live

hydrotherapy tissue; may be painful

Surgical, sharp Scalpel, scissor to remove Quick, effective; use for infection;
dead tissue; laser pain management needed
debridement
Enzymatic Topical agent to dissolve Use if no infection; may damage
dead tissue skin

Autolytic Allows dead tissue to self- Use if other methods not

digest tolerated and no infection; effect
delayed
Biosurgery Larvae to digest dead tissue Quick, effective, good option
when surgical debridement not an
option

WOUND CARE FOR DIABETIC WOUND

EQUIPMENT:

➢ Normal Saline
➢ Sterile Gauze
➢ Antibiotic ointment
➢ Kidney Basin
➢ Bandage Scissor
➢ Tape
➢ Gloves
➢ PPE if needed
➢ Googles

PROCEDURE:

1. Check for patient’s Data or Chart.

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2. Prepare materials to be use.
3. Explain the procedure to the patient and show equipments.
4. Put on PPE if needed.
5. Perform hand washing.
6. Don gloving.
7. Position the patient.
a. To a supine position while foot is hanging on the edge of the bed.
b. To a prone position while foot is hanging on the edge of the bed.
c. Position patient that expose affected area.
8. Start pouring normal saline solution to the affected area.
9. Clean the wound with saline thoroughly.
10. Let it dry for a while then start applying a Topical Gel or Antibiotic Ointment medication to
the wound.
11. After each application, wrap the wound with a clean wet gauze followed by a dry gauze
dressing.
12. After care, all the materials used should be discarded properly.
13. Remove PPE, ungloves.
14. Perform hand washing.

NURSING RESPONSIBILITIES DURING WOUND CARE:

• Assessing complex patient wounds when they develop or when patients are
admitted
• Cleaning patient wounds to remove bacteria and debris and minimize the
risk of infection
• Dressing patient wounds to create a barrier against bacteria
• Determining appropriate treatment to help wounds heal, such as regular
cleaning, antibiotics, hyperbaric oxygen therapy or surgery
• Teaching patients and caregivers how to treat and dress wounds to assist
healing and prevent infection after discharge.
• Giving verbal instruction and creating a patient care plan
• Completing paperwork for patient records and insurance reimbursement

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