March 2005

Nursing Best Practice Guideline

Shaping the future of Nursing

Assessment and Management

of Foot Ulcers for People with Diabetes

Greetings from Doris Grinspun

Executive Director
Registered Nurses Association of Ontario
It is with great excitement that the Registered Nurses Association of Ontario (RNAO)
disseminates this nursing best practice guideline to you. Evidence-based practice supports
the excellence in service that nurses are committed to deliver in our day-to-day practice.
We offer our endless thanks to the many institutions and individuals that are making
RNAOs vision for Nursing Best Practice Guidelines (NBPGs) a reality. The Government
of Ontario recognized RNAOs ability to lead this program and is providing multi-year funding. Tazim
Virani NBPG program director with her fearless determination and skills, is moving the program
forward faster and stronger than ever imagined. The nursing community, with its commitment and passion
for excellence in nursing care, is providing the knowledge and countless hours essential to the creation and
evaluation of each guideline. Employers have responded enthusiastically to the request for proposals
(RFP), and are opening their organizations to pilot test the NBPGs.
Now comes the true test in this phenomenal journey: Will nurses utilize the guidelines in their day-to-day practice?
Successful uptake of these NBPGs requires a concerted effort of four groups: nurses themselves, other
healthcare colleagues, nurse educators in academic and practice settings, and employers. After lodging
these guidelines into their minds and hearts, knowledgeable and skillful nurses and nursing students need
healthy and supportive work environments to help bring these guidelines to life.
We ask that you share this NBPG, and others, with members of the interdisciplinary team. There is much
to learn from one another. Together, we can ensure that Ontarians receive the best possible care every time
they come in contact with us. Lets make them the real winners of this important effort!
RNAO will continue to work hard at developing and evaluating future guidelines. We wish you the best for
a successful implementation!

Doris Grinspun, RN, MSN, PhD(cand), OOnt

Executive Director
Registered Nurses Association of Ontario

Nursing Best Practice Guideline

How to Use this Document

This nursing best practice guideline is a comprehensive document providing resources necessary
for the support of evidence-based nursing practice. The document needs to be reviewed and applied,
based on the specific needs of the organization or practice setting/environment, as well as the needs and
wishes of the client. Guidelines should not be applied in a cookbook fashion but used as a tool to assist in
decision making for individualized client care, as well as ensuring that appropriate structures and supports
are in place to provide the best possible care.
Nurses, other healthcare professionals and administrators who are leading and facilitating practice changes
will find this document valuable for the development of policies, procedures, protocols, educational
programs, assessments and documentation tools. It is recommended that the nursing best practice
guidelines be used as a resource tool. Nurses providing direct client care will benefit from reviewing the
recommendations, the evidence in support of the recommendations and the process that was used to
develop the guidelines. However, it is highly recommended that practice settings/environments adapt
these guidelines in formats that would be user-friendly for daily use. This guideline has some suggested
formats for such local adaptation and tailoring.
Organizations wishing to use the guideline may decide to do so in a number of ways:
Assess current nursing and healthcare practices using the recommendations in the guideline.
Identify recommendations that will address identified needs or gaps in services.
Systematically develop a plan to implement the recommendations using associated tools and resources.
RNAO is interested in hearing how you have implemented this guideline. Please contact us to
share your story. Implementation resources will be made available through the RNAO website at
www.rnao.org/bestpractices to assist individuals and organizations to implement best practice guidelines.

Assessment and Management of Foot Ulcers for People with Diabetes

Development Panel Members

Laura Teague, RN, MN, ACNP

Helen Fatum, RN, BScN, ET

Team Leader
Acute Care Nurse Practitioner Wound Care
St. Michaels Hospital
Toronto, Ontario

Enterostomal Therapist, Patient Educator

and Nurse Clinician
North Bay General Hospital
Tertiary Centre
North Bay, Ontario

Catherine Arnott, RPN

Laurie Goodman, RN, BA

Certified Footcare Nurse

Nurse Educator
Toronto, Ontario

IIWCC completed
Nurse Clinician, Skin and Wound Care
Credit Valley Hospital
Mississauga, Ontario

Karen Bruton, RN
IIWCC completed
ONA Representative (Local 105 Coordinator)
Clinical Resource Nurse
Northumberland Hills Hospital
Cobourg, Ontario

Theresa Mirka, RN, MHSc, ACNP

Associate Professor
School of Nursing, Laurentian University
Sudbury, Ontario

Karen Campbell, RN, MScN, PhD(c)

Heather Nesbeth, RN, BSN, CDE

Nurse Practitioner/Clinical Nurse Specialist

Specialized Geriatric Services
St. Josephs Healthcare
London, Ontario

Diabetes Educator
Trillium Health Centre Diabetes Centre
Toronto, Ontario

Heather Orsted, RN, BN, MSc, ET

Patricia Coutts, RN

Clinical Specialist for Skin

& Wound Management
Calgary, Alberta
Co-Director of the International
Interdisciplinary Wound Care Course
University of Toronto
Faculty of Continuing Education
Department of Medicine
Toronto, Ontario

IIWCC completed
Wound Care Specialist and
Clinical Trials Coordinator
Dermatology Office of Dr. R. Gary Sibbald
Mississauga, Ontario

Lillian Delmas, RN, BScN, CRRN

Nurse Clinician
The Ottawa Hospital Rehabilitation Centre
Ottawa, Ontario

Josephine Santos, RN, MN

Facilitator, Program Coordinator
Nursing Best Practice Guidelines Program
Registered Nurses Association of Ontario
Toronto, Ontario

Declarations of interest and confidentiality were made by all members of the guideline development panel.
Further details are available from the Registered Nurses Association of Ontario.

Nursing Best Practice Guideline

Assessment and Management

of Foot Ulcers for People with Diabetes
Program Team:
Tazim Virani, RN, MScN, PhD(candidate)
Program Director

Josephine Santos, RN, MN

Program Coordinator
Heather McConnell, RN, BScN, MA(Ed)
Program Manager

Stephanie Lappan-Gracon, RN, MN

Program Coordinator Best Practice Champions Network

Jane M. Schouten, RN, BScN, MBA

Program Coordinator

Bonnie Russell, BJ
Program Assistant

Carrie Scott
Administrative Assistant

Julie Burris
Administrative Assistant

Keith Powell, BA, AIT

Web Editor
Registered Nurses Association of Ontario
Nursing Best Practice Guidelines Program
111 Richmond Street West, Suite 1100
Toronto, Ontario M5H 2G4
Website: www.rnao.org/bestpractices

Assessment and Management of Foot Ulcers for People with Diabetes

Advisory Panel
Lynn Baughan, RN, BScN, CDE

Manager, Diabetes Education Programs & Strategies,

Canadian Diabetes Association, Toronto, Ontario

Paul Chapman, BSc, BScPT, CHT

Physiotherapist, Medical Student, University of Manitoba, Winnipeg, Manitoba

Jos Contreras-Ruiz, MD

Dermatology Fellow, Dermatology Day Care & Wound Healing Centre,

Sunnybrook & Womens College Health Sciences Centre, Toronto, Ontario

David Keast, MSc, MD, FCFP

Site Chief of Family Medicine, Parkwood Hospital, St. Josephs Healthcare,

Clinical Adjunct Professor of Family Medicine, University of Western Ontario,
London, Ontario

Anne Kenshole, MB, BS, FRCPC, FACP

Professor of Medicine, Womens College Hospital, University of Toronto,

Faculty of Medicine, Toronto, Ontario

Laura Lee Kozody, BSc, DCh

Chiropodist, Mississauga, Ontario

Katherine McAuliffe, RN, BN

Community Care Coordinator, Community Care Access Centre,

Womens College Hospital, Toronto, Ontario

Shannon McGrath, OT Reg(Ont)

Occupational Therapist, Shannon McGrath Occupational Therapy Service,

Ottawa, Ontario

Yvonne Mullan, BASc, RD, CDE

Clinical Dietitian, Diabetes Comprehensive Care Program,

St. Michaels Hospital, Centre for Diabetes and Osteoporosis,Toronto, Ontario

Gary Sibbald, BSc, MD, FRCPC(Med),

FRCPC(Derm), ABIM, DABD

Director of Dermatology Day Care & Wound Healing Clinic,

Sunnybrook & Womens College Health Sciences Centre, Associate Professor
and Director, Continuing Education, Department of Medicine,
University of Toronto, Toronto, Ontario, The Mississauga Dermatology Clinic,
Mississauga, Ontario

Nursing Best Practice Guideline

Acknowledgement
Stakeholders representing diverse perspectives were solicited for their feedback and the Registered Nurses Association
of Ontario wishes to acknowledge the following for their contribution in reviewing this Nursing Best Practice Guideline.

David G. Armstrong, DPM, MSc, PhD

Professor of Surgery, Dr. William M. Scholl College of Podiatric Medicine,

Rosalind Franklin University of Medicine and Science, North Chicago, Illinois

Patti Barton, RN, PHN, ET

Enterostomal Therapy Nurse Consultant, Specialty ET Services, Toronto, Ontario

Nancy Bauer, HonBA, Hon Bus.

Admin, RN, ET

Professional Practice Leader, Leamington District Memorial Hospital,

Leamington, Ontario

Lori Blais, RN, BScN(c)

Program Coordinator, Pioneer Manor, Sudbury, Ontario

Sandra Blais, RN, CRRN

Staff Nurse,The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario

Kathleen Callaghan, RN, BScN, ET, NCA

Enterostomal Therapist, Sudbury Regional Hospital, Sudbury, Ontario

Paul Chapman, BSc, BScPT, CHT

Physiotherapist, Medical Student, University of Manitoba, Winnipeg, Manitoba

Linda Christianson, RN, CRRN

Staff Nurse, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario

Debra Clarke, RN

Staff Nurse, Medicine/Surgery/ICU, Northumberland Hills Hospital,

Cobourg, Ontario

Maureen Coe, RN, MN, ET

Enterostomal Nurse Consultant, David Thompson Health Region, Red Deer, Alberta

Jos Contreras-Ruiz, MD

Dermatology Fellow, Dermatology Day Care & Wound Healing Centre,

Sunnybrook & Womens College Health Sciences Centre, Toronto, Ontario

Timothy Daniels, MD, FRCSC

Associate Professor, University of Toronto, Toronto, Ontario

Jerry De Ocampo, RPN

Staff Nurse, Toronto East General Hospital, Toronto, Ontario

Alfred DSa, MD, IIWCC completed

General Practitioner, Credit Valley Hospital, Mississauga, Ontario

John Embil, BSc(Hon), MD, FRCPC, FACP

Consultant, Infectious Diseases, Director, Infection Prevention and

Control Unit, Health Sciences Centre, Medical Director, Infection Prevention
and Control Program, Winnipeg Regional Health Authority, Coordinator,
Diabetic Foot and Complicated Wound Clinic, Associate Professor, Departments
of Internal Medicine, Infectious Diseases and Medical Microbiology,
Winnipeg Manitoba

Joanne Gauthier, RN, BScN, CRRN

Nurse Educator, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario

Dixie Goetz, RN, BScN, ET

Enterostomal Therapist, St. Marys General Hospital, Kitchener, Ontario

Diane Grgoire, RN, ET, BScN, MScN

Spina Bifida Coordinator, Childrens Hospital of Eastern Ontario, Ottawa, Ontario

Connie Harris, RN, ET, IIWCC completed

Enterostomal Therapist/Partner, E.T. NOW, Kitchener, Ontario

Cheri Ann Hernandez, RN, PhD, CDE

Associate Professor, Faculty of Nursing, University of Windsor, Windsor, Ontario

Robin Hokstad, RN, CDE

Collaborative Care Facilitator, North Bay General Hospital, North Bay, Ontario

Debbie Hollahan, RN, BHScN, CDE

Coordinator/Diabetes Nurse Educator, Credit Valley Hospital,

Diabetes Education, Mississauga, Ontario

Pamela Houghton, BScPT, PhD

Chair, MSc Program, Associate Professor, School of Physical Therapy,

University of Western Ontario, London, Ontario

David Keast, MSc, MD, FCFP

Site Chief of Family Medicine, Parkwood Hospital, St. Josephs Healthcare,

Clinical Adjunct Professor of Family Medicine, University of Western Ontario,
London, Ontario

Assessment and Management of Foot Ulcers for People with Diabetes

Kathryn Kozell, RN, BA, BScN,
MScN, ACNP, ET

Surgical Services/Ostomy and Wound Care, St. Josephs Health Care

London, Ontario

Laura Lee Kozody, BSc, DCh

Chiropodist, Mississauga, Ontario

Karen Laforet, RN, BA, CINA(c)

Professional & Technical Services for IV, Site Care Management and Wound Care,
3M Canada, London, Ontario

Carolyn Lawton, RN, MScN, CDE

Acute Care Nurse Practitioner Diabetes, Sunnybrook & Womens College

Health Sciences Centre, Toronto, Ontario

Cindy Lazenby, RN

Foot Care Educator/Provider, Amherstview Therapy Clinic, Amherstview, Ontario

Charles Lynde, MD, FRCPC

Assistant Professor, University of Toronto, Toronto, Ontario

Fran MacLeod, RN, MScN

Advanced Practice Nurse Wound Care, West Park Healthcare Centre,

Toronto, Ontario

James Mahoney, MD, FRCS(C)

Chief Division of Plastic Surgery, St. Michaels Hospital,Toronto, Ontario

Shannon McGrath, OT Reg(Ont)

Occupational Therapist, Shannon McGrath Occupational Therapy Services,

Ottawa, Ontario

Susan Mills Zorzes, RN, BScN, CWOCN

Enterostomal Therapy Nurse, St. Josephs Hospital, Thunder Bay, Ontario

Jan-Marie Morgan, RN(EC), BScN, MHSc(c)

Primary Health Care Nurse Practitioner, St. Josephs Healthcare,

Hamilton, Ontario

Alwyn Moyer, RN, PhD

Adjunct Professor, Consultant, School of Nursing, University of Ottawa,

Ottawa, Ontario

Yvonne Mullan, BASc, RD, CDE

Clinical Dietitian, Diabetes Comprehensive Care Program, St. Michaels Hospital,

Centre for Diabetes and Osteoporosis, Toronto, Ontario

Mary Beth Neibert, RN, MS, CDE, ACNP

Clinical Nurse Specialist Diabetes, St. Josephs Healthcare, Hamilton, Ontario

Sheri Oliver, RPN

Project Coordinator, MOHLTC Nursing Education Initiative,

Registered Practical Nurses Association, Toronto, Ontario

Nancy Parslow, RN, ET

Enterostomal/Wound Care Clinician, The Scarborough Hospital, Toronto, Ontario

Corinne Racioppa, RN

Director of Care, La Salle Manor, Scarborough, Ontario

Carolyn Recker, RN, CDE

Clinical Resource Nurse Diabetes Education,

Leamington District Memorial Hospital, Leamington, Ontario

Adele Redburn, RPN

In-patient Rehabilitation Unit, Northumberland Hills Hospital, Cobourg, Ontario

Susan Russell, RN, ET, BScN, MN

Clinical Nurse Specialist Wounds, Ostomy and Continence,

Saint Elizabeth Health Care, Burlington, Ontario

Sue Sebastian, RN, MN, GNC(C)

Professional Practice Leader/Educator, Sunnybrook & Womens College

Health Sciences Centre, Toronto, Ontario

Gary Sibbald, BSc, MD, FRCPC(Med),

FRCPC(Derm), ABIM, DABD

Director of Dermatology Day Care and Wound Healing Clinic, Sunnybrook

& Womens College Health Sciences Centre, Associate Professor and Director,
Continuing Education, Department of Medicine, University of Toronto,
Toronto, Ontario, The Mississauga Dermatology Clinic, Mississauga, Ontario

Sandy Takeda, RN, IIWCC completed

Primary Nurse Surgery, Plastics, Vascular Clinics, Credit Valley Hospital,

Mississauga, Ontario

Ruth Thompson, BSc, DCh

Chiropodist, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario

Donna Tucker, RN, MScN

Project Director, Healthy Workplace Environment Best Practice Guideline Program,

Registered Nurses Association of Ontario, Toronto, Ontario

Lisa Valentine, RN, BScN, MN

Practice Consultant, College of Nurses of Ontario, Toronto, Ontario

Kevin Woo, RN, BSc, MSc, PhD(c), ACNP

Clinical Nurse Specialist/Nurse Practictioner, Wound Specialist,

North York General Hospital, Toronto, Ontario

Nursing Best Practice Guideline

Assessment and Management

of Foot Ulcers for People with Diabetes
Disclaimer
These best practice guidelines are related only to nursing practice and not intended to take into account
fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to
accommodate client/family wishes and local circumstances. They neither constitute a liability or discharge
from liability. While every effort has been made to ensure the accuracy of the contents at the time of
publication, neither the authors nor the Registered Nurses Association of Ontario (RNAO) give any
guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to
loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any
reference throughout the document to specific pharmaceutical products as examples does not imply
endorsement of any of these products.
Copyright
With the exception of those portions of this document for which a specific prohibition or limitation against
copying appears, the balance of this document may be produced, reproduced and published, in any form,
including in electronic form, for educational or non-commercial purposes, without requiring the consent
or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or
citation appears in the copied work as follows:
Registered Nurses Association of Ontario (2005). Assessment and Management of Foot Ulcers for People
with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario.

Assessment and Management of Foot Ulcers for People with Diabetes

Table of Contents
Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Interpretation of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Responsibility for Guideline Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Purpose & Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Guideline Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Definition of Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Background Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Pathway to Diabetic Foot Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Guiding Principles in the Care of Patients with Diabetic Foot Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Practice Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Education Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Organization & Policy Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Research Gaps & Future Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Evaluation & Monitoring of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Implementation Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Process for Update/Review of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Nursing Best Practice Guideline

Appendix A: Search Strategy for Existing Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Appendix B: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Appendix C: University of Texas Foot Classification System
Categories 0-3: Risk Factors for Ulceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Appendix D: University of Texas Foot Classification System
Categories 4-6: Risk Factors for Amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Appendix E: University of Texas Health Science Center
San Antonio Diabetic Wound Classification System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Appendix F: Diabetic Foot Care Patient Handout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Appendix G: Diagnostic Tests to Determine Vascular Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Appendix H: Diagnostic Tests and Imaging to Determine Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Appendix I: Wound Swabbing Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Appendix J: Use of the Semmes-Weinstein Monofilament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Appendix K: Suggestions for Assessing and Selecting Shoes and Socks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Appendix L: Factors Affecting Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Appendix M: Topical Antimicrobial Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Appendix N: A Guide to Dressing Foot Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Appendix O: Offloading Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Appendix P: Resources for Diabetic Foot Ulcer Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Appendix Q: Description of the Toolkit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Assessment and Management of Foot Ulcers for People with Diabetes

Summary of Recommendations
RECOMMENDATION

*LEVEL OF EVIDENCE

Practice Recommendations
Patient Empowerment
and Education

Holistic Assessment

1.0 All patients with diabetic foot ulcer(s) (PWDFU) or caregivers should have an
understanding of their condition and the resources available to optimize their
general health, diabetes management and ulcer care.

Ia

1.1 Education is essential as an empowerment strategy for diabetes

self-management and prevention or reduction of complications.

IV

1.2.Education is based on identified individual needs, risk factors, ulcer status,

available resources and ability to heal.

IV

2.0 Complete and document a health history, including diabetes management,

allergies, medications, functional assessment and physical examination
(vascular status, infection, callus, neuropathy, foot deformity/pressure, ulcer).

Ib IV

Vascular Status

2.1 Clinically assess bilateral lower extremities for vascular supply and facilitate
appropriate diagnostic testing.

IIb IV

Infection

2.2 Assess all patients with diabetic foot ulcers for signs and symptoms of infection
and facilitate appropriate diagnostic testing and treatment.

Neuropathy

2.3 Identify peripheral neuropathy by assessing for sensory, autonomic

and motor (S.A.M.) changes.

II IV

Foot Deformity
and Pressure

2.4 Assess for foot pressure, deformity, gait, footwear and devices. Facilitate
appropriate referrals.

Ia IV

Foot Ulcer
Assessment

3.0 Describe and document the ulcer characteristics.

3.1 Identify the location, length, width, depth and classify the ulcer(s).

IIa

IV
Ia IV

3.2 Assess ulcer bed, exudate, odour and peri-ulcer skin.

IV

4.0 Define goals based on clinical findings, expert opinion and patient preference.

IV

4.1 Determine the potential of the ulcer to heal.

IV

4.2 Develop goals mutually agreed upon by the patient and healthcare professionals.

IV

5.0 Identify and optimize systemic, local and extrinsic factors that can influence
wound healing.

IV

Systemic Factors

5.1 Modify systemic factors and co-factors that may interfere with or impact on
healing.

IV

Local Factors

5.2 Provide local wound care considering debridement, infection control and
a moist wound environment.

Extrinsic Factors

5.3 Provide pressure redistribution.

Goals of Care

Management

*See page 12 for details regarding Interpretation of Evidence.

10

Ia-III

IIa

Nursing Best Practice Guideline

RECOMMENDATION
Non-healing diabetic
foot wounds
Evaluation

LEVEL OF EVIDENCE

5.4 Evaluate and implement treatment options for non-healable wounds.

IV

6.0 Evaluate the impact and effectiveness of the treatment plan.

IV

Reassess

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

III-IV

Other therapies

6.2 Consider the use of biological agents, adjunctive therapies and/or surgery
if healing has not occurred at the expected rate. Review each specific modality
for recommendations.

Ia-IV

Education Recommendations
Continuing
Professional
Development

7.0 Nurses and other members of the interdisciplinary team need specific
knowledge and skills in order to competently assess and participate in the
treatment of diabetic foot ulcers.

IV

Curriculum
Support and Resources

8.0 Educational institutions are encouraged to incorporate the RNAO Nursing Best
Practice Guideline Assessment and Management of Foot Ulcers for People with
Diabetes into basic RN, RPN, MD and allied health professional curricula.

IV

Organization & Policy Recommendations

System Support

9.0 Nursing best practice guidelines can be successfully implemented only where
there are adequate planning, resources, organizational and administrative
support, as well as appropriate facilitation. Organizations may wish to develop
a plan for implementation that includes:
An assessment of organizational readiness and barriers to education.
Involvement of all members (whether in a direct or indirect supportive
function) who will contribute to the implementation process.
Dedication of qualified individual(s) to provide the support needed
for the development and implementation process.
Ongoing opportunities for discussion and education to reinforce
the importance of best practices.
Opportunities for reflection on personal and organizational experience
in implementing guidelines.

IV

In this regard, RNAO (through a panel of nurses, researchers and administrators)

has developed the Toolkit: Implementation of Clinical Practice Guidelines, based
on available evidence, theoretical perspectives and consensus. The RNAO
strongly recommends the use of this Toolkit for guiding the implementation
of the best practice guideline on Assessment and Management of Foot Ulcers
for People with Diabetes.
Resources

9.1 Organizations are encouraged to develop policies that acknowledge and

designate human, material and fiscal resources to support the nurse and the
interdisciplinary team in diabetic foot ulcer management.

IV

Team Development

9.2 Organizations are encouraged to establish and support an interdisciplinary,

inter-agency team comprised of interested and knowledgeable persons to address
and monitor quality improvement in the management of diabetic foot ulcers.

IV

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Assessment and Management of Foot Ulcers for People with Diabetes

RECOMMENDATION

LEVEL OF EVIDENCE

Partnerships

9.3 Organizations are encouraged to work with community and other partners
to develop a process to facilitate patient referral and access to local diabetes
resources and health professionals with specialized knowledge in diabetic foot
ulcer management.

IV

Financial Support

9.4 Organizations are encouraged to advocate for strategies and funding to assist
patients in obtaining appropriate pressure redistribution devices.

IV

Advocacy

9.5 Organizations are encouraged to advocate for an increase in the availability

and accessibility of diabetic foot ulcer care for all residents of Ontario.

IV

Interpretation of Evidence
Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials.
Ib Evidence obtained from at least one randomized controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomization.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study,
without randomization.

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative
studies, correlation studies and case studies.

IV Evidence obtained from expert committee reports or opinions and/or clinical

experiences of respected authorities.

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Nursing Best Practice Guideline

Responsibility for Guideline Development

The Registered Nurses Association of Ontario (RNAO), with funding from the Government
of Ontario, has embarked on a multi-year program of nursing best practice guideline development, pilot
implementation, testing, evaluation and dissemination. In this fifth cycle of the program, one of the areas
of emphasis is on the assessment and management of diabetic foot ulcers. This guideline was developed
by a panel of nurses convened by the RNAO conducting its work independent of any bias or influence from
the Government of Ontario.

Purpose & Scope

Best practice guidelines (BPG) are systematically developed statements to assist nurses and patients
in decision-making about appropriate healthcare (Field & Lohr, 1990). This guideline has been developed to
address the question of how to assess and manage patients with established diagnosis of diabetic foot
ulcers. It will provide direction to practicing nurses (RNs and RPNs) who provide care in all healthcare
settings to patients (>15 years old) with type 1 and/or type 2 diabetes who have diabetic foot ulcers.
The guideline focuses its recommendations on four areas: (1) Practice Recommendations directed at the
nurse and other interdisciplinary healthcare professionals; (2) Educational Recommendations directed
at the competencies required for practice; (3) Organization and Policy Recommendations directed at
practice settings and the environment in order to facilitate nurses practice and (4) Evaluation and
monitoring indicators.
It is acknowledged that individual competencies of nurses vary between nurses and across categories of
nursing professionals (RNs and RPNs) and are based on knowledge, skills, attitudes and judgement
enhanced over time by experience and education. It is expected that individual nurses will perform only
those aspects of care for which they have received appropriate education and experience. Both RNs and
RPNs should seek consultation in instances where the patients care needs surpass the individual nurses
ability to act independently.
Caring for patients with diabetic foot ulcers is an interdisciplinary endeavour. Effective care depends on a
coordinated interdisciplinary approach incorporating ongoing communication between health professionals
and patients. It is however acknowledged that personal preferences and unique needs as well as the personal
and environmental resources of each individual patient must always be kept in mind.

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Assessment and Management of Foot Ulcers for People with Diabetes

Guideline Development Process

In January of 2004, a panel of nurses with expertise in practice, education and research related to
diabetic foot ulcers was established by the RNAO. At the onset, the panel discussed and came to consensus
on the scope of the best practice guideline.
A search of the literature for systematic reviews, clinical practice guidelines, relevant articles and websites
was conducted. See Appendix A for a detailed outline of the search strategy employed.
The panel identified a total of eight clinical practice guidelines related to diabetic foot ulcers. These
guidelines were reviewed according to a set of initial inclusion criteria, which resulted in elimination of one
guideline. The inclusion criteria were:

Guideline was in English, international in scope.

Guideline was dated no earlier than 1997.
Guideline was strictly about the topic area.
Guideline was evidence-based (e.g., contained references, description of evidence, sources of evidence).
Guideline was available and accessible for retrieval.

Seven guidelines were critically appraised with the intent of identifying existing guidelines that were
current, developed with rigour, evidence-based and which addressed the scope identified by the panel for
the best practice guideline. A quality appraisal was conducted on these seven clinical practice guidelines
using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE Collaboration, 2001). This
process yielded a decision to work primarily with the following seven guidelines.

Australian Centre for Diabetes Strategies (2001). National evidence based guidelines for the
management of type 2 diabetes mellitus Draft for public consultation 6 April 2001 for the
identification & management of diabetic foot disease. Australian Centre for Diabetes Strategies
[Electronic version].
Available: http://www.diabetes.net.au/PDF/evidence_based_healtcare/FootProblems.pdf

CREST Clinical Resource Efficiency and Support Team (1998). Guidelines for the management of
the diabetic foot: Recommendations for practice. Clinical Resource Efficiency and Support Team
[Electronic version]. Available: http://www.crestni.org.uk/publications/diabetic_foot.pdf

Frykberg, R. G., Armstrong, D. G., Giurini, J., Edwards, A., Kravette, M., Kravitz, S. et al. (2000).
Diabetic foot disorders: A clinical practice guideline. American College of Foot and Ankle Surgeons
[Electronic version]. Available: http://www.acfas.org/diabeticcpg.html

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Nursing Best Practice Guideline

Hutchinson, A., McIntosh, A., Feder, R.G., Home, P. D., Mason, J., OKeefee, C. et al. (2000). Clinical
guidelines and evidence review for type 2 diabetes: Prevention and management of foot problems.
Royal College of General Practitioners [Electronic version]. Available:
http://www.rcgp.org.uk/rcgp/clinspec/guidelines/diabetes/contents.asp

Inlow, S., Orsted, H., & Sibbald, R. G. (2000). Best practices for the prevention, diagnosis and
treatment of diabetic foot ulcers. Ostomy/Wound Management, 46(11), 55-68.

Ministry of Health Malaysia (2003). Clinical practice guidelines: Management of diabetic foot. Ministry
of Health Malaysia [Electronic version]. Available:
http://www.acadmed.org.my/cpg/Draft%20CPG%20%20management%20of%20diabetic%20foot.pdf

Royal Melbourne Hospital (2002). Evidence based guidelines for the inpatient management of acute
diabetes related foot complications. Melbourne Health [Electronic version]. Available:
http://www.mh.org.au/ClinicalEpidemiology/new_files/Foot%20guideline%20supporting.pdf

The panel members divided into subgroups to undergo specific activities using the short-listed guidelines,
other literature and additional resources for the purpose of drafting recommendations for nursing
interventions. This process yielded a draft set of recommendations.
An advisory panel was recruited to review and provide feedback on the draft recommendations. The
advisory panel represented physicians, other healthcare disciplines as well as professional associations. An
acknowledgement of the advisory panel is provided at the front of this document. Feedback on the
recommendations was obtained from healthcare consumers through a focus group. The panel members as
a whole reviewed the recommendations and the feedback from the advisory panel and consumers,
discussed gaps and available evidence, and came to a consensus on a draft guideline.
This draft was submitted to a set of external stakeholders for review and feedback of the content. It was also
critiqued using the AGREE instrument (AGREE Collaboration, 2001). An acknowledgement of these reviewers is
provided at the front of this document. Stakeholders represented healthcare consumers, various healthcare
disciplines as well as professional associations. External stakeholders were provided with specific
questions for comments, as well as the opportunity to give overall feedback and general impressions. The
results were compiled and reviewed by the development panel. Discussion and consensus resulted in
revision to the draft document prior to publication.

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Assessment and Management of Foot Ulcers for People with Diabetes

Definition of Terms
An additional Glossary of Terms related to clinical aspects of the document is located in Appendix B.

Clinical Practice Guidelines or Best Practice Guidelines: Systematically developed

statements (based on best available evidence) to assist practitioner and patient decisions about
appropriate healthcare for specific clinical (practice) circumstances (Field & Lohr, 1990).
Consensus: A process for making policy decisions, not a scientific method for creating new
knowledge. At its best, consensus development merely makes the best use of available information,
be that of scientific data or the collective wisdom of the participants (Black et al., 1999).
Education Recommendations:

Statements of educational requirements and educational

approaches/strategies for the introduction, implementation and sustainability of the best practice
guideline.

Evidence: An observation, fact or organized body of information offered to support or justify inferences
or beliefs in the demonstration of some proposition or matter at issue (Madjar & Walton, 2001, p.28).

Meta-Analysis: The use of statistical methods to summarize the results of independent studies,
thus providing more precise estimates of the effects of healthcare than those derived from the
individual studies included in a review (Alderson, Green & Higgins, 2004).

Organization & Policy Recommendations:

Statements of conditions required for a

practice setting that enable the successful implementation of the best practice guideline. The
conditions for success are largely the responsibility of the organization, although they may have
implications for policy at a broader government or societal level.

Practice Recommendations:

Statements of best practice directed at the practice of

healthcare professionals that are evidence-based.

Randomized Controlled Trial: For the purposes of this guideline, a study in which subjects
are assigned to conditions on the basis of chance, and where at least one of the conditions is a control
or comparison condition.

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Nursing Best Practice Guideline

Stakeholder: A stakeholder is an individual, group, or organization with a vested interest in the

decisions and actions of organizations that may attempt to influence decisions and actions (Baker et
al., 1999). Stakeholders include all individuals or groups who will be directly or indirectly affected by
the change or solution to the problem. Stakeholders can be of various types, and can be divided into
opponents, supporters, and neutrals (Ontario Public Health Association, 1996).

Systematic Review: Application of a rigorous scientific approach to the preparation of a review

article (National Health and Medical Research Council, 1998). Systematic reviews establish where the effects of
healthcare are consistent and research results can be applied across populations, settings, and
differences in treatment (e.g., dose); and where effects may vary significantly. The use of explicit, systematic
methods in reviews limits bias (systematic errors) and reduces chance effects, thus providing more
reliable results upon which to draw conclusions and make decisions (Alderson et al., 2004).

Background Context
Diabetes mellitus is serious, complex, life-long condition affecting 4.2% of the worlds population
and 1.5 million Canadians (Boulton, Meneses, & Ennis, 1999; Canadian Diabetes Association (CDA), 1998). Diabetes
seriously burdens individuals, their families and society. It is estimated that the cost of diabetes and its
chronic complications range from 4.6 to 13.7 billion U.S. dollars annually (Dawson, Gomes, Gerstein, Blanchard
& Kahler, 2002; Gordois, Scuffham, Shearer, Oglesby & Tobian, 2003). The aboriginal (First Nations, Metis and Inuit)
population in Canada demonstrates a prevalence of type 2 diabetes that is at least three times the national
average (Health Canada, 2000; 2002; Indian and Inuit Health Committee & Canadian Pediatric Society, 1994). This increased
incidence is reflected in high rates across all age groups. It is important to note that Aborignal ancestry has
been identifed as an independent risk factor for diabetes and despite this fact, little is known of this
particular group (Health Canada, 2000; 2002; Young, 2003; Young, Szathmary, Evers & Wheatley, 1990).
There are two major classifications of diabetes; Type 1 and Type 2. Type 1 diabetes, which affects 10-15% of
all people with diabetes, is primarily the result of the inability to produce insulin due to beta cell
destruction in the pancreas. While Type I diabetes accounts for fewer individuals with diabetes, it results in
a disproportionately higher frequency of diabetes related complications. Type 2 diabetes, affecting over
80% of those diagnosed with diabetes, results from a combination of insufficient insulin production and/or
resistance of the cells of the body to the actions of insulin (RNAO, 2004).
Control of blood glucose levels is paramount to minimizing complications related to diabetes (Diabetes
Control and Complication Trial (DCCT) Research Group, 1993; United Kingdom Prospective Diabetes Study (UKPDS) Group 33,
1998). This is achieved through lowering serum glucose using oral hypoglycemic agents, and/or

subcutaneous injections of insulin, dietary restriction and regular exercise. Other factors contributing to
delayed onset of complications include control of hypertension, hyperlipidemia and hyperinsulinemia.
Unfortunately, these treatments may not completely control the progression of diabetes-related changes
including neuropathy (CDA, 1998).

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Assessment and Management of Foot Ulcers for People with Diabetes

Regardless of the type of diabetes classification, over time, failure to achieve optimal glycemic control can
cause damage to the bodys small and large blood vessels and nerves. Damage to these vessels and nerves
can affect all organs in the body; however, the eyes, heart, kidneys, and skin are most commonly affected
in patients with diabetes.
These changes along with those previously mentioned lead to a cascade of events resulting in changes to
the foot itself. According to Boulton, Kirsner, & Vileikyte (2004), the triad of neuropathy, deformity and
trauma is present in almost two thirds of patients with foot ulcers (p. 49). The structural changes discussed
along with vascular insufficiency, infection and pressure predispose the person with diabetes (PWD) to
develop a foot ulceration (See Figure 1: Pathway to Diabetic Foot Ulcers).
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). Neuropathy is most commonly associated with the development of diabetic foot ulcers, but the
presence or co-existence of peripheral vascular disease and infection can also lead to skin breakdown. It is
widely known that diabetic foot ulceration is a significant end-stage complication of diabetes (Boulton et al.,
1999). Moreover, the risk of amputation increases 10-fold in patients with diabetes and concurrent end
stage renal disease (ESRD)(Eggers, Gohdes & Pugh, 1999).
It should be emphasized that the most common offending agent or cause of traumatic foot ulceration is
footwear (Birke, Patout Jr. & Foto, 2000; Tyrrell, 2002). The use of ill-fitting shoes are instrumental in the
development of blisters, callus and corns which can lead to ulceration in patients with diabetes. In
particular, peripheral neuropathy in people with diabetes leads to a cascade of events resulting in changes
to the foot itself. These changes, along with those previously mentioned, predispose the patient with
diabetes to the development of ulceration.
Given the data on the burden of illness and the significant long-term impact on health of people with
diabetes, care of persons with diabetic foot ulcers demands a systematic, team approach from healthcare
professionals (Dargis, Pantlejeva, Jonushaite, Vileikyte & Boulton, 1999; Sumpio, 2000). The development panel
recognizes the complexity of the treatment of individuals with diabetic foot ulcers, and acknowledges the
stressful conditions in which nurses work, in particular, the demands on the time of nurses in various
practice settings. To this end, the recommendations serve as a guide for nurses to identify and assess
patients in high risk groups who would benefit from specialized wound care. A specialized interdisciplinary
team should work closely with patients and their families to address the complex lifestyle, self-care and
multiple treatment demands of patients who have a diabetic foot ulcer. It is acknowledged that this level of
care is not yet accessible to or accessed by all people with diabetes. Moreover, fewer patients with foot
ulcerations receive optimal wound management (Boulton et al., 2004). Nurses can facilitate and positively
influence wound healing outcomes by promoting, collaborating and participating in interdisciplinary care
teams who follow best practice guidelines similar to those presented in this document.

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Nursing Best Practice Guideline

Figure 1: Pathway to Diabetic Foot Ulcers

Diabetes Mellitus

Peripheral arterial disease

O2 and
medication
delivery
impaired

Neuropathy

Sensory loss
of protective
sensation

Autonomic
skin changes

Motor foot
deformity

Autonomic/
Motor
Limited joint
mobility

Poor healing
Self care deficit
Poor glucose control
Improper footwear
Obesity

Ulceration

Infection

Amputation

Adapted with permission of Dr. M. E. Levin.

Levin, M. E. (2001). Pathogenesis and general management of foot lesions in the diabetic patient. In J. H. Bowker & M. A. Pfeifer
(Eds.), Levin and ONeals The Diabetic Foot. (6th ed.) (pp.222). St. Louis, MO: Mosby, Inc. uiding Principles in the Care of

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Assessment and Management of Foot Ulcers for People with Diabetes

Guiding Principles in the Care

of Patients with Diabetic Foot Ulcers
1. Diabetic foot ulcers are complex wounds, best treated with a team approach.
2. Nurses and their interdisciplinary colleagues require knowledge and collaboration to provide care.
3. Successful management of foot ulcers can significantly improve quality of life for patients with
diabetes, their family and caregivers.

4. Patients are empowered through education and involvement in the planning

and implementation of their care.

5. The V. I. P. principle (Vascular supply, Infection, and Pressure redistribution) guides the
assessment and management of diabetic foot ulcers.

6. Nurses and their interdisciplinary colleagues demonstrate integration of the best evidence
for practice and expertise in local wound care.

7. Patients with diabetes who are aware of their risk category and management strategies can
reduce ulcer re-ocurrence. Nurses and their interdisciplinary colleagues have a role in educating
their patients about reducing ulcer recurrence and further foot complications. Hence, it is highly
recommended by the development panel to implement this guideline in conjuction with the
RNAO (2004) Best Practice Guideline entitled Reducing Foot Complications for People with
Diabetes. This guideline is available to download at www.rnao.org/bestpractices.

8. Ulcer healing of patients with diabetes, improvement of quality of life and reduction in
amputation rate requires the successful implementation of a comprehensive foot ulcer program.

9. The development and implementation of a successful diabetic foot ulcer program

involves collaboration with practice leaders, educators and administrators.

10. Diabetic foot ulcer program outcomes should be evaluated and benchmarked for
continuous quality improvement.

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Nursing Best Practice Guideline

Practice Recommendations
Patient Empowerment and Education:
Recommendation 1.0:
All patients with diabetic foot ulcer(s)(PWDFU) or caregivers should have an understanding of their
condition and the resources available to optimize their general health, diabetes management and
ulcer care. (Level of Evidence =1a)

Discussion of Evidence:
In order to address the many individual variables involved in learning, the process of educating patients
with diabetes has become participative rather than didactic (Whittemore, 2000). Evidence supports
educational intervention for improvement in foot care knowledge and behaviour in the short term for
people with diabetes (Hutchinson et al., 2000; Valk, Kriegsman, & Assendelft, 2002). There is additional evidence to
support that people with diabetes who are at a higher risk for foot ulceration significantly benefit from
education and regular reinforcement of that education (ADA, 2001; CDA, 1998; 2003; Mason, OKeefee, Hutchinson,
McIntosh, Young & Booth, 1999a; The University of York NHS Centre for Reviews and Dissemination, 1999; New Zealand
Guidelines Group (NZGG), 2000). A three-fold increased amputation risk was demonstrated by Reiber, Pecoraro

& Koepsell (1992) for those people with diabetes who had not received formal diabetes education,
suggesting significant prevention is possible with appropriate teaching strategies.
Expert opinion supports the need for reinforcement of basic foot care education in patients with diabetes
and established foot ulcers. Nurses, as the single largest group of health professionals working in a range of
settings, are well positioned to monitor risk status for re-occurrence, identify new or deteriorating ulcers
and provide and/or reinforce basic foot care education. They may act as the primary diabetes foot care
educator, or as a link between patients and their primary care providers or within specialized diabetes care
teams (RNAO, 2004).

Recommendation 1.1:
Education is essential as an empowerment strategy for diabetes self-management and prevention
or reduction of complications. (Level of Evidence = IV)

Discussion of Evidence:
Diabetes education should be interactive, solution-focused and based on the experiences of the learner. It should
be staged and tailored to meet individual needs and abilities. The education of patients should be in keeping
with the principles of adult learning using a client-centred approach (Glasgow, 1999). The nurse should be sensitive
to socioeconomic, cultural, psycho-social and other individual domains when planning all interventions.
Randomized controlled trials evaluating education for people with diabetes are of poor quality and have significant
methodological issues (Valk, Kriegsman & Assendelft, 2004). The existing evidence, however, does indicate that foot
care knowledge and patient behaviour is positively influenced, albeit for a short time period, and education may
be of particular benefit to those patients at high risk (Valk et al., 2004). Group education and sustained long-term
follow-up have both been shown to enhance knowledge and produce positive outcomes (CDA, 2003).

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Assessment and Management of Foot Ulcers for People with Diabetes

Recommendation 1.2:
Education is based on identified individual needs, risk factors, ulcer status, available resources and
ability to heal. (Level of Evidence = IV)

Discussion of Evidence:
As visible care providers across the continuum, nurses are in a unique position to promote the maintenance
of healthy feet, identify problems at any stage, positively influence self-care practices, and refer higher risk
individuals for expert care (RNAO, 2004).
There is evidence that diabetes self-care behaviours influence blood glucose control. Improved glycemic
control facilitates healing of foot ulcers and delays and/or prevents diabetes related complications that
further contribute to peripheral neuropathies and reduced lower extremity circulation (DCCT Research Group,
1993; RNAO, 2004; UKPDS Group 33, 1998).
The needs assessment should be the driving force for individual program planning and management.
These assessments need to be tailored to determine appropriate allocation of personnel and resources to
ensure the education and healthcare needs of the individual are met (ADA, 1999). Personal attitudes and
cultural beliefs, level of literacy, age and physical condition will all influence the individuals ability to carry
out the recommended regimen (American Association of Diabetes Educators, 1999; Canadian Diabetes Association
Diabetes Educator Section, 2000).
Although education seems to have short term positive impact on foot care knowledge and patient
behaviour, it is uncertain whether it can prevent foot ulceration and amputation. In a systematic review
examining patient education regarding diabetic foot ulceration, Valk et al. (2002), conclude that further
research is required to recognize the impact of patient education on ulcer incidence and whether
education has different effects for individuals with different levels of risk of ulcer development.
As discussed in the best practice guideline Reducing Foot Complications for People with Diabetes (RNAO,
2004), the following elements should be included in basic foot care programs:

Awareness of personal risk factors;

Value of annual inspection of feet by a healthcare professional;
Daily self inspection of feet;
Proper nail and skin care;
Injury prevention; and
When to seek help or specialized referral
(ADA, 2001; Apelqvist, Bakker, van Houtum, Nabuurs-Franssen & Schaper, 2000; CDA, 1998; Diabetes Education Study
Group of the European Association for the Study of Diabetes, 2001; Institute for Clinical Systems Improvement, 2000; NZGG,
2000; Pinzur, Slovenkai & Trepman, 1999).

See Appendix C for the University of Texas Foot Classification System Categories 0-3: Risk Factors for Ulceration.

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See Appendix D for the University of Texas Foot Classification System Categories 4-6: Risk Factors for
Amputation
See Appendix E for the University of Texas Health Science Center San Antonio Diabetic Wound
Classification System.
See Appendix F for patient handout on diabetic foot care.

Holistic Assessment:
Recommendation 2.0:
Complete and document a health history, including diabetes management, allergies, medications,
functional assessment and physical examination (vascular status, infection, callus, neuropathy,
foot deformity/pressure, ulcer). (Level of Evidence = Ib IV)
The holistic assessment of patients with diabetes and foot ulceration should include:
History of presenting illness (Level of Evidence = IV)
Initiating event (trauma, shoe wear, etc.)
Duration of ulceration
Treatments prescribed
Outcome of the treatments
Past medical history (Level of Evidence = III)
Medications (Level of Evidence = IV)
Current diabetes management (Level of Evidence = Ib)
Allergies (Level of Evidence = IV)
Family history (Level of Evidence = III)
Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL)
or functional assessments (Level of Evidence = III)
Quality of life (Level of Evidence = III)

Discussion of Evidence:
A comprehensive assessment is required for all patients who present with diabetic foot ulceration.
This assessment must include the etiology, factors that influence healing and the patients
biopsychosocial status.

History of Presenting Illness (Level of Evidence = IV)

Initiating event
Duration of ulceration
Treatments prescribed
Outcome of the treatments

The evaluation of the patient with a diabetic foot ulcer requires a detailed history and physical
examination, appropriate diagnostic tests, and identification of risk factors for ulceration. People with
diabetic foot ulcers should be identified as high risk for amputation (Australian Centre for Diabetes Strategies,
2001; Falanga & Sabolinski, 2000).

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Assessment and Management of Foot Ulcers for People with Diabetes

Past Medical/Surgical History (Level of Evidence = III)

A careful history is required to determine general health, diabetes control and complications. This should include:
All other medical conditions (co-morbidities) and complications associated with diabetes
Any surgeries and/or previous amputation related to diabetes
History of previous ulcers related to diabetes

Co-morbidities and complications associated with Diabetes:

Renal impairment
Eggers et al. (1999), identified that patients with diabetes mellitus and end stage renal disease (ESRD),
accounted for 50% of amputations within this patient population. Those with ESRD only, without diabetes
mellitus had one-fifth the rate of amputations. Those with ESRD from other causes but had diabetes
mellitus as a risk factor accounted for approximately 25% of the amputations. In the ESRD post amputation
population, the survival rate at two years was 33%.
Hypertension
Results of the Hypertension Optimal Treatment and United Kingdom Prospective Diabetes Study (UKPDS) trials
report clinically important reductions in microvascular and macrovascular complications and diabetes
related death (CDA, 2003). Individuals with co-exisitng hypertension have a five-fold increased risk of
developing peripheral vascular disease (PVD) and therefore are at increased risk for amputation, compared
to normotensive individuals with diabetes (Royal Melbourne Hospital, 2002). Adler, Stratton, Neil, Yudkin,
Matthews, Cull et al. (2000) demonstrated that macro and microvascular (retinopathy, nephropathy)
complications are linked to elevated blood pressure.
Retinopathy
Reiber, Vileikyte, Boyko, Del Aguila, Smith, Lavery et al. (1999) reviewed seven studies indicating that
retinopathy is an independent predictor of amputation, possibly due to microvascular disease.
Hospital admissions and previous surgeries
A history of previous amputation is a strong predictor of future amputations. Up to 34% of patients develop
another ulcer within one year after healing while the 5 year rate of re-ulceration has been shown to be 70%
(Frykberg et al., 2000).

Medications (Level of Evidence = IV)

Medication records will provide the health practitioner with information regarding diabetes management,
as well as potential drug interactions, and those that may impair wound healing.

Current Diabetes Management (Level of Evidence = Ib)

Gylcemic Control
The complications from diabetes are strongly related to high blood glucose levels. Improved glycemic
control reduces complications. The United Kingdom Prospective Diabetes Study (UKPDS) showed that
intensive control of blood glucose resulted in a substantial reduction of the risk of complications of type 2
diabetes. Each 1% reduction in A1C produced significant decreases in complications. A1C values in the
normal range (<6%) comprised the lowest risk (Stratton, Adler, Neil, Matthews, Manley, Cull et al., 2000). The DCCT
Research Group (1993) concluded that intensive therapy to maintain blood glucose levels close to the

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Nursing Best Practice Guideline

normal range effectively delayed the onset and slowed the progression of diabetic retinopathy,
nephropathy and neuropathy in patients with insulin dependent diabetes (IDDM), now identified as type 1.
A Japanese study examining glycemic control and microvascular complications concluded that intensive
glycemic control can delay onset and progression of diabetic retinopathy, nephropathy and neuropathy in
Japanese patients with NIDDM (type 2 diabetes)(Ohkubo, Kishikawa, Araki, Miyata, Isami, Motoyoshi et al., 1995).
The Wisconsin Epidemiologic Study of diabetes retinopathy showed a consistent exponential relationship
between worsening glycemic control and complications (Moss, Klein & Klein, 1996). The CDA Clinical Practice
Guidelines (2003) recommends the following targets for glycemic control for most patients with type 1 and
type 2 diabetes:
A1C < 7.0% to reduce the risk of microvascular and macrovascular complications.
Fasting plasma glucose of 4.0 to 7.0 mmol/L and 2-hour postprandial plasma glucose
targets of 5.0 to l0.0 mmol/L.
The CDA (2003) advises that treatment goals and strategies must be individualized according to risk factors
such as complications and co-morbidities.

Allergies (Level of Evidence = IV)

Any allergies should be recorded in the medical history. Particular notes should be made of medications.

Family History (Level of Evidence = III)

Persons who have close relatives with certain diseases (e.g., heart disease, diabetes, and osteoporosis) are
more likely to develop those diseases themselves (Bennett, 1999). Family health history is an important
risk factor that reflects inherited genetic susceptibility, shared environment and common behaviours
(Centres for Disease Control and Prevention, 2004).

Activities of Daily Living (ADL) (Level of Evidence = III)

It is important to determine how the patient is able to function within the environment that they are living
in and how this impacts the patients quality of life. Ribu & Wahl (2004) conducted a qualitative study with
seven patients having type 1 or type 2 diabetes and foot ulcers to determine the patients perspective of
living with lower extremity ulcers and diabetes. The result indicates that patients experienced changes in
their feet, pain and insomnia, fatigue and limited mobility, social isolation and loneliness, a restricted life,
loss of control and fear for the future. When treating a patients foot ulcer, clinicians need to consider
patients subjective feelings toward the various aspects of their life situations and the impact of their
situation on their quality of life.

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Assessment and Management of Foot Ulcers for People with Diabetes

Vascular Status:
Recommendation 2.1:
Clinically assess bilateral lower extremities for vascular supply and facilitate appropriate
diagnostic testing. (Level of Evidence = IIb IV)
The assessment of vascular supply can be achieved through history, physical examination and diagnostic tests.

History and Physical Examination

of the Lower Extremities

Diagnostic Tests*

Peripheral pulses

Ankle brachial pressure index (ABPI)

Intermittent claudication

Arterial duplex scan

Colour (pallor on limb elevation, rubor

Toe and ankle pressures

on limb dependency, mottling)

Transcutaneous oxygen

Temperature

Capillary refill

Edema

Pain

Dry gangrene

RNAO Guideline Development Panel, 2005

*Accesibility of these diagnostic tests may be limited to centres with specialty in vascular surgery and wound care.

Discussion of Evidence:
The affected foot must have adequate blood flow to support healing (Birke et al., 2000; Reiber et al., 1999). The
literature supports the notion that peripheral arterial disease (PAD), also known as peripheral vascular
disease (PVD), is not the cause of skin breakdown alone, but can prolong wound healing and increase the
risk of subsequent amputation (Apelqvist, 1998; Birke et al., 2000; Crane & Branch, 1998; Sinacore & Mueller, 2000). In
persons with diabetes seen at a younger age, PAD is often bilateral. Moreover, risk of PAD increases with the
duration of the disease (Calhoun, Overgaard, Stevens, Dowling & Mader, 2002). Furthermore the risk of PAD
increases by ten-fold in those with diabetes and concurrent renal failure (Apelqvist, 1998; Eggers et al., 1999).
The presence of peripheral pedal pulses represents a minimum systolic pressure of 80 mmHg (Lavery &
Gazewood, 2000). The National Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus
(Australian Centre for Diabetes Strategies, 2001) states that the absence of peripheral pulses has prognostic
significance for future amputation in people with or without foot ulceration. With the distal nature of the
disease process, persons with diabetes may have ischemia in the presence of dorsalis pedis pulses (Boulton
et al., 1999).
One of the first classical symptoms of vascular insufficiency is claudication (calf pain). However, in patients
with diabetes, this classic symptom can be masked by the presence of neuropathy (Calhoun et al., 2002). A
cohort study by Eneroth, Apelqvist & Stenstrom (1997), found that claudication was an insignificant
predictor or symptom of vascular disease. A positive history of lower limb intermittent claudication
combined with non-palpable pedal pulses bilaterally increases the probability of vascular insufficiency in
diabetes (Boyko, Ahroni, Davignon, Stensel, Prigeon & Smith, 1997).

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Nursing Best Practice Guideline

Capillary refill is defined as abnormal if it takes longer than 5 seconds for the tissue to return to its normal
colour after applying pressure and releasing it.
The colour of the foot should be assessed for rubor on dependency, pallor on elevation, mottling and dry
gangrene, all of which are signs of ischemia (Bowker & Pfeifer, 2001). A vascular surgery referral is
recommended for patients with signs of arterial insufficiency in order that a comprehensive vascular
assessment can be completed.
See Appendix G for further details about diagnostics to determine vascular supply.

Infection:
Recommendation 2.2:
Assess all patients with diabetic foot ulcers for signs and symptoms of infection and facilitate
appropriate diagnostic testing and treatment. (Level of Evidence = IIa)

Discussion of Evidence:
Persons with diabetic foot ulcers may not be able to mount an inflammatory response due to impaired
immunodefense, decreased peripheral circulation and metabolic control (Armstrong, Lavery, Sariaya & Ashry,
1996; Eneroth et al., 1997). In addition, increased co-morbidities associated with aging places the person with
diabetes at a higher risk for infection.
Identifying infection in a chronic wound can be a challenge since the clinical assessment for infection in chronic
wounds differs from acute wounds. Gardner, Frantz & Doebbling (2001) validated the work by Cutting &
Harding (1994) and provided a checklist to aid the clinician in identifying the clinical signs of infection in chronic
wounds. Gardner et al. (2001), in a cross-sectional design study, identified the following signs and symptoms:
Increased pain (100% specificity)
Wound breakdown (100% specificity)
Friable granulation tissue (76% specificity)
Foul odour (88% specificity)
Deep infection will often cause erythema and warmth extending 2 cm or more beyond the wound margin.
This increased inflammatory response is painful and will cause the wound to increase in size or lead to
satellite areas of tissue breakdown which cause adjacent ulceration. Deep infections, especially in ulcers of
long duration can often lead to osteomyelitis. Probing to bone is a simple, non-invasive technique for rapid
identification of osteomyelitis and should be included in the initial assessment of all patients with
infected pedal ulcers (Grayson, Balaugh, Levin & Karchmer, 1995). When combined with clinical evaluation and
radiographic interpretation, probing to bone is a cost-effective and specific assessment tool (Caputo,
Cavanagh, Ulbrecht, Gibbons & Karchmer, 1994).
With infection, the wound may change in odour, colour, tissue quality and exudates. A healthy wound has
a faint but not unpleasant odour, infections usually result in a distinctive and slightly unpleasant smell
(Cutting & Harding, 1994).

27

Assessment and Management of Foot Ulcers for People with Diabetes

Based on the utilization of the signs and symptoms listed below, the timely diagnosis and treatment of
infection is vital to the healing of diabetic foot ulcers. Deep foot infections are serious, potentially limb
threatening and have been identified as the immediate cause of 25-51% of amputations in persons with
diabetes (Tennvall, Apelqvist & Eneroth, 2000).

Table 1: Clinical signs and symptoms of impaired bacterial balance in persons with a diabetic foot ulcer
SIGNS OF DEEP WOUND AND SYSTEMIC SIGNS OF INFECTION ARE POTENTIALLY LIMB
AND/OR LIFE THREATENING. THESE CLINICAL SIGNS AND SYMPTOMS REQUIRE
URGENT MEDICAL ATTENTION.

Non limb threatening infection

Superficial infection

Deep wound infection

Limb threatening infection

Systemic infection

Non-healing

Pain (in a previously insensate foot)

In addition to deep wound infection:

Bright red granulation tissue

Swelling, induration

Fever

Friable and exuberant granulation

Erythema (> 2 cm)

Rigours

New areas of breakdown or necrosis

Wound breakdown

Chills

Increased exudate

Increased size or satellite areas

Hypotension

Bridging of soft tissue

Undermining or tunnelling

Multi-organ failure

and the epithelium

Probing to bone

Foul odour

Flu-like symptoms

Anorexia

Erratic glucose control

RNAO Guideline Development Panel, 2005

Infection occurs when bacteria in a wound overcomes the natural defences of the hosts immune system.
The likelihood of a wound becoming infected is related to microbial load and the type of micro-organism.
However, equally important factors are the characteristics of the wound (type, site, size and depth), the
level of blood perfusion and the ability of the host to resist infection:
Infection

Number of organisms
x
Virulence of organisms
Host resistance

This equation represents a balance between increasing number of organisms and virulence that can eventually
overcome the hosts ability to contain infection (Dow, Browne & Sibbald, 1999; Peacock & Van Winkle, 1976).
While emphasis is frequently placed on bacterial burden, the host resistance (the patient with diabetes) is often
the critical factor in determining whether infection will develop. Persons with diabetes have compromised
immunity which leads to a reduced resistance to infection.

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Nursing Best Practice Guideline

Most chronic wounds contain more than three species of micro-organisms, which increases the risk of
infection as they may develop synergies with one another. In wounds that are infected with a number of
species it is not possible to distinguish which is the causative organism (Table 2).

Changes in microbial flora over time

The microbial flora in a chronic wound changes over time in a predictable fashion as seen in Table 2.

Table 2: Microbial flora in a chronic wound over time

Time

Type of micro-organism

First few days

Cutaneous flora

1 to 4 weeks

Cutaneous flora accompanied by Gram-positive

Purulent discharge

aerobic cocci, often beta-haemolytic Streptococci,

Gram-positive

S. aureus.

Single species

Cutaneous flora accompanied by Gram-negative

Tissue necrosis

facultative anaerobic bacteria, particularly coliforms

Undermining

followed by anaerobic bacteria and Pseudomonas

Deep involvement

4 weeks onwards

Clinical and laboratory findings

Poly-microbial mixture of aerobic

and anaerobic pathogens

Used with permission. Dow, G., Browne, A. & Sibbald, R. G. (1999). Infection in chronic wounds:
Controversies in diagnosis and treatment. Ostomy/Wound Management, 45(8), 23-27, 29-40.

Diagnostic tests and imaging are other procedures that are used to determine infection.
For diagnostic tests and imaging to determine infection, see Appendix H.
For description of swabbing technique, see Appendix I.

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Assessment and Management of Foot Ulcers for People with Diabetes

Neuropathy:
Recommendation 2.3:
Identify peripheral neuropathy by assessing for sensory, autonomic and motor (S.A.M.) changes.
(Level of Evidence = II IV)

Discussion of Evidence:
Lavery, Armstrong, Vela, Quebedeau & Fleishchli (1998) noted that patients with only peripheral
neuropathy and no other risk factors were 1.7 times more likely to develop ulceration. Patients with both
neuropathy and foot deformity were 12.1 times more likely to have an ulcer. Patients with neuropathy,
deformity and a history of amputation were 36.4 times likely to develop a foot ulcer.
There are three components to peripheral neuropathy. Listed below are the effects of each form of neuropathy
that the patient with diabetes may present with that will increase the risk of ulcer development:

Component

Pathophysiology

Sensory

Myelin sheath is disrupted

by hyperglycemia
Disruption leads to segmental
demyelinization process
accompanied by a slowing
of motor nerve conduction
and an impairment of
sensory perception
(Zangaro & Hull, 1999)

Assessment

Autonomic

Sympathetic Denervation
Loss of vasomotor control
Peripheral blood flow
Arteriovenous shunting
Bone blood flow hyperemia
Glycosylation of collagen

Motor

Non-enzymatic glycosylation
Atrophy of intrinsic muscles
of the foot (toe plantar
flexors)
Subluxation of metatarsophalangeal joints

Outcome

4 site testing including the great toe, first,

third and fifth metatarsal heads, using a
10-gram (5.07) monofilament* is
recommended as an appropriate
screening process to determine the
presence of protective sensation in the
persons with diabetes (ADA, 2001;
Campbell, Graham, Kidd, Molly, ORourke
& Coagiuri, 2000; Frykberg et al., 2000; Hunt,
2001; Hutchinson et al., 2000; Institute for
Clinical Systems Improvement, 2000; Lavery
& Gazewood, 2000; McCabe, Stevenson &
Dolan, 1998; NZGG, 2000; RNAO, 2004;
Smieja, Hunt, Edelman, Etchells, Cornuz &
Simel, 1999; Zangaro & Hull, 1999).
Gait analysis

Dry scaly skin caused by lack

of hydration
Inspect between the toes especially
between the fourth and fifth toes
for fissures
Maceration
Loss of hair growth and thickened toenails

Increased peak pressure

Range of motion
Absent deep tendon reflexes
Diminished vibratory sense

Loss of protective
sensation
Sensory ataxia
Falls (15-fold
increase compared
to those without
diabetes)

Anhydrosis
Callus
Fissure cracks
Onychomycosis
(fungal nails)
Peripheral edema
Waxy skin = altered
joint mobility
Claw toes
Hammer toes
Charcot arthropathy
Muscle weakness
Ankle equinus
Pes cavus
Pes planus
Contracture of
Achilles Tendon

*(Apelqvist,1998; Boyko, Ahroni, Stensel, Forsberg, Davignon & Smith, 1999; Bureau of Primary Health Care, 2005; Frykberg,
Lavery, Pham, Harvey, Harkless & Veves, 1998; Lavery, Armstrong, Wunderlich, Tredwell & Boulton; 2003; Shaw & Boulton, 1997).

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Nursing Best Practice Guideline

See Appendix J for description and use of monofilament.

Foot Deformity and Pressure:

Recommendation 2.4:
Assess for foot pressure, deformity, gait, footwear and devices. Facilitate appropriate referrals.
(Level of Evidence = Ia IV)

Discussion of Evidence:
Studies have demonstrated that while trauma to a neuropathic foot may be related to a single event, ulcers
frequently occur as a result of repeated minor trauma such as from footwear or elevated pressure on the
bottom of the foot. Foot deformities such as prominent metatarsal heads, clawing of the toes and limited
joint mobility alters the gait or mechanics of walking resulting in abnormal forces on the foot, poor shock
absorption, and shearing and stress to soft tissues (RNAO, 2004; Shaw & Boulton, 1997). People with diabetes
should be assessed regularly to detect foot deformities and should have interventions to reduce foot
pressure and ulcer risk (Australian Centre for Diabetes Strategies, 2001; Royal Melbourne Hospital, 2002).

Assess for Pressure

Elevated foot pressure is an important risk factor for foot complications (Lavery et al., 2003). The plantar
surface of the forefoot is found to be the most common location for the development of an ulcer (ADA, 1999).
Forefoot and rear foot pressure ratios are increased in the severe diabetic neuropathic foot indicating an
imbalance in pressure distribution. Equinus deformity with severe peripheral neuropathy may be an
important factor in ulcer etiology (Caselli, Pham, Giurini, Armstrong & Veves, 2002). Reduced plantar soft tissue
thickness at the metatarsal heads is associated with increased foot pressure and may predict development
of diabetic foot ulcer (Abouaesha, van Schie, Griffiths, Young & Boulton, 2001).
Pressure over bony prominences can lead to callus formation and in the absence of protective sensation
may predispose the area to breakdown (Australian Centre for Diabetes Strategies, 2001; Boyko et al., 1999; Frykberg et
al., 1998; Hutchinson et al., 2000). Callus may act as a foreign body elevating plantar pressures and there is
significant reduction in pressure when the callus is removed (Boulton et al., 1999; Murray, Young, Hollis & Boulton, 1996;
Pataky, Golay, Faravel, Da Silva, Makoundou, Peter-Riesch et al., 2002; Young, Cavanagh, Thomas, Johnson, Murray & Boulton, 1992).

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Assessment and Management of Foot Ulcers for People with Diabetes

Identify Structural Deformities

The physical examination of a person with diabetes should include assessment and intervention for foot
deformity (Australian Centre for Diabetes Strategies, 2001; Royal Melbourne Hospital, 2002). There is significant evidence
that with increased number of deformities, there is an increased risk and magnitude of plantar pressure
(Lavery et al., 2003).
Deformities may include, but are not limited to, hammer toe, claw toe, hallux deformity, pes planus, pes
cavus and Charcot arthropathy.

Deformity

Description and Evidence

With atrophy of the intrinsic muscles
of the foot, especially the toe plantarflexors, the flexor/extensor balance at
the metatarso-phalangeal joints is
altered. This causes clawing at the
toe and possible subluxation of the
metatarso-phalangeal joints. As a result,
the submetatarsal fat pads are displaced
and there is reduced pressure absorbing
subcutaneous tissue at the metatarsal
heads. In addition, glycosalation of
collagen from hyperglycemia results in
thickened, waxy skin which affects joint
mobility. All these factors contribute to
foot deformity and ulcer risk (Bennett,
Stocks & Whittam, 1996; Shaw & Boulton, 1997).

*Hammer Toe bent middle joint

*Claw Toe joint at base of toe is

bent up and middle joint is bent down

*Halgus Valgus or Small

Bunion (Mild/Moderate)
joint at the base of big toe
is pushed to the side

*Hallus Valgus or Large

Bunion (Severe)
big toe may move under
second toe

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Nursing Best Practice Guideline

Deformity

Description and Evidence

Pes planus produces flattening of the foot. Pes planus feet
have increased lateral talometatarsal angle and increased
second metatarsal length (Ledoux, Shofer, Ahroni, Smith,
Sangeorzan & Boyko, 2003). There are many reasons for this
condition, the first of which is heredity. Many have this
condition and never have any problems of any kind.
However, others will have this condition created through years
in soft, unsupportive shoes on hard surfaces, injury, pregnancy,
or other factors. This often leads to other problems.

Pes Planus

The arch in the foot is caused by a broad band of fibrous

connective tissue, called the longitudinal ligament. A ligament
is nothing more than connective tissue that connects bone to
bone. The longitudinal ligament connects the metatarsal
phalangeal joints to the os calcis or heel bone. Like a string on
a bow, they hold the two ends together and create an arch.
This arch is a shock absorption structure and it also helps to
maintain all the tarsals in proper erect anatomic position. As
this arch decreases, impact from the concrete becomes worse.
When the arch ligament stretches or tears, the arch falls. If it
falls far enough, the tarsals may begin to shift to the inside or
create pronation or a valgus (greater than 90 degree erect)
position at the ankle. This can cause problems in the origin
area, (the metatarsals) or in the heel. It also may cause
pressure on the medial (inner) knee and perhaps the hip and
back. It is like pulling the string on a marionette too tight, the
result is a kinked mass on one side. The human body is much
the same, put too much tension on major muscle groups and
the joints kink and yell back.

Pes Cavus

In pes cavus, the arch is abnormally high on weight bearing.

The heel is often tilted inwards at the ankle (but not always).
In many, the toes will appear clawed. When not standing the
front half of the foot (forefoot) will appear to be dropped
below the level of the rear foot. Ledoux et al. (2003) identified
biomechanical differences among pes planus and pes cavus
feet in persons with diabetes. They found pes cavus feet had
more prominent metatarsal heads, bony prominences,
hammer/claw toes, increased hallux dorsiflexion and
decreased hallux plantarflexion.

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Assessment and Management of Foot Ulcers for People with Diabetes

Deformity

*Charcot Arthropathy

Limited Joint Mobility

Description and Evidence

Charcot joint is a form of neuroarthropathy that occurs
most often in the foot. Nerve damage from diabetes causes
decreased sensation, muscle and ligamental atrophy and
subsequent joint instability. Walking on this insensitive and
weakened joint can cause even more damage to the foot
structure. In the acute stage there is inflammation and bone
reabsorption which destroys the bone. In later stages, the
arch falls and the foot may develop a rocker bottom
appearance. Weight distribution of the sole is altered
causing deformities leading to pressure points that
enhances ulcer development. Signs to assess for are: hot on
the onset, pain, discomfort, erythema, swelling, rigid
deformities, limited joint mobility, callus formation (ADA,
2001; Bowker & Pfeifer, 2001). One in 680 people with diabetes
develop Charcot joint with an incidence of 9-12%
individuals with documented diabetic peripheral
neuropathy (Royal Melbourne Hospital, 2002). It is important that
the Charcot foot is recognized early so that appropriate
treatment of the foot can be provided to prevent further
injury and promote a stable foot (Lavery et al., 1998). For
patient information on Charcot arthropathy, visit
www.rnao.org/bestpractices.
Progressive stiffening of collagen-containing tissues leads to
thickening of the skin, loss of joint mobility, and potential
fixed flexor deformity. Up to 30% of patients with diabetes
may have limited joint mobility. Reduction in mobility of
the ankle joint may cause increased plantar pressure when
walking and be a major risk factor in the pathogenesis of
diabetic foot ulcers (Fernando, Masson, Veves & Boulton, 1991;
Zimny, Schatz & Pfohl, 2004). Achilles tendon contracture is a
common cause of limited joint mobility causing increased
pressure on the forefoot during ambulation (Armstrong, Lavery
& Bushman, 1998; Mueller, Sinacore, Hastings, Strube & Johnson, 2004).

Above illustrations provided by Nancy A. Bauer, BA, Bus Admin, RN, ET.
* Reference:
Diabetes Nursing Interest Group & Registered Nurses Association of Ontario (2004). Diabetes foot: Risk assessment education
program. Images of the diabetic foot. Registered Nurses Association of Ontario [Electronic version]. Available:
www.rnao.org/bestpractices/PDF/BPG_Foot_Diabetes_Workshop_slides.pdf

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Nursing Best Practice Guideline

Gait Abnormality
Gait is the manner or style of walking. The neurodegenerative process is accelerated in diabetes and this
results in a decline in motor control and a pathology-related decline in postural stability/foot posture, and
abnormal weight bearing (Mason OKeefee, McIntosh, Hutchinson, Booth & Young, 1999b; Meier, Desrosiers, Bourassa &
Blaszczyk, 2001). Alterations in gait, balance and mobility are caused by sensory ataxia, poor vision,
debilitation and/or neuropathy in the patient with diabetes (Sinacore & Mueller, 2000). Assessment of gait is
important because patients with diabetes and neuropathy have a 15 times greater risk of experiencing a fall
compared to those without neuropathy (Sinacore & Mueller, 2000).
Some gait patterns that may be observed in a patient with diabetes are: ataxic (unsteady, uncoordinated,
employing a wide base of support), steppage (lift the foot higher to accommodate for foot drop and/or poor
ankle-joint mobility) and antalgic (a limp, usually signifying discomfort).

Footwear and Devices

Examination and use of existing footwear and devices should be assessed for areas of pressure and
adherence with wearing. Appropriate education should be provided. See Appendix K for suggestions in
assessing and selecting shoes and socks.
Shoes
It is imperative that patients with diabetes see a foot or healthcare specialist regularly for the assessment
of their feet as well as their shoes and other devices associated with ambulation as a preventative
measure to reduce the occurrence and re-occurrence of ulcers (ADA, 2001; Campbell et al., 2000; Frykberg et
al., 2000; Hunt, 2001; Hutchinson et al., 2000; Institute for Clinical Systems Improvement, 2000; Lavery & Gazewood, 2000;
McCabe et al., 1998; NZGG, 2000; Smieja et al., 1999; Zangaro & Hull, 1999).

Foot ulceration has been associated with constant or repetitive pressure from tight shoes over bony
prominences on the dorsum of the lesser toes, at the medial aspect of the first metatarsal head, or the
lateral aspect of the fifth metatarsal (Lavery et al., 1998). In a large prospective study, Abbott, Carrington,
Ashe, Bath, Every, Griffiths et al. (2002) found that the main cause (55%) of ulceration was pressure from
footwear.
In a systematic review of interventions to prevent diabetic foot ulcers, two randomized controlled trials
on patient footwear were reviewed. One study found that type of shoe may be independently important,
and that providing patients with normal well-fitting shoes that distribute abnormal pressures may also
reduce ulcer risk (Mason et al., 1999a). The second study reported that evidence does not support
widespread dispensing of therapeutic shoes and inserts for patients with diabetes and foot deformities.
Patient education may be a more important intervention. However, for those patients unable to be
closely monitored or who have severe deformities, specialized footwear may be beneficial (Reiber, Smith,
Wallace, Sullivan, Hayes, Vath et al. 2002). Maciejewski, Reiber, Smith, Wallace, Hayes & Boyko (2004) reported
results consistent with the second study.

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Assessment and Management of Foot Ulcers for People with Diabetes

Orthotics
Orthotics are custom-made shoe inserts which serve to correct or relieve misalignment and or pressure
areas of the foot. A systematic review was conducted to assess the effectiveness of pressure relieving
interventions in prevention and treatment of diabetic foot ulcers. Spencer (2004) reviewed four
randomized controlled trials of pressure relieving interventions and concluded that in-shoe orthotics
are of benefit.

Diagnostic Tests
Accessability of these tests may be limited to specialty centres.
X-ray
X-rays are useful primarily as imaging tools to identify possible osteomyelitis, foreign bodies, tissue
gas, or bony abnormalities (Royal Melbourne Hospital, 2002).
Pressure Map
Pressure mapping measures foot pressures in standing and walking positions. Lavery et al. (1998)
identified high plantar pressure (65 N/cm2) as a significant factor associated with the presence of foot
ulceration. Pham, Armstrong, Harvey, Harkless, Giurini & Veves (2000) using an F-Scan mat system,
found that foot pressures > 6kg/cm put patients at risk for foot ulcerations.

Foot Ulcer Assessment:

Recommendation 3.0:
Describe and document the ulcer characteristics. (Level of Evidence = IV)

Discussion of Evidence:
Good record keeping using common language and objective descriptors such as wound measurements
and ulcer grading can increase clarity and may improve outcomes. Careful monitoring of wound healing is
as important as initial assessment and treatment in influencing outcome (Krasner, 1998). At present, there is
a lack of clearly established standards for assessing and documenting wound progress.

Recommendation 3.1:
Identify the location, length, width, depth and classify the ulcer(s). (Level of Evidence = Ia IV)

Discussion of Evidence:
Identification of Ulcer on the Lower Extremity (Level of Evidence = IIa)
Location of a foot ulcer is determined by the site of trauma. In three large prospective studies, 53% of ulcers
involved the toes and 22% involved the first metatarsal area (Apelqvist et al., 2000; Armstrong, Lavery & Harkless,
1998a; Reiber et al., 1999).

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Nursing Best Practice Guideline

Measuring the Length and Width (Level of Evidence = Ia)

A systematic review evaluated treatments for diabetic foot ulcers by calculating length and width (Margolis,
Kantor & Berlin, 1999). As length and width decreased, the wound was classified as healing. It is important when
measuring a wound that the measurements are done using a consistent method such as tracings (Krasner &
Sibbald, 2001). This will greatly increase reliability in determining progress towards closure. Clinical studies
have shown that a reduction in ulcer area (approximately 20 to 40%) after 2 to 4 weeks of treatment is a good
predictor of healing (Margolis et al., 1999; Tallman, Muscare, Carson, Eaglstein & Falanga, 1997; van Rijswijk & Polansky, 1994).

Measuring the Depth (Level of Evidence = IV)

Wound depth is most commonly measured and quantified by gently inserting a sterile swab stick or probe
into the wound. Find the deepest point and put a gloved forefinger on the swab stick at the skin level. Place
next to a measuring guide. The presence or absence of undermining, a space between the surrounding skin
and wound bed, and tunneling can also be determined in this manner. If tunneling or undermining is
present, use the clock system to document location (e.g., area of the wound closest to the head is the 12
oclock position.
Standardizing the procedure for measurement is crucial in order to evaluate whether the wound is moving
in the direction of the goal of care. The University of Texas Health Science Center San Antonio Diabetic
Wound Classification System (see Appendix E) is an example of a grading system to stage the depth of
the wound.

Recommendation 3.2:
Assess ulcer bed, exudate, odour and peri-ulcer skin. (Level of Evidence = IV)

Discussion of Evidence:
The aim of wound bed assessment is to identify and plan the management of factors that will promote an
optimal healing environment (Vowden & Vowden, 2002). The condition of the periwound area provides
important information about the status of the wound and can influence choice of treatment. Surrounding
skin assessment includes evaluating colour, callus formation, induration, moisture and edema. Redness
can be indicative of unrelieved pressure or prolonged inflammation (Boulton, 1991). When the surrounding
skin has been exposed to moisture for a prolonged period of time, signs of maceration (pale, white or grey
tissue) may be observed. Callus formation is indicative of ongoing pressure to the affected area.
Debridement of callus is generally performed to facilitate accurate assessment of the wound. Induration
(an abnormal firmness of the tissue) and edema are assessed by gently pressing the skin within 4 cm of the wound.

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Assessment and Management of Foot Ulcers for People with Diabetes

Wound exudate characteristics, e.g., type and amount of drainage, provide important information about the
status of the wound. Rating the amount of drainage is useful only if a description of each rating is provided.
Wound is dry = no exudate
Moist wound = scant or small
Wet/saturated = heavy
In addition to amount, the type of exudate should be described.
Serous = clear yellow fluid without blood, pus or debris
Serosanguinous = thin, watery, pale red to pink fluid
Sanguinous = bloody, bright red
Purulent = thick, cloudy, mustard yellow or tan
All wounds, especially those treated with moisture retentive dressings, can emit an odour. Necrotic
wounds tend to have more offensive odour than clean wounds, while wounds infected with anaerobes
tend to produce a distinct acrid or putrid odour. A descriptive odour assessment can provide important
information, as a change in odour may be indicative of an alteration in bacterial balance.

Goals of Care:
Recommendation 4.0:
Define goals based on clinical findings, expert opinion and patient preference. (Level of Evidence = IV)

Recommendation 4.1:
Determine the potential of the ulcer to heal. (Level of Evidence = IV)

Recommendation 4.2:
Develop goals mutually agreed upon by the patient and healthcare professionals.
(Level of Evidence = IV)

Discussion of Evidence:
The perceived value of treating foot ulcers varies from the point of view of the patients and healthcare
professionals. The role of the nurse in the management of patients with a diabetic foot ulcer is to advocate,
collaborate and facilitate the process of goal directed care. The healing potential of a wound must be taken
into consideration. See Figure 2 for factors affecting healing potential.

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Nursing Best Practice Guideline

Figure 2: Healing Potential

Local

Host

Necrosis

Infection

Environment

Access to care

ESRD

Access to appropriate offloading

Offloading

Renal transplant

Family support

Microvascular supply

Inflammatory condition

Healthcare sector

Foreign body

Visual impairments

Geographic

Iatrogenic

Glycemic control

Socioeconomic status

Cytotoxic agents

Co-morbidities

Nutrition

PVD

CAD (Coronary Artery Disease)

Adherence to plan of care

Cultural/personal beliefs

RNAO Guideline Development Panel, 2005

The primary goal in the treatment of diabetic foot ulcers is to obtain wound closure as expeditiously as
possible. The resolution of foot ulcers and decreasing the rate of re-ocurrence can lower the probability of
lower extremity amputation in patients with diabetes.
According to the American Diabetes Association (1999) Consensus Development Conference of Diabetic
Foot Wound Care, foot wounds in patients with diabetes should be treated for several reasons improve
function and quality of life; control infection; maintain health status; prevent amputation; and reduce costs.
Healing of foot wounds improves the appearance of the foot and may allow the patient to return to
ambulation in appropriate footwear. Improving function and return to well-being are important goals of
therapy (ADA, 1999). With impaired mobility, foot wounds often lead to general deconditioning and
psychosocial dysfunction.
Frequent re-evaluation with response-directed treatment is essential. Once the ulcer is closed, the
management of PWDFU should include strategies to decrease the probability of re-ocurrence. Patient
involvement is an essential component of diabetic foot ulcer care, particularly when the encouragement of
adherence, with chronic or complex treatment regimens, is imperative. The care of the patient should be
based on a patient or client centred care approach (See the RNAO guideline [2002a] on Client Centred
Care). Patient-focused care involves a collaborative care planning and interdisciplinary team approach to
assessing, planning, implementing, monitoring and evaluating the care with the patient (Carter, 1995).
Diabetic foot ulcer management in a patient-focused model of care is a holistic approach that offers an
integrated care pathway, identifying the nursing, medical and paramedical activities that must be
synchronized to ensure the patient receives the appropriate treatment from experts of each discipline
(Carter, 1995). Carter (1995) also states that fragmentation of care may lead to conflicting advice for the
patient, and the potential for wastage of time and effort which may lead to protracted wound healing. In a
consumer focus group session led by the development panel, patients who were interviewed consistently
expressed dissatisfaction with limited healthcare expertise and access to specialized services, fragmented
care and long wait times.

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Assessment and Management of Foot Ulcers for People with Diabetes

Management:
This section will discuss the management of diabetic foot ulcers based on a holistic assessment as
discussed in the previous section. The Principles of Management should include:
Vascular management of ischemia and existing co-morbidities
Infection control and removal of necrotic tissue
Plantar pressure offloading intrinsic and extrinsic
The following model assists the clinician in providing a practice framework for treatment of persons with
diabetic foot ulcers (PWDFU).

Figure 3: Framework for Practice

Diabetic Foot Ulcers

Treat the Cause

Debridement

Local Wound Care

Infection Control

Client Centred Care

Moisture Balance

Edge of Wound

Biological Agents/
Adjunctive Therapies

Reprinted with permission of Dr. R. G. Sibbald. Adapted from: Sibbald R. G., Orsted, H. L., Schultz, G. S., Coutts, P., & Keast, D. (2003).
Preparing the wound bed 2003: Focus on infection and inflammation. Ostomy/Wound Management, 49(11), 24-51.

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Nursing Best Practice Guideline

Recommendation 5.0:
Identify and optimize systemic, local and extrinsic factors that can influence wound healing.
(Level of Evidence = IV)

Discussion of Evidence:
Patients with diabetes often have a combination of complicating factors. These factors maybe categorized as
systemic, local and extrinsic (see Appendix L). Morris, Jones & Harding (2001) indicate that there is no strong
evidence to support that correcting all these factors will necessarily improve wound healing. However, addressing
factors that can be controlled or optimized may increase the potential for healing and quality of life.

Systemic Factors:
Recommendation 5.1:
Modify systemic factors and co-factors that may interfere with or impact on healing.
(Level of Evidence = IV)

Discussion of the Evidence:

Healing diabetic foot ulcers is a complex process. One cannot expect healing to occur just by simply
dressing the wound. Early identification of the co-factors for impaired healing allows the clinician to
initiate appropriate referrals and develop a comprehensive interdisciplinary plan of care. By utilizing a
systematic approach in the management of each patient with a diabetic foot ulcer, the wound care
clinician increases the probability of achieving wound closure. According to McGuckin, Goldman, Bolton,
& Salcido (2003) and Seaman (2000), the team directing the patient care must perform a thorough history
and physical examination and order relevant investigative studies.

Local Factors:
Recommendation 5.2:
Provide local wound care considering debridement, infection control and a moist wound
environment. (Level of Evidence = Ia III)

Discussion of Evidence:
If healing potential is not established, aggressive debridement and moist interactive healing is not
recommended. Wounds that have the greatest potential for healing at an optimal rate require care that
includes:
Debridement
Infection control
Moisture balance

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Assessment and Management of Foot Ulcers for People with Diabetes

Figure 4: Local Wound Care Model

Local Wound Care

Debridement

Infection Control

Moisture Balance

Edge of Wound

Reprinted with permission of Dr. R. G. Sibbald. Adapted from: Sibbald R. G., Orsted, H. L., Schultz, G. S., Coutts, P., & Keast, D. (2003).
Preparing the wound bed 2003: Focus on infection and inflammation. Ostomy/Wound Management, 49(11), 24-51.

Debridement
Although debridement methods vary, common methods of debridement for diabetic foot ulcers include:
Mechanical irrigation with saline solution
Use of autolytic agents (e.g., hydrogels)
Sharp, using a scalpel or scissors (method of choice in an infected wound)
Surgical (occurs in the operating room with anesthesia and surgical instruments)
The frequency of debridement is scheduled at the discretion of the clinician (Inlow et al., 2000).
Callus Reduction
Debridement of callus can significantly reduce pressure at the callus site by approximately 30% (Pitei, Foster
& Edmonds, 1999; Young et al., 1992). Debridement of callus is within the nurses scope of practice, assuming
that the nurse has the knowledge, skill and judgement to perform this procedure.
Tissue Debridement
The removal of nonviable, contaminated and infected tissue from the wound area has been shown to
increase the rate of healing of diabetic foot ulcers (Inlow et al., 2000; Rodeheaver, 2001). In a post-hoc analysis
conducted by Steed, Donohoe, Webster & Lindsley (1996), lower rates of healing were correlated with less
frequent debridement practices. These observations were confirmed in a prospective trial where sharp
debridement may be associated with better outcomes in patients with diabetic foot ulcers (Saap & Falanga, 2002).
Smith (2004) conducted a systematic review to determine the effectiveness of debridement methods for
diabetic foot ulcers. Five randomized controlled trials (RCTs) were identified: three involved the use of
hydrogels and two involved the use of sharp debridement. The results suggest that hydrogels were
significantly more effective than gauze or standard care in healing diabetic foot ulcers. However, sharp

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debridement has not been shown to be of significant benefit in promoting wound healing. It should be
noted that the clinical trials on sharp debridment are inadequately powered. There is a need for more
research to evaluate the effects of a range of widely used debridement methods and of debridement per se.
Sharp debridement is a high-risk procedure. Debridement with a scalpel should be undertaken
with caution and performed by specially trained and experienced healthcare professionals.
Subcutaneous debridement with a scalpel is a controlled act that must be carried out by a physician
or the delegate. Nurses should be aware of the policies and procedures of their facility.

Infection Control
Infections in a diabetic patient must be treated urgently. Diabetic foot infections can rapidly progress to
limb- or life-threatening situations. The amputation rate in diabetic populations with foot infections has
been reported to range from 12-92% (Tennvall et al., 2000).
Management of diabetic foot ulcer infections should focus on four integrated parameters of care:
Controlling bacterial balance;
Host response/defence;
Complete pressure offloading; and
Local wound care.
According to Peacock and Van Winkle (1976), infection occurs when the number of organisms exceeds the
ability of local tissue defenses to handle them. Maximizing the host ability to fight the infections should be
a major consideration. This includes correction of hyperglycemia, stabilization of other co-morbidities,
good nutrition and rest. Local wound care should include wound cleansing and debridement to remove
devitalized tissue and reduce bacterial load in the wound (Saap & Falanga, 2002; Steed et al., 1996).
Antimicrobial management of diabetic foot infection should be based on the Ontario Anti-infective Guidelines
for Community Acquired Infections (Ontario Anti-infective Review Panel, 2001). The prescribed antibiotic(s) should
be based on the results of the culture and sensitivity of the organism(s) in conjunction with the physicians
clinical judgement.
Once a treatment plan is developed and initiated, an evaluation period should be established to determine
the patients response to treatment.
Application of moisture retentive dressings in the context of ischemia and or dry gangrene
can result in a serious life- or limb-threating infection.
See Table 3 for Treatment of Infection.

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Assessment and Management of Foot Ulcers for People with Diabetes

Table 3: Treatment of Wound Infection

Non-limb-threatening infection
Superficial infection

Deep wound infection

Limb-threatening infection
Systemic infection

Support host defences

As in superficial infection

As in deep wound infection

Requires a team approach

Polymicrobial

Will require hospitalization

Cleanse and debride wound

Will require oral/IV antibiotics

Will require IV antibiotics

May be monomicrobial

May require surgical debridement

Topical antimicrobials

Non weight bearing

May require oral/IV antibiotics

Consider hospitalization
Consider Infectious Disease consultation
Ongoing evaluation based

(based on host risk)

Offloading

Ongoing evaluation based

Ongoing evaluation based

on clinical findings

Bedrest

on clinical findings

on clinical findings

Patient education

RNAO Guideline Development Panel, 2005

A. Non-Limb-Threatening Infections
Ulceration does not need to be present since non-limb-threatening infections can result from small
puncture wounds, scratches, nail trauma or heel (fissure) cracks. Mild to moderate infection can usually be
managed on an outpatient basis with close supervision by the medical practitioner. Topical antimicrobials
can be used to reduce bacterial burden in superficial infections. There are several iodine and silver preparations
now available that are safe, effective and economical (Sibbald et al., 2003). Systemic antibiotics may be prescribed
by the physician or the Registered Nurse/Extended Class (RN/EC) in the community. See Appendix M for
a list of Topical Antimicrobial Agents.
If the wound still fails to heal and there is evidence of increased superficial bacterial burden or delayed
healing with no evidence of deep infection, use local antimicrobials with debridement and moisture
balance. If there is evidence of deep infection, or if the wound fails to demonstrate signs of healing within
two weeks with topical antimicrobials, systemic antibiotics may be considered.

B. Limb-Threatening Infections
Diabetic foot infections in this category may have cellulitis that extends greater than 2 cm beyond the
wound border including cardinal signs of infections such as fever, edema, lymphangitis, hyperglycemia,
leukocytosis, and/or ischemia (Frykberg et al., 2000). An ulcer that probes to the bone or joint is highly
predictive of osteomyelitis (Grayson et al., 1995). Since the patient with diabetes with a relatively severe
infection may not necessarily present with these signs and symptoms, it is important to review the entire
clinical assessment to guide the clinician to the proper course of treatment. A patient presenting with wet
gangrene, deep abscesses, and advancing cellulitis must be transferred to a medical facility for urgent care.
Hospitalization is required in order to treat the infection as well as the systemic sequelae. Patients with
poor vascular status and deep infections may require vascular surgery and infectious disease consultation.
Urgent surgical intervention may be required. Although many wound drainage procedures can be done at
the bedside for patients with diabetic ulcers, most will require thorough debridement in the operating
room (Frykberg et al., 2000). Even the sickest of patients should be considered for emergent incision, drainage,

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and debridement procedures since their illness is directly attributable to the severity of their infection. Lifethreatening infections necessitate immediate surgical attention and such procedures should not be
delayed while waiting for radiologic or medical workup of other co-morbid conditions (Frykberg et al., 2000).
Polymicrobial infection should be anticipated in patients with a diabetic foot ulcer, with a variety of grampositive cocci, gram-negative rods, and anaerobic organisms predominating. Empirical antibiotic therapy
typically includes broad-spectrum coverage for more common isolates from each of these three categories
(Frykberg et al., 2000). Once wound culture results have been obtained, the initial antimicrobial therapy may
require adjustment to provide more specific coverage or to provide therapy against resistant organisms. If
there is persistent infection while on antibiotic therapy, surgical assessment and wound culture should be
revisited. Methicillin-resistant staphylococci aureus (MRSA) has been emerging as an important pathogen
in chronic diabetic foot ulcers (Frykberg et al., 2000).

C. Osteomyelitis
Osteomyelitis and joint infection will require excision of bone for microbiological and histopathological
evaluation (Frykberg et al., 2000). If the affected bone has been completely resected or amputated, the infection
may be treated as a soft-tissue infection. However, if residual bone is present in the wound, the patient will
likely require 4-8 weeks of antibiotic therapy based on the culture results (Frykberg et al., 2000). Intravenous
or oral agents may be used, depending on the microbial isolates and the infection severity.

Moisture Balance
Dressing selection should promote a moist wound environment that minimizes trauma and risk of
infection. Selection should be based on the wound to provide local moisture balance. Modern, moist
interactive dressings used for diabetic foot ulcers include foams (high absorbency), calcium alginates
(absorbent, hemostasis), hydrogels (moisture balance), hydrocolloids (occlusion), and adhesive
membranes (protection) (Inlow et al., 2000). Consideration should be given to the following when choosing a
moist wound dressing for a diabetic foot ulcer (Sibbald, Williamson, Orsted, Campbell, Keast, Krasner et al., 2000):

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 above wound
environment.
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 caregiver time when selecting a dressing.
Eliminate wound dead space by loosely filling all cavities with dressing material.
Assure that the patient is aware that there is to be reduced pressure to the affected area.
Evaluate the wound frequently to determine efficacy of treatment plan.

Systematic reviews in the past have shown no differences in chronic wound healing outcomes (Hutchinson et
al., 2000; Ovington, 1999). However, in a recent systematic review by Smith (2004), hydrogels were shown to be

of some benefit in improving diabetic foot ulcers. Consideration of caregiver time is essential to cost
efficency (Ovington, 1999). For information on dressing selection see Appendix N.

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Assessment and Management of Foot Ulcers for People with Diabetes

Extrinsic Factors
Recommendation 5.3:
Provide pressure redistribution. (Level of Evidence = IIa )

Discussion of Evidence:
Ninety four percent of diabetic foot ulcers occur at areas of increased pressure (Fleischli, Lavery, Vela, Ashry & Lavery, 1997).
Elevated plantar pressures coupled with neuropathy (lack of sensation) can lead to callus formation. The
callus build-up (hyperkeratosis) is a normal response to the stress of elevated pressures on the foot and if
untreated leads to ulcer formation. For a diabetic foot ulcer to heal the repetitive pressure must be reduced.
This can be accomplished by the application of a number of external devices. It is important that there is a
member of the team skilled in the fabrication and modification of offloading devices, such as a foot care
specialist. See Appendix O for examples and considerations in selecting offloading devices.
One randomized controlled trial showed that total contact casting (TCC) was effective in treating well
vascularized non-infected plantar forefoot diabetic foot wounds. Healing rates range from 72% to 100%
over a course of five to seven weeks (Armstrong, Nguyen, Lavery, van Schie, Boulton & Harkless, 2001). Spencer (2004)
conducted a systematic review evaluating the effectiveness of various offloading modalities to treat
diabetic foot ulcers. One randomized controlled trial on total contact casting was identified showing weak
evidence on its effectiveness in the treatment of diabetic foot ulcers.
It is important that the patient with a diabetic foot ulcer recognizes that pressure is the cause of their foot
ulcer and the offloading is required whenever they are on their feet. In a study by Armstrong, Lavery,
Kimbriel, Nixon and Boulton (2003) describing adherence to offloading devices, subjects were found to be
only 25% compliant with their prescribed device.

Non-healing diabetic foot wounds

Recommendation 5.4:
Evaluate and implement treatment options for non-healable wounds. (Level of Evidence = IV)

Discussion of Evidence:
While complete wound closure is widely accepted to be an objective endpoint in wound healing, this may
not always be appropriate in assessing outcomes in chronic wounds (Enoch & Price, 2004). There are various
factors that can contribute to the chronicity of such wounds.

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Examples of factors contributing to poor healing outcomes include:

Inadequate blood supply;
Poor glycemic control;
Non-adherence with treatment plan;
End-stage renal disease;
Transplant recipients;
Differing individual goals;
Malnutrition;
Connective tissue disorders;
Systemic conditions such as sickle cell disease;
Osteomyelitis;
Immobility;
Heart disease;
Dementia;
Cancer; and
Advancing age.
Goals of care must be mutually agreed upon by the individual and the healthcare team, reflecting a realistic
outcome based on quality of life. The significance of managing exudate, controlling infection, relieving pain,
and minimizing odour in a non-healing wound must be established and accepted as legitimate outcome
measures (Enoch & Price, 2004).
When healing is not the goal, wound management should incorporate:
A palliative wound management model that includes pain control, infection control,
exudate management and odour control.

Keep wound bed dry, moist wound care is not recommended:

If the patient cannot fight infection the moist wound will be a breeding ground for infection.
Use dry dressing.

Using a topical, cost effective and potentially cytotoxic antiseptic such as povidine iodine can be
considered when the risk of infection outweighs the healing potential.

Evaluation:
Recommendation 6.0:
Evaluate the impact and effectiveness of the treatment plan. (Level of Evidence = IV)

Discussion of Evidence:
Assuming that all systemic and local factors have been addressed, Sheehan, Jones, Caselli, Giurini & Veves
(2003) have shown that a 50% reduction in wound surface area at four weeks is a good predictor of wound
healing at 12 weeks. Furthermore, Flanagan (2003) has shown that a 20% 40% reduction of wound area in
two and four weeks is likely to be a reliable predictive indicator of healing.

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Assessment of the edge of the wound will determine if cell migration has begun. According to Schultz,
Barillo, Mozingo, Chin & The Wound Bed Advisory Board Members (2004), wound proliferation occurs
when keratinocytes and responsive wound cells migrate; thus advancing the edge of the wound. Healthy
wounds have a pink wound bed and an advancing wound margin while unhealthy wounds have a dark,
friable wound bed and an undermined wound margin.

Reassess:
It should not be expected that all diabetic foot ulcers will have closure of the wound as a primary outcome.
Wounds that are unlikely to heal need to have alternative outcome expectations such as wound
stabilization, reduced pain, reduced bacterial load and decreased dressing changes (Enoch & Price, 2004).
Ongoing wound assessment should be comprehensive and support the rationale for care. The guideline
development panel suggests these questions below as an approach to evaluating outcomes of care.
1. Is the treatment plan effective?
2. How is wound healing evaluated?
3. Is wound closure the only successful wound care outcome?

Recommendation 6.1:
Reassess for additional correctable factors if healing does not occur at the expected rate.
(Level of Evidence = III IV)

Discussion of Evidence:
Reassessment of the entire treatment program is the first step to establishing a new directed approach.
The most common reason for delayed healing in PWDFU is inadequate pressure offloading. If appropriate
offloading is not prescribed, the patient should be referred to a centre specializing in diabetic foot ulcer care.
Revisiting adherence to prescribed offloading devices may uncover the reason why the wound is not healing
(Armstrong et al., 2003).
Infection should always be considered as a possible cause of non-healing in combination with glycemic
control. Revisiting the health history, co-morbidities and overall diabetes management may maximize the
desired outcome.
If patient and wound are optimized and edge is still not migrating, consider tissue culture, biopsy and other
diagnostic tests to rule out other conditions.
If delayed healing occurs, continuously evaluate. Vascular, infection and pressure parameters can change
quickly; frequent monitoring for change in status or parameters is required. See Table 3 for treatment of
wound infection in Recommendation 5.2.
If healing is still delayed, adjunctive approaches should be considered. See Recommendation 6.2.

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Other Therapies
Recommendation 6.2:
Consider the use of biological agents, adjunctive therapies and/or surgery if healing has not occurred
at the expected rate. Review each specific modality for recommendations. (Level of Evidence = 1a IV)

Discussion of Evidence:
Care for diabetic foot ulcers that have not healed at the expected rate may include the use of:
Biological agents
Adjunctive therapies
Surgery (e.g., skin graft, Achilles tendon lengthening, bony reconstruction)

Type of Adjunctive Therapy

Description and Evidence

Electrical Stimulation

This procedure involves applying a low level electrical current to the

base of the wound or the peri-wound using conductive electrodes.
It must be performed by trained healthcare professionals.

Evidence:
A meta analysis (Foster, Smith, Taylor, Zinkie & Houghton, 2004) of 17 RCTs
showed that electrical stimulation was effective in treating chronic
wounds (p< 0.0001), included in this analysis were 3 RCTs with patients
with diabetic foot ulcers (Baker, Chambers, DeMuth & Villar, 1997; Lundeberg,
Eriksson & Malm, 1992; Peters, Lavery, Armstrong & Fleischli, 2001).
(Level of Evidence = 1a)

Hyperbaric Oxygen
Therapy (HBOT)

In this procedure, systemic (inhaled) subatmospheric oxygen

is delivered via hyperbaric chamber.
It increases oxygen tension in the tissues.

Evidence:
The routine management of diabetic foot ulcers with HBOT is not
justified by the evidence found in the systematic review conducted by
Kranke, Bennett & Roeckl-Wiedmann (2004). Although HBOT significantly
reduced the risk of major amputation and may improve the chance of
healing at one year, economic evaluations should be undertaken. With
methodological shortcomings and poor reporting of the studies that
were reviewed, Kranke et al. (2004) cautions that any benefit from HBOT
will need to be examined further using rigorous randomized trials.
(Level of Evidence = III)

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Assessment and Management of Foot Ulcers for People with Diabetes

Type of Adjunctive Therapy

Topical Negative Pressure

(TNP) Therapy

Description and Evidence

It is a subatmospheric pressure device delivered to the wound by an open

cell foam dressing covered with a clear membrane over the wound.
The dressing is attached to a pump that delivers equalized intermittent
or continuous suction within a prescribed range of settings.
Vacuum Assisted Closure (VAC) Therapy is a commercial brand
of topical negative pressure.

Evidence:
The two small trials that evaluated the effectiveness of TNP on chronic
wound healing provide weak evidence suggesting that TNP may be
superior to saline gauze dressings in healing chronic human wounds.
Findings: Due to the small sample sizes and methodological limitations
of these trials, there is weak evidence to date.
The effect of TNP on cost, quality of life, pain and comfort was not
reported. It was not possible to determine which was the optimum TNP
regimen (Armstrong, Lavery, Abu-Rumman, Espensen, Vazquez, Nixon et al., 2002;
Ballard & McGregor, 2001; Clare, Fitzgibbons, McMullen, Stice, Hayes & Henkel, 2002;
McCallon, Knight, Valiulus, Cunningham, McCulloch & Farinas, 2000; Sibbald,
Mahoney & VAC Therapy Canadian Consensus Group, 2003).

A case series of 31 patients with diabetic foot ulcers showed a statistical

reduction in wound size at four weeks on the continuous setting at
~100 mm Hg (Teague, Newbatt, Zschape, Daniels, Rankine, Hoeflock et al., 2004).
(Level of Evidence = 1b)

Biological Agents

Description and Evidence

Growth Factors

Wound bed vascularization can be achieved by applying

recombinant human platelet derived growth factor BB(PDGF)
Becaplermin gel, also known as Regranex, is an example
of a growth factor.
The biological activity of becaplermin is similar to that of naturally
occurring PDGF and includes promoting chemotaxic requirement and
proliferation of cells involved in the wound repair process (Smiell, 1998).

Evidence:
Four multicentre, randomized paralled group studies found that once-daily
topical administration of becaplermin gel in conjuction with good ulcer
care was effective and well tolerated in patients with full-thickness,
lower extremity diabetic ulcers (Smiell, Wieman, Steed, Perry, Sampson &
Schwab, 1999). (Level of Evidence = 1b

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Nursing Best Practice Guideline

Biological Agents

Bioactive Agents

Description and Evidence

Bioactive agents can be acellular or cellular and have the potential to

stimulate, through topical activation the normal or enhanced activity
of mechanisms involved in tissue repair.
Dermagraft is an example of living tissue equivalents.
Dermagraft is a cultured human dermis. It consists of human neonatal
and dermal fibroblasts cultured in vitro onto a bioabsorbable mesh
to produce a living metabolically active tissue containing normal
matrix proteins and cytokines (Gentzkow, Iwasaki, Hershon, Mengel,
Prendergast, Ricotta et al., 1996; Gentzkow, Jensen, Pollak, Kroeker, Lerner, Lerner

et al., 1999; Marston, Hanft, Norwood & Pollak, 2003) (Level of Evidence = 1b)
Oasis, Promogran and Hyalofil are examples of acellular bioactive agents.
Oasis is a freeze dried wound matrix derived from porcine (pig)
small intestinal submucousa (Brown-Etris, Cutshall & Hiles, 2002).
Xenograft: Oasis, a relatively new product, is a xenogeneic, acellular,
collagen matrix derived from porcine small intestinal submucosa in
a way that allows extracellular matrix and natural growth factors to
remain intact. This provides a scaffold for inducing wound healing.

Evidence:
In a small multicentre clinical study evaluating the efficacy of Oasis
compared to Regranex, Niezgoda (2004) found similar wound healing
outcomes in both treatment groups. (Level of Evidence = IIa)

Promogran is a freeze dried sponge prepared from bovine collagen

and oxidized regenerated cellulose prepared in acetic acid. It reduces
protease MMPs known to promote inflammation in chronic wounds
and protect endogenous growth factors.

Evidence:
One RCT comparing Promogran to moistened gauze dressings showed
that at 12 weeks, no statistical differences were found in the healing rates
between the two groups (Veves, Sheehan & Pham, 2002). Ghatnekar, Willis &
Persson (2002) suggest that Promogran may be cost effective as a result
of reduced dressing frequency. (Level of Evidence = Ib)

Hyalofil is a hyaluronic acid ester which is thought to provide

structural support, developmental regulation and assists with
receptor mediated gene expression as a major molecule in the extra
cellullar matrix. It affects inflammation, regulation, angiogenesis,
granulation formation and re-epithelialization. To date, only anecdotal
results are available. (Level of Evidence = IV)

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Assessment and Management of Foot Ulcers for People with Diabetes

Surgery

Surgical
(Skin Graft Autologous)

Surgical
(Achilles tendon lengthening)

Description and Evidence

This procedure requires surgical transplant of epidermis and dermis

from the same patients donor site.
(Level of Evidence = IV)

Lengthening the tendon or an attached calf muscle increases ankle

dorsiflexion, thus reducing wound healing time and ulcer re-occurrence
(Level of Evidence = 1b)

Evidence:
Mueller et al. (2004) compared the effect of Achilles tendon lengthening
to treatment with total contact casting. The outcomes measured were
healing rates and ulcer re-occurrence at seven-months follow up and
two-year follow up. Although the initial wound healing outcomes were
similar, statistical reduction in ulcer re-occurrence was noted at sevenmonths and at two-years follow up.

Other surgical procedures

Surgery for foot deformities can be beneficial in preventing the

development and re-ocurrence of ulcers.
Careful patient selection is critical, primarily with regard to an intact
vascular supply.
In appropriate cases, arthroplasty, digital amputation, bunionectomy,
metatarsal osteotomy or ray resection, may be indicated (Muha, 1999).
To date, only anecdotal results are available. (Level of Evidence = IV)

Education Recommendations
Continuing Professional Development:
Recommendation 7.0:
Nurses and other members of the interdisciplinary team need specific knowledge and skills in
order to competently assess and participate in the treatment of diabetic foot ulcers.
(Level of Evidence = IV)

Curriculum Support and Resources:

Recommendation 8.0:
Educational institutions are encouraged to incorporate the RNAO Nursing Best Practice Guideline
Assessment and Management of Foot Ulcers for People with Diabetes into basic RN, RPN, MD and
allied health professional curricula. (Level of Evidence = IV)

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Discussion of Evidence:
Nurses play a vital role in the early detection and ongoing assessment of diabetic foot ulcers. They are also
in a pivotal position to facilitate an evidence-based, team approach to treatment (Mason et al., 1999a;
Whittemore, 2000). If nurses are to fulfill these roles, they must utilize the nursing process and evidence to
support patient care decisions. Nurses need to avail themselves of recognized, accredited continuing
educational opportunities that support the interdisciplinary team approach to diabetic foot ulcer care. In
order to improve health outcomes for persons with diabetic foot ulcers and increase job satisfaction for
nurses, agencies need to provide a full scope of support (financial, education, and human resources) for
nurses seeking professional education (Best & Thurston., 2004; Gottrup, 2004).
Refer to Appendix P for a list of resources for diabetic foot ulcer information.

Organization & Policy Recommendations

System Support:
Recommendation 9.0:
Nursing best practice guidelines can be successfully implemented only where there are adequate
planning, resources, organizational and administrative support, as well as appropriate facilitation.
Organizations may wish to develop a plan for implementation that includes:
An assessment of organizational readiness and barriers to education.
Involvement of all members (whether in a direct or indirect supportive function) who will
contribute to the implementation process.
Dedication of a qualified individual(s) to provide the support needed for the development and
implementation process.
Ongoing opportunities for discussion and education to reinforce the importance of best practices.
Opportunities for reflection on personal and organizational experience in implementing guidelines.
In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the
Toolkit: Implementation of Clinical Practice Guidelines, based on available evidence, theoretical
perspectives and consensus. The RNAO strongly recommends the use of this Toolkit for guiding the
implementation of the best practice guideline on Assessment and Management of Foot Ulcers for
People with Diabetes. (Level of Evidence = IV)

Resources:
Recommendation 9.1:
Organizations are encouraged to develop policies that acknowledge and designate human, material
and fiscal resources to support the nurse and the interdisciplinary team in diabetic foot ulcer
management. (Level of Evidence = IV)

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Assessment and Management of Foot Ulcers for People with Diabetes

Team Development:
Recommendation 9.2:
Organizations are encouraged to establish and support an interdisciplinary, inter-agency team
comprised of interested and knowledgeable persons to address and monitor quality improvement
in the management of diabetic foot ulcers. (Level of Evidence = IV)

Partnerships:
Recommendation 9.3:
Organizations are encouraged to work with community and other partners to develop a process to
facilitate patient referral and access to local diabetes resources and health professionals with
specialized knowledge in diabetic foot ulcer management. (Level of Evidence = IV)

Financial Support:
Recommendation 9.4:
Organizations are encouraged to advocate for strategies and funding to assist patients in obtaining
appropriate pressure redistribution devices. (Level of Evidence = IV)

Advocacy:
Recommendation 9.5:
Organizations are encouraged to advocate for an increase in the availability and accessibility of
diabetic foot ulcer care for all residents of Ontario. (Level of Evidence = IV)

Discussion of Evidence:
In order to achieve optimal outcomes for individuals with diabetic foot ulcers, diabetes ulcer care should
be platformed around an interdisciplinary healthcare team that can establish and sustain a communication
network between the person with diabetes and the necessary healthcare and community systems.
Frykberg (1998), through a retrospective review of the literature reported a reduction in non-traumatic
amputation rates ranging from 58% to 100% after the implementation of a multidisciplinary approach to
foot care. The team should be dedicated to both maintaining the overall well-being of the patient with
diabetes and to preserving the integrity of their lower extremities (Inlow et al., 2000). Key players on the team,
along with patients and families, may include diabetologists/endocrinologists, vascular surgeons, plastic
surgeons, dermatologists, chiropodists/podiatrists, infectious disease specialists, family physicians, nurses
specializing in diabetes and wound care, occupational therapists, physiotherapists, and dietitians. Teams
can work without walls (not necessarily on the same site, but accessible to each other). However,
coordination takes more effort to ensure the goal(s) remain consistent (Inlow et al., 2000). Both the
organization and the delivery of diabetes foot care should be comprehensive, supported by evidence-based
clinical practice guidelines, and equitable in access throughout the persons lifetime. Diabetes foot ulcer
care should be community based and respectful of age, gender, cultural beliefs and socioeconomic
dispositions. Organizations have a role to play in advocating and facilitating access to diabetes care and
foot ulcer care services.

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Graham, Harrison, Bouwers, Davies & Dunn (2002) indicate that in order for guidelines to be implemented
successfully, a critical initial step must be the formal adoption of the guideline recommendations into the
policy and procedure structure. This key step provides direction regarding the expectations of the
organization, and facilitates integration of the guideline into such systems as the quality management process.
New initiatives such as the implementation of a best practice guideline require strong leadership from nurses
who understand concepts of planned change, program planning and evaluation and research utilization.
This knowledge will empower the nurse to effectively transform organizations in changing practice. This
can be achieved by developing a program plan. Pollack (1994) developed a four-step planning process
called pre-start plan. The process includes mission statement clarification, stakeholder analysis, problem
identification, and strength, weakness, opportunities and threats (SWOT) analysis.
Further, it is suggested that the RNAO Toolkit (2002b) be considered to assist organizations develop the
leadership required for successful implementation. Refer to Appendix Q for a description of the RNAO
Toolkit: Implementation of Clinical Practice Guidelines.

Research Gaps & Future Implications

The guideline development panel found that there is little research to support:

Establishment of a standardized assessment and documentation tools for diabetic foot ulcers.
Dressing choices for local wound care.
Effectiveness of adjunctive therapies to promote wound healing.
Effectiveness of various devices utilized for pressure redistribution/offloading.
Health delivery issues (government support and funding of programs and treatment for diabetic foot
ulcer management, cultural beliefs, high risk patient populations).
Impact of sharp/surgical debridement on wound healing.
Impact of education on healthcare provider and specific patient outcomes (ulcer healing/re-occurrence).
Pharmacoeconomics of secondary and tertiary prevention strategies.

The above list, although in no way exhaustive, is an attempt to identify and prioritize the enormous
amount of research that is needed in this area. Some of the recommendations in the guideline are based
on evidence gained from quantitative and qualitative research. Other recommendations are based on
consensus or expert opinion. Further substantive research is required to validate the expert opinion.
Increasing the research can impact knowledge that will lead to improved practice and outcomes for
patients who experience diabetic foot ulcers.

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Assessment and Management of Foot Ulcers for People with Diabetes

Evaluation & Monitoring of Guideline

Organizations implementing the recommendations in this nursing best practice guideline
are encouraged to consider how the implementation and its impact will be monitored and evaluated. The
following table, based on a framework outlined in the RNAO Toolkit: Implementation of Clinical Practice
Guidelines (2002b), illustrates some indicators for monitoring and evaluation:
Level of
Indicator

Structure

Process

Outcome

Objectives

To evaluate the supports

available in the organization
that allow for nurses and
the interdisciplinary team
to integrate in their practice
the assessment and
management of diabetic
foot ulcers.

To evaluate the changes in

practice that lead towards
assessment and
management of diabetic
foot ulcers.

To evaluate the impact of

implementation of the
recommendations.

Organization/
Unit

Review of best practice

recommendations by
organizational committee(s)
responsible for policies and
procedures.

Incorporation of assessment and

management of diabetic foot
ulcers in staff orientation
program.

Availability of patient
education resources that are
consistent with best
practice recommendations.

Development of forms or
documentation systems
that encourage
documentation of
assessment and
management of diabetic
foot ulcers.

Referrals internally and

externally.

Evidence of documentation in the

patients record consistent with
the guideline recommendations.
Referral to the following services or
resources within the community
or within the organization as
necessary Chiropodist/
Podiatrist, Wound Care Clinic,
Diabetes Education Centre, Nurses
specializing in wound and diabetes
care, Dermatologist, Infectious
Disease Specialist, Vascular Surgeon,
Plastic Surgeon, Family Physician,
Endocrinologist/Diabetologist,
Dietitian, Occupational Therapist,
Physiotherapist.
Provision of education and support
to patient and family members.
Patient/family satisfaction.

Provider

Provision of accessible
resource people for nurses
and the interdisciplinary
team to consult for ongoing
support during and after
initial implementation
period.

Percentage of healthcare
providers attending the best
practice guideline
education sessions on
assessment
and management of diabetic
foot ulcers.

Concrete procedures for

making referrals to internal
and external resources and
services.

Self-assessed knowledge of
assessment and
management of diabetic
foot ulcers.

Average self-reported
awareness levels of
community referral
sources for patients with
diabetic foot ulcers.

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Nursing Best Practice Guideline

Level of
Indicator
Patient

Structure

(new or
recurrent
diabetic
foot ulcer)

Financial
Costs

Percentage of patients
admitted to unit/facility or
seen at the clinic with
diabetic foot ulcers.

Provision of adequate
financial resources for the
level of staffing necessary to
implement guideline
recommendations.

Process

Percentage of patients who

were assessed and treated
using the V.I.P. (vascular
supply, infection, and
pressure redistribution/
offloading) principle.

Cost related to implementing

guideline:
Education and access to
on the job supports.
New documentation
systems.
Support systems.
Cost related to diagnostic
services, equipment,
devices and products
(e.g., monofilaments,
patient resource materials,
biological agents, surgical
interventions; adjunctive
therapies, pressure
redistribution/offloading).

57

Outcome

Improvement in quality of life

and satisfaction.

Percentage of patients adhering

to treatment plan at three
months post-discharge.

Percentage of patients with ulcers

partially or fully healed at three
months post-discharge.

Percentage of patients who

regularly examine their feet.

Percentage of patients accessing

referral sources in community.

Percentage of patients seen or to

be seen for referral.

Cost efficiency and effectiveness

of treatment.

Overall resource utilization.

Length of stay in health system.

Hospital readmission rates.

Reintegration into community.

Assessment and Management of Foot Ulcers for People with Diabetes

Implementation Strategies
The Registered Nurses Association of Ontario and the guideline development panel have
compiled a list of implementation strategies to assist healthcare organizations or healthcare disciplines
who are interested in implementing this guideline. A summary of these strategies follows:

Have at least one dedicated person such as an advanced practice nurse or a clinical resource nurse
who will provide support, clinical expertise and leadership. The individual should also have good
interpersonal, facilitation and project management skills.

Conduct an organizational needs assessment related to diabetic foot ulcer management to identify
current knowledge base and further educational requirements.

Initial needs assessment may include an analysis approach, survey and questionnaire, group format
approaches (e.g., focus groups), and critical incidents.

Establish a steering committee comprised of key stakeholders and interdisciplinary members

committed to lead the change initiative. Identify short term and long term goals. Keep a work plan to
track activities, responsibilities and timelines.

Create a vision to help direct the change effort and develop strategies for achieving and sustaining
the vision.

Program design should include:

Target population;
Goals and objectives;
Outcome measures;
Required resources (human resources, facilities, equipment); and
Evaluation activities.

Design educational sessions and ongoing support for implementation. The education sessions may
consist of presentations, faciltators guide, handouts, and case studies. Binders, posters and pocket
cards may be used as ongoing reminders of the training. Plan education sessions that are interactive,
include problem solving, address issues of immediate concern and offer opportunities to practice new
skills (Davies & Edwards, 2004).

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Nursing Best Practice Guideline

Provide organizational support such as having the structures in place to facilitate the implementation.
For example, hiring replacement staff so participants will not be distracted by concerns about work
and having an organizational philosophy that reflects the value of best practices through policies and
procedures. Develop new assessment and documentation tools (Davies & Edwards, 2004).

Identify and support designated best practice champions on each unit to promote and support
implementation. Celebrate milestones and achievements, acknowledging work well done (Davies &
Edwards, 2004).

Organizations implementing this guideline should adopt a range of self-learning, group learning,
mentorship and reinforcement strategies that will, over time, build the knowledge and confidence of
nurses in implementing this guideline.

Beyond skilled nurses, the infrastructure required to implement this guideline includes access to
specialized equipment and treatment materials. Orientation of the staff to the use of specific products
and technologies must be provided and regular refresher training planned.

Teamwork, collaborative assessment and treatment planning with the patient and family and
interdisciplinary team are beneficial in implementing guidelines successfully. Referral should be
made as necessary to the following services or resources in the community or within the organization:
Chiropodist, Wound Care Clinic, Diabetes Education Centre, Nurses specializing in wound and
diabetes care; Dermatologist, Infectious Disease Specialist, Vascular Surgeon, Plastic Surgeon, and
other healthcare professionals who provide care to patients with diabetic foot ulcers such as Family
Physician, Dietitian, Occupational Therapist and Physiotherapist.

The RNAOs Advanced/Clinical Practice Fellowships (ACPF) Project is another resource that registered
nurses in Ontario may apply for a fellowship and have an opportunity to work with a mentor who has
expertise in diabetic foot ulcer management. With the ACPF, the nurse fellow will have the opportunity
to hone their skills in assessing and managing diabetic foot ulcers.

In addition to the strategies mentioned above, the RNAO has developed resources that are available on
their website. A Toolkit for implementing guidelines can be helpful if used appropriately. A brief
description about this Toolkit can be found in Appendix R. A full version of the document in pdf format is
also available at the RNAO website, www.rnao.org/bestpractices.

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Assessment and Management of Foot Ulcers for People with Diabetes

Process for Update/Review of Guideline

The Registered Nurses Association of Ontario proposes to update this best practice guideline
as follows:
1. Each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the
topic area every three years following the last set of revisions.
2. During the three-year period between development and revision, RNAO Nursing Best Practice
Guidelines program staff will regularly monitor for relevant new literature in the subject area.
3. Based on the results of the monitor, program staff will recommend an earlier revision period.
Appropriate consultation with a team of members comprised of original panel members and other
specialists in the field will help inform the decision to review and revise the guideline earlier than
the three-year milestone.
4. Three months prior to the three year review milestone, the program staff will commence the
planning of the review process by:
a. Inviting specialists in the field to participate in the Review team. The Review Team will be
comprised of members from the original panel as well as other recommended specialists.
b. Compiling feedback received, questions encountered during the dissemination phase as well as
other comments and experiences of implementation sites.
c. Compiling new clinical practice guidelines in the field, systematic reviews, meta-analysis
papers, technical reviews, randomized controlled trial research, and other relevant literature.
d. Developing a detailed work plan with target dates and deliverables.
The revised guideline will undergo dissemination based on established structures and processes.

60

Nursing Best Practice Guideline

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Appendix A: Search Strategy for

Existing Evidence
STEP 1 DATABASE Search
A database search for existing diabetes foot ulcer guidelines was conducted by a university health sciences
library. A computerized search of the Medline, Embase and CINAHL databases for guidelines and other
literature published from January 1, 1995 to December 2003 was conducted using the following search
terms: diabetic foot ulcers, foot ulceration, NOT venous leg ulcers or arterial ulcers, peripheral
neuropathy, diabetes complications, prevention, assessment, management, amputation, factors
influencing wound healing, patient/family education, randomized controlled trials, systematic
reviews, practice guideline(s), clinical practice guideline(s), standards, consensus statement(s),
consensus, evidence-based guidelines and best practice guidelines.

STEP 2 Structured Website Search

One individual searched an established list of websites for content related to the topic area. This list of sites,
reviewed and updated in October 2002, was compiled based on existing knowledge of evidence-based
practice websites, known guideline developers, and recommendations from the literature. Presence or
absence of guidelines was noted for each site searched as well as date searched. The websites at times did
not house a guideline but directed to another website or source for guideline retrieval. Guidelines were
either downloaded if full versions were available or were ordered by phone/e-mail.

Agency for Healthcare Research and Quality: http://www.ahcpr.gov

Alberta Heritage Foundation for Medical Research Health Technology Assessment: http://www.ahfmr.ab.ca//hta

Alberta Medical Association Clinical Practice Guidelines: http://www.albertadoctors.org

American College of Chest Physicians: http://www.chestnet.org/guidelines

American Medical Association: http://www.ama-assn.org

British Medical Journal Clinical Evidence: http://www.clinicalevidence.com

Canadian Coordinating Office for Health Technology Assessment: http://www.ccohta.ca

Canadian Task Force on Preventive Healthcare: http://www.ctfphc.org

Centers for Disease Control and Prevention: http://www.cdc.gov

Centre for Evidence-Based Mental Health: http://www.cebmh.com

Centre for Evidence-Based Pharmacotherapy: http://www.aston.ac.uk/lhs/teaching/pharmacy/cebp

Centre for Health Evidence: http://www.cche.net/che/home.asp

Centre for Health Services and Policy Research: http://www.chspr.ubc.ca

Clinical Resource Efficiency Support Team (CREST): http://www.crestni.org.uk

CMA Infobase: Clinical Practice Guidelines: http://mdm.ca/cpgsnew/cpgs/index.asp

Cochrane Database of Systematic Reviews: http://www.update-software.com/cochrane

Database of Abstracts of Reviews of Effectiveness: http://nhscrd.york.ac.uk/darehp.htm

Evidence-Based On-Call: http://www.eboncall.org

Government of British Columbia Ministry of Health Services: http://www.hlth.gov.bc.ca/msp/protoguides/index.html

Institute for Clinical Systems Improvement: http://www.icsi.org/index.asp

Institute of Child Health: http://www.ich.ucl.ac.uk/ich

Joanna Briggs Institute: http://www.joannabriggs.edu.au/about/home.php

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Assessment and Management of Foot Ulcers for People with Diabetes

Medic8.com: http://www.medic8.com/ClinicalGuidelines.htm

Medscape Womens Health: http://www.medscape.com/womenshealthhome

Monash University Centre for Clinical Effectiveness: http://www.med.monash.edu.au/healthservices/cce/evidence

National Guideline Clearinghouse: http://www.guidelines.gov

National Institute for Clinical Excellence: http://www.nice.org.uk

National Library of Medicine Health Services/Technology Assessment: http://hstat.nlm.nih.gov/hq/Hquest/screen/HquestHome/s/64139

Netting the Evidence: A ScHARR Introduction to Evidence-Based Practice on the Internet: http://www.shef.ac.uk/scharr/ir/netting

New Zealand Guidelines Group (NZGG): http://www.nzgg.org.nz

NHS Centre for Reviews and Dissemination: http://www.york.ac.uk/inst/crd

NHS Nursing & Midwifery Practice Development Unit: http://www.nmpdu.org

NHS R & D Health Technology Assessment Programme: http://www.hta.nhsweb.nhs.uk/htapubs.htm

PEDro: The Physiotherapy Evidence Database: http://www.pedro.fhs.usyd.edu.au/index.html

Queens University at Kingston: http://post.queensu.ca/~bhc/gim/cpgs.html

Royal College of General Practitioners: http://www.rcgp.org.uk

Royal College of Nursing: http://www.rcn.org.uk/index.php

Royal College of Physicians: http://www.rcplondon.ac.uk

Sarah Cole Hirsch Institute: http://fpb.cwru.edu/HirshInstitute

Scottish Intercollegiate Guidelines Network (SIGN): http://www.sign.ac.uk

Society of Obstetricians and Gynecologists of Canada Clinical Practice Guidelines: http://www.sogc.medical.org/sogcnet/index_e.shtml

The Canadian Cochrane Network and Centre: http://cochrane.mcmaster.ca

The Qualitative Report: http://www.nova.edu/ssss/QR

Trent Research Information Access Gateway: http://www.shef.ac.uk/scharr/triage/TRIAGEindex.htm

TRIP Database: http://www.tripdatabase.com

U.S. Preventive Service Task Force: http://www.ahrq.gov/clinic/uspstfix.htm

University of California, San Francisco: http://medicine.ucsf.edu/resources/guidelines/index.html

University of Laval Directory of Clinical Information Websites: http://132.203.128.28/medecine

University of York Centre for Evidence-Based Nursing: http://www.york.ac.uk/health-sciences/centres/evidence/cebn.htm

STEP 3 Search Engine Web Search

A website search for existing diabetic foot ulcer guidelines was conducted via the search engine Google,
using the search terms identified above. One individual conducted this search, noting the results of the
search term results, the websites reviewed, date and a summary of the results. The search results were
further critiqued by a second individual who identified guidelines and literature not previously retrieved.

STEP 4 Hand Search/Panel Contributions

Additionally, panel members were already in possession of a few of the identified guidelines. In some
instances, a guideline was identified by panel members and not found through the previous search
strategies. These were guidelines that were developed by local groups or specific professional associations
and had not been published to date.

STEP 5 Core Screening Criteria

This above search method revealed eight guidelines, several systematic reviews and numerous articles
related to diabetic foot ulcers.

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The final step in determining whether the clinical practice guideline would be critically appraised was to
have two individuals screen the guidelines based on the following criteria. These criteria were determined
by panel consensus:
Guideline was in English, international in scope.
Guideline dated no earlier than 1997.
Guideline was strictly about the topic area.
Guideline was evidence-based, (e.g. contained references, description of evidence, sources of evidence).
Guideline was available and accessible for retrieval.

RESULTS OF THE SEARCH STRATEGY

The results of the search strategy and the decision to critically appraise identified guidelines are detailed
below. Seven guidelines met the screening criteria and were critically appraised using the Appraisal of
Guidelines for Research and Evaluation (AGREE Collaboration, 2001) instrument.

TITLE OF THE PRACTICE GUIDELINES CRITICALLY APPRAISED

Australian Centre for Diabetes Strategies (2001). National evidence based guidelines for the management
of type 2 diabetes mellitus Draft for public consultation 6 April 2001 for the identification & management
of diabetic foot disease. Australian Centre for Diabetes Strategies [Electronic version]. Available:
http://www.diabetes.net.au/PDF/evidence_based_healtcare/FootProblems.pdf
CREST Clinical Resource Efficiency and Support Team (1998). Guidelines for the management of the
diabetic foot: Recommendations for practice. Clinical Resource Efficiency and Support Team [Electronic
version]. Available: http://www.crestni.org.uk/publications/diabetic_foot.pdf
Frykberg, R. G., Armstrong, D. G., Giurini, J., Edwards, A., Kravette, M., Kravitz, S. et al. (2000). Diabetic
foot disorders: A clinical practice guideline. American College of Foot and Ankle Surgeons [Electronic
version]. Available: http://www.acfas.org/diabeticcpg.html
Hutchinson, A., McIntosh, A., Feder, R. G., Home, P. D., Mason, J., OKeefee, C. et al. (2000). Clinical
guidelines and evidence review for type 2 diabetes: Prevention and management of foot problems. Royal College
of General Practitioners [Electronic version]. Available:
http://www.rcgp.org.uk/rcgp/clinspec/guidelines/diabetes/contents.asp
Inlow, S., Orsted, H., & Sibbald, R. G. (2000). Best practices for the prevention, diagnosis and treatment
of diabetic foot ulcers. Ostomy/Wound Management, 46(11), 55-68.
Ministry of Health Malaysia (2003). Clinical practice guidelines: Management of diabetic foot.
Ministry of Health Malaysia [Electronic version]. Available:
http://www.acadmed.org.my/cpg/Draft%20CPG%20%20management%20of%20diabetic%20foot.pdf
Royal Melbourne Hospital (2002). Evidence based guidelines for the inpatient management of acute
diabetes related foot complications. Melbourne Health [Electronic version]. Available:
http://www.mh.org.au/ClinicalEpidemiology/new_files/Foot%20guideline%20supporting.pdf

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Appendix B: Glossary of Terms

A1C (formerly referred to as Glycosylated Hemoglobin or HBA1C): The A1C test
measures the average glycemia over the preceding 2-3 months and, thus, assesses glycemic control.
When the A1C is done every three months, it can detect whether glycemic control has been reached
and maintained within the target range and also reflects departures from the target range.

Abscess: A

circumscribed collection of pus that forms in tissue as a result of acute or chronic

localized infection. It is associated with tissue destruction and frequently swelling.

Anhydrosis: Failure of the sweat glands to produce sweat, resulting in dryness in the skin, often a
result of damaged nerves or neuropathy.

Ankle Brachial Pressure Index (ABPI):

A comparison between the brachial systolic

pressure and ankle systolic pressure. It gives an indication of arterial perfusion. The normal resting
pressure is 1.0.

Antibiotic: An agent that is synthesized from a living organism (e.g., penicillin from mold ) and can
kill or halt the growth of microbes or bacteria.

Antimicrobial: An agent that is used to kill bacteria or microbes, that is not synthesized from a
living organism (e.g., iodine or silver).
Antiseptic (Topical):

Product with antimicrobial activity designed for use on skin or other

superficial tissues; may damage cells.

Callus: An area of skin that is abnormally thick or hard, usually from continual pressure or friction,
sometimes over a bony prominence.

Cellulitis: An infection of the skin characterized most commonly by local heat, redness (erythema),
pain and swelling.

Claw Toes: Same as hammer toes.

Culture (Swab): Techniques involving the use of a swab to remove bacteria from a wound and
place them in a growth medium for propagation and identification.
Diabetic Neuropathy: Peripheral, somatic or autonomic nerve damage attributable solely to
diabetes mellitus.

Edge of Wound: It is an important part of the algorithm for wound management in diabetic foot
ulcers. It provides an outcome statement (goal of care), provides structure for care (enabler), and it
supports the use of a common language to determine healing (links practitioners). It determines if
cell migration has begun.

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Exuberant Granulation Tissue: New granulation tissue that is proliferating above the normal rate.
Fissures: A long, narrow opening or gap that can extend into other cavities or areas of the body.
Friable Tissue: Granulation tissue that bleeds easily with minimal stimulation. Normal healthy
tissue is not friable.

F-Scan mat:

Measures dynamic plantar pressures (foot pressure in standing and walking

positions). This device measures peak pressures under the forefoot and the rear foot and is used to
assist healthcare providers in reducing pressure areas to the foot.

Hallux Deformity: A deformity of the great toe.

Hammer Toes: A hammer toe is a toe that is contracted at the middle joint, which may cause
severe pressure and pain. The ligaments and tendons that have tightened cause the toes joints to curl
downwards and may occur in any toe except the great toe.

Infection:

The presence of bacteria or other micro-organisms in sufficient quantity to damage

tissue or impair healing. Clinical experience has indicated that wounds can be classified as infected
when the wound tissue contains 105 or greater micro-organisms per gram of tissue. Clinical signs of
infection may not be present, especially in the immuno-compromised patient or the patient with a
chronic wound.

Local Clinical Infection. A clinical infection that is confined to the wound and within a few
millimeters of its margins e.g., purulent exudate, odour, erythema, warmth, tenderness,
edema, pain, fever, and elevated white cell count.

Systemic Clinical Infection. A clinical infection that extends beyond the margins of the wound.
Some systemic infectious complications of pressure ulcers include cellulitis, advancing
cellulitis, osteomyelitis, meningitis, endocarditis, septic arthritis, bacteremia, and sepsis.

Insensate: A word that describes a region of the body where the person cannot feel a stimulus. An
example is when a monofilament is applied using proper technique, if the person does not feel the
filament, that area of the foot is described as insensate.
Malnutrition:

State of nutritional insufficiency due to either inadequate dietary intake or

defective assimilation or utilization of food ingested.

Metatarsal Heads: The metatarsal region of the foot is the area on the bottom of a foot just
before the toes, more commonly referred to as the ball-of-the-foot.
MRSA:

Methicillin-resistant staphylococcus aureus (MRSA) is a strain of the staphylococcus

bacterium which is resistant to the main groups of antibiotics.

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Onychomycosis:

Fungal infection in the toe nails. Nails may appear dry, thickened, white or

yellow and flaky.

Pallor: White, pale, blanched colour of a limb when in the upright position.
Pes Cavus: A foot characterized by an abnormally high arch. Hyperextension of the toes may be
present which can give the foot the appearance of a claw.

Pes Planus: A foot that has a fallen arch and appears abnormally flat or spread out.
Photoplethysmography: Photoplethysmography uses infra-red light to assess changes in the
blood volume in the micro-circulation.

Rubor: Dark purple to bright red colour of a limb when in a dependent position.
Sensory Ataxia: Is an impairment of ones sense of body position. It may be characterized by
striking the ground forcibly with the bottom of the foot as well as a stiff fling of the leg with walking.
Specificity: The chance of having a negative test result given that one does not have a disease.
Sensitivity: The chance of having positive test result given that one does have a disease.
Toe Pressure: See photoplethysmography.

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Appendix C:
University of Texas Foot Classification System
Categories 0-3: Risk Factors for Ulceration
Category 0: No Pathology

Category 1: Neuropathy, No Deformity

Patient diagnosed with Diabetes Mellitus

Protective sensation absent

Protective sensation intact

Ankle Brachial Pressure Index (ABPI) > 0.80

and toe systolic pressure >45 mmHg

Ankle Brachial Pressure Index (ABPI) > 0.80

and toe systolic pressure >45 mmHg

No history of ulceration

Foot deformity may be present

No history of ulceration

No history of diabetic neuropathic

osteoarthropathy (Charcots joint)

No foot deformity

POSSIBLE TREATMENT FOR CATEGORY 1

POSSIBLE TREATMENT FOR CATEGORY 0

Two to three visits a year to assess neurovascular

status, dermal thermometry, and foci of stress

Possible shoe accommodations

Patient education

Same as Category 0 plus:

Category 2: Neuropathy with Deformity

Possible shoe gear accommodation

(pedorthic/orthotist consultation)

Quarterly visits to assess shoe gear

and monitor for signs of irritation

Category 3: History of Pathology

Protective sensation absent

Protective sensation absent

Ankle Brachial Pressure Index (ABPI) >0.80

and toe systolic pressure >45 mmHg

Ankle Brachial Pressure Index (ABPI) >0.80

and toe systolic pressure >45 mmHg

No history of neuropathic ulceration

History of neuropathic ulceration

No history of Charcots joint

History of Charcots joint

Foot deformity present (focus of stress)

Foot deformity present (focus of stress)

POSSIBLE TREATMENT FOR CATEGORY 2

POSSIBLE TREATMENT OF CATEGORY 3

Same as Category 1 plus:

Same as Category 2 plus:

Pedorthic/orthotist consultation for possible

custom molded/extra depth shoe
accommodation

Possible prophylactic surgery to alleviate focus

of stress (e.g., correction of hammer toe or bunion
deformity)

Pedorthic/orthotist consultation for custom

molded/extra depth shoe accommodation

Possible prophylactic surgery to alleviate

the focus of stress (e.g., correction of bunion
or hammer toe)

More frequent visits may be indicated for

monitoring

Copyright 1997 by D.G. Armstrong, L.A. Lavery, L.B. Harkless. Reprinted with permission of Dr. D. G. Armstrong.

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Appendix D:
University of Texas Foot Classification System
Categories 4-6: Risk Factors for Amputation
Category 4A: Neuropathic Wound

Category 4B: Acute Charcots Joint

Protective sensation absent

Protective sensation absent

Ankle Brachial Pressure Index (ABPI) > 0.80

and toe systolic pressure >45 mmHg

Ankle Brachial Pressure Index (ABPI) > 0.80

and toe systolic pressure >45 mmHg

Foot deformity normally present

Non-infected neuropathic ulceration

(ALL UT* STAGE A wounds)

Non-infected neuropathic ulceration

may be present

Diabetic neuropathic osteoarthropathy

(Charcots joint) present

No acute diabetic neuropathic osteoarthorpathy

(Charcots joint) present

POSSIBLE TREATMENT FOR CATEGORY 4B

POSSIBLE TREATMENT FOR CATEGORY 4A

Pressure reduction program instituted

Same as Category 3 plus:

Thermometric and radiographic monitoring

If ulcer is present, treatment same as Category 4A

Pressure reduction program instituted

Wound care program instituted

Category 5: The Infected Diabetic Foot

Category 6: The Ischemic Limb

Protective sensation may or may not be present

Protective sensation may or may not be present

Infected wound

Ankle Brachial Pressure Index (ABPI) <0.80 and

Charcots Joint may be present

ALL UT* STAGE B wounds

toe systolic pressure <45 mmHg or Pedal

Transcutaneous Oxygen Tension < 40 mmHg

POSSIBLE TREATMENT FOR CATEGORY 5

Debridement of infected, necrotic tissue

and/or bone, as indicated

Possible hospitalization, antibiotic

treatment regimen

Ulceration may be present

ALL UT* STAGE C AND D wounds

POSSIBLE TREATMENT OF CATEGORY 6

Medical management

Vascular consult, possible revascularization

If infection present, treatment same as for

Category 5. Vascular consultation concomitant
with control of sepsis.

Legend: *UT = University of Texas

Copyright 1997 by D.G. Armstrong, L.A. Lavery, L.B. Harkless. Reprinted with permission of Dr. D. G. Armstrong.

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Appendix E:
University of Texas Health Science Center
San Antonio Diabetic Wound Classification System
GRADES
0

II

III

Pre-or postulcerative lesion

Superficial wound,
not involving tendon,
capsule, or bone

Wound penetrating
to tendon or capsule

Wound penetrating
to bone or joint

Pre- or post-ulcerative
lesion, completely
epithelialized with
infection

Superficial wound, not

involving tendon, capsule,
or bone with infection

Wound penetrating
to tendon or capsule
with infection

Wound penetrating
to bone or joint with
infection

Pre- or post-ulcerative
lesion, completely
epithelialized with
ischemia

Superficial wound, not

involving tendon, capsule,
or bone with ischemia

Wound penetrating
to tendon or capsule
with ischemia

Wound penetrating
to bone or joint with
ischemia

Pre- or post-ulcerative
lesion, completely
epithelialized with
infection and ischemia

Superficial wound, not

involving tendon, capsule,
or bone with infection
and ischemia

Wound penetrating to
tendon or capsule with
infection and ischemia

Wound penetrating to
bone or joint with
infection and ischemia

Reprinted with permission:

Armstrong, D., Lavery, L. A. & Harkless, L. B. (1998b). Validation of a diabetic wound classification system: The contribution
of depth, infection and ischemia to risk of amputation. Diabetes Care, 21(5), 855-859. Copyright 1998 American Diabetes
Association.

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Appendix F:
Diabetic Foot Care Patient Handout
Any healthcare team member can assess the patient and/or caregivers knowledge regarding their foot care.
This patient handout was designed to assist team members in reviewing basic foot care strategies. Each
item is explained in details on p.84 while p.85 is an easy to use checklist that encourages the patient to
check each important aspect of care, using a simple check mark in each box. The make notes section is
intended to remind patients to discuss any changes or questions with their healthcare provider.

Reprinted with permission: Laurie Goodman, RN, BA, IIWCC, Nurse Clinician, Skin & Wound Care, Credit Valley Hospital.

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Reprinted with permission: Laurie Goodman, RN, BA, IIWCC, Nurse Clinician, Skin & Wound Care, Credit Valley Hospital.

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Appendix G:
Diagnostic Tests to Determine Vascular Supply
Diagnostic Test

Description

Arterial
Duplex Scan

Transcutaneous
Oxygen (TcpO2)

Non-invasive ultrasound test that can identify macro- and microvascular

changes in the arterial tree.
Used to diagnose aneurysm for large vessel stenosis >50%.
Patients with suspected superficial artery stenosis and claudication may
undergo duplex scanning to identify a lesion that is amenable to angioplasty,
before subjected to angiogram (Sales, Goldsmith & Veith 1994).
Non-invasive arterial duplex scan as having sensitivity and specificity rates
greater than 90% (Kravitz, McGuire & Shanahan, 2003).
Measures absolute oxygen partial pressure in the dermis. According to Goldman and
Salcido (2002), TcpO2 less than 20 mmHg gives a guarded prognosis for healing.
40 mmHg is a good indication for healing (Goldman & Salcido, 2002).
TcpO2 should be measured on upper leg and dorsum of the foot for best results.
Areas of callus, edema or bony prominences produce inaccurate results.
Valuable for evaluating perfusion and is a good predictor of amputation in the
lower limbs (Adler, Boyko, Ahroni & Smith, 1999; Ballard, Eke, Bunt & Killeen, 1995; Lehto,
Ronnemaa, Pyorala & Laakso, 1996; Mayfield, Reiber, Sanders, Janisse & Pogach, 1998;
Pecoraro, Ahroni, Boyko & Stensel, 1991; Reiber et al., 1992).

Toe and Ankle

Pressures

TcpO2 < 30 mmHg was an independent predictor of diabetic foot ulceration

(McNeely, Boyko, Ahroni, Stensel, Reiber, Smith et al., 1995).

Systolic toe and ankle pressures are measured with a fitted occluding cuff
placed most often around the base of the first toe and around both ankles.
Toe pressure of >45 mmHg is necessary for optimal healing (Apelqvist, Castenfors,
Larsson, Stenstrm & Agardh, 1989; Frykberg et al., 2000).
Most patients with toe blood pressures >30mmHg healed with conservative
management (Apelqvist et al., 1989; Kalani, Brismar, Fagrell, Ostergren & Jorneskog, 1999;
Royal Melbourne Hospital, 2002).
With ankle pressures > 80 mmHg, most patients had an amputation or died
before healing occurred (Apelqvis et al., 1989).
Kalani et al. (1999) suggests a cut-off of 25mmHg for TcpO2 and 30mmHg for
toe blood pressure as predictors of wound healing, with TcpO2 being the
better predictor in patients with diabetes and chronic foot ulcers. Toe
pressures, however, may be more technically and economically feasible.

Ankle-Brachial
Pressure Index
(ABPI)

ABPI or ratio of systolic blood pressure in the lower extremity to blood pressure
in the arm is a common clinical measure of reduced circulation (Boyko et al., 1999).

Caution:
This should not be the sole diagnostic test performed.
In patients with diabetes, ABPI results can be unreliable (falsely negative)
due to calcification of the arterial vessels (Apelqvist et al., 1989).

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References:
Adler, A. I., Boyko, E. J., Ahroni, J. H., & Smith, D. G. (1999). Lower-extremity amputation in diabetes:
The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care, 22(7), 1029-1037.
Apelqvist, J., Castenfors, J., Larsson, J., Stenstrm, A., & Agardh, C.-D. (1989). Prognostic value of systolic ankle
and toe blood pressure levels in outcome of diabetic foot ulcer. Diabetes Care, 12(6), 373-378.
Ballard, J. L., Eke, C. C., Bunt, T. J., & Killeen, J. D. (1995). A prospective evaluation of transcutaneous oxygen measurements
in the management of diabetic foot problems. Journal of Vascular Surgery, 22(4), 485-492.
Boyko, E. J., Ahroni, J. H., Stensel, V., Forsberg, R. C., Davignon, D. R., & Smith, D. G. (1999). A prospective study of risk factors for diabetic
foot ulcers: The Seattle diabetic foot study. Diabetes Care, 22(7), 1036-1042.
Frykberg, R. G., Armstrong, D. G., Giurini, J., Edwards, A., Kravette, M., Kravitz, S. et al. (2000). Diabetic foot disorders:
A clinical practice guideline. American College of Foot and Ankle Surgeons [Electronic version].
Available: http://www.acfas.org/diabeticcpg.html
Goldman, R. J. & Salcido, R. (2002). More than one way to measure a wound: An overview of tools and techniques.
Advances in Skin and Wound Care, 15(5), 236-245.
Kalani, M., Brismar, K., Fagrell, B., Ostergren, J., & Jorneskog, G. (1999). Transcutaneous oxygen tension and toe blood
pressure as predictors for outcome of diabetic foot ulcers. Diabetes Care, 22(1), 147-151.
Kravitz, S. R., McGuire, J., & Shanahan, S. D. (2003). Physical assessment of the diabetic foot. Advances in Skin and Wound
Care, 16(2), 68-75.
Lehto, S., Ronnemaa, T., Pyorala, K., & Laakso, M. (1996). Risk factors predicting lower extremity amputations in patients
with NIDDM. Diabetes Care, 19(6), 607-612.
Mayfield, J. A., Reiber, G. E., Sanders, L. J., Janisse, D., & Pogach, L. M. (1998). Preventive foot care in people with diabetes.
Diabetes Care, 21(12), 2161-2177.
McNeely, M. J., Boyko, E. J., Ahroni, J. H., Stensel, V. L., Reiber, G. E., Smith, D. G. et al. (1995). The independent contributions
of diabetic neuropathy and vasculopathy in foot ulceration: How great are the risks? Diabetes Care, 18(2), 216-219.
Pecoraro, R. E., Ahroni, J. H., Boyko, E. J., & Stensel, V. L. (1991). Chronology and determinants of tissue repair in diabetic
lower-extremity ulcers. Diabetes, 40 1305-1313.
Reiber, G. E., Pecoraro, R. E., & Koepsell, T. D. (1992). Risk factors for amputation in patients with diabetes mellitus: A casecontrol study. Annals of Internal Medicine, 117(2), 97-105.
Royal Melbourne Hospital (2002). Evidence based guidelines for the inpatient management of acute diabetes related foot
complications. Melbourne Health [Electronic version]. Available:
http://www.mh.org.au/ClinicalEpidemiology/new_files/Foot%20guideline%20supporting.pdf
Sales, C., Goldsmith, J., & Veith, F. J. (1994). Handbook of Vascular Surgery. St. Louis, MO: Quality Medical Publishing.

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Appendix H: Diagnostic Tests

and Imaging to Determine Infection
Diagnostic tests
Accessability and interpretation of these tests may be limited to certain areas of specialty. Diagnostic tests
are performed in conjunction with the clinical assessment. Utilizing isolated test results in isolation may
lead the clinician to a misdiagnosis (RNAO Guideline Development Panel, 2005).

Wound cultures
Cultures of the wound should be obtained to guide antibiotic therapy effectively and accurately.
Bacterial swabs can provide information on the predominant flora within a non-progressing,
deteriorating or heavily exudating wound. See Appendix I for swab techniques. Blood cultures are
useful if sepsis is suspected (Perry, Pearson & Miller, 1991). Bacterial swabs or wound cultures do not
diagnose infection but they can be used as guidance for antimicrobial therapy. The diagnosis of
infection is based on clinical symptoms and signs.

C-reactive protein
The sensitivity and specificity of serological markers of infection, e.g., C-reactive protein, tends to
increase with more severe infection (Royal Melbourne Hospital, 2002).

White Blood Cell Count (WBC) and Erythrocyte Sedimentation Rate (ESR)
Elevated lab values should alert the clinician to the possibility of sepsis; however, normal values
should not be used to rule out infection (Armstrong et al., 1996). These lab tests are helpful but must be
considered in conjunction with the clinical assessments of infection.

Imaging
Imaging presentation will vary and should only be conducted to establish or confirm a suspected diagnosis
and/or direct patient management. Accessability and interpretation may be limited to certain areas of specialty:

X-Ray
Plain X-rays are a useful primary imaging tool as they may reveal changes consistent with
osteomyelitis, the presence of foreign bodies, tissue gas or bony abnormalities (Bonham, 2001). Bone
destruction and periosteal changes are not usually evident for 10-21 days following infection (Royal
Melbourne Hospital, 2002).

Bone / Gallium scans

Gallium 67citrate is a nuclear medicine technique that is not used as frequently today due to more accurate
alternative imaging studies (Frykberg et al., 2000; Johnson, Kennedy, Shereff, Patel & Collier, 1996; Keenan, Tindel &
Alavi, 1989; Longmaid III & Kruskal, 1995). Edelson, Armstrong, Lavery & Caicco (1996) established that the
technetium bone scan is an expensive, non-specific test for evaluating bony pathology (e.g.,
osteomyelitis).

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Nursing Best Practice Guideline

CT scan
CT scans may be indicated in the assessment of suspected bone and joint pathology not evident on
plain radiographs (Frykberg et al., 2000; Lipsky, 1997).

Magnetic Resonance Imaging (MRI)

MRI has superior sensitivity and specificity (approximately 90-95% for each) for diagnosing
osteomyelitis. If plain X-ray is not sufficient MRI may be subsequently ordered to confirm the
diagnosis and to determine the extent of osteomyelitis.

References:
Armstrong, D. G., Lavery, L. A., Sariaya, M. & Ashry, H. (1996). Leukocytosis is a poor indicator of acute osteomyelitis of the foot in
diabetes mellitus. The Journal of Foot and Ankle Surgery, 35(4), 280-283.
Bonham, P. (2001). A critical review of the literature: part I: diagnosing osteomyelitis in patients with diabetes and foot ulcers.
Journal of Wound, Ostomy and Continence Nurses Society, 28(2), 73-88.
Edelson, G. W., Armstrong, D. G., Lavery, L. A. & Caicco, G. (1996). The acutely infected diabetic foot is not adequately
evaluated in an inpatient setting. Journal of the American Podiatric Medical Association, 87(6), 260-265.
Frykberg, R. G., Armstrong, D. G., Giurini, J., Edwards, A., Kravette, M., Kravitz, S. et al. (2000). Diabetic foot disorders:
A clinical practice guideline. American College of Foot and Ankle Surgeons [Electronic version]. Available:
http://www.acfas.org/diabeticcpg.html
Johnson, J. E., Kennedy, E. J., Shereff, M. J., Patel, N. C. & Collier, B. D. (1996). Prospective study of bone, indium-111-labeled white
blood cell, and gallium-67 scanning for the evaluation of osteomyelitis in the diabetic foot. Foot and Ankle International, 17(1),
10-16.
Keenan, A. M., Tindel, N. L. & Alavi, A. (1989). Diagnosis of pedal osteomyelitis in diabetic patients using current scintigraphic
techniques. Archives of Internal Medicine, 149(10), 2262-2266.
Lipsky, B. A. (1997). Osteomyelitis of the foot in diabetic patients. Clinical Infectious Diseases, 25(6), 1318-1326.
Longmaid III, H. E. & Kruskal, J. B. (1995). Imaging infections in diabetic patients. Infectious Disease Clinics of North America,
9(1), 163-182.
Perry, C. R., Pearson, R. L. & Miller, G. A. (1991). Accuracy of cultures of material from swabbing of the superficial aspect of the
wound and needle biopsy in the perioperative assessment of osteomyelitis. Journal of Bone and Joint Surgery, 73(5), 745-749.
Royal Melbourne Hospital (2002). Evidence based guidelines for the inpatient management of acute diabetes related foot
complications. Melbourne Health [Electronic version]. Available:
http://www.mh.org.au/ClinicalEpidemiology/new_files/Foot%20guideline%20supporting.pdf

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Assessment and Management of Foot Ulcers for People with Diabetes

Appendix I: Wound Swabbing Technique

Obtain a wound culture when clinical signs and symptoms of infection are present.
NB: In Ontario, the Ontario Laboratories Act requires a physicians order to process the culture.

Semi-quantitative Swab Sample Technique:

Semi-quantitative swab results are equally effective with quantitative biopsy results if the wound is
properly prepared (Dow et al., 1999).
Use sterile cotton tipped swab and culture medium in a pre-packaged collection and transport system
available from the hospital or Gamma, MDS or CML laboratories. Community nurses should not allow
transport medium to freeze or become overheated in the car before using it.
Thoroughly rinse wound with normal saline (non-bacteristatic).
Dont swab pus, exudate, hard eschar or necrotic tissue.
Rotate the swab tip in a 1 cm square area of clean granulation tissue using enough pressure to release
tissue exudate for a period of 5 seconds. This may be painful so warn the patient of the possibility of
pain and pre-medicate with analgesic if possible.
Remove protective cap from culture medium and insert cotton tipped applicator into the culture
medium without contaminating the applicator.
Transport to the laboratory at room temperature within 24 hours.

Interpretation of semi-quantitative results:

Many labs that service the community do not provide quantitative results or report gram stains. The
following chart can be used to compare semi-quantitative results with a quantitative report.

Surface Cultures Growth at 24 48 hours

Rx
(1+ to 4+)

Semi-quantitative result
(terms will vary
with each lab)

Suggested
Antibiotic Treatment

No growth
No growth
No growth
No growth

No growth
I
I, II
I, II, III

No growth
Scant or light
Small to moderate
Moderate to heavy

Bacteria observed

I, II, III, IV

Large or heavy

None
None
None
Treat if localized signs
of infection present
Treat considered
infected

Quantitative Growth
(Colony Forming Units/
Gm)

Gram Stain Results

<10 to the 3rd

>= 10 to the 3rd
>=10 to the 4th
>=10 to the 5th
>=10 to the 6th

Sector

Prepared by and reprinted with permission of Connie Harris, RN, ET, IIWCC 2000.

References:
Dow, G., Browne, A. & Sibbald, R. G. (1999). Infection in chronic wounds: Controversies in diagnosis and treatment.
Ostomy/Wound Management, 45(8), 23-27, 29-40.
Herruzo-Cabrera, R., Vizcaino-Alcaide, M. J., Pinedo-Castillo, C. & Rey-Calero, J. (1992). Diagnosis of local infection of a burn by
semiquantitative culture of the eschar surface. Journal of Burn Care and Rehabilitation, 13(6), 639-641.

Stotts, N. (1995). Determination of bacterial bioburden in wounds. Advances in Wound Care, 8(4), 28-46.

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Nursing Best Practice Guideline

Appendix J:
Use of the Semmes-Weinstein Monofilament
Directions for use of Semmes- Weinstein Monofilament
1. Assess integrity of monofilament (no bends/breaks).
2. Show the monofilament to the patient. Place the end of the monofilament on his/her hand or arm to
show that the testing procedure will not hurt.
3. Ask the patient to turn his/her head and close his/her eyes or look at the ceiling.
4. Hold the monofilament perpendicular to the skin.
Bend

Monofilament

Release

Skin

5. Place the end of the monofilament on the sole of the foot. Ask the patient to say yes when he/she feels
you touching his/her foot with the monofilament. DO NOT ASK THE PATIENT did you feel that? If the
patient does not say yes when you touch a given testing site, continue on to another site. When you
have completed the sequence RETEST the area(s) where the patient did not feel monofilament.
6. Push the monofilament until it bends, then hold for 1-3 seconds.
7. Lift the monofilament from the skin. Do not brush or slide along the skin.
8. Repeat the sequence randomly at each testing site on the foot (see pictures below).

Sites on the sole of the foot for monofilament testing

Loss of protective sensation = absent sensation at one or more sites

Right Foot

Left Foot

Notes
Apply only to intact skin. Avoid calluses, ulcerated or scarred areas. DO NOT use a rapid or tapping movement.
If the monofilament accidentally slides along the skin, retest that area later in the testing sequence.
Store the monofilament according to the manufacturers instructions.
Clean the monofilament according to agency infection control protocols.
Reference: Registered Nurses Association of Ontario (2004). Reducing Foot Complications for People with Diabetes. Toronto,
Canada: Registered Nurses Association of Ontario.

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Assessment and Management of Foot Ulcers for People with Diabetes

Appendix K: Suggestions for Assessing

and Selecting Shoes and Socks
Shoes

Shoes should be comfortable and well-fitting.

Have both feet measured each time shoes are bought.
Buy new shoes late in the day since feet often swell or enlarge during the day. Buy shoes to fit the larger
foot if there is a difference.
Choose shoes with a wide and deep toe box (test depth with a looney put in sideways, test width by
outlining your foot on a piece of paper and placing the shoe over the drawing).
When buying shoes, wear the type of socks that you will be wearing with those shoes.
Choose shoes made of calfskin or soft leather, if possible.
Buy shoes with laces. These provide more support, distribute pressure around the sides and top and
allow adjustment for swelling.
Shoes should have good, non-skid soles, closed toes and heels, with no ridges, wrinkles or seams in
the linings (good running shoes or walking shoes are recommended).
Avoid slip-on shoes, shoes with pointed toes and sandals, especially sandals with thongs between the toes.
Do not wear shoes with heels higher than 1 inch (2.5cm) as they increase pressure on the metatarsal
heads.
Break new shoes in gradually, adding one hour of wearing time each day. Frequently inspect the feet,
looking for areas of redness that indicate potential problems.
Do not wear any shoes longer than six hours without removing. Each pair of shoes fits differently and
distributes pressure differently.
Check shoes before wearing for small stones or puckered or bunched up areas.

Socks

Wear clean socks everyday. Cotton or wool is best to absorb perspiration.

Socks should fit well. Avoid tight elastic at the top.
If wearing knee-high hosiery, make sure it has a wide band at the top.
Check socks for irritation or bunching. Avoid seams if possible.
Do not wear mended socks; they may cause an area of pressure.
Do not wear socks with holes; they may cause an area of friction.

Adapted from: Zangaro, G. A. & Hull, M. M. (1999). Diabetic neuropathy: Pathophysiology and prevention of foot ulcers.
Clinical Nurse Specialist, 13(2) 57-65

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Nursing Best Practice Guideline

Appendix L: Factors Affecting Wound Healing

Systemic Factors
Affecting Wound Healing

Age
Anemia
Anti-inflammatory drugs
Auto-immune disorders
Blood supply
Cytotoxic drugs
Fever
Hypotension
Jaundice
Malignant disease
Malnutrition
Obesity
Renal Failure
Systemic infection
Trauma
Smoking
Vasculopathy
Vitamin deficiency
Zinc deficiency

Local Factors
Affecting Wound Healing

Blood supply
Denervation
Edema
Hematoma
Iatrogenic causes
psychosocial/cognitive
impairment
poor surgical
use of cytotoxic agents
Local infection
Mechanical stress
Radiation
Suture material
Type of tissue

Extrinsic Factors
Affecting Wound Healing

Cultural beliefs
Footwear
shoes
orthotics
Offloading devices

RNAO Guideline Development Panel, 2005

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Assessment and Management of Foot Ulcers for People with Diabetes

Appendix M: Topical Antimicrobial Agents

TOPICAL ANTIMICROBIAL AGENTS
Agent

Spectrum
SA

Safe & Effective

Cadexomer Iodine

MRSA Strep

Comments

PS

Anaerobic

VRE

Broad spectrum.
Effective for fungi & virus.
Widely available.
Sheet requires wound contact.
Caution if on thyroid medication.

Ionized Silver

Broad Spectrum.
Effective for fungi & virus.
Sheet requires wound contact.

Silver Sulphadiazine

Limited potential for resistance.

Available in paste or ointment.
Do not use if sulfa sensitive.

Polymyxin B Sulphate
Bacitracin Zinc
Selective Use

Metronidazole
gel/cream
Benzyl/ Peroxide

Sheet requires wound contact.

Reserve for anaerobes & odour

control.

Reserve for MRSA & other

resistant gram positive.

Acetic Acid
Mupuricin
Bactroban

Povidone iodine

Used in 0.25% (e.g. 1/4 of 1.0%

maximum concentration).
Should be reserved
for MRSA colonization.

Use with caution.

This agent is cytotoxic.

Chlorhexidine

Use during inflammatory phase.

Cytotoxic during proliferative
phase.

Caution

Gentamycin

Fucidic Acid

Polymixin B Sulphate
Bacitracin Zinc
Neomycin

Reserve for oral/IV use.

Sensitizer.

Potent Sensitizer.

Not

Alcohol

Cytotoxic.

Recommended

Hydrogen peroxide

No antimicrobial properties.

Hypochlorite solution

Cytotoxic.

(Dakens)

Legend: (SA = Staphylococcus Aureus), (MRSA = Methicillin Resistant Staph Aureus), (Strep = Streptococci),
(PS = Pseudomona), (F = Fungi Mucor, Aspergillus, Candida Albicans, Candida Tropicalis,
Candida Glabrata, & Saccharomyces), (VRE = Vancomycin-Resistant Enterococci)
Reprinted with permission from Dr. R. Gary Sibbald.

94

95

AHCPR (1994)

Ranked according to toxicity

Dermagran cleanser
Restore
Other

Cleanses wound debris with

minimal trauma.

Normal saline preferred.

CLEANSERS
Normal Saline
Shur-Clens

Adjustable spray nozzle provides

variable pressures for cleansing
(from gentle flush to 15 psi).

May contain surfactants to assist

with removal of debris.

Commercial wound cleansers.

Not harmful to tissue.

Physiologic.

Indications

Description

Examples

Wound Care Products

Note: Read the product monographs for specific details.

Caution Wound cleansers are for wounds. Skin cleansers are for
intact skin only.

Risk of contamination is reduced in unclean situations.

Ease of use facilitates patient independence.

Cleansers contain mild preservatives, which stabilize the product

but may cause irritation and increase toxicity.

Levels of toxicity vary among commercial wound cleansers. Some

contain antimicrobial agents, which may be toxic to new tissue.
Read literature and product monograph to determine safety.

Considerations

There is limited evidence that any specific dressing type enhances the speed of healing of diabetic foot ulcers. It is clear, however, that a moist wound
environment results in more rapid wound healing. Many factors need to be considered when selecting a dressing and these factors may change over
time, necessitating a change in dressing type. Influencing factors include wound type, wound depth, presence and volume of exudates, presence of
infection, surrounding skin condition, likelihood of re-injury and cost. Dressings should never be commenced in isolation and should be a part of the
treatment package of debridement, dressings, pressure offloading and when clinically indicated, antibiotics. This list is not exhaustive. These are
common products used in Ontario. Please check with local suppliers to see what specific dressings are used in your region.

Appendix N: A Guide to Dressing Foot Wounds

Nursing Best Practice Guideline

Protects intact skin from friction

or irritants.
Secondary cover dressing to
enhance moisture and odour
containment.

Impermeable to water molecules

and bacteria.
Incapable of absorbing moisture.

Non-sterile roll is intended for

use on intact skin or as a
secondary cover dressing.

Some are shaped to fit problem

areas.

96

IMPREGNATED/
TULLE
Adaptic
Bactigras
Fucidin
Jelonet
Sofratulle

NON-IMPREGNATED
Alldress
ETE
Melolite
Mepitel
Primapore
Release
Tegapore
Telfa
Others

*see Topical Antimicrobial Agents,

Appendix M

Some tulle dressings contain

minimal amounts of antibiotic.

Tulle dressings contain either

petrolatum, antiseptics or
antibiotics.

Mepitel is a silicone mesh.

Minimal absorption capability.

Some have plastic coating to

create semi-occlusion.

Varied densities, sizes and

shapes of woven mesh.
Wound contact layer to:
Protect fragile tissue
Maintain some wound
hydration
Protect post-operative
incision
Prevent painful dressing
adherence

Supports autolytic debridement.

Superficial wounds, skin breaks

with minimal drainage.

A flexible outer dressing for

uneven areas.

Wounds at risk for contamination.

Semi- permeable adhesive sheets.

Transparency permits wound

visualization.

Indications

Description

Moisture Retentive: Non-Adherents

TRANSPARENT
Examples
ADHESIVE DRESSINGS
TRANSPARENT ADHESIVE
DRESSINGS
Bioclusive
MeFilm
Opsite FlexiFix
Opsite
Tegaderm

Consider alternative product if dressing adheres.

Infection requires appropriate systemic management.

Products containing antiseptics and antibiotics reported

to assist with local bacterial control in a contaminated wound.
Long term use increases risk of local sensitization and the
development of resistant bacteria.

Most require secondary cover dressing to absorb drainage

and enhance stability. Some are self-adhesive.

Slight overlap onto peri-wound skin stabilizes dressing

and decreases pain.

Layering tulle dressings increases semi-occlusion.

Plastic coated products may macerate peri-wound skin.

Protect skin with suitable barrier.

Some mesh dressings can remain in place up to 7 days.

Outer absorbent dressings can be replaced as needed.

Removal by stretching the edges will minimize superficial tears.

Not suitable if skin is evidencing yeast infection.

Use of liquid skin barriers on peri-wound skin increases adhesion.

Decrease wound pain by protecting superficial nerve endings.

For removal, stretch product to break adhesive bond

and prevent skin stripping.

Use with caution on fragile peri-wound skin.

Moisture resistance allows for bathing.

Can be cut to accommodate difficult areas or used as adhesive strips to

waterproof dressing edges.

Considerations

Assessment and Management of Foot Ulcers for People with Diabetes

97
Comes in thick and thin versions.

Do not confuse characteristic

odour with infection.

Minimal to moderate absorbency.

Some have tapered or adhesive
borders to increase stability.
Interactive dressings.

Thickness, size, absorption

capability, and transparency
varies.

Sheet dressings have an

occlusive or semi-occlusive
polyurethane outer layer.

May contain gelatin, sodium

carboxymethylcellulose, and
pectin.

May be used for prevention.

Protects underlying skin from

tape injury.

A moisture retentive secondary

dressing.

An aesthetic cover dressing.

Protects from contamination.

Promotes granulation and

epithelialization.

Wounds requiring autolytic

debridement.

Wounds with minimal drainage.

Available as adhesive sheets,

powders or pastes.

HYDROCOLLOIDS

Comfeel
Comfeel Plus
Cutinova Hydro
DuoDERM CGF
RepliCare
Restore
SignaDress
Tegasorb
Triad
Others

Indications

Description

Examples

Wound Hydration: Hydrocolloids

Use liquid skin barriers on peri-wound skin to decrease risk

of maceration and to increase adherence.

If signs and symptoms of clinical infection should develop,

appropriate medical treatment should be initiated.
Use is not appropriate if infection suspected.

Not advised for copiously draining wounds.

Can be used over absorbent alginates or hydrofibers to contain drainage.

Change by 3-4 days.

May remain in place for 3-7 days. Frequency of change is determined

by amount of drainage and before leakage occurs.

Dressings create an occlusive barrier.

Caution with use of adhesive dressings on fragile peri-wound skin.

Use of additional tapes or transparent film dressings to edges may

improve stability in areas of high stress.

Sheets can be customized to fit difficult areas.

Size must always extend 2.5-5 cm beyond wound margins to ensure
adherence and wear time.

Considerations

Nursing Best Practice Guideline

Available as liquid gels, in solid

sheets or imbedded into gauze
dressings.

Some contain preservatives.

Non-adherent.

Non-toxic.

Moisture donating.

Maintains wound moisture,

decreasing need for frequent
changes.

Minimally exudating wounds.

Wounds requiring autolytic

debridement.

Prevents dressing adherence,

bleeding or pain.

Granulating wounds.

Polymers with high water

content.

HYDROGELS

Curagel
DuoDERM Gel
Intrasite Gel
Normgel
Nu-Gel
Puriclens
Restore Gel
Tegagel
WounDres
Others

Indications

Description

Examples

Wound Hydration: Hydrogels

98

Prevent contamination of opened product. Handle and discard

according to the product monograph.

Sheet gels can be cut to slightly larger than wound.

Wear time varies from 1 to 3 days according to amount of drainage

(read product monograph).

Not advised for copiously draining wounds.

Can be used in combination with transparent films, foams,

hydrocolloids or other non-adherent cover dressing.

Secondary dressing is required to retain moisture, absorb excess

drainage and to stabilize gels over wounds.

Gel can be applied to gauze ribbon packing to fill deep areas and
promote autolytic debridement .

Cross-hatch eschar to promote penetration of gel.

Protect peri-wound skin from maceration with suitable barrier.

Monitor closely for infection during autolysis.

Considerations

Assessment and Management of Foot Ulcers for People with Diabetes

Exudating wounds during

autolytic debridement.
Bleeding wounds.
Post sharp debridement.
Reduces the need for bulky
dressings.

Sheets or fibrous ropes of

calcium sodium alginate.
Seaweed derivative.
Applied in dry state.
As drainage is absorbed, it
converts to a gelatinous mass.

99
Tegagen offers a choice of
a high gelling or a high integrity
product. Review product
monograph and wound needs.

Fibracol contains collagen.

Non-adhesive.

Calcium and sodium interact to

promote clotting.

Hemostatic capabilities.

Wounds with visible depth

requiring soft filler.

Absorbs moderate to large

amounts.

ALGINATES

Algisite
Calcicare
Curasorb
Fibracol
Kaltostat
Melgisorb
Seasorb
Tegagen

Indications

Description

Examples

Absorbent Dressings: Alginates

Low tensile strength. Do not use in a wound without a

visible base.

Maintains wound cleansing in gel state.

Occlusive cover dressings can enhance absorptive capabilities.

Requires moisture retentive cover dressing to avoid drying by

evaporation.

Maximum wear time is 5 days.

If dressing dries and adheres due to decreased moisture,

review product choices. Select alternative or extend wear
time of alginate.

Remove residue by flushing with saline.

Considerations

Nursing Best Practice Guideline

100

Curasalt
Mesalt
Hypergel

HYPERTONIC
SALINE DRESSING
Product absorbs drainage,
becoming an isotonic normal
saline dressing.

Sheet, ribbon gauze, or gel

impregnated with salt
concentrate

Fibres maintain integrity in gelstate, facilitating intact removal.

Non-adhesive.
Vertically absorbs, contains
drainage.

Apply dry.
Converts to a solid gel when
activated by moisture.

Tensile strength decreases when over-saturated.

Not compatible with ointments or creams.

Promotes comfort.
Decreases dressing bulk.

Evaluate for alternative product choice when drainage decreases

or wound base becomes clean.

Consider gel for dry necrosis

Moisture-retentive cover dressing is advised.

Consider risk of loose fibres if cutting products.

May be painful for sensitive patient.

May damage granulation tissue if drainage is minimal. Adequate

wound drainage is essential to prevent dressing adherence or damage
from concentrated salts.

Debridement of slough.
Infected wounds.

Apply in a dry state to wound.

Copiously draining wounds.

Do not use in a wound without a visible base.

Wear time is 1-4 days depending on volume of drainage.

Layering dressing increases absorption capability.

Vertical absorption prevents maceration of peri-wound skin.

Product may slightly increase in size with absorbing action.

Flush to remove all residue.

Dressing can extend beyond wound margin onto peri-skin.

Concentrates drainage.

Considerations

Prevents leakage and peri-skin

breakdown.

Manages large amounts of

drainage.

Prevents trauma to fragile

wound tissue.

Supports debridement of
exudating wounds.

Pack wounds with a visible base.

Soft, non-woven fibrous sheet or

packing strip of sodium
carboxymethylcellulose.
Highly absorbent.

HYDROFIBRE

Aquacel

Indications

Description

Examples

Absorbent Dressings: Hydrofibre, Hypertonic Gauze

Assessment and Management of Foot Ulcers for People with Diabetes

101

*See: Skin Barriers

Foam dressings do not provide pressure relief.

Some occlusive products facilitate odour containment.

Maintain peri-wound skin with a protective barrier*

if drainage is excessive.

Extend wear time as volume of drainage decreases

to a maximum of 4 to 7 days.

Flexibility and moldability

varies.

Do not overpack the cavity products.

Porous foams may not maintain moist wound base,

requiring suitable cover dressing.

May not support autolysis if drainage is minimal.

Secure dressing with slight pressure to enhance absorption.

Assure product has contact with wound base.

Protects peri-wound skin from

irritation and maceration.

Reduces dressing bulk.

Aesthetic cover dressing.

Product integrity is maintained despite copious discharge.

Considerations

Bordered adhesive products

may provide occlusion.

Some are semi-occlusive and

only for use as cover dressings.
Others may be used to fill
wound defect. Read product
monograph.

Various thickness.

Absorbs small, moderate to

copious amounts of drainage.

Non-adherent polyurethane foam.

FOAMS

Allevyn
Cutinova
Hydrasorb
Lyofoam Extra
Mepilex
Polymem
3M Foam
Tielle
Biotain

Indications

Description

Examples

Absorbent Dressings: Foams

Nursing Best Practice Guideline

102

CombiDERM
CombiDERM ACD
Tielle
Exudry
Versiva

COMPOSITES

Iodosorb

Combination of several products

prevents lateral migration of
drainage.

Inner layers absorb and retain

drainage, preventing pooling at
wound base.

Highly absorbent multi-layered

island dressings.

Changes from brown to yellow

colour.

Cadexomer iodine in paste or

ointment 0.9% slow-release.

Maximum dose of iodosorb is 150 mg/week.

Superficial broad spectrum

coverage, gram + , fungi, MRSA,
& VRE.

Iodine Agents:

Improves integrity of
macerated skin.

Reduces dressing bulk.

Aesthetic cover.

Maintains a moist wound

environment.

Copiously draining wounds.

Critically colonized or infected

wounds

Expect to see discolouration in wound bed (graying)

Please refer to manufacturers

product monograph.

Acticoat
Aquacel AG
Contreet
Actisorb

Adhesive styles may facilitate odour containment.

Some products are self-adhesive to skin.

Patient independence is enhanced by ease of application.

Wear time determined by volume of drainage (2-7 days).

Non adherent to wound base.

Flush iodosorb to remove residue.

May be used in conjunction with systemic antibiotic.

Critically colonized or infected

wounds.

See Appendix M

Antimicrobial
Silver Agents:

Considerations

Indications

Description

Examples

Absorbent Dressings: Composites, Odour Specific

Assessment and Management of Foot Ulcers for People with Diabetes

103
Available as moistened wipes,
applicators or spray.

Some contain alcohol of variable

amounts.

Durability varies.

Quickly drying liquid to provide

a thin layer of skin protection.

Provide increased protection of

peri-wound skin for scant to
copious exudate.

Enhances adhesion of some

cover dressings.

Protects peri-wound skin from

maceration, irritation or tape
injury.

Any odorous wound during

autolytic debridement.

Not for use on open wounds.

Allow product to dry before cover dressing is applied.

Products without alcohol increases comfort and may be

used on intact or broken skin.

Products containing alcohol can cause transient

burning or stinging if skin is broken.

Ensure that dressing edges are sealed for

maximum odour containment.

Some products can be applied directly to the wound base. Other

products become inactivated when wet.

Choose highly absorptive products when drainage is copious.

Ensure underlying infection has been evaluated

and treated, prior to use.

Considerations

Reprinted with permission and revised by Barton and Parslow, 2001 from Caring for Oncology Wounds, Management Guidelines, 1998, ConvaTec Canada

Coloplast
ConvaCare
No Sting
Skin Gel
Skin Prep
Sween
Others

LIQUID BARRIERS

Skin Barriers

CarboFlex contains alginate and

hydrofibre in the contact layer to
also absorb drainage.

Some contain silver to enhance

antibacterial capability.

Ability to absorb odour varies.

Products containing odour

absorbent charcoal layered
within product.

Actisorb adsorbs endotoxins.

Activated charcoal in some

products works by adsorption.

CHARCOAL

Actisorb Plus
CarboFLEX
Carbonet Odour
Absorbent Dressing

Indications

Description

Examples

Nursing Best Practice Guideline

Assessment and Management of Foot Ulcers for People with Diabetes

Appendix O: Offloading Devices

The selection of the appropriate device is based on the following considerations:
1. The ability to effectively remove all pressures from the ulcer site.
2. Cost effectiveness of the device.
3. Ease of use and/or skill required for the application of the device.
4. Characteristics of the diabetic ulceration.
5. The ability to encourage patient adherence.

Offloading Device

Advantages

Total Contact Cast (TCC)

A well-molded minimally
padded cast that maintains
contact with the entire aspect
of the foot and lower leg

Scotchcast Boot

A fibreglass boot that reduces

pressure over the wound

Removable walker

A commercially available
removable boot that reduces
plantar pressures

Halfshoes

Offer support only under the

rear and mid-foot

Healing Sandals

Application of a rigid rocker

to the bottom of a shoe or
sandal

Mabal Shoe

Cross between healing sandal

and TCC

Felted Foam

Bilayered felted foam over the

plantar surface with opening
for the wound

Crutches, Walkers, and

Wheelchairs

Disadvantages

Highest healing rates (gold standard)

Distributes pressure over the
entire plantar surface
Completely offloads
Protects foot from infection
Controls edema
Maintains patient adherence
as non-removable

Lighter with high integral strength

Removable for examination
Can be non-removable for
poorly adherent patients
Promotes continued ambulation

Easily removable allowing wound

inspection and treatment
Allows more comfortable bathing and
sleeping
Can be used for infected wounds and
superficial ulcers

Inexpensive
Easy to apply

Limit dorsiflexion therefore distributes

pressure of metatarsal heads
Lightweight and stable
Reusable

Removable (inspection)
Better contact with foot than healing sandal
Comparative rates of healing with TCC

Inexpensive
Accessible

If used consistently will offload pressure

Rentable

Therapeutic Footwear
Depth inlay shoes

Beneficial in preventing ulcerations

104

Requires trained technician

Cannot assess foot on a daily basis
Affects sleeping and bathing
Exacerbate postural instability
or cause poor balance
Cannot use if wound infected
Cannot be used in the
neuro-ischemic limb
If removable poor adherence
Has not yet been compared in studies
to other forms of offloading for efficacy

Removable nature of cast reduces

adherence
No clinical data to support its efficacy
compared to TCC

Less effective than TCC

Hampers gait

Requires significant amount of time

and experience to produce therefore
not easily accessible
Not as efficient compared to other
methods of offloading
Removable (reduces adherence)
Expertise required to make & apply

Can produce pressure and shear at

wound edges
No studies to suggest its efficacy in
offloading
Requires upper body strength
and endurance
May not be used all the time
Difficulty in navigating indoors
Can increase pressures on
contralateral side
No proof of efficacy in healing ulcers
Allow up to 900% more pressure in
forefoot than TCC and removable walker

Nursing Best Practice Guideline

References:
Armstrong, D. G. & Lavery, L. A. (1998a). Evidence-based options for offloading diabetic wounds. Clinics in Podiatric Medicine
and Surgery, 15(1), 95-105.
Armstrong, D. G, Lavery, L. A., Kimbriel, H. R., Nixon, B. P., & Boulton, A. J. M. (2003). Activity patterns of patients with diabetic
foot ulceration: Patients with active ulceration may not adhere to a standard pressure offloading regimen. Diabetes Care, 26(9),
2595-2597.
Armstrong, D. G., Nguyen, H. C., Lavery, L. A., Van Schie, C. H. M., Boulton, A. J. M., & Harkless, L. B. (2001). Offloading the
diabetic foot wound: A randomized clinical trial. Diabetes Care, 24(6), 1019-1022.
Armstrong, D. G., van Schie, C. H. M., & Boulton, A. J. M. (2001). Offloading foot wounds in people with diabetes.
In D. L. Krasner, G. T. Rodehaver, & R. G. Sibbald (Eds.), Chronic wound care: A clinical resource book for healthcare professionals.
(3rd ed.). (pp. 599-615). Wayne, PA: HMP Communications.
Birke, J. A., Pavich, M. A., Patout Jr., C. A., & Horswell, R. (2002). Comparison of forefoot ulcer healing using alternative
offloading methods in patients with diabetes mellitus. Advances in Skin & Wound Care, 15(5), 210-215.
Fleischli, J. G., Lavery, L. A., Vela, S. A., Ashry, H., & Lavery, D. C. (1997). Comparison of strategies for reducing pressure at the
site of neuropathic ulcers. Journal of the American Podiatric Medical Association, 87(10), 466-472.
Inlow, S., Kalla, T. P., & Rahman, J. (1999). Downloading plantar foot pressures in the diabetic patient. Ostomy/Wound
Management, 45(10), 28-38.
Knowles, E. A., Armstrong, D. G., Hayat, S. A., Khawaja, K. I., Malik, R. A., & Boulton, A. J. M. (2002) Offloading diabetic foot
wounds using the scotchcast boot: A retrospective study. Ostomy/Wound Management, 48(9), 50-53.
Zimny, S., Schatz, H., & Pfoh, U. (2003). The effects of applied felted foam on wound healing and healing times in the therapy
of neuropathic diabetic foot ulcers. Diabetes Medicine, 20 622-625.

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Assessment and Management of Foot Ulcers for People with Diabetes

Appendix P:
Resources for Diabetic Foot Ulcer Information
The following websites provide information on diabetic foot ulcers. These are examples only and are not
intended to be a comprehensive listing.

Organizations

American Academy of Wound Management www.AAWM.org

American Academy Wound. Net www.Wound.net

American Physical Therapy Association www. APTA.org

Association for the Advancement of Wound Care www.AAWC1.com

Australian Wound Management Association www.AWMA.com.au

Canadian Association of Enterostomal Therapy www.CAET.ca

Canadian Association of Wound Care www.CAWC.net

Centres for Disease Control www.CDC.gov

IDF Consultative Section on the Diabetic Foot/IWGDF www.diabetic-foot-consensus.com

Journal of Wound Care www.journalofwoundcare.com

National Coalition of Wound Care linked to AAWC

Tissue Viability Society www.TVS.org.uk

Wound Care Information Network www.medicaledu.com/wndguide.htm

Wound Healer www.woundhealer.com

Wound Healing Society www.woundheal.org

Wound, Ostomy & Continence Nurses Society www.WOCN.org

Corporations

Carrington www.carringtonlabs.com

Coloplast www.us.coloplast.com

Convatec www.convatec.com/en-ca

Hollister www.hollister.com

ICN www.icncanada.com

Johnson & Johnson www.jnjgateway.com

Kendall www.kendallhq.com

3M www.mmm.com or www.3m.com

Molnlycke www.molnlycke.com

Smith & Nephew www.wound.smith-nephew.com/ca-en/wound

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Nursing Best Practice Guideline

Essential Services for Pressure Offloading

Orthotic fabrication
custom-made, adjustments, braces, aircast or TCC

Regular shoe fitting

width fittings, comfort laced walking shoes

Specialty shoe fitting

deep toe box, post-op boots, custom made shoes

Shoe modification
rocker sole, sole widening

Assistive devices
canes and walkers, hosiery, heel protectors

Service Providers

Pedorthists

orthotics, shoes, shoe mods

Canada: www.pedorthic.ca

U.S: www.pedorthics.org

Orthotists

othotics, braces, TCC, shoe mods

Canada: www.pando.ca

U.S.: www.oandp.org

Chiropodists/Podiatrists

orthothics, soft tissue management

Ontario: www.cocoo.on.ca

Canada: www.podiatrycanada.org

Occupational Therapists

assistive devices, orthotics

Canada: www.caot.ca

U.S.: www.aota.org

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Assessment and Management of Foot Ulcers for People with Diabetes

Appendix Q: Description of the Toolkit

Toolkit: Implemention of Clinical Practice Guidelines
Best practice guidelines can only be successfully implemented if there are: adequate planning, resources,
organizational and administrative support as well as appropriate facilitation. RNAO, through a panel of nurses,
researchers and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines
based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for
guiding the implementation of any clinical practice guideline in a healthcare organization.
The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating,
and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in
implementing a guideline:
1.
2.
3.
4.
5.
6.

Identifying a well-developed, evidence-based clinical practice guideline

Identification, assessment and engagement of stakeholders
Assessment of environmental readiness for guideline implementation
Identifying and planning evidence-based implementation strategies
Planning and implementing evaluation
Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact
is a complex undertaking. The Toolkit is one key resource for managing this process.

The Toolkit is available through the Registered Nurses Association of Ontario. The document is
available in a bound format for a nominal fee, and is also available free of charge from the RNAO
website. For more information, an order form or to download the Toolkit, please visit the RNAO
website at www.rnao.org/bestpractices.

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Nursing Best Practice Guideline

Notes:

109

Assessment and Management of Foot Ulcers for People with Diabetes

Notes:

110

Nursing Best Practice Guideline

Notes:

111

Assessment and Management of Foot Ulcers for People with Diabetes

Notes:

112

March 2005

Nursing Best Practice Guideline

Assessment and Management
of Foot Ulcers for People with Diabetes

This program is funded

by the Government of Ontario

0-920166-68-7