Nursing insights for diabetic foot care

1. Nursing insights for diabetic foot
care
Dr. Nafisa Moustafa Abdallah Elpasiony
Lecturer of medical surgical nursing
Faculty of nursing
Beni-Suef University

2. Introduction
According to international diabetes federation 425 million
people have diabetes in the world and more than 39
million people in the Middle East and North Africa
(MENA) Region; by 2045 this will rise to 67 million.
There were 8.222.600 cases of diabetes in Egypt in 2017
which accounts about 15.1%.

3. As diabetes is a chronic disease, it needs proper control of glucose
level to prevent complications.
One of the major complications is diabetic foot which accounts
about 15% of diabetic patients (Salamaa A A., et al ,2018).
Approximately 50-70% of all non-traumatic amputations of lower
limb on patients with diabetes (Apelqvist J., (2018).

4. Diabetic foot

5. Definition
• According to the World Health Organization
and to the International Working Group on the
Diabetic Foot (IWGDF) , diabetic foot is
defined as the foot of diabetic patients with
ulceration, infection and/or destruction of the
deep tissues, associated with neurological
abnormalities and various degrees of
peripheral vascular disease in the lower limb

6. Causes
• High Blood Sugar Levels
• Poor Circulation
• Nerve Damage
• Immune System Issues
• Infection

7. Causes

8. Stages
Meggitt– Wagner’s classification of foot ulcer
• Stage 0 = Foot at risk
• Stage 1 = Superficial ulcer/full thickness ulcer,
limited to the dermis
• Stage 2 = Deep ulcers with exposed tendon or
bone and without osteomyelitis or abscess
formation
• Stage 3 =Deep ulcer with osteomyelitis, abscess
formation
• Stage 4 = Fore-foot gangrene
• Stage 5 = foot with extensive gangrene

9. The Diabetes Nurse role in Foot Care
Knowledge : foot anatomy, vulnerability, types of injuries
(mechanical, thermal, chem.) weight bearing walking
dynamics ,etc.
Clinical examination Skills : (Inspection, palpation…etc)
Management skills according to her training.
Level I : e.g. dressings, nail cut, etc.
Level II : e.g. ulcer debridement , etc
Education Skills for patients on : self inspection, shoes ,
stockings,, preventing mech., thermal and chemical
injuries, etc

10. Clinical foot examination
• Routine screening of the foot is very
important to protect foot from complications
• It should be done every 3months or one year
according patients’ condition

11. 1. Inspection of
• Skin:
Color
Temperature
Integrity
presence of callus
• Presence of bony prominences or joint
abnormalities or deformities

12.  Daily foot inspection
look at the top, between the toes and the sole
look and feel for breaks in the skin, cuts, scratches, bruises, blisters, sores, and
discoloration
“use mirror for better viewing”

13. 2. Vascular assessment
 Assess peripheral
vascular disease
through
• Palpate peripheral
pulse
• Doppler test

14. Doppler test to assess pulse in feet

15. The ankle-brachial index (ABI)
Highest ankle systolic pressure
Highest brachial systolic pressure
A quick, noninvasive way to
check for peripheral artery
disease (PAD).
(0.9-1.3)
ABI <0.90 should be considered
abnormal and requires further
care.
ABI >1.3 vascular diagnostic
assessment must be considered

16. 3. Neurological assessment
Pain
Fine touch is detected by
nylon monofilament.
According to Shohod (2017),
it is effective and applicable
method to detect
neuropathy in diabetic
patients
Also, it is safe and can
decrease follow up visits as
it can be done at home

17. Vibration sensation is
detected by tuning fork.

18.  Thermal sensation is tested by hot
and cold test tubes.
 Failure to perceive variances in
temperature in the extremities is
the most decisive early symptom of
distal symmetric polyneuropathy

19. 4. Foot wear examination
Features of best shoes
a) Excellent Ventilation
b) Minimal or No Seams
c) Wider at the toes
d) Removable Insoles
e) Adjustable fit

20. Diabetic foot is a preventable disease.
This can be caused by increasing patients’
awareness regarding diabetes and diabetic foot
care.

21. Approaches to prevention
• Five key elements have been identified by the
IWGDF
1. Identification of the at-risk foot
2. Regular inspection and examination of the at-
risk foot
3. Education of patient, family and healthcare
providers
4. Routine wearing of appropriate footwear
5. Treatment of pre-ulcerative signs

22. Treatment
Foot ulcer treatment is underpinned by seven key
elements:
1. Relief of pressure and protection of the ulcer
2. Metabolic control and treatment of comorbidity
3. Restoration of skin perfusion
4. Treatment of infection
5. Local wound care
6. Education for patient and relatives
7. Prevention of recurrence

23. 1. Relief of pressure “Off loading”
To redistribute pressures evenly in at-risk feet and to relieve pressure where an ulcer
exists
• Total contact casting
The cast cannot be
removed
It should not be used in
the presence of
infection or excessive
drainage.

24. • Removable cast walkers
commonly used in place of the
total contact cast.
• As the device is removable:
 The wound can be
monitored daily
 It can be used in the
presence of infection.
 It allows the patient to
remove the device during
sleep and bathing.
However, because this device is removable, its success is
dependent on patient compliance.

25. (Lewis and Lipp, 2013) found that non-
removable casts may be more effective in healing
diabetes-related plantar foot ulcers than
removable casts or dressings alone.

26. 2. Metabolic control
Intensive treatment of blood glucose
concentration has been shown to delay the
onset and slow the progression of peripheral
neuropathy

27. 3. Treating infection
It remains unclear “if any one systemic antibiotic treatment is better than others in
resolving infection or in terms of safety”
• Cefazolin and beta-lactamase inhibitor
agents are effective empirical agents for
such infections.
• Definitive therapy may be instituted when
culture and sensitivity results have been
obtained.
• Incision and drainage should be performed
when deep infection or abscess is present.
• When osteomyelitis is present, antibiotic
therapy combined with surgical
debridement, with removal of infected
bone, is generally necessary.

28. 4. Wound care
IWGDF Wound Healing Interventions Guidelines (2019)
A. Remove slough, necrotic tissue and
surrounding callus of a diabetic
foot ulcer with sharp debridement
in preference to other methods,
taking relative contraindications
such as pain or severe ischemia
into account.

29. B. Dressing
• Select dressings principally on the basis of
exudate control, comfort and cost.
• Do not use dressings/applications containing
surface antimicrobial agents with the sole aim of
accelerating the healing of an ulcer.
• Consider the use of the sucrose-octasulfate
impregnated dressing in non-infected, neuro-
ischemic diabetic foot ulcers that are difficult to
heal despite best standard of care.

30. C. Oxygen therapy
• Suggest not using topical
oxygen therapy as a
primary or adjunctive
intervention in diabetic
foot ulcers including
those that are difficult to
heal.

31. • Consider the use of
systemic hyperbaric
oxygen therapy as an
adjunctive treatment in
non-healing ischemic
diabetic foot ulcers
despite best standard of
care.

33. D. Negative pressure wound therapy
• Consider the use of negative pressure wound
therapy to reduce wound size, in addition to best
standard of care, in patients with diabetes and a
post-operative (surgical) wound on the foot.
• As negative pressure wound therapy has not
been shown to be superior to heal a non-surgical
diabetic foot ulcer, we suggest not using this in
preference to best standard of care.

35. According to hasaballah, et al., 2019
The use of NPWT should be recommended for
acute wounds in the heel and ankle regions to
obtain a faster complete healing and desired
wound closure in such critical areas.

36. New treatment techniques
• Consider the use of placental derived products as an
adjunctive treatment, in addition to best standard of care,
when the latter alone has failed to reduce the size of the
wound.
According to zeng et al. (2017) after three-week topical
treatment with placenta-derived mesenchymal stem cells
hydrogel in a patient with diabetic foot ulcer
The patient's foot ulcer was almost healed, and foot function
in walking was well preserved. No complications were
observed. No recurrence occurred in the subsequent 6
months.

37. • Consider the use of autologous combined
leucocyte, platelet and fibrin as an adjunctive
treatment, in addition to best standard of
care, in non-infected diabetic foot ulcers that
are difficult to heal.

38. Avoid
We suggest not using the following agents
reported to improve wound healing by altering
the wound biology:
• Growth factors,
• Autologous platelet gels,
• Bioengineered skin products, ozone, topical
carbon dioxide and nitric oxide, in preference
to best standard of care.

39. • Do not use agents reported to have an effect on
Wound healing through alteration of the physical
environment including through the use of
electricity, magnetism, ultrasound and
shockwaves, in preference to best standard of
care.
• Don’t use interventions aimed at correcting the
nutritional status (including supplementation of
protein, vitamins and trace elements,
pharmacotherapy with agents promoting
angiogenesis) of patients with a diabetic foot
ulcer, with the aim of improving healing, in
preference to best standard of care.

40. References
• https://www.evidentlycochrane.net/foot-care-people-with-diabetes/
• Hasaballah A., Aboloyoun, H., Elbadawy , A. and Ezeldeen M., (2019). Impact of
negative pressure wound therapy in complete healing rates following surgical
debridement in heel and ankle regions in diabetic foot infections, The egyptian
journal of surgery, Vol. 38, No. 1, pp. 165-169, Egypt.
• https://iwgdfguidelines.org/guidelines/guidelines/
• https://idf.org/our-network/regions-members/middle-east-and-north-
africa/members/34-egypt.html
• Salama A. A., et al , (2018). Risk Factors of Diabetic Foot in Type 2 Diabetic
Patients, Menoufia University Hospital, The egyptian journal of community
medicine, Vol. 36, No. 2, Egypt
• Apelqvist J., (2018). The diabetic foot syndrome today A pandemic uprise, Vol. 26,
pp. 1-18, Karger Medical and Scientific Publishers, Sweden
• Shohod, s. (2017). Predicting the diabetic foot ulcer risk using sensory
monofilament among diabetic patients at benha universities
• Lewis J, Lipp A (2013) Pressure-relieving interventions for treating diabetic foot
ulcers. CochraneDatabaseSystRev1:CD002302