OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 1

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer (DFU)

Section 1: Differentiating between DFUs/ Pressure Ulcers / Arterial Foot Ulcers

Etiology Example

Foot ulcers are one of the major complications of neuropathy in people with diabetes. Neuropathy eliminates the protective signal of pain, and the motor component leads to muscle atrophy, foot deformity, altered biomechanics, and increased plantar pressure, often resulting in traumatic injuries and skin breakdown. Due to the three types of neuropathy there will be anatomical changes that cause the toes to draw up and the arch to drop and flatten, or drop foot to occur due to a shortened Achilles tendon. This results in the inevitable biomechanical changes. The ulcers are usually in areas of the toes, the met heads or the mid foot when there is a fallen arch or Charcot foot. The increased local plantar pressure and trauma is associated with callus formation that usually precedes skin breakdown. Without callus debridement and pressure relief, the persons with diabetes develop chronic non-healing ulceration. Sharp removal of plantar callus, reduces pressures by < 30 percent, creating an environment conducive to healing. DFUs can occur on the heel but these usually relate more to fissuring.

Pressure Ulcers on the other hand are most often associated with boney prominences and if you ask for their daily and sleeping patterns (i.e. sleep positions) you can often see the exact cause. People with diabetes who have arterial disease have increased risk of developing pressure ulcers.

Arterial disease can be present in patients presenting with neuropathy-related foot ulcers and pressure ulcers on the feet. Generally, arterial foot ulcers occur:

heels and malleoli

tips of toes

between the toes where the toes rub against one another

any area where bony prominences rub against bed sheets, socks or shoes

toes where the toenail cuts into the skin

related to aggressive toe nail trimming or removal of an ingrown toenail

Contents: 1. Differentiating between DFUs/ Pressure Ulcers / Arterial Foot Ulcers 2. Testing for Loss of Protective Sensation (LOPS) 3. Foot Deformities Associated with Diabetic Foot Neuropathies 4. Infections in Diabetic Feet 5. Wound Cleansing and Dressing Table for Neuropathic DFU 6. Daily Visit Frequency as Exceptional Situation

7. Algorithm for OBP Pathway

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 2

Section 2: Testing for Loss of Protective Sensation (LOPS)- one of the best ways to raise a person’s awareness of their risk for developing a diabetic foot ulcer with possible amputation, is to demonstrate to them that they have lost some or all of the “protective sensation” that tells them that they have discomfort or pain.

Use the monofilament available through our OBP forms department at Head office. They are also provided in the OBP/Evidence-Based Diabetic Foot Pathway.

Tell the patient that you are going to test to see if they have a loss of sensation (due to neuropathy) that helps to protect their feet from injury.

The filament is pressed against part of the foot (Step 1)

When the filament bends, its tip is exerting a pressure of 10 grams (Step 2) (therefore this monofilament is often referred to as the 10 gram monofilament).

To demonstrate, have press it gently on the back of their hand so that they can tell what it will feel like.

Ask them to close their eyes and say yes whenever they feel that sensation on their foot

Don’t prompt them by asking if they can feel it each time you move to a different spot.

There are ten spots each foot—nine on the plantar aspect and one on the dorsum (see diagram at right)

Use a random sequence to check the areas

Do NOT use directly in an open wound or if a thick callus is present

If they cannot feel the monofilament, they have lost enough sensation in that area to be at high risk of developing a neuropathic ulcer.

Score is out of ten for each foot.

Image from http://www.diabetesclinic.ca

Section 3: Foot Deformities Associated with Diabetic Foot Neuropathies

Components of the normal foot: Image from www.eorthopod.com

Description of Foot Deformity Pictorial Examples

Hammer toes - in a hammertoe deformity, the first joint (MTP) is cocked upward, and the middle joint (PIP) bends downward.

Illustration used with permission of artist Nancy Bauer and the Registered Nurses’ Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses’ Association of Ontario.

Step 1 and 2 Images from: LEAP http://www.hrsa.gov/hansensdisease/leap/

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 3

Hallux valgus (bunion deformity) – occurs when the great toe begins to deviate, developing a firm bump on the inside edge of the foot. It is not painful at first, but when the toes deviate even more, redness, swelling and pain at or near the joint occur. The pain is caused by pressure of the footwear on the bunion or from the pressure inside the joint. Hallux valgus describes the change in position of the toe, and bunion describes the bump on the foot. http://www.epodiatry.com/bunion.htm Illustration used with permission of artist Nancy Bauer and the Registered Nurses’ Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses’ Association of Ontario.

Fixed ankle joint- Fibrous or bony ankylosis at the ankle can occur because of immobility (joint assumes the least painful position and becomes fixed). There is a characteristic “shuffling” gait because of the loss of ankle mobility, and the calf muscle pump action is impaired. Image of Ankle Joint Movement from stephensmith.ie

Cannot extend or dorsiflex

Claw toes - A claw toe deformity has a cocked up MTP joint, and both the middle joint (PIP) and the tiny joint at the end of the toe (the DIP) are curled downward like a claw. Illustration used with permission of artist Nancy Bauer and the Registered Nurses’ Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses’ Association of Ontario.

Hallus rigidus – caused by osteoarthritis in the MTP joint at the base of the big toe, causing pain and loss of motion in the MTP joint. Image obtained from: http://www.drwolgin.com/Pages/HalluxRigidus.aspx

Dropped arch- Pes Planus also called “fallen arches or flat foot”

Images obtained from: www.family-foot.com and galleriapodiatry.com.au

Dropped MTH – Pes Cavus—the arch is abnormally high, with the forefoot extended below. The toes are often clawed. Illustration used with permission of artist Nancy Bauer and the Registered Nurses’ Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses’ Association of Ontario.

Claw Toe

Halgus Valgus or Small Bunion(Mild/Moderate) – joint at the base of big toeis pushed to the side

Hallus Valgus or Large Bunion (Severe) –big toe may move under second toe

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 4

Charcot Joint- a form of neuroarthropathy. Nerve damage causes the ligaments and muscles to atrophy, which causes joint instability. Walking on this without proper protection causes more damage to the foot structure. In advances state, the sole of the foot forms a rocker shape, increasing the risk of ulceration. Illustration used with permission of

artist Nancy Bauer and the Registered Nurses’ Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses’ Association of Ontario.

Corns - A corn is thickened skin on the top or side of a toe, usually from shoes that do not fit properly. Corns may cause discomfort, while calluses normally do not.

Calluses-

A callus is thickened skin caused when there is foot deformity secondary to neuropathy or other causes. Motor neuropathy leads to muscle atrophy, foot deformity, altered biomechanics, and increased plantar pressure. The increased local plantar pressure and trauma is associated with callus formation that usually precedes skin breakdown. Without callus debridement and pressure relief the persons with diabetes develop chronic non-healing ulceration.

Fissures – these commonly occur on the heels, but can develop elsewhere on the foot if there is thickened hyperkeratotic skin caused by dryness, walking barefoot or wearing sandals or open-backed shoes or from inactive sweat glands caused by neuropathy. These can pose a serious risk as they can be a pathway for bacteria and infection. They can also be present with Athlete’s foot.

Ingrown Toenail - are nails whose corners or sides dig painfully into the soft tissue of nail grooves, often leading to irritation, redness, and swelling and can become infected. Usually, toenails grow straight out. Sometimes, however, one or both corners or sides curve and grow into the skin. Cutting down the sides or curving the nail can lead to tissue overgrowth at the sides, and an ingrown nail. http://www.footnyc.com/ingrown-toenails.cfm

www.premierpodiatrygroup.com Adapted from SWRWCF Toolkit: Section B.2.1 Purpose and Instructions for the Lower leg Assessment Tool. www.woundcare.thehealthline.ca Used with permission. March 2013. All photographs unless otherwise credited © CarePartners.

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 5

Section 4: Infections in Diabetic Feet

Athlete's foot (tinea pedis or moccasin foot[) is a common and contagious fungal infection of the skin that causes scaling, flaking, and itching of the affected areas, and macerated skin with open areas between the toes. The dry scaling rash can be sometimes be seen at the sides of the foot, about the area that the edge of a shoe or moccasin would be, as a distinct stop-and-start line. The disease is typically transmitted in moist communal areas where people walk barefoot, such as showers or bathhouses, and requires a warm moist environment, (e.g., the inside of a shoe) to incubate. Infected shoes must be discarded as part of the treatment to prevent recurrence. Adapted from: http://en.wikipedia.org/wiki/Athlete%27s_foot

www.amazon.co.uk

www.ourhealthnetwork.com

Signs of Osteomyelitis in DFU

Signs Diagnostic of Infection in DFU

Other Signs of Infection in DFU

Ulcer probes to bone: you can feel bone with a probe or sterile q tip.

Visible bone in the wound

Bone fragments are protruding from wound

The ulcer is non-healing despite adequate offloading and perfusion for >6 weeks OR ulcer of >2 weeks duration with clinical evidence of infection

Cellulitis

Erythema > 2 cm beyond wound edge can be limb-threatening infection

Phlegmon

(spreading diffuse inflammatory process with formation of suppurative/ purulent exudate or pus)

Purulent exudate

Pus/abscess

Unexpected pain/tenderness in a foot that is normally insensate

Lymphangitis (inflammation of the lymphatic channels appear as thin red lines running along the course of the lymphatic vessels in the affected area, accompanied by painful enlargement of the nearby lymph nodes)

Crepitus in the joint

Erythema

Fluctuation

Increase in exudate volume

Induration

Malodour

Blue-black discolouration + haemorrhage(halo)

Bone or tendon becomes visible in base of wound

Deterioration of the wound

Friable granulation tissue that bleeds easily

Local oedema

Sinuses develop in an ulcer

Ulcer base changes from healthy pink to yellow or grey

Spreading necrosis/gangrene

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 6

Section 5: Wound Cleansing and Dressing Table for Neuropathic DFU Use Product Picker to identify products available in your CCAC

Principle/ Clinical Situation

Intervention

Dressing Contraindications:

Application of moisture retentive dressings (e.g. hydrocolloid, some foams, hydrofibers covered by transparent films) in the context of arterial ischemia and/or dry gangrene can result in a serious life- or limb-threatening infection (RNAO BPG)

Cleansing

AVOID soaking the foot in a basin of water, which introduces bacteria to the wound. Irrigate the wound with 7-15 PSI using at least 100 cc of solution (for large wounds) or a smaller amount of a commercial spray wound cleanser with surfactants at room or body temperature. Cleanse and protect the periwound skin.

Wound Assessment: Assess the wound and periwound skin for bacterial balance, exudate level and the need for debridement.

General Principles of Dressing Selection for all types of DFUs:

Foam dressings do NOT offload pressure, and some CCAC’s do not provide foam if the dressing frequency is daily

Keep the wound bed continuously moist and the peri-wound skin dry to prevent maceration.

Manage exudate to prevent strike-through (exudate soaking through to outside of dressing, which allows bacteria to migrate into the wound from the environment.)

Loosely fill all cavities with dressing material

*The patient should be comfortable with using the dressing.

Dressing Exudate Handling Capacity

Small [1+], Moderate [2+], Large [3+], Copious [4+] Each dressing type suggested in this table has been assigned with an exudate capacity.

Healable dry DFUs: Goal: rehydrate by adding moisture

Hydrogel [1+](to rehydrate) covered with a non-occlusive moisture-retentive composite dressing [2+-3+], foam[2+] . Once the wound is rehydrated and moisture is retained, anticipate that it will produce exudate.

Healable exudating DFUs

Hydrofibres and alginates [1+ to 2+] - form a gel-like mass on the wound surface (require secondary dressing)

Composite dressings [2+ to 3+] (can be primary or secondary)

Foam border dressings [2+ to 3+] (can be primary or secondary) (Not appropriate for daily dressing changes)

NEVER use a hydrocolloid on a plantar surface DFU

Maintenance or Non-healing DFUs

Paint with betadine/ povidone, or betadine/povidone wet-to-dry, gauze [1+] to cover. May need non-adherent layer [0+] if painful to prevent gauze from sticking.

Comfort measures i.e. analgesia for neuropathic/arterial pain

Localized or

A topical antimicrobial should be used for no more than two weeks before reassessment.

Diabetic foot ulcers require close evaluation, as infections can be rapid and have catastrophic consequences

Signs of an infection in a diabetic foot ulcer can be masked due to the immuno-compromised

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 7

spreading infection: *Require urgent medical attention

status of the individual

Pain alone in a previous insensate diabetic foot ulcer is a indicator of infection

*Mild DF infection involves the skin and s/c tissues, with < 2 cm cellulitis around the wound

*Erythema & warmth > 2cm indicates moderate infection in the deep tissue compartment and can become limb-threatening

*Severe infection has systemic sepsis and metabolic instability--can lead to multi-organ failure and death

Topical antimicrobial dressings (e.g. cadexomer or povidone iodone, silver, PHMB, Manuka honey) can be used to reduce surface bacteria but NEVER take the place of systemic antibiotics for deeper infections, which usually contain aerobic and anaerobic bacteria, and require coverage for both

NEVER use an occlusive dressing as the cover dressing in the presence of signs and symptoms of infection; NEVER use a hydrocolloid on a plantar surface DFU

Increase dressing change frequency for infected DFU until symptoms of infection are resolved.

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 8

Section 6: Daily Visit Frequency as Exceptional Situation for Healable* Wounds

*It is understood that there must be a mutual agreement between the physician, the nursing team and the client regarding setting goals about the “healability” of the wound. Please see definitions on next page.

Box 1. Orders received for OD or BID dressings for a Healable Wound:

This dressing frequency will be considered to be an “exceptional” order to be approved/ utilized for the following criteria: 1. The exudate amount exceeds what can be managed by less frequent dressing changes (the periwound skin will be

compromised). Appropriate exudate -absorptive dressings and peri-wound skin protection should be utilized in an attempt to manage the exudate and reduce the dressing frequency. Treat the cause wherever possible.

2. There is a need for mechanical debridement using normal saline/ betadine/ hygeol solutions with gauze or the AMD-impregnated gauze. This should be discontinued once the debridement has been achieved, and a moisture-retentive advanced wound dressing initiated, due to the non-selective nature of mechanical debridement using gauze. Porous gauze adheres to the wound and painfully disrupts healthy tissue on removal (Armstrong and Price 2004).

3. The wound/ surrounding tissue is infected and antimicrobial dressings such as silver, cadexomer iodine or AMD-impregnated gauze will be used in conjunction with systemic antibiotics where indicated. The dressing frequency will be decreased as soon as the exudate levels start to decrease.

4. The wound is located near the anus and fecal contamination of the wound/dressing cannot be avoided (pilonidal/perianal etc.)

Box 2. Provided that the characteristics described in Box 1 above have been resolved, or are not present, the nurse will contact the primary physician to discuss alternative dressings and frequency, based on the wound characteristics. There are several reasons why daily or BID visits for wound care, particularly with gauze and wet-to-dry gauze dressings, are not desirable:

1. This frequency utilizes a high volume of nursing visits, compared to 2-3 x weekly frequencies. This means that nursing agencies are often unable to take new referrals, having no capacity for more visits.

2. Each time that the dressing is removed and the wound cleansed, there is a delay in healing. Myers (1982) reported a three-hour delay of mitotic activity and inhibition of leukocytes with a 40 minute drop in wound temperature following wound cleansing (n=420).

3. Advanced wound dressings (Thomas 1997) provide moist, isotonic, interactive and non-toxic environments for healing, but only function optimally when they match the characteristics of the wound (Schultz et al. 2003). Marks et al. (1987) described the ideal characteristics of a wound dressing, including: impermeability to water and bacteria, freedom from particulate matter, thermal insulation, absorption and retention of exudate, prevention of trauma on removal, removal of toxic substances from the wound surface, prevention of dehydration, allow for gaseous exchange, and provide pain relief and comfort (Sharp and McLaws 2001). Of these characteristics, gauze allows for gaseous exchange only. Owens (1943) reported that bacteria readily infiltrated 64 layers of dry gauze, while Alexander et al.(1992) demonstrated that Staphylococcus Epidermis migrated through 5 layers of moist gauze in less than 30 seconds when placed on uncoated paper wrappers on a contaminated agar plate (p=0.0495). Hutchinson and McGuckin (1990) reviewed infection rates in wounds healing by secondary intention, citing a 7.1% rate with gauze versus 1.3% with occlusive dressings.

4. The visit frequency may be able to be reduced, utilizing advanced wound products and in conjunction with other modalities to correct underlying etiological factors (e.g assessing whether compression therapy is indicated) in collaboration with the physician. This represents a more cost-effective method promote healing.

Box 3. If the physician declines to change the treatment plan and frequency, request an Enterostomal Therapy/Wound Care Specialist Nurse consultation based on the following criteria: The “FUN” acronym indicates situations in which wound healing is not progressing as expected (criteria not met).

F (Frequency) - If the frequency of dressing changes has not decreased to 3 x Week by 3 weeks

U (Unknown) - If the cause of the wound is unknown

N (Number) - If the size of the wound has not decreased by 20-30% in 3 weeks of treatment. The physician will be notified of the ETN/WCS recommendations. If the physician declines to change the treatment plan and frequency in collaboration with the ETN/ WCS, the care team needs to determine next steps.

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 9

Daily Visit Frequency as Exceptional Situation for NON-Healable and Maintenance* Wounds

Daily Visits as Exceptional Situations is adapted from SWRCF Toolkit E.1.3_SWCCAC Wound Dressings daily frequency rev Feb 3 2010

Box 2. Provided that the characteristics described in Box 1 above have been resolved, or are not present, the nurse will contact the primary physician to discuss alternative dressings and frequency, based on the wound characteristics and “healability” of the wound:

1. Daily or BID visits for wound care utilizes a high volume of nursing visits, compared to 2-3 x weekly frequencies. This means that nursing agencies are often unable to take new referrals, having no capacity for more visits.

2. In general, advanced wound products will not be utilized when the wound is considered NON-healable or Maintenance, but this will be balanced with the need for exudate management and reduced visit frequency.

3. The wound care resources in this document can be used to identify appropriate alternate treatment suggestions.

*It is understood that there must be a mutual agreement between the physician, the nursing team and the client regarding setting goals about the “healability” of the wound. Please see definitions at bottom of this page.

Box 1. Orders received are for OD dressings e.g. with topical antiseptics such as Betadine or Chlorhexidine, or for any dressing frequency for advanced wound products intended to enhance healing. **NB- do not use Chlorhexidine near the ear due to the danger of hearing loss if the product enters the ear canal**** 1. The use of topical antiseptics OD should be reserved for when: Non-healable wounds where dessication of the tissue is desired to stabilize or maintain (e.g. Betadine for a gangrenous toe.) Daily visits are usually required until the line of demarcation between the eschar and the viable tissue has becomes dry and dessicated. This is not a predictable time: the wound must be assessed on each visit. Wherever possible, teach and reduce visit frequency. Once the tissue is dry with no further exudate and no s&s of infection are noted, the frequency of dressing changes can be decreased to 2 - 3 x / week and the change is communicated in writing to the physician.

Box 3. If the physician declines to change the treatment plan and frequency, request an Enterostomal Therapy/Wound Care Specialist Nurse consultation based on the following criteria: The “FUN” acronym indicates situations in which wound healing is not progressing as expected (criteria not met).

F (Frequency) - If the frequency of dressing changes has not decreased to 3 x Week by 3 weeks

U (Unknown) - If the cause of the wound is unknown

N (Number) - If the size of the wound has not decreased by 20-30% in 3 weeks of treatment. The physician will be notified of the ETN/WCS recommendations. If the physician declines to change the treatment plan and frequency in collaboration with the ETN/ WCS, the care team needs to determine next steps.

*Definitions re: “Healability”

Healable: Have sufficient vascular supply, underlying cause can be corrected, & health can be optimized.

Maintenance: have healing potential, but various patient factors are compromising wound healing at this time (Despatis et al 2008)

Non-healable/Palliative wound: has no ability to heal due to untreatable causes such as terminal disease or end-of-life (Despatis et al 2008)

OBP/Evidence-Based Pathway Resources: Diabetic Foot Ulcer 10

Section 7: OBP Algorithm

Care Partners Diabetic Foot Ulcer Pathway for OBP Oct 2014

Reporting Interval 1:0-7 Days

Reporting Interval 2:21 to 28 days

Reporting Interval 3:77- 84 days

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CCAC Indicators for Interval 1 Reporting: √ Performs Holistic patient and wound assessment√ Wound Resource Nurse or ETN/WCS performs LLA and ABPI √ Correct outcome-based pathway confirmed (wound is healable) √ Wound therapy initiated

√ Initiate pressure offloading measures √ Recommend non-weight bearing (if plantar surface ulcer) until offloading device obtained √ patient discharge planning initiated for patient independence and prevention of complications (e.g. teaching return to full activities)

Due at CP Office by Day 6

Give patient ‘My Diabetic Foot Ulcer’ & ‘My Diabetic Foot Ulcer self-care teaching guide’

Initiate teaching per Self-Management & Discharge Plan page 3

Engage patient with patient Personal Action Plan (NCR paper)

7-28 daysEach nurse

teachesre: optimizing

health for healing, -------------------

Wound is responding to treatment

and decreasing

in size weekly

NO

CCAC Indicators for Interval 2 Reporting: √ 20-30% wound

reduction √ Self-management plan initiated √ Referral for long term pressure redistribution (offloading)

Due at CP Office by Day 27

CCAC Indicators for Interval 3 Reporting:√ Wound is healed√ Pressure redistribution system in place and adhered to (patient is using offloading device at all times when on feet)

Due at CP Office by Day 84

LegendETN/WCS= Enterostomal Therapy Nurse or Wound Care Specialist NurseLLA- Lower Leg AssessmentABPI- Ankle Brachial Pressure IndexWound SPR- CCAC Wound Service Provider Report

Document

Decision

ASSESS

NO Discharge patient

Yes

28-60 daysEach nurse

reinforces teaching re: optimizing

health for healing-------------------

Wound is responding to treatment

and decreasing

in sizeweekly

YES

YESpatient Teaching Handouts

Start/End

NO

VARIANCES: Barriers are identified that will prevent meeting CCAC OBR Pathway outcomes: Wound/ callus need debrided +/or is older than 2 months +/or is > 2cm

2?------------------------------------------------------------ Wound infected with signs of osteomyelitis ordeep/spreading infection?Dressing type and frequency are not appropriate ------------------------------------------------------ Fasting blood sugar is NOT within normal limits-------------------------------------------------------

patient needs financial assistance to purchase offloading devices ----------------------------------------- patient needs assistance with mobility aids

------------------------------------------ Nutritional intake is not adequate for wound healing despite teaching ---------------------------------- patient/caregiver is NON-Compliant or NON-Adherent to aspects of treatment plan

Visiting Nurse Initiates CP Care Pathway for

Diabetic Foot Ulcer

Notify CP Nurse manager and complete Wound SPR and forward to CCAC Case

Manager with any VARIANCE

Request referral for ETN/WCS for wound consult

Contact Physician/ NP

Contact Physician +/or Diabetic Clinic

Request referral to Dietician

YES

AND

AND

AND

AND

Assign to a different pathway

Wound Resource Nurse visits

within 7days and performs LLA and

ABPI

Automatically Assigned by TA

YES

Request referral to Social Worker

Request referral to Physiotherapist

AND

AND

Continue to Day X (84+42=Day 126)

Healed by Day X or before

NO

YESNO

YESYES