Management of Diabetic Foot Ulcers: Best Practices for Care Professionals

This article discusses the best practices for care professionals in managing diabetic foot ulcers. It covers topics such as early detection, multidisciplinary approach, self-management strategies, barriers to compliance, and evidence-based treatments. The article emphasizes the importance of knowledge and awareness for positive patient outcomes.

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Introduction:
Diabetic foot ulcer can be defined as a complication that results due to Diabetes
mellitus. The condition is also referred to as diabetic foot. The normal physiological process
of wound healing comprises of a stepwise process of repairing the extracellular matrix which
forms the largest part of the dermal skin. However, it should be critically noted that the
normal wound healing procedure is disrupted in certain cases of metabolic and physiological
orders. One such condition includes the case of the metabolic disorder Diabetes mellitus that
delays the normal process of wound healing. Studies have indicated that the condition of
Diabetes mellitus interferes with the process of wound healing and present a prolong period
of inflammation (Alavi et al. 2014). The long period of inflammation leads to a delay in the
formation and maturation of a granulation tissue that subsequently leads to a reduction in the
tensile strength of the wound. Typically, the characteristics of a diabetic foot ulcer varies
across different demographics (Martins et al. 2014). In general the treatment intervention
used for treating diabetic foot ulcers include monitoring and controlling the blood glucose
level, removal of dead tissues from the wound, administering effective wound dressings and
eliminating pressure from the wounds with the help of techniques that include, total contact
casting and in extreme cases surgery or amputation. Hyperbaric oxygen therapy is also
administered in certain cases, however it is not used commonly on account of greater cost.
Diabetic foot ulcer is extremely common and it affects 15% of the patients who are diagnosed
with Diabetes mellitus (Martins et al. 2014). It should be further noted that diabetic foot ulcer
precedes 84% of the fatal conditions that results in leg amputation.
Discussion:
Prior to discussing about the best practice for the management of foot ulcer, it is
important to note that diabetic foot ulcers are categorized into several levels. These levels are

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referred to as Grades. Grade 0 represents no ulcers in a high risk foot. Grade 1 represents
superficial ulcers that involves complete skin thickness but does not include the underlying
tissues (Iraj et al. 2013). Grade 2 includes deep ulcers that penetrate to the muscles and
ligaments, however it does not involve the bones in the process of an abscess formation (Iraj
et al. 2013). Grade 3 includes, deep ulcers characterised by cellulitis and abscess formation
which leads to a condition known as osteomyelitis (Iraj et al. 2013). Grade 4 includes
localized gangrene and Grade 5 comprises of the extensive gangrene that covers the entire
foot (Iraj et al. 2013). It should be mentioned in this regard that a number of risk factors that
lead to the development of diabetic foot ulcers include old age, infection, diabetic
neuropathy, peripheral vascular disease, poor glycaemic regulation, cigarette smoking,
ischemia of blood vessels and previous history of foot amputation or ulcers (Rice et al. 2014).
In addition to this, previous medical history of foot disease, renal failure, oedema and foot
deformities could also lead to diabetic foot ulcer. Patients suffering from Diabetes also suffer
from a condition of diabetic neuropathy that is caused due to impaired neurovascular and
metabolic factors. In this regard, it should be noted that peripheral neuropathy leads to
numbness within the toes, feet, legs or arms due to the damage caused within the distal nerves
and interrupted blood flow (Armstrong et al. 2017). Further, blisters and sores manifest on
the numbed regions of the feet and legs which includes the matatarso-phalangeal joint region
and the heel region (Armstrong et al. 2017). On account of the numbness the injuries remain
unnoticed and invariably become sites of bacterial infections (Rice et al. 2014).
Nurses and allied health care professionals have been invariably involved in the
management of foot ulcers in Diabetic patients. Nurses are primarily concerned with the
process of imparting self-management training and education about foot ulcers. As mentioned
by Morua et al. (2013), nurses ideally identify the changes in the pattern of foot and skin
sensation which helps in the early detection of foot ulcers (Moura et al. 2013). Further, caring

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for foot ulcers involve administering foot care, application of dressing and novel technology
in order to promote recovery. According to the National Institute of Clinical Excellence
(NICE), the Putting Feet First framework helps in the process of identifying and classifying
the foot ulcers under the risk categories of green, amber and red algorithms (Nice.org.uk
2019). Based on the level of emergency the patient is referred to the multidisciplinary team
that is responsible for rendering foot care. The guideline further recommends that the best
nursing management practice to manage foot ulcers must comprise of frequent risk
assessments and regular follow up sessions (Nice.org.uk 2019). Studies reveal that the
treatment management for diabetic foot must include a special foot care team of professionals
who would manage wounds and ulcers with the help of non-weight bearing boots or casts,
administration of antibiotics, application of dressings and the process of wound debridement
(Alavi et al. 2014; Yazdanpanah et al. 2015). In cases of profound ischemia, it is
recommended that the patient must be assessment and must be sent for a vascular referral. It
is important to note that the primary role of a care professional while managing a Diabetic
foot is to regulate the blood pressure and blood glucose level and ensure cessation of
smoking.
A study conducted by Kapp et al. (2013), evaluated the effectiveness of the care
professionals in treating and managing the condition of diabetic foot within the geriatric
patients. The care professionals typically made use of compression stockings to treat venous
ulcer reoccurrence within a healthcare setting in Victoria. The results significantly revealed
that risk of recurrence of the ulcer reduced by 3 times in patients who used compression
stockings against the risk increasing 9 times in patients who did not use high compression
stockings (Kapp et al. 2013). Another study conducted by Chang et al. (2013), evaluated the
effectiveness of managing the condition of Diabetic foot in a rural Taiwanese population with
the use of screening tools that included Michigan neuropathy Screening Instrument, Ankle

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Branchial Index, Optimal Scaling combination of MNSI, King’s College Classification and
Texas Risk Classification. The findings indicated that the use of the mentioned community
screening tools helped in the early detection of neurovasculopathy. Also, care providers
effectively made use of the cost effective MNSI or the OSC screening tools in cases where
the ABI tool was unavailable to detect the prevalence of neurovasculopathy (Chang et al.
2013).
Another research study conducted by Barker et al. (2013), focused on assessing the
efficacy of the care professionals in providing care to patients with diabetic foot ulcers. The
researchers considered the patient data of a cohort over nine years. The criteria assessed by
the researcher included measuring the performance of the care professionals in complying
with the practice guideline of accessing the ulcer and intervention checklist, accurately
perform risk assessment and use of prevention strategies to address pressure ulcers. The
researchers considered a sample size of 270 patients and the effectiveness of usual care
nurses and experienced injury prevention nurses in providing care to the patients (Barker et
al. 2013). The findings specifically revealed that the compliance level of the usual care nurses
was significantly lower compared to the injury prevention nurses.
Therefore, on the basis of the evidence base, it can be mentioned that care
professionals can effectively treat foot ulcers in patients with stringent compliance to the
NICE guidelines of effective treatment and management of Diabetic foot. As a matter of fact,
studies have revealed that there has been a reduction in the prevalence of hospital acquired
foot ulcers in Diabetic patients globally. However, effective strategies could be undertaken by
care professionals in order to promote positive outcome. This would majorly comprise of
addressing the barriers that lead to decreased compliance with the prevention strategies in
care professionals. The identified barriers majorly include, excessive workload and lack of

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knowledge best evidence based practice for the treatment of foot ulcer (Lindholm and Searle
2016).
Conclusion:
Hence, to conclude it can be mentioned that care professionals to a significant extent
are capable of managing the condition of Diabetic foot in patients. The evidences collected
from the research papers reveal that the best management practice for Diabetic foot involves
early detection and adaption of a multidisciplinary approach in order to facilitate care. It
should further be mentioned that stringent monitoring of the blood glucose level as well as
the cessation of smoking habit can help in managing Diabetic foot. Also, imparting health
literacy to the patient in combination with training self-management strategies was identified
as the best management practices that could procure positive patient outcome. Despite the
presence of the effective guidelines for managing Diabetic foot ulcers, studies have indicated
that care professionals fail to comply with the recommended guidelines. Two major factors
have been identified as the potential barriers that hinder effective compliance. These factors
are excessive workload and lack of knowledge and awareness about the best practice. In this
regard, it can be commented that extensive research can help care professionals in essentially
identifying the best evidence based practice available for the treatment of the foot ulcers
which would eventually yield positive patient outcome.

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References:
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