Comprehensive Review: Nurses' Role in Diabetic Foot Ulcer Prevention

This literature review examines the multifaceted role of nurses in preventing diabetic foot ulcers, a critical complication of diabetes. The review encompasses various aspects, including education programs for foot care and self-care practices, emphasizing the importance of patient understanding and adherence to preventative measures. Nurses are central in conducting screening assessments to identify patients at risk, utilizing tools like the Ankle Brachial Index and assessing foot sensation. The paper further explores the role of nurses in treatment and referral to multidisciplinary teams, highlighting the importance of appropriate wound dressing and holistic care approaches. The literature underscores the significance of nurses in providing patient education, promoting lifestyle modifications, and offering support for patients with assistive devices, thereby contributing to improved patient outcomes and reduced rates of amputation. The review also addresses the need for nurses to provide care in both clinical and home settings, including education for the patient's support system.

Running head: NURSES IN PREVENTING DIABETC FOOT ULCER
Role of Nurses in Preventing Diabetic Foot Ulcer
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Table of Contents
Introduction......................................................................................................................................2
Analysis and Discussion..................................................................................................................2
Education Programs for Diabetic Foot Ulcer, Foot Care & Self Foot Care...............................3
Screening Assessment by Nurses.................................................................................................5
Holistic Care................................................................................................................................7
Conclusion.....................................................................................................................................11
References......................................................................................................................................12

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Introduction
Diabetes is a non communicable infection that has increased dramatically in the recent
decades. There are two types of diabetes which are diabetes mellitus and diabetes insipidus.
Diabetes mellitus is the most common across the globe with its epidemiological studies showing
it has increased from 30 million record in the year 1985 to 177 million in the millennium, 285
million in 2010 and a possibility of infecting 380 million and above people by 2030 if the
epidemic isn’t controlled. The disease makes an individual prone to many complications one of
the complications being diabetic foot ulcer (Lone, Vedhara, Searle, Kemple, Terry & Campbell,
2008). A reasonable number of individuals with diabetes end up getting this complication whose
prevalence have also dramatically increased in the past two decades.The aim of this paper is to
carry out a detailed literature review on the role of nurses in preventing diabetic foot ulcer
Literature review
Education Programs for Diabetic Foot Ulcer, Foot Care & Self Foot Care
Educational interventions from nurses can help to prevent diabetic foot ulcer and
amputation of the lower limbs. Fan, Sidani, Cooper-Brathwaite, and Metcalfe (2014) denote that
this can be achieved through healthcare provision based on the screening results. The basics of
care for the feet are passed to all the patients who are at risk of the DFU so as to ensure they
practice hygiene in caring for the feet(Lincoln, Radford, Game, & Jeffcoate, 2008). In their
study, Lincoln et al. denote that nurses can intervene to help the patients on how to conduct
preliminary physical examination and take care of their feet on a daily basis. Simple rules such
as checking the shoes before wearing, ensuring feet cleanliness, caring for the skin, caring for the
nails and choice of shoes are inculcated since they are very essential in foot care. Nurses can at

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the same time identify the specific need of a patient and develop an appropriate intervention for
the given patients.
In support to the assertion, Daly, Arroll, Sheridan, Kenealy, Stewart, and Scragg (2013)
point out that the patients are made aware of the basic principles of foot care which should be
practiced at home and in the health care facilities for those who are on hospitalization. The feet
should be keenly examined on a daily basis for swelling, cracks on the skin, pain, numbness and
discoloration which are some of the first signs of Diabetes foot ulcer. Personal examination
methods e.g. using hands, observing and use of mirrors are recommended so as to enhance easy
identification of abnormalities. Hygiene is encouraged through washing and thoroughly drying
the feet to avoid wetness which may significantly increase the chances of infection. The
temperature of water used to wash the feet should be controlled with an aim of preventing scars
associated with using too hot water (Schmidt, Mayer, Panfil, 2008). Bare footedness is
discouraged since the feet changes color hence one is unable to exactly tell what the cause of the
change might be. Choice of shoes then should be determined by the size of foot and the shoes
should not be worn without socks. Manipulation of lesions and indirect cutting of nails is
discouraged since this activities increase the chances of injury that might later lead to DFU.
Creams used to moisturize dry parts of the feet are recommended and the way it is used is made
known to the people to avoid misuse.
In their study, Daly, Arroll, Sheridan, Kenealy, Stewart, & Scragg (2013) point out that a
suitable life style helps to reduce the mortality rate of diabetes. Patients with blood sugar levels
complications are educated on the ways blood sugar levels can be controlled. This helps them to
regulate their ways of living and intake of certain foods is balanced. This therefore means
awareness is very important to the patient and to those who will be providing care an aspect that

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prompts training more nurses to raise this awareness to the people so as to limit ignorance
associated amputations and deaths brought about by diabetic foot ulcer.
Screening Assessment by Nurses
The three major factors that lead to gangrene and amputation of organs infected by
diabetic foot ulcer are peripheral vascular disease, neuropathy and infection. Peripheral
neuropathy is the greatest causative factor and is responsible for more than 75% of foot ulcers in
patients suffering from diabetes. This does not only help in neurological examination as the first
step to be followed in screening of patients in a bid to identify those at the risk of getting foot
ulcer but also indirectly emphasizes to the nurses their role in the performance of diabetic foot
examination in collaboration with other diabetic foot ulcer stake holders (Pocuis, Man-Hoi Li,
Janci & Thompson, 2017). The nurses who are direct specialists of foot care are conducted in the
earliest stages to provide care and treatment. These specialists perform foot examination to
determine the extent of DFU, dress wounds professionally to ensure there is at least some
comfort. It is also their role to encourage the patients as well as their family members to practice
appropriate care as well as regular follow-up visits.
The reason for screening is usually to detect the presence of diabetic foot problem,
identifying the patients at risk and at the same time plan and device ways to reduce the risk of the
foot ulcers.The DFU foot examination is conducted in all visits with an aim of screening those at
higher risk. After the examination report is given to the members of the multidisciplinary team so
as to make appropriate actions. Ankle brachial index (ABI) as well as toe pressure is accessed in
the special diabetic foot clinic. The sole pressure and foot temperature are accessed using a
thermometer and a pedography system so as the severity of the extent of the foot problem and
being at risk of the condition are identified.

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Treatment and Referral to Multidisciplinary Team
Lavery, Hunt, Lafontaine, Baxter, Ndip, and Boulton (2010) argue that the type of ulcers
that is active in the patients foot prompts the type of dressing to be used. It is the nurse’s role to
identify whether the wound is dry or wet and provide the most appropriate way of dressing. The
wound is kept clean at all times and the wound moisture is maintained in a bid to facilitate
debridement and significantly reduce the number of bacteria that might invade the wound and
further the damage (Lavery, Hunt, Lafontaine, Baxter, Ndip, & Boulton, 2010). The varieties of
novel dressing which apply to different types of wounds, awareness of the impact of the dressing
used and knowledge of nurses in the discipline should be improved. Time intervals should be
developed for each patient as part of the care plan. The patients then follow this time intervals set
for them to attend to the clinics for follow-up on the management of the condition.
All referrals to the diabetic clinic should be evaluated and proper diagnosis carried out so
as to develop a comprehensive foot care plan to be followed annually.
Patients who have other associated disabilities such as limited or lack of eyesight to an extent
that they cannot examine their feet for diabetic foot ulcer are then hospitalized for daily foot care
in cases where there are no close relatives to help.Some complications arise causing difficulty in
foot care. Such conditions as peripheral vascular disease, reduced foot sensationand delayed
wound healing contribute to lengthened diabetic foot ulcers battle. These conditions therefore
should be evaluated by nurses both in the clinics and at the home visits so as to know the way
forward. At the various moments of conducting examination, the diabetic foot nurses should
complete a patient’s evaluation list so as to examine the movement of the limb, health, color,
temperature, swelling or edema, pain, moisture and sensation of the foot. This evaluation will
therefore contribute to appropriate care whether in the clinic or at home.

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Nurses in cases where patients have lost their foot to amputation have a bigger role to
play. This is because they have to teach the patient to move with the help of assistive devices.
They also play an active role in encouraging the patients to accept themselves they way they are
at that particular moment and accept to move on with life. At the same time they identify the
various types of assistive devices and the applications in preparation to introduce them to the
patients based on the patient’s condition and ability to maintain their movement. The nurse’s
duties in advanced cases of the condition introduce the assistive devices to the patients. They
then take an initiative to train them on how the devices are used. The patients are then
encouraged to participate in making use of the devices. Some of the devices e.g. canes, walkers
and wheelchair remove pressure completely from the foot and since the devices are new to the
patient then they have to be trained. The training continues until the patient is comfortably able
to walk using the provided devices.
Holistic Care
Diabetic foot ulcer holistic care should be practiced both at home and at the clinics where
diabetic patients are either hospitalized or go for check up. This is achieved through nurse’s role
in passing the information to those who assist t the patients at home as pointed out by Schmidt,
Mayer, and Panfil (2008). The study denote that during home visits, new techniques can be
passed to the patients so as to demand specific attendance from the care takers who are also
taught the importance of compliance to the patients needs. The various educative issues and
screening results should be made known to the patients so as to help them follow the advisories
issued. In cases where assistive devices are in use, proper use of the devices as well as re-training
is passed to the patients so as to try and maintain their movement abilities. Regular wounds
cleaning, removal of debris and other associated growths will help to lower the risks of

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immobility.Topical treatment is easy to facilitate hence any individual can undertake. Ulcer
drainage should be done regularly with the aim of promoting wound healing. The treatment also
reduces gangrene and amputation rate.
In their research, Metcalf, and Musgrove (2017) based their study in the United Kingdom
where people from the upper economic class were sampled for the study. The people were
attended to from their own places of convenience where basic diabetic foot ulcer care was
practiced by the nurses on practice. The design is of significant importance to the developed
nations but it ignores its developing and under-developed counterparts where diabetic prevalence
is also very high. The study should have been conducted across a wider base to determine the
levels of prevalence in the various countries in all the economic divides.
Pocuis, Janci, and Thompson(2014) also found out that nursing students in the second
year of study in the nursing profession were used to carry out prevention of diabetic foot ulcer
where a majority of them were exposed to diabetes patients for the very first time. This aspect
has led to undesired outcomes due to fear and uncertainties. The process was therefore not very
competent and successful. The patients used were from a developed country united kingdom
where the technology has reduced the prevalence of the disease. In other parts of the world
mostly in the developing and under-developed countries the rate is very high hence the study
might not apply so well across the board. The number of people who were used to carry out the
activities was majorly from the upper economic class hence the clear picture of the entire
population may not be reflected.
Ethics and rules of conduct are always observed for the success of any process. Among
the ethics that were observed is respect for privacy of the patients. This is evident in the home

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visits where the patients were only attended to at their own place of convenience and those who
felt insecure to allow nurses at their homes took appointments to have their checkups from the
clinics. All the decisions made were autonomous whether amputation or use of assistive devices,
patients were allowed to choose what they think suits them but clear advice and education was
provided. Rules and regulation within the medical law also took their priority in the process of
assessment evaluation and healthcare provision.
Delayed diabetes diagnosis puts more patients at the risk of diabetic foot ulcer. This
condition then leads to hospitalization, deformities which prompt use of assistive devices and
amputation in advanced cases. It is reported that a higher percentage of diabetes patients are at a
higher risk of foot ulcer. Appropriate education, communication to the members of the multi-
disciplinary team and referrals are very necessary for the patients. This will help to reduce the
risk of immobility related to diabetic foot ulcers. Orthotics have been shown to be effective in
reducing foot pain and treating pathologies (Beattie, Campbell, & Vedhara, 2012) when proper
prescription is given in casessuch as plantar fasciitis, metatarsalgia, hallux limitus, adult acquired
flat foot, rheumatoid arthritis, tarsal tunnel syndrome, and lateral ankle instability.Patient’s
education plays a major and an important role in the assurance of positive long term outcomes.
Foot and nail care which are essential for DFU prevention, requires collaborative practice
among many disciplines which include podiatry, primary care, registered dietician, wound care
center, and social services. Pocuis, Janci, and Thompson(2017) point out that all these practices
are required in a bid to prevent the condition. The global increasing prevalence of diabetes stands
at a record of 30 million people in the year 1985 to 177 million in the millennium, 285 million in
2010 and a possibility of infecting 380 million and above people by 2030 if the epidemic isn’t
controlled.

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The DFU condition over the years since the discovery of diabetes remains the main cause
of hospitalization. The health of a patient deteriorates with time since this condition limits
mobility hence the patient may develop other complications in the process. In most cases a
diabetic health care provider is allocated to the prevention and early diagnosis of any chances of
the condition development. The care provider then is supposed to keenly and professionally
handle all the complications that might pose a risk of causing diabetic foot ulcer. Besides playing
their role in the care provision sector, diabetic foot ulcer nurses and diabetes care team also play
a major role in the education of patients (Nemcova& Hlinkova, 2013) and the general public,
manage health systems, improve the quality of life of the patient by provision care and attend
numerous technologically advanced trainings so as to remain posted on the recent dimensions of
diabetes. The special trainings are aimed at facilitating effective services and promote diabetic
patients health.
Fan, Sidani, Cooper-Brathwaite, and Metcalf (2014) denote that in the entire globe the
number of diabetic patients has been raising dramatically and the methods in which the pandemic
is being handled are continuously advancing an aspect that prompts nurses to be on toss in
involvement in the specialized trainings on diabetes. Though the training of specialized nurses to
handle diabetic foot ulcer has not been handled with seriousness, care being provided is still
based on the earlier inventions an aspect that has made DFU to remain a top killer in all diabetic
cases. Therefore, Lone, Vedhara, Searle, Kemple, Terry and Campbell (2018) are for the idea
that novel approaches remain to be the main ways to assess, evaluate and attend to diabetic foot
ulcer patients in the process of care provision.
In their analysis, Fan, Sidani, Cooper-Brathwaite, & Metcalfe (2014) denote that
advanced therapies have been introduced in the past decade to help in the management of DFU

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that has turned unmanageable from the use of other therapeutic methods. Hyperbaric oxygen
therapy has lately been used as it works excellently in the cure and care of DFU wounds.
However, Metcalf and Musgrove (2017) have a contrary opinion by pointing out the
disadvantage associated with the strategy. To them, diabetic foot ulcer nurses have no major
knowledge of the therapeutic measure since it is expensive and those in the high economic class
are the only who can afford it. Electric stimulation has also been working perfectly in the recent
past. However it is limited to a knowledgeable person who poses a greater understanding of its
performance. It has been reported that more than 65% of patients who use it are healed of the
DFU condition. Associated complications such as poor blood flow, infection, and deficient
cellular responses are minimized. This method of therapy is a safe, not expensive, and it is a
relatively simple intervention to facilitate the process of wound healings in patients with DFU.
Pocuis, Janci, and Thompson(2014) in their study found out that Interviews method of
data collection was used to collect data from different DFU patients and specialized nurses. The
results were then analyzed by a group of professionals who later come up with the findings
(Pocuis, Janci, and Thompson, 2017). The students then launched out to find out the appropriate
ways of dealing with DFU.
A group of 2nd year students in the university who were studying nursing in the faculty of
Diabetic Foot Ulcer were dispatched to carry out the given research. The sampled a group of 864
people who had DFU (Schmidt, Mayer, and Panfil, 2008). Most of them were from the upper
economic class. Some of them were under care of nurses at home and others in hospital. Beattie,
Campbell, & Vedhara (2012) denotes that the medical code of conduct and ethics was highly
applied in the fieldwork. The students strictly adhered to the rules without any form of

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negligence. In cases where patients were not positive to their study, they opted to stay away. Any
of them that responded and had a decision to take, they were allowed to do it for their own good.
According to Metcalf and Musgrove (2017), the results implicated from the study is that
most cases of death resulting from diabetes, are directly associated with Diabetic Foot Ulcer. The
condition also contributes to amputation of the foot that is affected hence the patients result to
using movement assistive devices (Metcalf and Musgrove, 2017). The nurses role in the
management of DFU is very significant when the patient cooperates. Educating care givers and
close relatives who will take care of the patient further improves the chances of reducing DFU.
In their study, Beattie, Campbell, and Vedhara (2014) denote that different literature have
different ideas concerning the prevention and treatment of this condition. For instance, Lincoln,
Radford, Game, and Jeffcoate (2018) denote that diabetic foot ulcer is a major cause of
immobility which often leads to hospitalization of diabetic patients. The condition most often
leads to feet amputation, gangrene and death in cases where appropriate care has not been
undertaken. Most of the lower feet amputation cases are as a result of this condition which is said
to contribute to more than 50% of all amputations. The study also denote that the condition is
associated with emotional distress, physical distress, financial loses and a generally lowered
quality of life. Lone, Vedhara, Searle, Kemple, Terry and Campbell (2008) also assert that most
expenditure for diabetes revolves around this condition because amputation as well as post
healthcare are expensive hence economic constraints are uncontrolled.
Like other professions, nurses have responsibilities within their professional jurisdictions
to meet the patients at their points of needs. These responsibilities can be direct service delivery
or to creation of awareness depending on the needs of the population. In their study, Beattie,