Diabetic Diabetic Foot UlcersDiabetic Foot...

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Diabetic Foot UlcersDiabetic Foot UlcersDiabetic Foot UlcersDiabetic Foot Ulcers

© 2015 Axxess. Unauthorized use is prohibited. © 2015 Axxess. Unauthorized use is prohibited.

Alex Khan Alex Khan APRN ACNS-BC MSN CWCN CFCN WCN-C

Advanced Practice Nurse / Adult Clinical Nurse Specialist

ObjectivesObjectives

Identify Diabetic/Neuropathic Ulcers.Identify Diabetic/Neuropathic Ulcers.

Understand adverse effects of Diabetes.Understand adverse effects of Diabetes. Understand adverse effects of Diabetes.Understand adverse effects of Diabetes.

Understand neuropathy, types of neuropathy and its effects on Diabetic Ulcer.Understand neuropathy, types of neuropathy and its effects on Diabetic Ulcer.

Perform comprehensive clinical assessment of patients with Diabetic ulcers.Perform comprehensive clinical assessment of patients with Diabetic ulcers.

Perform Diabetic Ulcer risk assessment.Perform Diabetic Ulcer risk assessment.


Perform Diabetic Ulcer risk assessment.Perform Diabetic Ulcer risk assessment.

Diabetic Ulcer management strategies.Diabetic Ulcer management strategies.

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DefinitionDefinition

A diabetic | Neuropathic ulcer is defined as an injury A diabetic | Neuropathic ulcer is defined as an injury causing loss of skin or tissue often on the feet due to causing loss of skin or tissue often on the feet due to

lack of sensation (neuropathy). lack of sensation (neuropathy). lack of sensation (neuropathy). lack of sensation (neuropathy).


Diabetic Diabetic UlcerUlcer


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PrevalencePrevalence

16 million people in the U.S. have Diabetes Mellitus.16 million people in the U.S. have Diabetes Mellitus. 15% of patients with Diabetes will develop a foot ulcer. 15% of patients with Diabetes will develop a foot ulcer. 20% of patients with DFU have PAD.20% of patients with DFU have PAD. 20% of patients with DFU have PAD.20% of patients with DFU have PAD. 50% of patients with DFU have PN.50% of patients with DFU have PN. 30% of patients with DFU have both PAD and Neuropathy.30% of patients with DFU have both PAD and Neuropathy. 13.9 % Patients with DFU in 2008 had lower extremity 13.9 % Patients with DFU in 2008 had lower extremity

amputations.amputations. According to WHO by 2025 , 300 million world wide will According to WHO by 2025 , 300 million world wide will


According to WHO by 2025 , 300 million world wide will According to WHO by 2025 , 300 million world wide will have Typehave Type--II Diabetes MellitusII Diabetes Mellitus..

AHRQ 2011

Diabetes Diabetes & & Wound HealingWound Healing

Damage to blood vessels / Decreased circulation Damage to blood vessels / Decreased circulation (PAD & PVD)(PAD & PVD)

ADVERSE EFFECTS

(PAD & PVD)(PAD & PVD) Damage to nerves Damage to nerves -- NeuropathyNeuropathy Decreased immune responseDecreased immune response Delayed response to tissue injuryDelayed response to tissue injury Defective Matrix production & depositionDefective Matrix production & deposition


Defective Matrix production & depositionDefective Matrix production & deposition DeformityDeformity

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NeuropathyNeuropathy

Neuropathy involves functional disturbances , pathologic Neuropathy involves functional disturbances , pathologic changes and degeneration of peripheral nerves , changes and degeneration of peripheral nerves ,

characterized by :characterized by :characterized by :characterized by :Numbness and pain in hands and feetNumbness and pain in hands and feet

Tingling or burning sensationTingling or burning sensationSensitivity to touch or muscle weaknessSensitivity to touch or muscle weakness

Myers, B. (2012).


NeuropathyNeuropathy

Neuropathy associated with Diabetes Mellitus can be Neuropathy associated with Diabetes Mellitus can be classified as:classified as:

Sensory NeuropathySensory NeuropathySensory NeuropathySensory NeuropathyMotor NeuropathyMotor Neuropathy

Autonomic NeuropathyAutonomic Neuropathy


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Sensory Sensory NeuropathyNeuropathy

The most common type of diabetic The most common type of diabetic neuropathy, causes pain or loss of neuropathy, causes pain or loss of feeling in the toes, feet, legs, hands, feeling in the toes, feet, legs, hands, feeling in the toes, feet, legs, hands, feeling in the toes, feet, legs, hands, and armsand arms


Sensory Sensory NeuropathyNeuropathy


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Motor Motor NeuropathyNeuropathy

Leads to paralysis of the foot's intrinsic Leads to paralysis of the foot's intrinsic muscles resulting in muscle atrophy that muscles resulting in muscle atrophy that

predispose patients with diabetes to plantar predispose patients with diabetes to plantar predispose patients with diabetes to plantar predispose patients with diabetes to plantar ulceration by increasing plantar pressures ulceration by increasing plantar pressures

and shear forces.and shear forces.


Autonomic NeuropathyAutonomic Neuropathy

Increases the risk of neuropathic ulceration Increases the risk of neuropathic ulceration due to disturbances in sweating mechanisms, due to disturbances in sweating mechanisms,

callus formation, and blood flow. It also callus formation, and blood flow. It also callus formation, and blood flow. It also callus formation, and blood flow. It also effects heart, blood vessels, digestive system, effects heart, blood vessels, digestive system,

urinary tract, eyes, lungs & sex organs.urinary tract, eyes, lungs & sex organs.


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Autonomic Autonomic NeuropathyNeuropathy


Comprehensive Comprehensive AssessmentAssessment

Health History Health History : Allergies, Smoking, Medications etc.: Allergies, Smoking, Medications etc.

Duration of UlcerationDuration of Ulceration: Current & Previous treatments: Current & Previous treatments

Diabetes ManagementDiabetes Management: Hemoglobin A1c: Hemoglobin A1c

Foot & Shoe ExamFoot & Shoe Exam: Deformity, Improper shoes , Circulation / : Deformity, Improper shoes , Circulation /

Pedal Pulses, Skin Color, Temperature, Neuropathy, CallousPedal Pulses, Skin Color, Temperature, Neuropathy, Callous

Mobility StatusMobility Status: Ambulatory, Wheelchair, Walker etc.: Ambulatory, Wheelchair, Walker etc.


Mobility StatusMobility Status: Ambulatory, Wheelchair, Walker etc.: Ambulatory, Wheelchair, Walker etc.

NutritionNutrition: Pre: Pre--Albumin, Vitamin D, Vitamin CAlbumin, Vitamin D, Vitamin C

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Comprehensive Comprehensive AssessmentAssessment

Location of wound Location of wound : Plantar | Lateral or Medial aspect: Plantar | Lateral or Medial aspect

Duration of UlcerationDuration of Ulceration: When ulcer was first discovered: When ulcer was first discovered Duration of UlcerationDuration of Ulceration: When ulcer was first discovered: When ulcer was first discovered

Grading of UlcerGrading of Ulcer: Wagner grading scale: Wagner grading scale

Drainage or Odor: Drainage or Odor: Type of drainage and odor; if anyType of drainage and odor; if any

Wound edgesWound edges: Calloused | Pink & soft | Rolled: Calloused | Pink & soft | Rolled


Wound edgesWound edges: Calloused | Pink & soft | Rolled: Calloused | Pink & soft | Rolled

Presence of PainPresence of Pain: Assessing sensory loss: Assessing sensory loss

Wagner Wagner Grading ScaleGrading Scale

Wagner Grading System Wagner Grading System

1.1.Grade 1Grade 1: Superficial Diabetic Ulcer

2.2.Grade 2Grade 2: Ulcer extension

1.Involves ligament, tendon, joint capsule or fascia

2.No abscess or Osteomyelitis

3.3.Grade 3Grade 3: Deep ulcer with abscess or Osteomyelitis


4.4.Grade 4Grade 4: Gangrene to portion of forefoot

5.5.Grade 5Grade 5: Extensive gangrene of foot

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HgbA1c HgbA1c & Wound Healing& Wound Healing

Diabetes Management: Hemoglobin A1c LevelDiabetes Management: Hemoglobin A1c LevelA1c levels Measures Blood Glucose Control for 2-3 Months

HgbA1c HgbA1c –– 5.6% 5.6% Wound Healing Rate 0.35cm² / day Wound Heals in 64 days

HgbA1c HgbA1c –– 11.1% 11.1% Wound Healing Rate 0.001cm² / day Wound did not heal


did not heal

Patient Patient Compliance Compliance

Identify Compliance Issues = Patient EducationIdentify Compliance Issues = Patient Education

Better Blood Glucose Control (≤ 7.0) = Better OutcomesBetter Blood Glucose Control (≤ 7.0) = Better Outcomes

Hyperglycemia = Delayed Wound Healing & ComplicationsHyperglycemia = Delayed Wound Healing & Complications


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Ankle Ankle Brachial Index (ABI) Brachial Index (ABI)

Screening: 2004 ADA recommendationScreening: 2004 ADA recommendation“Consider” at age 50 years and every 5 years“Consider” at age 50 years and every 5 years

DiagnosisDiagnosis:Claudication:Claudication, absent DP/PT pulses, foot ulcer, absent DP/PT pulses, foot ulcerDiagnosisDiagnosis:Claudication:Claudication, absent DP/PT pulses, foot ulcer, absent DP/PT pulses, foot ulcerLimitationsLimitations:Underestimates:Underestimates severity in calcified arteriesseverity in calcified arteries

InterpretationInterpretation ABIABINormalNormal 0.900.90--1.301.30Mild obstructionMild obstruction 0.700.70--0.890.89Moderate obstruction*Moderate obstruction* 0.400.40--0.690.69


Moderate obstruction*Moderate obstruction* 0.400.40--0.690.69Severe obstruction*Severe obstruction* <0.40<0.40Poorly compressible**Poorly compressible** >1.30>1.3022°° to medial calcificationto medial calcification

Ankle Ankle Brachial Index (ABI) Brachial Index (ABI)


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Monofilament Monofilament Test Test


Diabetic Diabetic Foot Ulcer Foot Ulcer


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Management Management Strategies Strategies

Identifying “ High Risk” Patients during admission assessmentIdentifying “ High Risk” Patients during admission assessment

1. Diabetic for > 10 years 2. Diagnosis of Neuropathy 2. Diagnosis of Neuropathy 3. Past History of Diabetic Foot Ulcers 4. Past History of Amputation associated with Diabetes or PVD 5. HgbA1c > 7.0% 6. Current or past history of Tobacco use 1 7. Ankle Brachial Index < 0.8 8. Diagnosis of Peripheral Vascular Disease (PVD) 9. BMI ≥ 35 10. Patient is able to ambulate self. (Ambulatory)


10. Patient is able to ambulate self. (Ambulatory) 11. Diabetes managed with Insulin 12. Presence of foot or ankle deformity 13. Not able to conduct own visual foot exam

Total Score Total Score 1313

SCORE INTERPRETATION:SCORE INTERPRETATION:LOW RISK LOW RISK = 1 TO 3= 1 TO 3MEDIUM RISK MEDIUM RISK = 4 TO 6= 4 TO 6HIGH RISK HIGH RISK = 7 TO 13= 7 TO 13

Management Strategies Management Strategies

Patient Education Patient Education OffOff--LoadingLoading Sharp DebridementSharp Debridement Sharp DebridementSharp Debridement Managing Bacterial Burden Managing Bacterial Burden –– Wound Cultures & AntibioticsWound Cultures & Antibiotics Monitor HgbA1c levels and maintaining at Below 7%Monitor HgbA1c levels and maintaining at Below 7% Maintaining wound moistMaintaining wound moist


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Questions Questions ? ?

Alex Khan, APRN ACNSAlex Khan, APRN ACNS--BC BC Advanced Practice Nurse / Adult Clinical Nurse SpecialistWound Care Consultant | Educator Wound Care Consultant | Educator Phone: (972) 584-7616Fax: (214) 853-5364Email: [email protected]


Email: [email protected] resource: www.woundcarenurses.org

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