November is National Diabetes Month: A Snapshot of Assessing Diabetic Foot Ulcers

As seen in the Consultant Connection November 2013 Issue
Author: Erin McClure, BSN, RN, WCC, ICP Nurse Consultant, Email: emcclure@icppharm.com


National Diabetes Month is observed each year in November.  This is a time for Associations including; The American Diabetes Association (ADA), National Institute of Health (NIH), and Centers for Disease Control and Prevention (CDC) in partnership with communities across the country – and the world – to shine a spotlight on diabetes and encourage action to change the way diabetes is treated. Diabetes doesn’t stop. It is 24/7, 365 days a year. It is very important to understand diabetes in order to prevent serious health problems such as heart disease, stroke, blindness, kidney disease, and nerve damage that can lead to amputation.
Why is awareness about diabetes important?
  • Nearly 26 million Americans have diabetes
  • Another 79 million adults in the United States have prediabetes, a condition that increases their chances of developing type 2 diabetes
  • If left undiagnosed or untreated, diabetes can lead to serious health problems such as heart disease, blindness, kidney disease, stroke, amputation and even death. With early diagnosis and treatment, people with diabetes may prevent the development of these health problems
  • The total estimated cost of diagnosed diabetes in 2012 is $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity.

Diabetic foot ulcers (DFUs) are defined as; Ulcers caused by the neuropathic and small blood vessel complications of diabetes, from the Resident Assessment Instrument (RAI) Manual, Section M. Diabetic foot problems, such as ulcerations, infections, and gangrene, are the most common cause of hospitalization among diabetic patients. Routine ulcer care, treatment of infections, amputations, and hospitalizations cost billions of dollars every year and place a tremendous burden on the health care system.
Diabetic foot ulcers typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot. These ulcers are usually deep; with necrotic tissue, moderate amounts of exudate, and callused wound edges. The wounds are very regular in shape and the wound edges are even with a punched-out appearance, and sometimes callused. These wounds are typically not painful due to the peripheral neuropathy which causes loss of sensation.
Diabetic peripheral neuropathy is caused by high blood glucose which damages nerves and blood vessels.  This is because nerves carry messages back and forth between the brain and other parts of the body and the small blood vessels provide nerves with nutrients and oxygen required to survive and function. These nerves are extremely sensitive to any change in nutrients and oxygen supply. High blood glucose damages these small blood vessels that feed the nerves. When the vessels are damaged, a sufficient supply of nutrients and oxygen no longer reaches the nerve, causing the nerve to become damaged and eventually die. High blood glucose also damages the outer protective layer of nerves, affecting their ability to transmit signals. Foot ulcer evaluation should be three-fold including; assessment of neurological status, vascular status, and evaluation of the wound itself.
Neurological status can be checked by using the Semmes-Weinstein monofilaments to determine whether the patient has “protective sensation,” which means determining whether the patient is sensate to the 10-g monofilament.  Monitoring the resident's blood glucose levels in conjunction with the hemoglobin A1C is vital as high blood glucose levels impair healing of ulcers and is a causative factor in diabetic neuropathy.
Vascular assessment is important for eventual ulcer healing and is essential in the evaluation of diabetic ulcers. Vascular assessment includes checking pedal pulses, the dorsalis pedis on the dorsum of the foot, and the posterior tibial pulse behind the medial malleolus, as well as capillary filling time to the digits. The capillary filling time is assessed by pressing on a toe enough to cause the skin to blanch and then counting the seconds for skin color  to return. A capillary filling time > 5 seconds is considered prolonged. If pedal pulses are nonpalpable, the patient should be sent to a noninvasive vascular laboratory for further assessment, which may include checking lower extremity arterial pressures by Doppler and recording pulse volume waveforms. The ankle brachial index is often not helpful because of high pressures resulting from noncompressible arteries. Other components of the vascular assessment should include checking; lower extremity color, temperature, hair distribution, skin condition, nail condition, and pain.
Ulcer evaluation should include documentation of the wound’s location, size, shape, depth, base, and border. Determining depth is important to identify whether the depth extends to full thickness which may include; to a tendon, joint, or bone. X-rays should be ordered on all deep or infected wounds, but magnetic resonance imaging often is more useful because it is more sensitive in detecting osteomyelitis and deep abscesses. Signs of infection, such as the presence of cellulites, odor, or purulent drainage, should be documented and aerobic and anaerobic cultures should be obtained of any purulent exudates. Culturing a dry or clean wound base has proven to be useless because most wounds are colonized, and this practice leads to over-prescribing of antibiotics. 
A thorough assessment accompanied by accurate and complete documentation is a vital component in treatment and preventive strategies for Diabetic foot ulcer management, and to maintain compliance with F 309: Quality of Care which states that the facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process. Under Non-Pressure Related Ulcers, where Diabetic Foot Ulcers are found in the regulation, documentation must include:
  • Assessment and diagnosis
  • Clinical basis for the ulceration
  • Ulcer Ddges and wound bed
  • Shape of wound
  • Condition of periwound tissue
  • At least daily, staff should remain alert to potential changes in skin condition and should evaluate and document identified changes-F 314 (Monitoring, pg. 209)

In summary, ensure that your facility is utilizing the most current standards of practice for the prevention and management of diabetic foot ulcers. An excellent resource to utilize is the Wound Ostomy and Continence Nurses Society publication titled, Guideline-Management of Wounds in Patients with Lower Extremity Neuropathic Disease, found at their website: http://www.wocn.org.  In addition, make sure your nursing staff is educated on facility policies and procedures pertaining to wound care in conjunction with utilizing facility wide protocols, if applicable. Educating staff is a vital component in order to enhance the quality of care provided to the resident, which is why we are in the healthcare profession.

References:
2011 National Diabetes Fact Sheet, Retrieved October 1, 2013: http://www.diabetes.org/in-my-community/local-offices/miami-florida/assets/files/national-diabetes-fact-sheet.pdf
CMS RAI Version 3.0 Manual Chapter 3, MDS Section M. (http://cms.gov)
WOCN. Quick Assessment of Leg Ulcers. Glen View, Illinois, USA. Retrieved from http://www.wocn.org


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