Assessment and Management of Foot Ulcers for People with Diabetes

Recommendation 1.0: Obtain a comprehensive health history and perform physical examination of affected limb(s). 

Recommendation 1.1: Identify the location and classification of foot ulcer(s) and measure length, width and depth of wound bed. 

Recommendation 1.2: Assess bed of foot ulcer(s) for exudate, odour, condition of peri-ulcer skin and pain. 

Recommendation 1.3: Assess affected limb(s) for vascular supply and facilitate appropriate diagnostic testing, as indicated. 

Recommendation 1.4: Assess foot ulcer(s) for infection using clinical assessment techniques, based on signs and symptoms, and facilitate appropriate diagnostic testing, if indicated. 

Recommendation 1.5: Assess affected limb(s) for sensory, autonomic and motor changes. 

Recommendation 1.6: Assess affected limb(s) for elevated foot pressure, structural deformities, ability to exercise, gait abnormality, and ill-fitting footwear and offloading devices. 

Recommendation 1.7: Document characteristics of foot ulcer(s) after each assessment including location, classification and any abnormal findings.

Recommendation 2.0: Determine the potential of the foot ulcer(s) to heal and ensure interventions to optimize healing have been explored. 

Recommendation 2.1: Develop a plan of care incorporating goals mutually agreed upon by the client and health-care professionals to manage diabetic foot ulcer(s). 

Recommendation 2.2: Collaborate with the client/family and interprofessional team to explore other treatment options if healing has not occurred at the expected rate. 

Recommendation 2.3: Collaborate with client/family and the interprofessional team to establish mutually agreed upon goals to improve quality of life if factors affecting poor healing have been addressed and complete wound closure is unlikely.

Recommendation 3.0: Implement a plan of care to mitigate risk factors that can influence wound healing. 

Recommendation 3.1: Provide wound care consisting of debridement, infection control and moisture balance where appropriate. 

Recommendation 3.2: Redistribute pressure applied to foot ulcer(s) by the use of offloading devices. 

Recommendation 3.3: Provide health education to optimize diabetes management, foot care and ulcer care. 

Recommendation 3.4: Facilitate client-centred learning based on individual needs to prevent or reduce complications.

Recommendation 4.0: Monitor the progress of wound healing on an ongoing basis using a consistent tool, and evaluate the percentage of wound closure at 4 weeks. 

Recommendation 4.1: Reassess for additional correctable factors if healing does not occur at the expected rate.

Recommendation 5.0: Health-care professionals participate in continuing education opportunities to enhance specific knowledge and skills to competently assess and manage clients with diabetic foot ulcers, based on the RNAO Nursing Best Practice Guideline, Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.). 

Recommendation 5.1: Educational institutions incorporate the RNAO Nursing Best Practice Guideline, Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.), into basic registered nurse, registered practical nurse, doctor of medicine and interprofessional curricula to promote a culture of evidence-based practice.

Recommendation 6.0: Use a systematic approach to implement the Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.) clinical practice guideline and provide resources and organizational and administrative supports to facilitate clinician uptake. 

Recommendation 6.1: Develop policies that acknowledge and designate human, material and fiscal resources to support the interprofessional team in diabetic foot ulcer management. 

Recommendation 6.2: Establish and support an interprofessional, inter-agency team comprised of knowledgeable and interested persons to address and monitor quality improvement in the management of diabetic foot ulcers. 

Recommendation 6.3: Develop processes to facilitate the referral of clients with diabetic foot ulcers to local diabetes resources and health-care professionals. 

Recommendation 6.4: Advocate for strategies and ongoing funding to assist clients in obtaining appropriate pressure redistribution devices during and after ulcer closure.