Diabetic Foot Ulcer (DFU)
Diabetic foot ulcers are serious complications of diabetes, associated with infection, amputation, and even death. The complexity of their development involves various factors at different stages. Even after healing, there’s a high risk of recurrence and amputation, necessitating careful management and nursing plans.
Risk Factors for Diabetic Foot Ulcers (DFUs)
| Risk Factor | Description |
|---|---|
| Neuropathy | 1. Affects sensory, motor, and autonomic nerves. 2. Leads to loss of sensation and poor wound healing. 3. The initial damage typically occurs in small, unmyelinated nerve fibers, such as C-type fibers, which are responsible for transmitting sensory signals. |
| Motor Neuropathy | 1. Causes atrophy of specific foot muscles, resulting in foot arch changes and joint malpositioning. |
| Autonomic Dysfunction | 1. Leads to sweating dysfunction, causing overheating of the skin and weakening the skin's barrier. |
| Peripheral Arterial Disease (PAD) | 1. Results in partial or complete occlusion of peripheral arteries, leading to tissue ischemia. |
| Foot Deformities | 1. Include joint and arch deformities, contributing to unequal foot load and gait issues. |
Impact of Risk Factors on DFUs
| Combination of Risk Factors | Effect on DFUs |
|---|---|
| Neuropathy + Motor Neuropathy | 1. Unequal foot load, insecure gait, pain insensitivity, foot deformity. 2. Over-pressure-loaded plantar are constantly worn and develop hyperkeratosis over time, promoting the development of ulcers |
| Neuropathy + Autonomic Dysfunction | Anhidrotic and fissural skin, weakened skin barrier. |
| Neuropathy + PAD | Increased risk of ulceration and amputation. |
| Foot Deformities + Neuropathy | Increased risk of wound formation and ulceration. |
| Foot Deformities + PAD | Increased risk of ulceration and amputation. |
Diabetic wound classification systems:
| Classification system | Ischemic rest pain | Ulcer | Gangrene | Ischemia | Infection |
|---|---|---|---|---|---|
| Fontaine | Yes | Yes | Yes | Yes | No |
| Rutherford | Yes | Yes | Yes | Yes | No |
| PEDIS | No | Yes | No | Yes | Yes |
| UT (University of Texas) | No | Yes | No | Yes | Yes |
| S(AD) SAD system {size (area, depth), sepsis, arteriopathy, denervation system} | No | Yes | No | Only pulse palpation | Yes |
| Saint Elian | No | Yes | No | Yes | Yes |
| IDSA | No | No | No | No | Yes |
| Wagner | No | Yes | Yes | No | No |
| Society for Vascular Surgery WIfI (wound, ischemia, foot infection) classification | No | Yes | Yes | Yes | Yes |
Management Strategies for DFUs
| Treatment Approach | Description |
|---|---|
| Preventive Education | Focuses on foot care and self-examination. Provides guidance on foot hygiene and proper footwear. |
| Glycemic Control | 1. Aims to regulate blood glucose levels for improved wound healing and reduced complications. 2. Hemoglobin A1c (HbA1c) is an important clinical predictor of wound healing that shows an increase of 1% when wound healing decreases by 0.028 cm2 |
| Infection Control | Focuses on identifying and controlling infections to prevent complications |
| Exercise | Helps improve claudication distance and disrupts progression of DPN. |
| Offloading | 1. Reduces high foot pressure through redistribution to other regions. 2. The total contact cast (TCC) is often considered the gold standard device, and has been recommended by the guideline as the first-choice treatment option. 3. Other options are: RCW (removable knee-high offloading device), Therapeutic footwear |
| Debridement | Involves removal of nonviable tissue to promote wound healing. |
| Surgery | Addresses structural deformities through procedures like tendon release. |
| Assessment of Quality of Life | Evaluates physical health, pain, social function, and other aspects to guide treatment decisions |
- Wang, Xuan et al. “Diabetic foot ulcers: Classification, risk factors and management.” World journal of diabetes vol. 13,12 (2022): 1049-1065. doi:10.4239/wjd.v13.i12.1049
- Aboyans, Victor et al. “2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS).” European heart journal vol. 39,9 (2018): 763-816. doi:10.1093/eurheartj/ehx0951996;348:1329–133
- Gerhard-Herman, Marie D et al. “2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.” Circulation vol. 135,12 (2017): e686-e725. doi:10.1161/CIR.0000000000000470