Pressure Ulcers

Pressure Ulcers
Definition and Location
Classification
Risk Factors
Prevention
Treatment
Pressure Ulcers treatment for each stage
Complications
What is a Pressure Ulcer?
Definition: A pressure ulcer is a localized injury
to the skin or underlying tissue, usually over a bony
prominence, that is a result of pressure or of
pressure combined with shear or friction.
Reported prevalence rates have ranged
from 2.3 percent to 28 percent and reported
incidence rates from 2.2 percent to 23.9
percent


What is a Pressure Ulcer?
95% of pressure ulcers develop on the lower body
(about 65% in the pelvic area and 30% in the lower
extremities)
2-6 times greater mortality risk
Effective pressure ulcer treatment best
achieved through interdisciplinary team
approach
Pressure Ulcers
Location
Pressure ulcers commonly occur over the :
Sacrum
Greater trochanter
Ischial tuberosity
Malleolus
Heel
Fibular head
Scapula
Areas of pressure
Pressure Ulcers
Risk Factors
Spinal cord injuries
Traumatic brain injury
Neuromuscular disorders
Immobility
Malnutrition
Fecal and urinary
incontinence
Altered level of
consciousness

Chronic systemic illness
Fractures
Aging skin
decreased epidermal
turnover
dermoepidermal junction
flattens
fewer blood vessels
Decreased pain perception

Contributory factors:
Internal/patient-related factors:
Systemic disease: metabolic, neurological,
vascular, terminal illness
Reduced mobility or immobility
Sensory impairment
Psychological e.g. depression
Anaemia
Malnutrition
Level of consciousness
Extremes of age
Previous history of pressure damage or poor
skin condition
Acute or chronic oedema
Dehydration/fluid status- sweat, incontinence
External factors:
Pressure - support surfaces, change of
position
Shear - positioning, mobility
Friction - moving and handling
techniques, patient education,
splinting, casts, positioning
Other factors
- Moisture - incontinence, sweating,
pyrexia, wound exudate
- Medication



Guidelines for Pressure Ulcers
Care
Recognition
Assessment Diagnosis
Prevention and Treatment
Monitoring
Recognition Steps
Examine the patients skin thoroughly to
identify existing pressure ulcers
Identify risk factors for developing pressure
ulcers
Review records/resident interview to
identify previous history of pressure ulcers
Ulcer Type Pathophysiology Location
Diabetic Peripheral neuropathy secondary to
small or large vessel disease in
chronic, uncontrolled diabetes
Usually lower extremities
Ischemic Reduction in blood flow to tissues
caused by coronary artery
disease, diabetes mellitus,
hypertension, hyperlipidemia,
peripheral arterial disease, or
smoking
Usually distal lower extremities
Tips of toes
Pressure Unrelieved pressure resulting in
damage to skin or underlying
tissue
Usually over bony prominences (e.g.,
buttocks, elbows, heels, ischium,
medial and lateral malleolus,
sacrum, trochanters)
Venous Venous hypertension resulting from
incompetence of venous valves, post-
phlebitic syndrome, or venous
insufficiency. Tend to be
irregularly shaped
Usually lower leg region
Distinguishing Features of Common
Types of Ulcers
Risk Assessment and Evaluation
Braden Scale
Push Tool
Braden Scale
Sensory Perception 1-4
Moisture 1-4
Physical Activity 1-4
Mobility 1-4
Nutrition 1-4
Friction & Shear 1-3
Score 18+ Low risk
15-18 Mild risk, 13-14 Moderate risk, 10-12
High risk, below 10 Very High Risk
Prevention
Aims
Reduce Pressure and Shearing effects
Reduce Moisture
General Skin Care
Nutrition
Co-morbidities
Involve patient, family, caregivers
Prevention
Daily skin inspection
Bathing and skin cleaning frequency
Moisturize skin; avoid hot water or harsh
solutions
Assess and treat incontinence; use topical barriers
or absorbent padding when needed
Proper re-positioning frequently; q2hrly for those
bed-bound, q1hrly for those in wheelchairs; self
re-positioning every 15 minutes for those in
wheelchairs
Avoid manipulating bony prominences
Prevention
Practice proper positioning, transferring and turning
techniques to avoid friction and shearing forces; lift
dont shift
Use dry lubricants (cornstarch) or protective
coverings to reduce friction injury
Institute a rehabilitation program to maintain or
improve mobility/activity status
Consider nutritional supplementation/support for
nutritionally compromised persons
Prevention
Use adjunct devices (air mattresses, limb
padding) where necessary
Use pillows or padding to avoid bony
prominences such as knees from having direct
contact
Elevate the head of the bed no more than 30
unless absolutely necessary
Monitor and document interventions and
outcomes
Have a fixed repositioning schedule
Staging of pressure ulcers
Suspected deep tissue injury
Purple or maroon localized area of
discolored intact skin or blood-filled
blister due to damage of underlying
soft tissue from pressure and/or
shear*. The area may be preceded by
tissue that is painful, firm, mushy,
boggy, warmer or cooler as
compared to adjacent tissue.



Suspected Deep Tissue Injury
Purple or maroon localized area of discolored
intact skin or blood-filled blister due to
damage of underlying soft tissue from pressure
and/or shear.
Deep Tissue Injury
Pressure Ulcers on Mucous
Membranes
Pressure ulcers can develop on mucous
membranes from pressure exerted by a
medical device in use at the location of the
ulcer.
LAYERS:
g = epithelium
f = lamina propria
e = muscularis mucosa
c = smooth muscle (location specific
presence )
Staging of pressure ulcers
Stage I
Intact skin with non blanchable
redness of a localized area, usually
over a bony prominence. Darkly
pigmented skin may not have visible
blanching; its color may differ from
the surrounding area.


Stage 1
STAGE I



Stage 1 pressure ulcer on the
foot.
Staging of pressure ulcers
Stage II
Partial thickness loss of dermis
presenting as a shallow open ulcer with a
red pink ulcer bed, without slough*. May
also present as an intact or
open/ruptured serum-filled blister.


STAGE II
Stage 2 pressure ulcer on the ear.
Staging of pressure ulcers
Stage III
Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining* and
tunneling*.


STAGE III
STAGE III
Staging of pressure ulcers
Stage IV
Full thickness tissue loss with
exposed bone, tendon or muscle.
Slough or eschar may be present
on some parts of the ulcer bed.
Often include undermining and
tunneling.
.

Grade 4
Staging of pressure ulcers
Unstageable
Full thickness tissue loss in which
the base of the ulcer is covered by
slough (yellow, tan, gray, green or
brown) and/or eschar (tan, brown
or black) in the ulcer bed.

UNSTAGEABLE
Factors that can affect ulcer
treatment and healing
Physiologic factors
Functional factors
Psychosocial factors
Ethical considerations
Pressure Ulcer Prevention Plan,
Documentation and Education of Patient
and Caregivers
The prevention of pressure ulcers incorporates
the interventions below:
I. Minimize or eliminate friction and shear
II. Minimize pressure (off-loading)
III. Support surfaces
IV.Manage moisture
V. Maintain adequate nutrition/hydration

Treatment
Assessment
History and Physical Examination
Assessing Complications
Nutritional Assessment and Management
Pain Assessment and Management
Psychosocial Assessment and Management

Pressure Ulcers
Ulcer care
The four basic components
1. debridement of necrotic tissue as needed on initial and
subsequent assessments
2. cleansing the wound initially and with each dressing
change
3. prevention, diagnosis, and treatment of infection
4. using a dressing that keeps the ulcer bed moist and
the surrounding intact tissue dry
Debridement
Moist, devitalized tissue supports the growth of
pathological organisms.
Therefore, the removal of such tissue favorably
alters the healing environment of a wound.
Removal of devitalized tissue is considered
necessary for wound healing

Adjunctive Therapies
The therapies included :
electrical stimulation
hyperbaric oxygen
infrared and ultraviolet light
low-energy laser irradiation
ultrasound
miscellaneous topical agents (including cytokine
growth factors)
systemic drugs other than antibiotics
Wound Cleansing
Remove necrotic tissue, exudate, and metabolic
wastes from the wound.
Minimum of chemical and mechanical trauma. .
Cleanse wounds initially and at each dressing
change
Do not clean ulcer wounds with skin cleansers or
antiseptics
Use normal saline for cleansing
Consider whirlpool treatment for ulcers that
contain thick exudate, slough, or necrotic tissue.
Dressings
Keep the ulcer bed continuously moist.
Wet-to-dry dressings should be used only
for debridement
No differences in pressure ulcer healing
outcomes with diverse dressings
Keep the surrounding intact (periulcer) skin
dry while keeping the ulcer bed moist.
Dressings
Control exudate but do not desiccate the
ulcer bed.
Consider caregiver time
Eliminate wound dead space by loosely
filling all cavities with dressing material.
Avoid overpacking the wound.
Monitor dressings applied near the anus
Pressure Ulcers
Treatment for each stage
Stage 1
Intensive implementation of preventive measures
as usual
Polyurethane dressings (transparent) applied every
1 to 10 days (Tegaderm)
They are semipermeable films, permeable to water
vapor, oxygen and other gases and impermeable to
water and bacteria
Most lesions can be expected to heal by 2 weeks

Stage 2
The same as for stage I but
Wound should be inspected for signs of
infection
Polyurethane dressings are more effective
and less costly than wet-to-dry dressings
(Tegaderm or thin Duoderm )
Wet-to-dry dressings are rarely indicated at
this stage

Stage 3
Remove necrotic material
Small eschar:
Debridement by experienced PCP
Topical application of enzymatic debriding agents
Eschar should be scored
Enzymes must not touch surrounding areas
Large eschar: Surgical consultation


Stage 3
Loose material can be debrided with wet-to-dry
dressings every 8 hours
Polyurethane and hydrocolloid dressings
(Duoderm) are more effective
Hydrocolloids are impermeable to gas and
moisture and are changed every 1-4 days
Deeper stage 3 or 4: Wounds need to be packed
with material depending on exudate

Stage 3
Hydrocolloid dressings are not appropriate
Dry wounds: less absorptive Hydrogels or
moist soaks with normal saline
Exudative wounds: Absorptive dressings such
as Hydrophilic foam alginates (Kaltostat ) or
saline impregnated gauze
Packings are changed daily



Stage 3
Consider specialized beds:
air fluidized beds
low-air-loss beds
They should be used for at least 60 days
Patients with large defects: surgery consult
Patients with large defects in the sacral area and
urinary incontinence may require catheterization
Stage 4
They require surgical intervention for initial
debridement
Wet-to-dry dressings may help
Whirlpool baths may facilitate debridement
Clean deep ulcers require packing
Consider grafting procedures
Always keep in mind the goals of the
patient




Dressings
Dressing Type Description Indication Brand Names
Transparent Film Adhesive, semi-
permeable, allows
vaporization
Stage I and II with
light or no exudates
Opsite, Tegaderm
Hydrogel Water/Glycerin based
gels on gauze or
dressings
Stage II, III, IV; deep
ulcers; necrosis &
slough
Acryderm, Flexigel,
Intrasite
Alginate From Seaweed Stage III, IV with
moderate to heavy
exudate
Algicell, Algisite,
Tegagen
Foam Moist, thermal
Insulation
Stage II to IV with
varying drainage
Hydrocell, Polyderm
Hydrocolloid Occlusive or
semiocclusive;
gelatin and pectin
Stage II to IV with
sough and necrosis
Dermafilm,
Tegaderm
Moistened Gauze Gauze in saline Stage III to IV
Managing Bacterial Colonization and
Infection
Stage 2, 3 and 4 pressure ulcers are invariably
colonized with bacteria.
In most cases, adequate cleansing and debridement
prevent bacterial colonization from proceeding to
the point of clinical infection
If purulence or foul odor is present, more frequent
cleansing and possibly debridement are required.
Infected Pressure Sore
Managing Bacterial Colonization and
Infection
Do not use swab cultures to diagnose wound
infection (colonization)
Consider 2-week trial of topical antibiotics for
clean pressure ulcers that are not healing or
producing exudate
Effective against gram negative, positive, and
anaerobes
Perform quantitative bacterial cultures of soft
tissue and evaluate for osteomyelitis when ulcer
does not respond to topical antibiotic therapy.
Managing Bacterial Colonization and
Infection
Systemic antibiotic therapy for patients with
bacteremia, sepsis, advancing cellulitis, or
osteomyelitis.
Do not use topical antiseptics (povidone iodine,
iodophor, Dakins solution, hydrogen peroxide,
acetic acid) to reduce bacteria in wound tissue.
Systemic antibiotics are not required for pressure
ulcers with signs of local infection.
Protect pressure ulcers from exogenous sources of
contamination
Infection Control
Follow body substance isolation precautions or an
equivalent system.
Use clean gloves for each patient.
When treating multiple ulcers on the same patient,
attend to the most contaminated ulcer last
Use sterile instruments to debride ulcers
Use clean dressings, rather than sterile ones, to
treat pressure ulcers.
Operative Repair of Pressure Ulcers
Operative procedures to repair pressure
ulcers include one or more of the following:
Direct closure
Skin grafting
Skin flaps
Musculocutaneous flaps
Free flaps.

Operative Repair of Pressure Ulcers
Consider for operative repair when clean Stage
III-IV do not respond to optimal patient care
Candidates are medically stable, well nourished
and can tolerate operative blood loss and postop
immobility.
Correct factors that may be associated with
impaired healing (smoking, spasticity, levels of
bacterial colonization, incontinence, and UTI)
Minimize pressure to the operative site by use of
special beds
Assessment of Ulcer Healing
Evaluate at least weekly
If general condition deteriorates, the ulcer should
be reassessed promptly
Evaluate using size, depth, presence of exudate,
epithelialization, granulation tissue, necrotic
tissue, sinus tracts, undermining, tunneling,
purulent drainage or signs of infection.
A clean pressure ulcer with adequate innervation
and blood supply should show progress toward
healing in 2 to 4 weeks
Monitoring
Healing ulcers should be assessed regularly
Monitor the individual's general health, nutritional
status, psychosocial support, pain level and be
alert to signs of complications
The frequency of monitoring should be
determined by the clinician based on the condition
of the patient, ulcer, rate of healing, and the health
care setting.
Complications
Pressure Ulcers
Complications
Amyloidosis
Endocarditis
Heterotopic bone
formation
Maggot infestation
Meningitis
Perineal-urethral fistula
Pseudoaneurysm
Septic arthritis
Sinus tract or abscess
Squamous cell carcinoma
in the ulcer
Systemic complications of
topical treatment
Osteomyelitis
Bacteremia
Advancing cellulitis
Case review
Adult male presented with a Sacral pressure
ulcer, bilateral superficial trochanteric ulcers.
he was manged in a single stage by ulcer
excision and bilateral superior gluteus
maximus V-Y advancement flap coverage. his
post operative period was uneventful.
Pressure Ulcer Staging Quiz
The test is comprised of 12 pictures of pressure
ulcers.
Question 1

Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Please make a selection
Question 2

Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 3
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 4
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 4
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 5
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 6
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 7
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 8
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 9
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 10
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 10
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 11
Category/Stage I
Category/Stage II
Category/Stage III
Category/Stage IV
Unstageable/Unclassified
Deep Tissue Injury
Question 12

DIABETIC FOOT ULCERS



Dr Sedaka Donaldson
CASE: Mr. M.C.
64 yr-old obese white male, not seen x 12 mo
Type 2 DM (15 yrs)
BP | (18 yrs)
Dyslipidemia (18 yrs)
CABG (10 yrs ago)
Claudication (today; 25 yds)
Insulin/Metformin/Statin/ARB/Hctz/CCB/ASA
Sore on my left foot, Doc


CASE: Mr. M.C.
Clinical evaluation of heel ulcer:
Probe reached bone
Extensive subcutaneous abscess
MRI: extensive osteomyelitis
ABI: 0.2
Angiography: severe infrapopliteal, suprapopliteal obstruction
Not amenable to revascularization
Uncontrolled infection despite antibiotics/drainage
AMPUTATIONS IN DIABETES
Common:
Worldwide amputation 2 to diabetes q 30 sec.
U.S.A. 80,000 amputations/y (2002)
Higher rates in men, racial/ethnic minorities

Costly:
$60,000/amputation
$2 billion/y total costs

Lancet 2005; 366:1719 Diabetes Care 2004; 27:1598 Diabetes Care 2003;
26:495
AMPUTATIONS IN DIABETES
Tragic: Rule of 50
50% of amputations transfemoral/transtibial level

50% of patients 2
nd
amputation in s 5y

50% of patients Die in s 5y

Clinical Care of the Diabetic Foot, 2005
FOOT ULCERS IN DIABETES
Precipitate 85% of amputations: Rule of 15
15% of diabetes patients Foot ulcer in lifetime

15% of foot ulcers Osteomyelitis

15% of foot ulcers Amputation


Clinical Care of the Diabetic Foot, 2005
FOOT ULCERS IN DIABETES
Costly:
$30,000/ulcer
$9 billion/y total costs

Tragic:
Quality of life: ulcer patient s amputation patient
Burden of non-weight-bearing as ulcer heals
Lifetime behavioral adaptations to prevent recurrence
Fear of recurrent ulcer/amputation
70% ulcer recurrence in s 3y

Foot Ankle Int 2005; 26:32, 128 Clin Infect Dis 2004; 39(Suppl 2):S129

Sensory + Joint Motor Autonomic PAD
Neuropathy Mobility Neuropathy Neuropathy

+Protective Muscle atrophy and + Sweating Ischemia
sensation 2 foot deformities 2 dry skin

Foot pressure | Foot pressure Fissure + Healing
+Minor trauma esp. over
recognition bony prominences


Callus Pre-ulcer ULCER Infection AMPUTATION
Minor Trauma: Interdigital Maceration
Mechanical (Moisture, Fungus)
Chemical
Thermal
PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION
OTHER RISKS FOR ULCER/AMPUTATION
Failure to adequately care for the feet:
Inadequate patient education
Inadequate patient motivation
Depression, anxiety, anger more common in diabetes
Physical disability
Cannot see feet 2 to retinopathy
Cannot reach feet 2 to obesity, age (?50% of patients)
Limited access to medical services

Age Ageing 1992; 21:333 Diabetes Care 2003; 29:495 Diab Metab Res Rev 2004; 20(Suppl 1):S13
CAUSAL PATHWAYS FOR FOOT ULCERS
% Causal Pathways
NEUROPATHY Neuropathy: 78%
Minor trauma: 79%
DEFORMITY Deformity: 63%
Behavioral issues ?
MINOR TRAUMA
- Mechanical (shoes) POOR SELF-
- Thermal FOOT CARE
- Chemical

ULCER
Diabetes Care 1999; 22:157
DETECTING FEET-AT-RISK
History:
Prior amputation
Prior foot ulcer
PAD: known or claudication at < 1 block

Exam:
Insensate to 5.07/10g monofilament
Major foot deformities
PAD
Absent DP and PT pulses
Prolonged venous filling time
Reduced Ankle-Brachial Index (ABI)
Pre-ulcerative cutaneous pathology
Arch Intern Med 1998; 158:157
RISK STRATIFY FOR FOOT ULCERATION
Foot Ulcer, % Office Patients
Risk Level %/yr (diabetes clinics)
3: prior amputation 28.1% 7%
prior ulcer 18.6%

2: insensate 6.3% 10%
and
foot deformity
or
absent pedal pulses

1: insensate 4.8% 17 - 30%

0: all normal 1.7% 66%

Diabetes Care 2001; 24:1442 Diabetes Metab 2003; 29:261
PHYSICAL EXAMINATION OF THE FEET
IN PERSONS WITH DIABETES
SENSORY NEUROPATHY IN DIABETES
Loss of protective sensation in feet
Sensory loss sufficient to allow painless skin injury
Major risk factor for foot ulcer in diabetes
Detect with 5.07/10g Semmes-Weinstein monofilament
Prevalence of insensate feet to 10g monofilament:
Age > 40y: 30% of diabetic patients
Age > 60y: 50% of diabetic patients
Up to 50% have no neuropathic symptoms

Diabetes Care 2006; 29(Suppl 1):S24 Diabetes Care 2004; 27:1591
UTILITY OF MONOFILAMENT TESTING
Predicts ulcer/amputation in 5 prospective studies:
NPV (normal sensing) = 90-98%
PPV (fail to sense) = 18-36%
Prospective 32 mo observational study:
80% of ulcers/100% of amputations in insensate feet
Superior predictive value to other tests:
Pin prick, cotton wisp, symptoms
? 128 Hz tuning fork?
ADA recommendation, 2006: also test vibration


Diabetes Care 2006; 29(Suppl 1):S25 J Fam Pract 2000; 49:S30 Diabetes Care 1992; 15:1386
USING THE 5.07/10gm MF (Tool-Kit)

Demonstrate sensation on
the forearm or hand
Place monofilament
perpendicular to test site
Bow into C-shape for one
second
Test four sites/foot: Predicts
95% of ulcer formers vs. 8
sites
Heel testing does not
discriminate ulcer formers
Avoid calluses, scars, and
ulcers
USING THE 5.07/10g MF (Tool-Kit)
Minimize bias:
Test sites in random sequences
Test each site X3, sham test as 1 of 3
Do you feel it? Yes or No?
Retest site if patient fails (misses 2/3 responses)
Insensate at 1 site = insensate feet
Falsely insensate with edema, cold feet
Test annually when sensation normal
Use < 100x/d; replace if bent; replace q 3 mo.
Purchase calibrated MF (See Tool-Kit)
PAD IN DIABETES
Prevalence (ABI < 0.9): 20-30%
10-20% in type 2 diabetes at Dx
30% in diabetics > age 50y
40-60% in diabetics with foot ulcer

Complications:
Claudication and functional disability
Increases risk for concurrent CAD and CVD
Delays ulcer healing
Increases amputation risk
Not increase foot ulcer risk

JACC 2006; 47:921 Diabet Med 2005; 22:1310 Diabetes Care 2003; 26:3333
HX TO DETECT PAD IN DIABETES
Claudication at < 1 block suggests severe ischemia
Vascular Level Site of Pain
Aorto-iliac Buttocks/Thigh
Femoral Calf
Tibioperoneal Foot/Ankle

Rest pain indicates critical ischemia
Toes and forefoot
Difficult to distinguish from neuropathic pain
INTERPRETATION OF THE ABI
ABI
Normal 0.91-1.30
Mild obstruction 0.71-0.90
*Moderate obstruction 0.41-0.70
*Severe obstruction s 0.40
**Poorly compressible >1.30
2 to medial Ca
++

*Poor ulcer healing with ABI s 0.50
**Further vascular evaluation needed
MOTOR NEUROPATHY AND FOOT DEFORMITIES
Hammer toes

Claw toes

Prominent metatarsal heads

Hallux valgus

Collapsed plantar arch
From Levin and Pfeifer, The Uncomplicated Guide
to Diabetes Complications, 2002
Hammer
Toes



Claw Toes
From Levin and Pfeifer, The Uncomplicated
Guide to Diabetes Complications, 2002
Hallux
Valgus
From Boulton, et al Diabetic Medicine 1998, 15:508
PRE-ULCER CUTANEOUS PATHOLOGY
Neuropathy inappropriate footwear:
Persistent erythema after shoe removal
Callus
Callus with subcutaneous hemorrhage: pre-ulcer

Autonomic neuropathy and secondary dry skin:
Fissure ulceration
Augment callus formation

Poor self-care of the feet:
Interdigital maceration with fungal infection
Nail pathology
RISK-STRATIFIED FOOTCARE
MANAGEMENT FOR DIABETES PATIENTS
LOW RISK: CATEGORY 0 PATIENTS
Annual comprehensive foot examination
Questionnaire completed by patient in waiting room
Examination form with decision-support
(See Tool-Kit)
Every visit visual inspection if higher risk
Racial/ethnic minorities; alcoholism; homeless

Basic education: self-management, appropriate
footwear
Brief counseling
Written handout

JAMA 2005; 293:217
HIGH RISK: CATEGORY 1-3 PATIENTS
Annual comprehensive foot exam

Inspect feet at every office visit

Podiatry care stratified to risk level

Intensive patient education

Detect/manage barriers to foot care

Therapeutic footwear, if needed
HIGH RISK: CATEGORY 1-3 PATIENTS
Nursing tasks to facilitate foot exams:
High Risk Feet stickers to each chart (Tool-Kit)
Remove patients shoes/socks
Increases % of foot exams in observational studies
Determine that patient can reach/see soles of feet
Stock 10g monofilament in each room
Consider training to perform 10g monofilament exam
Provide patient education forms
Literacy/language appropriate

Diabetes Care 1983; 6:499 J Gen Intern Med 2003; 18:258
HIGH RISK: CATEGORY 1-3 PATIENTS
Regular prophylactic podiatry care:
Provide nail and skin care
Assess footwear needs
RCT: 48% RRR for recurrent ulceration
Optimal visit frequency not evidence-based:
Category 1 q 3-6 mo
Category 2 q 2-3 mo
Category 3 q 1-2 mo

Diabetes Care 2003; 26:1691 J Fam Practice 2000; 49(Suppl):S30
HIGH RISK: CATEGORY 1-3 PATIENTS
Intensive patient education:
1 care clinician, podiatrist, educator contribute
Reinforce frequently low retention documented
Patient to demonstrate self-care knowledge
Questionnaires, tests are available (see Tool-Kit)
Utility:
? Reduced foot ulcer/amputation rates?

Cochrane Database Syst Rev 2005 Jan 25;(1)CD001488 Foot Ankle Int 2005; 26:38
BASIC FOOT CARE CONCEPTS
Daily foot inspection
May require mirror, magnification, or caregiver
Educate patient to recognize/report ASAP:
Persistent erythema
Enlarging callus
Pre-ulcer (callus with hemorrhage)
BASIC FOOT CARE CONCEPTS
Commitment to self-care:
Wash/dry daily
Avoid hot water; dry thoroughly between toes
Lubricate daily (not between toes)
Debride callus/corn to reduce plantar pressure 25%
Avoid sharp instruments, corn plasters
No self-cutting of nails if:
Neuropathy, PAD, poor vision
BASIC FOOT CARE CONCEPTS
Protective behaviors:
Avoid temperature extremes
No walking barefoot/stocking-footed
Appropriate exercise if sensory neuropathy
Bicycle/swim > walking/treadmill
Inspect shoes for foreign objects
Optimal footwear at all times
FOOT CARE EDUCATION TOOLS
Diabetic Foot Care
American Orthopedic Foot and Ankle Society
Multilingual translation
Available in 20 languages
Reference:

EDUCATIONAL DEFICIENCIES:
HIGH RISK PATIENTS
558 high risk patients:
Deficiency % Deficient
Not inspect feet regularly 50%
Walk barefoot/stockings 62%
Seldom/never test water temp. 40%
Trim callus with sharp object 48%
Not know to call ASAP for foot ulcer 58%
Not know how to select footwear 57%
From GE Reiber, 2003
BASIC FOOTWEAR EDUCATION
Avoid:
Pointed-toes
Slip-ons
Open-toes
High heels
Plastic
Black color
Too small
Favor:
Broad-round toes
Adjustable (laces, buckles,
Velcro)
Athletic shoes, walking shoes
Leather, canvas
White/light colors
between longest toe and
end of shoe
Diabetes Self-Management 2005; 22:33
THERAPEUTIC FOOTWEAR: GOALS
Inappropriate footwear:
Contributes to 21-76% of ulcers/amputations
Optimal footwear should:
Protect feet from external injury
Reduce plantar pressure, shock and shear forces
Accommodate, stabilize, support deformities
Suitable for occupation, home, leisure

Diabetes Care 2004; 27:1832 Diab Metab Res Rev 2004; 20(Suppl1):S51
THERAPEUTIC FOOTWEAR: COMPONENTS
Padded socks (eg. CoolMax, Duraspun, others)
Cushion metatarsal heads, heels, and decrease plantar
pressure
White, seamless, absorbent acrylic fibers
Shoe inserts/insoles (closed-cell foam, viscoelastic)
Off-the-shelf
Custom-molded
Therapeutic shoes
Extra-depth extra-width
Rigid rocker outsoles
Custom-molded
FOOTWEAR RECOMMENDATIONS BY RISK LEVEL

Low Risk (0) Proper style/fit, cushioned stock shoes

+ Sensation (1) Deep toe box shoes, cushioned insoles

Callosities, ulcer Hx Extra-depth stock shoes, custom-molded insole

Severe deformities Custom-molded extra-depth shoes and insoles,
rigid rocker outsoles

Modified from The Foot in Diabetes, 2000, p.136
THERAPEUTIC FOOTWEAR: EFFICACY
Decreases plantar pressure 50-70%
Uncertain reduction in ulcer rate:
1 prevention: no data
2 prevention: controversial reduction of ulcer recurrence
Analytic/descriptive studies decreases ulcers 50-75%
2 RCTs no benefit
Benefits vary with footwear use, risk level?
Severe foot deformity, prior toe/ray amputation?

Diabetes Care 2004; 27:1774
Referencs
1. http://www.worldwidewounds.com/2005/july/Romanelli/Wound-Bed-Preparation-Pressure-
Ulcer.html#Romanelli-ear
2. http://diabeticfootsalvage.blogspot.in/
3. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009).
Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington DC:
National Pressure Ulcer Advisory Panel. http://www.npaup.org
4. www.aafp.org
5. http://en.wikipedia.org/wiki/Braden_Scale_for_Predicting_Pressure_Ulcer_Risk
6. www.niddk.nih.govhttp://ndep.nih.gov/materials/pubs/feet/broch
ure/index.htm
7. www.ndep.nih.gov/diabetes/pubs/FootTips.pdf
8. www.ndep.nih.gov/diabetes/pubs/feet_kit_Eng.pdf
9. Trepman E, et al. Foot and Ankle International
2005; 26:64-107.


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