WOUNDS UK DEBATE Diabetic foot or pressure ulcer on the foot? Diabetes is one of the greatest health A pressure ulcer is defined as an The National Institute for Health challenges facing the United Kingdom area of localised damage to the skin and Clinical Excellence provide (UK) today, with 2.5 million people caused by prolonged or excessive soft guidance for practitioners on best diagnosed with diabetes in the UK, tissue pressure along with shear or practice treatment on individuals not including up to half a million friction, or a combination of these with either a diabetic foot ulcer people who have the condition but (European Pressure Ulcer Advisory (NICE, 2004) or a pressure ulcer are unaware of it (Diabetes UK, 2009). Panel [EPUAP], 2005). (NICE, 2005). However, how can we be satisfied that appropriate Disease of the foot is a The heel has been identified guidance is being followed by the complication of diabetes caused by as the second most common site multidisciplinary team? Diabetes UK damage to the nerves and blood for pressure ulcer development, strongly recommend that effective vessels that serve the limbs (Diabetes accounting for up to 28% of all management of disease of the foot in UK, 2009). Active foot disease may be reported ulcers (Barczak et al, 1997). diabetes, requires effective integration either of recent onset or chronic Indeed, Clark et al (2004) concurred, of the input of different healthcare but deteriorating. identifying in their survey that 261 professionals, who together have the (25.8%) patients experienced their skills necessary to assess and treat The term active foot disease refers most severe ulcers in the heel area. foot lesions. KO to anyone with diabetes who has: 8 An ulcer, blister or break in the Published literature has skin of the foot identified inconsistencies, and 8 Inflammation or swelling of any deficits, in the knowledge base Do practitioners differentiate between a part of the foot, or any sign of many healthcare professionals diabetic foot ulcer and a pressure ulcer of infection involved in the management of on the foot? 8 Unexplained pain in the foot diabetic foot disease and diabetic 8 Fracture or dislocation in the foot ulceration (Mitchell et al PC: This whole area relates foot with no preceding history of 2000; Mackie, 2006). One survey to the use of strict definitions significant trauma investigated the educational needs regarding the grading and classifying 8 Gangrene of all or part of the of nurses involved in wound care, of lower extremity wounds. It has foot (Diabetes UK, 2009). by exploring areas of deficiency become more problematic due to and proficiency in education and the admirable drive to reduce the People at highest risk are those practice (Edwards et al, 2005). They number of pressure ulcers. I think who have a previous history of ulcers, highlighted that 35% of nurses had many practitioners struggle to neuropathy or nerve damage and only minimal knowledge of the differentiate between a pressure ulcer circulatory problems. diabetic foot, despite the fact that (PU) and a diabetic foot ulcer (DFU). 85% of the nurses questioned were A recent prevalence survey in my involved in the management of local hospital showed a larger than diabetic foot ulceration (Edwards expected increase in the number of et al, 2005). This may be surprising, pressure ulcers. When this data was Karen Ousey (KO) is Reader, Advancing yet it evokes the question of examined, it was found that nursing Clinical Practice, School of Human and staff on the ward were counting all Health Sciences, University of Huddersfield; whether individuals with diabetes Paul Chadwick (PC) is Principal Podiatrist, are receiving optimum care, and DFUs as pressure ulcers. While this Department of Podiatry, Hope Hospital, Salford; if practitioners are being taught may be strictly true in that most DFUs Leanne Cook (LC) is Lecturer Practitioner, how to undertake an effective and have some kind of pressure within Division of Podiatry, Department of Health evidence-based assessment of their aetiology, most DFUs (with the Sciences, University of Huddersfield health needs. obvious exception of heel wounds) Wounds UK, 2011, Vol 7, No 3 105 Debate7(3)C.indd 3 06/09/2011 09:00 WOUNDS UK DEBATE PC: The paradox is that often within DFU management, reduction of mobility to offload the ulcer is advocated, whereas the focus of pressure ulcers is to keep people moving and mobilise where possible. LC: ... the real issue is not whether the ‘label’ of the wound is correct, but that the patient receives the most appropriate care through assessment and correct referral within a prompt time-frame to a ‘specialist’ in that area. are not ‘classic’ pressure ulcers. Work status, risk factor management and the most appropriate care through done by McIntosh and Ousey (2008) diabetes management. assessment and correct referral within confirmed this confusion. When they a prompt time-frame to a ‘specialist’ showed a picture of a wound on a Is there in fact a difference? in that area. These are commonly heel of a patient with diabetes to a attached to the diabetic centres where cohort of podiatrists and a cohort PC: There is a difference, but I full assessment is undertaken in line of nurses, they found that ‘nurses think confusion lies with the term with NICE guidance, and links are were generally of mixed opinion, with ‘pressure’ ulcer. Many ulcers, including established to provide access to the 46% claiming they would manage DFUs, have a type of pressure within full multidisciplinary team, including this wound as a pressure ulcer and their aetiology which could be, diabetologist, diabetic nurse specialists, 54% as a diabetic foot ulcer. There among others, shear or intermittent dieticians, orthopaedic consultants, was a general consensus across the compressive stress. What most vascular consultants, etc. podiatrists that this wound would people mean by a pressure ulcer, be managed as a diabetic foot ulcer as defined above by EPUAP may Do you think treatment for foot ulcers (85%), with the minority (15%) involve shear, but is most commonly is dependent on which healthcare providing pressure ulcer care’. also associated with immobility and professional group assesses the individual consistent pressure. The old-fashioned on first contact? LC: I believe that many term of decubitus ulcer or bed sore practitioners try to differentiate could be seen as more appropriate. PC: As the work above by between diabetic foot ulceration The paradox is that often within DFU McIntosh and Ousey (2008) supports, and pressure ulceration, as many management, reduction of mobility to it obviously does. I think the message understand the need for correct offload the ulcer is advocated, whereas needs to be, that with all ulcers, the diagnosis of aetiology to ensure that the focus of pressure ulcers is to aetiology is the primary factor to effective treatment is recommended. keep people moving and mobilise address. If the cause is due to a patient The difficulty comes when the where possible. being immobilised, use of pressure- ulceration may have a number relieving supports and repositioning of causative factors, for example, LC: There are differences between is vital. If the aetiology is due to a patient with diabetes who has pressure ulcer per se and diabetic neuropathy and resultant altered foot peripheral arterial disease with foot lesions, but pressure from an ill- shape and abnormal stresses, the reduced mobility develops a heel fitting shoe can cause ulceration in use of offloading devices to reduce ulcer. Is this due directly to pressure, the diabetic foot patient. Is this due to mobility and subsequent stresses is ischaemia or secondary to diabetic pressure or underlying neuropathy? also vital. The common denominator is neuropathy, or is it ok just to say the The neuropathy precludes the patient the reduction of pressure. The role of ulcer is multifactorial? What is vital from having normal protective pain addressing systemic factors and taking for effective management is to ensure sensations. Then again, you could argue an holistic approach to care within that all patients with diabetes who that spinal injuries are insensate, but if the management is also crucial. Thus, develop foot ulceration, regardless a sacral pressure ulcer developed on addressing diabetes control, vascular of the location of the ulcer or a spinal patient who had been sitting supply, managing infection, etc need to whether it is thought to be directly on an inappropriate surface for a be central. related to pressure, are seen and number of hours, you would be clear assessed by a member of staff, be that this has developed due to direct LC: Yes most certainly, the focus that medical, nursing or podiatry, who pressure. The important message to on treatment depends greatly on are competent at holistic assessment get across is that the real issue is not which healthcare practitioner group of the diabetic foot. This includes whether the ‘label’ of the wound is the patient is seen by. In general, assessment of neuropathy, arterial correct, but that the patient receives community nursing teams tend to 106 Wounds UK, 2011, Vol 7, No 3 Debate7(3)C.indd 4 06/09/2011 09:00 WOUNDS UK DEBATE LC: Amputations are highly costly procedures both financially and, more importantly, in terms of the negative effect on patient quality of life. PC: ... the nurse should be able to recognise a problem and have unfettered access to expert opinion. This role of identification should be supported again by good multidisciplinary team-working and education. focus on wound bed preparation, PC: I think this is a broad a vital role in the management of and community podiatry teams on statement. I know some nurses who both acute and chronic diabetic foot aspects of pressure from footwear have an excellent knowledge of the ulceration and are key members of and offloading techniques.