Foot and Nail Care J Wound Ostomy Continence Nurs. 2019;46(3):241-245. Published by Lippincott Williams & Wilkins Guidelines for Diabetic Foot Care A Template for the Care of All Feet Tara L. Beuscher he specialty of nursing foot care is growing rapidly. In Seventy-fi ve percent of LEAs are performed in patients with T 2005, the Wound Ostomy Continence Nursing Certifi ca- diabetes. Worldwide 200,000 individuals with diabetes un- tion Board initiated the certifi ed foot care nurse credential that dergo amputation each year, with an incidence ranging from 3 provided a mechanism for this specialty to fl ourish, with over 78 to 704 per 100,000 people. In the United States, over 1000 certifi ed nurses. Th ese nurses are prepared to care for 83,000 amputations, or 230 individuals have an amputation performed each day. Th ese prevalence statistics are expected to individuals with numerous problems ranging from dystrophic rise as the population of older adults and those with diabetes toenails to heel fi ssures. Almost 50% of older individuals, and increase, with a 2-fold increase expected in men. 4 those with chronic conditions aff ecting the feet and functional Foot ulcers are often precursors of LEA. It is estimated that, impairments who are unable to care for their lower legs, are annually, foot ulcers develop in 9.1 million to 26.1 million in dire need of foot care. However, those at highest risk for people with diabetes worldwide. 5 Th e lifetime incidence of poor foot health outcomes and in greatest need are persons foot ulcers is between 19% and 34% of persons with diabetes.6 with diabetes. Interprofessional teams that include foot care Th e risk of death at 5 years for a person with a diabetic foot nurses have been shown to improve outcomes by identifying ulcer is 2.5 times higher than for an individual with diabetes high-risk individuals and targeting prevention and delivery of who does not have a foot ulcer.7 Ulcer infection and peripheral focused foot care and education. 1 Th e purpose of this article is artery disease (PAD) increase the risk of amputation. 2-fold: to review the scope of diabetes-related foot conditions Peripheral artery disease is generally caused by accelerat- ed atherosclerosis and is present in up to 50% of patients with and complications, and describe established national and in- a diabetic foot ulcer. Peripheral artery disease is an important ternational guidelines for prevention and management; and, risk factor for impaired wound healing and LEA. A small por- to introduce a comprehensive examination model designed to tion of foot ulcers are purely ischemic; these ulcers are usually identify risk factors for foot complications associated with dia- painful and caused by minor trauma. Th e majority of PAD- betes that can act as a template for examining all feet. related foot ulcers are neuro-ischemic, caused by combined neu- ropathy and ischemia, and induced by trauma such as friction and DEMOGRAPHICS AND COMPLICATIONS OF pressure. In these patients symptoms may be absent because of the DIABETES neuropathy, despite severe pedal ischemia. Diabetic microangiop- athy (so-called “small vessel disease”) is not likely to be the prima- In the United States, 1.5 million individuals are diagnosed ry cause of an ulcer or poor wound healing in patients with PAD.5 with diabetes mellitus every year. In 2015, 30.3 million or With appropriate therapy—surgical debridement, off -loading 9.4% of the population had diabetes; however, 23.1 million of pressure, attention to infection, and if necessary, vascular were diagnosed while 7.2 million remained undiagnosed. Th e reconstruction—diabetic foot ulcers heal in many patients, highest population group is older adults 65 years and older, and the need for amputation is averted. Unfortunately, even representing 25.2% or 12 million individuals with both di- after the resolution of a foot ulcer, recurrence rates are high: agnosed and undiagnosed diabetes. Diabetes remains the sev- approximately 40% reoccur within 1 year of ulcer healing, 2 enth leading cause of death in the United States. In 2015, the 60% within 3 years, and 65% within 5 years. Factors associat- global prevalence of diabetes mellitus was reported to be 8.8%, ed with recurrence include peripheral neuropathy, foot defor- 3 which corresponds to 415 million individuals. mity, increased plantar stress, and peripheral vascular disease, While it is diffi cult to obtain accurate prevalence data on which are concomitant conditions and generally not resolved foot-related consequences of diabetes, estimates remain stag- following ulcer healing. 6 gering. One of the most devastating consequences is lower Research on prevention of foot ulcers is sparse. It is esti- extremity amputations (LEAs) that often occur as a result mated that 75% of foot ulcers in persons with diabetes are of neurologic and vascular changes associated with diabetes. preventable. 8 Guidelines have been developed to reduce the risk of foot ulceration both internationally 9 and nationally. 10 , 11 Tara L. Beuscher, DNP, Doctors Making Housecalls, Durham, North Carolina. Years of guideline implementation led to a steady decline in The author declares no confl icts of interest. the LEA rate in the United States between 1999 and 2009. Correspondence: Tara L. Beuscher, DNP, Doctors Making Housecalls, Unfortunately, there has been a slight increase since then, par- 2511 Old Cornwallis Rd, Ste, 200, Durham, NC 27713 ( tbeuscher@ ticularly in younger age groups, 12 hence the need to continue doctorsmakinghousecalls.com ). the focus on prevention. Guidelines developed by the Interna- DOI: 10.1097/WON.0000000000000532 tional Working Group on the Diabetic Foot (IWGDF) include Copyright © 2019 by the Wound, Ostomy and Continence Nurses Society™ JWOCN ¡ May/June 2019 241 Copyright © 2019 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. 242 JWOCN ¡ May/June 2019 www.jwocnonline.com 5 key elements that underpin prevention of foot problems: (1) identifi cation of the at-risk foot; (2) regular inspection and ex- amination of the at-risk foot; (3) education of patient, family, and healthcare providers; (4) routine wearing of appropriate footwear; and (5) treatment of preulcerative signs. 5 Foot care nurses can provide a vital service in implementing guidelines to identify the high-risk condition, and prevent the occurrence of foot ulcers and other complications. IDENTIFICATION OF THE AT-RISK FOOT History Taking a focused history is the basis for identifi cation of the at-risk foot. Ask the person with diabetes about the history of previous foot ulceration or LEA, PAD, foot deformity, Figure 1. Toe deformities (ScienceDirect.com). preulcerative signs on the foot including callus, blistering, or hemorrhage, ability to perform foot hygiene by self or with assistance of other, and type and frequency of wearing foot- PAD wear. 5 Individuals may not be aware if footwear is ill-fi tting or Inspect the feet using the 6 “Ps” as a guide to detect arterial inadequate. Persons with poor eyesight, diminished sensation insuffi ciency and critical limb ischemia. Th e Ps include pallor of the feet, or inability to position feet for self-inspection may (pale), pain, paresthesia (abnormal sensations), polar or poi- not be aware of skin problems. kilothermia (cold), paralysis, and pulselessness. Dry fl aky or shiny skin are also signs of PAD. Skin Conditions Callus is a thickened hyperkeratotic tissue that is a response to Peripheral Neuropathy stress, pressure, fi ction, or sheering forces from ill-fi tting foot- Both the IWGDF and the American Diabetes Association wear. Initially, a callus is a protective mechanism; however over (ADA) recommend annual examination of the feet to iden- time, the callus can become so thick and hard that it creates tify signs or symptoms of peripheral neuropathy. Th e ADA 10 even more pressure and can ulcerate. Dark red streaks espe- recommends the use of the 10-g monofi lament along with at cially in the center of calluses are considered a preulcerative least one other test (pinprick, ankle refl ex, and vibration) to lesion. Fluid-fi lled blisters can occur with friction/sheer forces identify peripheral neuropathy. and should be investigated and managed. 13 Th e monofi lament is placed on the plantar surface skin in several places ( Figure 2 ), hard enough to bend without sliding. Hygiene Instruct the patient to close eyes. Th en ask the patient to iden- Poor foot hygiene can occur when individuals are unable to tify (say yes) when the monofi lamentes touch the skin. Ab- physically care for their feet or do not have the environment or sence of sensation in one or more of the tested areas suggests equipment in which to do so. Skin that is too dry or too moist loss of protective sensation. can crack leading to fi ssures. Disrupted skin integrity can act as Select one of the following tests to perform in addition to a portal of entry for infection. Feet should be free of dirt and monofi lament testing: pinprick, ankle refl exes, or vibration. debris, which helps to decrease microbial burden and allows for Th e 128-Hz tuning fork can be used to test vibratory sensa- direct visualization of skin. Supple skin is better able to remain tion. Th e patient is asked to close eyes. Th e examiner strikes intact when in contact with friction forces associated with wear- ing shoes and ambulation. Routine application of fragrance-free lotion or cream can assist in keeping dry skin supple. Proper care of the toenails is an important aspect of hygiene. Individuals may require assistance with nail care, especially if nails are thick or hard. Fungal infections are common infections of the nails, aff ecting 14% to 23% of the population worldwide.