Diabetic foot ulcers (DFUs) or Pressure ulcer?
In this blog we will be looking at the risk factors of developing a pressure ulcer for residents with diabetes. Pressure ulcers and diabetic foot ulcers otherwise known as DFU, can often be difficult to diagnose. This requires the specialist input and advice from a podiatrist. As a rule of thumb anybody with diabetes with a below ankle foot ulcer should be referred to podiatry for advice.
Why is the diabetic foot so vulnerable to ulceration?
Neuropathy (nerve damage)
Hypoglycaemia (uncontrolled blood sugars)
A common condition in diabetes in the latter stages where there is uncontrolled glycaemic control may be a condition called peripheral neuropathy. This is where there is reduced sensation in the feet due to nerve damage, meaning your resident may be walking around with an innocent looking pair of slippers on, however only needs to be very very small bump in that slipper to be causing continuous pressure and friction leading to an alteration. If the resident equally has any circulation issues these ulcers can be very hard to heal. Another cause is ischaemia due to large and/or small vessel disease. Due to this a susceptibility of an underlying infection for ischaemic foot ulcers on the diabetic patient a specialist management plan will be detailed by the podiatrist, this is key as quite often these types of wounds are kept dry rather than the moist wound healing environment we would think of for other ulcers to encourage healing.
Signs of neuropathy may include:
Reduced sensation on the foot
Cracks in the skin (fissures). This is very common in aging feet and a Urea based ointment should be part of the daily skin routine. Get advice from the GP on what Urea ointment to recommend.
“Every 30 seconds a lower limb is lost to diabetes somewhere in the world”
“Up to 85% of all amputations began with an ulcer”
”People with diabetes are 40 times more likely to undergo lower extremity amputation than those without diabetes.”
Bakker K, Time to Act; Diabetes and Foot Care International Diabetes Federation, International Working Group on the Diabetic Foot. 2005 p34
In my experience as a pressure ulcer investigator, quite often here, where there has been a reported deep tissue injury on the foot of the resident, if this resident is diabetic it may be called a diabetic foot ulcer before being seen by a podiatrist.
This can be a grey area and we have to be careful here, because somebody is diabetic we cannot assume that the ulceration has not been caused by a degree of pressure, if the resident has peripheral neuropathy secondary to their diabetes even though they cannot feel the bump in their slipper is still caused by pressure.
It is therefore vital that staff are aware of the referral process for diabetic residents, that they are checking the skin and applying prevention pathways, and delivering foot care prevention planning.
To do this we need to include in our risk assessments foot care prevention planning to diabetic residents, along with advice and prevention strategies on how to care for the feet must be explained and given to the resident if they have capacity.
When it comes to skin inspection feet is one area of the body the resident may be able to check themselves, giving the resident information and instructions on foot care enables a good self-care model and informed design making.
When it comes to a root cause analysis for a deep tissue injury on a diabetic patient, remember with one of the above complications, diabetes may be a largely contributing factor, BUT we must have this evidenced by an expert such as a podiatrist or Tissue viability nurse and be able to evidence that there were no omissions in care for the standard pressure ulcer prevention principles.
Using the SSKIN care model will help with your assessment for potential omissions in care.
As NHS Improvement has recently recommended updating the SSKIN to ‘ASSKING’ which now includes A=Assessment and G=Giving information. For those with complications we must now evidence we have assessed this risk due to there contusion and given the resident and/or carer this information where possible so they are informed.
See below link for the (2015) NICE guidelines on prevention and management of diabetic foot complications.
Another great resource is available at Age UK. See below link: