These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from the Registered Nurses' Association of Ontario. Appropriate credit or citation must appear on all copied materials as follows: Registered Nurses' Association of Ontario (2013). Assessment and Management of Foot Ulcers for People with Diabetes (2 nd ed.). Toronto, ON: Registered Nurses' Association of Ontario.# Assessment and Management of Foot Ulcers for People with Diabetes

# Second Edition
Greetings from Doris Grinspun, Chief Executive Officer, Registered Nurses' Association of Ontario
The Registered Nurses' Association of Ontario (RNAO) is delighted to present the second edition of the clinical best practice guideline, Assessment and Management of Foot Ulcers for People with Diabetes. Evidence-based practice supports the excellence in service that health professionals are committed to delivering every day. RNAO is pleased to provide you with this key resource, selected by the Council of the Federation for national implementation.
We offer our heartfelt thanks to the many stakeholders that are making our vision for Best Practice Guidelines (BPG) a reality: the Government of Ontario, for recognizing RNAO's ability to lead the program and for providing multi-year funding; Drs. Irmajean Bajnok and Monique Lloyd, Director and Associate Director (respectively) of the RNAO International Affairs and Best Practice Guidelines (IABPG) Centre, for their expertise and leadership in advancing the development of BPGs; and Expert Panel Chair Laura Teague, Wound Specialist at Saint Michael's Hospital in Toronto, Canada, for her exquisite expertise and stewardship of this guideline. Thanks also to RNAO staff Rishma Nazarali, Sarah Xiao, Anastasia Harripaul and Andrea Stubbs, for their intense work in the production of this second edition. Special thanks to the entire BPG Expert Panel for generously providing time and expertise to deliver a rigorous and robust clinical resource. We couldn't have done it without you! The nursing and health-care community, with their unwavering commitment and passion for excellence in patient care, have provided the expertise and countless hours of volunteer work essential to the development and revision of each guideline. Employers have responded enthusiastically by nominating best practice Champions, implementing guidelines, and evaluating their impact on patients and organizations. Governments at home and abroad have joined in this journey. Together, we are building a culture of evidence-based practice.
Successful uptake of BPGs requires a concerted effort from educators, clinicians, employers, policy makers and researchers. After lodging the evidence into their minds and hearts, knowledgeable and skillful health professionals and students need healthy work environments to enable guideline use and practice changes.
We ask that you share this guideline with members of the interprofessional team, as there is much to learn from one another. Together, we must ensure that the public receives the best possible care every time they come in contact with us -making them the real winners in this important effort! Doris Grinspun, RN, MSN, PhD, LLD (Hon), O. ONT. Chief Executive Officer Registered Nurses' Association of Ontario

# How to Use this Document
This nursing best practice guideline G is a comprehensive document that provides resources necessary for the support of evidence-based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client G. This guideline should be applied as a tool or template that is intended to enhance decision making in the provision of individualized care. In addition, the guideline provides an overview of appropriate structures and supports necessary for the provision of the best possible evidence-based care.
Nurses, other health-care professionals and administrators who lead and facilitate practice changes will find this document invaluable for the development of policies, procedures, protocols, educational programs and assessments, interventions and documentation tools. Nurses providing direct care will benefit from reviewing the recommendations, the evidence G in support of the recommendations and the process that was used to develop this edition of the guideline. However, it is highly recommended that practice settings/environments adapt these guidelines in formats that would be user-friendly for daily use. This guideline has some suggested formats for local adaptation and tailoring.
Organizations adopting the guideline are advised to carry out the following processes: a) Assess current nursing and health-care practices using the recommendations in the guideline. b) Identify recommendations that will address needs or gaps in services. c) Develop a plan to implement the recommendations systematically using associated tools and resources, with particular attention to the RNAO Implementation Toolkit (2012b).
The Registered Nurses' Association of Ontario is interested in hearing how you have implemented this guideline. Please contact us to share your story. Implementation resources are available through the RNAO website (www.RNAO.ca) to assist individuals and organizations to implement best practice guidelines.
Throughout this document, terms marked with the superscript symbol G ( G can be found in the Glossary of Terms (Appendix A).

# BAC K G R O U N D
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Purpose and Scope
Best practice guidelines are systematically developed statements designed to assist nurses and clients in decision making about appropriate health care (Field & Lohr, 1990). This guideline has been developed to address the question of how to assess and manage people with established diagnosis of diabetic foot ulcer(s) G. It provides evidencebased recommendations to all nurses and the interprofessional team G who provide care in all health-care settings to people (>15 years of age) with type 1 and/or type 2 diabetes and who have established diabetic foot ulcers.
Caring for people with diabetic foot ulcers is an interprofessional endeavour. Effective care depends on a coordinated interprofessional approach incorporating ongoing communication between health-care professionals and people with diabetic foot ulcers. It is, however, acknowledged that personal preferences and unique needs as well as the personal and environmental resources available to each client must always be considered in the delivery of care. The intent of this document is to assist all nurses and the interprofessional team to focus on evidence-based strategies, within the context of the health-care professional-client relationship. It is further acknowledged that individual competencies of nurses may vary among nurses and across categories of nursing professionals. These competencies are based on knowledge, skills, attitudes and judgment enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of care for which they have received appropriate education and experience. All nurses should seek consultation in instances where the client's care needs surpass the individual nurse's ability to act independently.
See Appendix A for a glossary of terms. See Appendices B and C for the guideline development process and process for systematic review G /search of the literature.

# BAC K G R O U N D
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Summary of Recommendations
This guideline is a new edition of, and replaces, the 2005 publication of the RNAO Nursing Best Practice Guideline: Assessment and Management of Foot Ulcers for People with Diabetes. Recommendations are marked as , , or NEW according to the following:
 No change was made to the recommendation as a result of the systematic review evidence.
 The recommendation and/or supporting evidence were updated as a result of the systematic review evidence.
NEW A new recommendation was developed as a result of the systematic review evidence.

# PRACTICE RECOMMENDATIONS G

# LEVEL OF EVIDENCE
Assessment 1.0 Obtain a comprehensive health history and perform physical examination of affected limb(s).

# Ib -IV

# Stakeholder Acknowledgement
Stakeholders G representing diverse perspectives were solicited for their feedback, and the Registered Nurses' Association of Ontario wishes to acknowledge the following individuals for their contribution in reviewing this Nursing Best Practice Guideline.

# BAC K G R O U N D
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Background Context
Diabetes mellitus is a serious and complex life-long condition affecting 8.3% of the world's population and 2.7 million Canadians (Canadian Diabetes Association (CDA), 2010; International Working Group on the Diabetic Foot (IWGDF), 2011; Lipscomb & Hux, 2007). The prevalence of diabetes has increased 70% since the 1998 publication of the CDA clinical practice guidelines G and the rate continues to increase across all age groups. Between 1995 and 2005, the prevalence of diabetes in Ontario increased steadily by an average of 6.2% per year (Lipscomb & Hux, 2007). The rate of diabetes is increasing the greatest among Aboriginal Canadians, who have a three to five times higher rate of diabetes than the general population (Doucet & Beatty, 2010). Diabetes seriously burdens individuals, their families and society. With the increasing prevalence of diabetes in Canada, the annual economic cost attributable to the condition is estimated to rise from $5.2 billion in 1998 to $16.9 billion by 2020 (Lau, 2010).
There are two major classifications of diabetes: type 1 and type 2. Type 1 diabetes, also known as insulin-dependent diabetes mellitus (IDDM), affects 10 to 15% of all people with diabetes and is primarily the result of an inability to produce insulin due to beta cell destruction in the pancreas. While type 1 diabetes accounts for fewer individuals with diabetes, it results in a disproportionately higher frequency of diabetes-related complications. Type 2 diabetes, also known as noninsulin-dependent diabetes mellitus (NIDDM), accounts for 90% of those diagnosed with diabetes and results from a combination of insufficient insulin production and resistance of the body's cells to the actions of insulin (CDA, 2010).
Control of blood glucose levels is paramount to minimizing complications related to diabetes (Diabetes Control and Complication Trial (DCCT) Research Group, 1993; United Kingdom Prospective Diabetes Study (UKPDS) Group 33, 1998). This is achieved through lowering of serum glucose levels using oral hypoglycemic agents, subcutaneous injections of insulin, dietary restriction and regular exercise. Other factors contributing to delayed onset of complications include control of hypertension, hyperlipidemia and hyperinsulinemia. Unfortunately, these treatments may not completely control the progression of diabetes-related changes, such as neuropathy (Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPG) Expert Committee, 2008).
Diabetic foot ulceration and amputation are a result of complications of diabetes such as peripheral arterial disease (PAD) and neuropathy (see Figure 1). Worldwide, the number of lower limb amputations has increased as a result of diabetes. According to the IWGDF, over one million amputations are performed on people with diabetes each year (2011). PAD, also known as peripheral vascular disease, is a circulatory problem in which narrowed arteries reduce blood flow to the lower limbs. This can result in poor oxygen circulation and medication delivery thereby impacting the ability to heal and increasing the risk for ulceration. Neuropathy occurs when the nerves of the peripheral nervous system are damaged (by diabetes) and can result in loss of sensation, skin changes, deformities and limited joint mobility of the foot. When combined with other factors, such as inadequate self care, poor glucose control, improper footwear, obesity and lack of timely resources, these neuropathic changes may lead to foot ulceration.
While the majority of ulcers eventually heal, approximately one third may result in some form of amputation (IWGDF, 2011). Moreover, there is a possibility of infection occurring in any foot ulcer in a person with diabetes. Diabetic foot infections require medical attention ranging from minor (e.g., debridement, antibiotics) to major (resection, amputation) intervention (Lipsky et al, 2012).

# BAC K G R O U N D
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition Ulcers and amputations result in enormous societal costs, including lost wages, job loss, prolonged hospitalization, lengthy rehabilitation and an increased need for home care and social services. Given the data on the burden of illness and the significant long-term health impact, care of persons with diabetic foot ulcers demands a systematic, team approach from health-care professionals (IWGDF, 2011).
The panel recognizes the complexity of the treatment of persons with diabetic foot ulcers and acknowledges the realities of practice settings that may influence resources available to identify the highest quality evidence to direct care.
To this end, the recommendations serve as an evidence-based guide for nurses and other health-care professionals to identify and assess people in high-risk groups who would benefit from specialized wound care. Interprofessional health-care teams should work closely with clients and their families to address the complex lifestyle, self care and multiple treatment demands of people with diabetes diagnosed with diabetic foot ulcer(s). It is acknowledged that this level of care is not yet fully accessible to or accessed by all people with diabetes. Moreover, few people with foot ulcerations receive optimal wound management (Boulton, Kirsner, & Vileikyte, 2004). Nurses can facilitate and positively influence wound healing outcomes by promoting, collaborating and participating in interprofessional health-care teams that follow best practice guidelines as presented in this document.  The management of persons with foot ulcers is complex. According to Weir (2010), diabetic foot ulcers should be regarded a medical emergency. Principles of clinical management of the person with diabetic foot ulcers involve assessing for: vascular supply (V); infection (I); structural or bony deformities, foot wear and sensation to determine pressure related issues (P); and, sharp debridement of non-viable tissue (s). These principles are often termed by their acronym, VIPs (Inlow, Orsted, & Sibbald, 2000).
The Canadian Association of Wound Care Wound Bed Preparation framework is helpful in outlining the key clinical symptoms and issues related to diabetic foot ulcers and approaches to management utilizing the above principles of VIPs (Botros et al., 2010). This framework is presented in Figure 2.  Obtain a comprehensive health history and perform physical examination of affected limb(s).

# Level of Evidence = Ib -IV

# Discussion of Evidence:
A comprehensive health history is required for all clients who present with diabetic foot ulceration. This health history must include a history of presenting illness, past medical history, glycemic control, nutritional status, allergies, medications, family history and psychological well-being.

# History of Presenting Illness (Level of Evidence = IV)
Assessment of the person with a diabetic foot ulcer requires a detailed history of the presenting illness, including:  Initiating event;  Duration of ulceration;  Treatments undertaken; and  Outcome of the treatments.

# Past Medical History (Level of Evidence = III)
A history of diabetic foot ulcers and several diabetes-related complications are associated with lower limb amputations. Therefore, a thorough past medical history is important to identify individuals at high risk for amputation, and it should include: A) An assessment of co-morbidities and complications associated with diabetes; B) Previous ulcers related to diabetes; and C) A history of smoking.
People with diabetic foot ulcers should be identified as high risk for amputation (Australian Centre for Diabetes Strategies (ACDS), 2001; Falanga & Sabolinski, 2000;IWGDF, 2011).
See Appendix D for risk factors for amputation.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# A. Co-morbidities and Complications Associated with Diabetes
There are multiple co-morbidities and complications associated with diabetes (CDA CPG Expert Committee, 2008).
The following discussion will focus on co-morbidities of renal impairment, hypertension and retinopathy. Early identification of co-morbidities and complications allows the health-care professional to initiate appropriate referrals and develop a comprehensive interprofessional plan of care.

# Renal Impairment
Renal impairment is a prevalent microvascular complication. Fifty percent of people with diabetes have renal impairment (CDA CPG Expert Committee, 2008). In a retrospective observational study, Eggers, Gohdes and Pugh (1999) identified that amputation rates for people with diabetes and end-stage renal disease increased 10-fold compared to people with diabetes alone. Furthermore, the post-amputation survival rate for clients with diabetes and end-stage renal disease was approximately 33% (Eggers et al., 1999).
The majority of people with diabetes will develop hypertension, a treatable risk factor (CDA CPG Expert Committee, 2008). Adler and colleagues (2000) identified that elevated blood pressure is strongly linked to macrovascular (e.g., peripheral vascular disease) and microvascular (e.g., retinopathy and nephropathy) complications. Peripheral vascular disease places individuals at a significantly increased risk for amputation (Royal Melbourne Hospital, 2002). Improved control of hypertension results in clinically significant reductions in microvascular and macrovascular complications and diabetes-related death (CDA CPG Expert Committee, 2008).
Diabetic retinopathy may be the most common microvascular complication of diabetes, affecting 23% of people with type 1 diabetes and 14% of people with type 2 diabetes (CDA CPG Expert Committee, 2008). A multi-national study by Chaturvedi and colleagues (2001) demonstrated that vascular complications, including retinopathy, are a significant risk factor for amputation in both type 1 and type 2 diabetes. A descriptive-analytic study by Shojaiefard, Khorgami, and Larijani (2008) also suggests that the presence of retinopathy increases a client's risk for amputation.

# B. Previous Ulcers
A history of previous ulcers is a strong predictor of future ulcers. Up to 34% of people develop another ulcer within 1 year after healing from the previous ulcer. The 5-year rate of re-ulceration has been shown to be 70%. While two thirds of ulcers heal, one third may result in some form of amputation (IWGDF, 2011).

# C. Smoking
Smoking is an independent risk factor for cardiovascular disease and a significant risk factor for chronic kidney disease for people with diabetes (Scottish Intercollegiate Guidelines Network 2010). It may also be a risk factor for retinopathy in type 1 diabetes. Smoking cessation reduces these risks and may optimize conditions for wound healing (SIGN, 2010).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Glycemic Control (Level of Evidence = Ib)
Improved glycemic control reduces complications and optimizes wound healing (Marston & Dermagraft Diabetic Foot Ulcer Study Group, 2006). In a cohort study by Moss, Klein and Klein (1996), elevated blood glucose levels were highly correlated with complications of diabetes. In a randomized controlled trial, pharmacological control of blood glucose was shown to reduce diabetes-related complications in overweight clients with type 2 diabetes (UKPDS, 1998).
Similarly, a study examining glycemic control and microvascular complications in Japanese people with type 2 diabetes concluded that intensive glycemic control may delay onset and progression of diabetic retinopathy, nephropathy and neuropathy (Ohkubo et al., 1995). Results of a prospective observational study suggested that each one percent reduction in mean hemoglobin A1c G (HbA1c; a measure of glycemic control) produced significant decreases in the rate of complications and deaths related to diabetes (Stratton et al., 2000). Furthermore, HbA1c values in the normal range (<6.0%) comprised the lowest risk of complications (Stratton et al., 2000).
From a wound healing perspective, a secondary analysis of data from a prospective, randomized controlled trial by Marston and Dermagraft Diabetic Foot Ulcer Study Group (2006) found that people treated with a human fibroblast-derived dermal substitute had better wound healing rates when A1c levels were controlled or reduced over a 12-week period. Similarly, in a retrospective cohort study by Markuson et al. (2009), patients with higher A1c levels did experience wound healing, but over a significantly longer period than those with lower A1c.
The Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CDA CPG Expert Committee, 2008) recommends the following targets for glycemic control for most people with type 1 and type 2 diabetes:  A1c  7.0% to reduce the risk of microvascular and macrovascular complications;  Fasting plasma glucose of 4.0 to 7.0 mmol/L; and  2-hour postprandial plasma glucose targets of 5.0 to l0.0 mmol/L (5.0 to 8.0 mmol/L if A1c targets not being met).

# Nutritional Status (Level of Evidence = IV)
The overall nutritional health of a person with diabetes will have an effect on wound healing. Macronutrients and micronutrients play an important role in the different stages of wound healing. A person with diabetes should ensure adequate intake of calories, protein, fat, fluids, vitamins and minerals to achieve positive outcomes. A nutritional assessment by a registered dietician is indicated if nutritional deficits are identified.

# Allergies (Level of Evidence = IV)
A comprehensive health history should include a record of any allergies. Allergies pertinent to foot ulcers may consist of medication allergies and sensitivities to dressing adhesives and debridement materials. Being aware of allergies allows the health-care professional to make appropriate choices with regards to medications for treatment of infections, wound dressings and solutions used for debridement.

# Medications (Level of Evidence = IV)
A record of current medications should be included as part of the health history. Medication records provide healthcare professionals with the necessary information for proper pharmacological diabetes management, such as drug contraindications, potential drug interactions and identification of medications that may impair wound healing.

# Family History (Level of Evidence = III)
It is important that people with diabetes are asked about their family health history. Family health history reflects inherited genetic susceptibility and shared environment, behaviours and habits (Centers for Disease Control and Prevention, 2004). People with a family history for certain diseases (e.g., heart disease, diabetes and osteoporosis) are more likely to develop those diseases themselves (Bennett, 1999).

# Psychological Well Being (Level of Evidence = IV)
It is important to determine the psychological well being of individuals with diabetes as it can impact on their ability to manage their condition. Clinical depression, anxiety and eating disorders are known factors associated with poor control of type 1 diabetes (SIGN, 2010). More specifically, depression, affecting approximately 15% of people with diabetes, is associated with, but not limited to, poor self-care behaviours and decreased quality of life (CDA, 2012;CDA CPG Expert Committee, 2008;SIGN, 2010). Therefore, health professionals should explore psychological well being as part of a comprehensive health history as it may impede self-management strategies to prevent and manage diabetic foot ulcers.

# RECOMMENDATION 1.1:
Identify the location and classification of foot ulcer(s) and measure length, width and depth of wound bed.

# Level of Evidence = Ia -IV

# Discussion of Evidence:

# Identification of Ulcer Location (Level of Evidence = III)
The location of the foot ulcer is important to identify as this information may have an impact on care planning and the use of appropriate pressure redistribution devices. According to a prospective observational study by Reiber et al. (1999), the plantar region of the toes, forefoot and midfoot were the most frequent sites of ulceration followed by the dorsal region of the toes and heels.

# Classification (Level of Evidence = 1a)
Diabetic foot ulcer stratification systems are essential tools for predicting a client's risk of developing a foot ulcer (Monteiro-Soares, Boyko, Rebeiro, Rebeiro, & Dinis-Rebeiro, 2011). In addition, using a stratification system facilitates effective communication between health-care professionals regarding the client's risk for amputation, and can facilitate data collection related to disease severity.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition
The following five stratification systems were identified by a systematic review:
- University of Texas (Armstrong, Lavery, & Harkless, 1998a;Lavery, Armstrong, Vela, Quebedeaux & Fleischli, 1998; see Appendices D, E, F); 2. International Working Group on the Diabetic Foot (Diabetic foot ulcer classification system for research purposes; see Appendix G); 3. Scottish Intercollegiate Guideline Network (SIGN); 4. American Diabetes Association; and 5. Boyko and colleagues. (Monteiro-Soares, 2011) Five core factors to assess for were identified in all scales: diabetic neuropathy G peripheral vascular disease, foot deformity, previous foot ulcer and previous amputation (Monteriro-Soares et al., 2011). The authors concluded that while classification of foot ulcers in itself was important, the best system to use for specific health-care settings could not be determined.

# Measuring the Length and Width (Level of Evidence = Ia)
Standardizing the procedure for measurement of diabetic foot ulcers is crucial to evaluate whether the wound is moving towards desired outcomes. Consistent and accurate measurements of length and width aid in reliable tracking of wound closure progress. Wound measurements should be completed using a consistent method such as tracings (Krasner & Sibbald, 2001). A systematic review evaluating treatments for diabetic foot ulcers classified wounds as healing when the wound length and width decreased (Margolis, Kantor, & Berlin, 1999). Furthermore, a prospective trial conducted by Sheehan, Jones, Caselli, Giurini and Veves (2003) demonstrated that a 50% reduction in wound surface area (length and width) at 4 weeks is a good predictor of complete wound healing at 12 weeks.

# Measuring the Depth (Level of Evidence = IV)
Measuring wound depth should accompany the measurement of wound length and width as together they provide quantifiable data to accurately determine wound healing. Wound depth is most commonly measured by gently inserting a sterile swab stick or probe into the wound. The presence of undermining and tunneling can also be determined in this manner by probing a space between the surrounding skin and wound bed. The RNAO expert panel recommends using the "clock" system to document the location of tunneling or undermining (e.g., area of the tunneling or undermining closest to the head is the 12 o'clock position).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# RECOMMENDATION 1.2:
Assess bed of foot ulcer(s) for exudate, odour, condition of peri-ulcer skin and pain.

# Level of Evidence = IV

# Discussion of Evidence:

# Exudate (Level of Evidence = IV)
Wound exudate characteristics (e.g., amount and type of drainage) provide important information about the status of the wound. The RNAO expert panel recommends rating the amount of exudate observed using the following terms:

# Odour (Level of Evidence = IV)
All wounds, especially those treated with moisture retentive dressings, can emit an odour, and it is important to assess the foot ulcer bed for the characteristics of this odour. A change in odour may be indicative of an alteration in bacterial balance. A healthy wound has a faint but not unpleasant odour; infections often result in a distinctive and slightly unpleasant odour (Butalia, Palda, Sargeant, Detsky, & Mourad, 2008;Cutting & Harding, 1994). Necrotic wounds tend to have more offensive odours than clean wounds. Wounds infected with anaerobes, suggestive of gangrene, tend to produce a distinct acrid or putrid odour.

# Condition of Peri-Ulcer Skin (Level of Evidence = IV)
The condition of the peri-ulcer skin provides important information about the status of the wound and can influence choice of intervention and treatment. The RNAO expert panel recommends a surrounding skin assessment that includes an evaluation of:
 Skin colour and temperature: Redness may be indicative of unrelieved pressure or prolonged inflammation (Boulton, 1991). Pale, white or grey tissue may be indicative of prolonged exposure to moisture. Increased temperature (erythema) in the ulcer area may also indicate infection in the wound (Sibbald, Goodman, Woo, Krasner, & Smart, 2012).  Callus G formation: Callus formation is indicative of ongoing pressure to the affected area. Debridement of callus may be indicated to facilitate accurate assessment; and  Induration and edema: Induration (an abnormal firmness of the tissue) and edema (swelling) are indicative of infection. They are assessed by gently pressing the skin within 4 cm of the wound. Firmness may be observed.

# Pain (Level of Evidence = III)
Although pain may be uncommon in diabetic foot disorders, evidence of increasing pain accompanied by wound breakdown are strong indicators (100% specificity G of chronic wound infection (Gardner, Frantz, & Doebbeling, 2001). Pain in a previously insensate G foot may also indicate active charcot arthropathy G (see Appendix H for a description).
Charcot arthropathy can be difficult to distinguish from wound infection or cellulitis G. Left untreated, charcot arthopathy may lead to serious foot structure damage and injury. X-rays should be done to differentiate an active charcot foot from infection.
Persons with diabetes may suffer from neuropathic foot pain. This pain is often described as burning and stabbing in nature, and its presence is generally independent of foot position or movements. Neuropathic pain can be difficult to manage and requires careful assessment and monitoring.
As demonstrated in Figure 1, diabetic neuropathy increases the risk of foot ulceration and subsequent amputation (Frykberg, 1991). In the presence of diabetic neuropathy and amputation, clients may suffer from phantom limb pain in the absent leg. Referral to physiotherapy for pain relieving modalities such as transcutaneous electrical nerve stimulation may be necessary to treat both neuropathic and phantom limb pain (CDA CPG Expert Committee, 2008).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# RECOMMENDATION 1.3:
Assess affected limb(s) for vascular supply and facilitate appropriate diagnostic testing, as indicated.

# Level of Evidence = III -IV

# Discussion of Evidence:
The assessment of vascular supply can be achieved through a health history, physical examination and diagnostic testing. The RNAO expert panel recommends the following physical assessment considerations and appropriate diagnostic tests for vascular supply, outlined in Table 1. See Appendix I for further detail about these specialized diagnostic tests.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition Peripheral arterial disease (PAD), also known as peripheral vascular disease, is a narrowing of the peripheral arteries resulting in insufficient vascular supply to the lower extremities. PAD can prolong wound healing and increase the risk of amputation (Apelqvist, 1998;Birke, Patout, & Foto, 2000;Crane & Branch, 1998;Sinacore & Mueller, 2000). The risk of people with diabetes developing PAD increases as the disease progresses (Calhoun, Overgaard, Stevens, Dowling, & Mader, 2002). This risk increases 10-fold in those with diabetes and concurrent renal failure (Apelqvist, 1998;Eggers et al., 1999). In the younger client population, PAD often presents bilaterally. Therefore, adequate blood flow to the affected extremities is essential to support wound healing (Birke et al., 2000;Reiber et al., 1999). Positive findings should be discussed with a vascular surgeon in order to determine potential for intervention.
Bilateral lower extremity assessment should include, at minimum, the assessment of:
 Intermittent claudication;  Peripheral pedal pulses; and  Colour.

# Intermittent Claudication (Level of Evidence = III)
One of the first presenting symptoms of vascular insufficiency is intermittent claudication, or calf pain. A history of intermittent lower limb claudication combined with non-palpable pedal pulses in both feet increases the probability of vascular insufficiency in clients with diabetes (Boyko et al., 1997).

# Peripheral Pedal Pulses (Level of Evidence = IV)
Palpating for the presence of a plantar pulse, such as the dorsalis pedis or posterior tibial, is essential during assessment. The presence of peripheral pulses is represented by a minimum systolic pressure of 80 mmHg and may suggest adequate vascular supply to support wound healing (Lavery & Gazewood, 2000). The National Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus states that the absence of peripheral pulses has prognostic significance for future amputation in people with or without foot ulceration (ACDS, 2001).
Some regions of the foot with palpable pulses, however, may not be well-perfused. According to the angiosome model, the foot is delineated into five angiosomes, each consisting of skin, subcutaneaous tissue, fascia, muscle and bone, fed by a source artery. The presence of a peripheral pulse may not necessarily indicate that all of the components within a particular angiosome are well-perfused. Although a foot pulse might be palpable, the foot ulcer might be situated in a different angiosome (Sibbald et al., 2011). This concept may help the clinician determine appropriate measures to support successful ischemic ulcer treatment (Attinger, Evans, & Mesbahi, 2006).

# Colour (Level of Evidence = IV)
The colour of the foot should be assessed for rubor on dependency, pallor on elevation, mottling and dry gangrene, all of which are signs of ischemia (Bowker & Pfeifer, 2001). A comprehensive vascular assessment is recommended for clients with these signs of arterial insufficiency.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# RECOMMENDATION 1.4:
Assess foot ulcer(s) for infection using clinical assessment techniques, based on signs and symptoms, and facilitate appropriate diagnostic testing, if indicated.

# Level of Evidence = Ia
Discussion of Evidence:
The diagnosis of foot ulcer infection is based on a clinical examination (IWGDF, 2011). Infection is a destructive process that occurs when bacteria in a wound overcomes the natural defenses of the host's immune system. The likelihood of a wound becoming infected is related to the type of micro-organism and the microbial load. However, equally important factors to consider are the characteristics of the wound (location, classification, length, width and depth), level of blood perfusion and ability of the host to resist infection.
While emphasis is frequently placed on microbial load, the host's resistance is often the critical factor in determining whether infection will develop. Diabetes increases susceptibility to infection. People with diabetes may not be able to mount an effective inflammatory response due to impaired immunodefenses, decreased peripheral circulation and decreased metabolic control (Armstrong, Lavery, Sariaya, & Ashry, 1996;Eneroth, Apelqvist, & Stenstrom, 1997). Increased occurrence of co-morbidities may place older people with diabetes at higher risk for infection than younger people with the disease as the severity of the infection may be masked by the co-morbidities. Use of an assessment tool, such as the Diabetic Foot Infection (DFI) scoring system, validated by Lipsky, Polis, Lantz, Norquist and Abramson (2009), may aid in predicting foot ulcer healing outcomes.
The microbial load in a wound advances over time in a predictable fashion (see Table 2). Most chronic wounds contain more than three species of micro-organisms, increasing the risk for infection as these organisms may develop synergies. In wounds that are infected with a number of species, distinguishing the causative organism is unlikely (Dow, Brown, & Sibbald, 1999). Correct wound swabbing G technique should be followed when collecting a culture swab to ensure accurate measure of wound microbial load. See Appendix J for wound swabbing technique.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition The RNAO expert panel recommends using clinical assessment with diagnostic testing in the assessment of foot ulcer infection.

# Signs and Symptoms of Infection
The presence of infection should be assessed based on the presentation of two or more of the following signs and symptoms of inflammation or purulence (Lipsky et al., 2012 The signs and symptoms of non-limb-threatening or superficial infection, and limb-threatening or deep wound and systemic infection G are summarized in Table 3.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition  (Falanga, 2000;Lipsky et al., 2012;Schultz et al., 2003;Sibbald, Orsted, Schultz, Coutts, & Keast, 2003;Sibbald et al., 2000) Identifying infection in a chronic wound can be a challenge as the clinical assessment for infection in chronic wounds differs from acute wounds.  identified the following signs and symptoms of soft tissue infection in a cross-sectional study of 64 subjects with diabetic foot ulcers:
 Increased pain;  Wound breakdown;  Friable granulation tissue G ; and  Foul odour.
Deep foot infections have been identified as the immediate cause of 25 to 51% of amputations in persons with diabetes (Tennvall, Apelqvist, & Eneroth, 2000). Deep infections often present with erythema and warmth extending two centimeters or more beyond the wound margin (Woo & Sibbald, 2009). This increased inflammatory response may be painful and cause the wound to increase in size or lead to satellite areas of tissue breakdown, known as adjacent ulceration (Woo & Sibbald, 2009).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition Deep infections, especially in chronic ulcers, can often lead to osteomyelitis, or bone infection, in the diabetic foot (Lipsky et al., 2012). Probing to bone is a simple technique for rapid identification of osteomyelitis and should be included in the initial assessment of all people with infected pedal ulcers (Grayson, Balaugh, Levin, & Karchmer, 1995). Other methods to diagnose the presence of osteomyelitis in clients with foot ulcers include laboratory and radiographic testing. A systematic review by Butalia et al. (2008) assessed evidence related to using historical features, physical examination and laboratory and basic radiographic testing in the diagnosis of lower extremity osteomyelitis in people with diabetes. The study concluded that, on physical examination, predictors of osteomyelitis included an ulcer area greater than 2cm 2 and a positive probe-to-bone test. Through laboratory testing, an erthrocyte sedimentation rate of more than 70 mm/h was also indicative of osteomyelitis (Butalia et al., 2008).
Signs of deep wound and systemic signs of infection are potentially limb and/or life threatening. These clinical signs and symptoms require urgent medical attention.

# Diagnostic Testing of Infection
The timely diagnosis and treatment of infection is vital to the healing of diabetic foot ulcers. Diagnostic tests may be performed in conjunction with the clinical assessment when infection is suspected.
Lipsky et al. (2012) recommend that persons with new diabetic foot infections have plain radiographs to identify bony abnormalities such as bone deformity or destruction, foreign bodies or soft tissue gas. An abnormal plain radiograph finding can be helpful in the diagnosis of osteomyelitis (Butalia et al., 2008).
Magnetic resonance imaging (MRI) is recommended for clients who require additional imaging, especially if soft tissue abscess G or osteomyelitis is suspected (Lipsky et al., 2012). In a meta-analysis conducted by MRI was determined to be the most accurate imaging test for diagnosis of osteomyelitis. Furthermore, osteomyelitis was found to be highly unlikely in a client with a normal MRI result (Butalia et al., 2008). If MRI is unavailable or contraindicated, a labeled white blood cell scan is the best alternative (Lipsky et al., 2012). It is important to note that accessibility to and interpretation of these tests may be limited to specific geographic locations and medical specialists.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition RECOMMENDATION 1.5:
Assess affected limb(s) for sensory, autonomic and motor changes.

# Level of Evidence = IIa
Discussion of Evidence:
The presence of peripheral neuropathy, or nerve damage, is determined by assessing for specific changes in sensory, autonomic and motor function. Identifying peripheral neuropathy is particularly important, as it will enable the health-care professional to identify associated potential risk factors for ulcer development. In a case-controlled study, Lavery et al. (1998) noted that clients with peripheral neuropathy and no other risk factors were 1.7 times more likely to develop foot ulceration. Table 4 illustrates the associated pathophysiological involvement, assessment considerations, and clinical indications specific to each of the three components of peripheral neuropathy. Appendix K provides a more detailed description of the monofilament assessment technique for sensory perception in the foot.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition RECOMMENDATION 1.6:
Assess affected limb(s) for elevated foot pressure, structural deformities, ability to exercise, gait abnormality, and ill-fitting footwear and offloading devices.

# Level of Evidence = Ia -IV

# Discussion of Evidence:
Foot ulcers frequently occur as a result of repeated minor trauma, such as from ill-fitting footwear or elevated pressure on the sole of the foot. People with foot ulcers should be assessed regularly for potential causes of such trauma and be provided with interventions to reduce trauma and ulcer risk (IWGDF, 2011;Jeffcoate & Rayman, 2011;Rizzo et al., 2012;Royal Melbourne Hospital, 2002).

# Elevated Foot Pressure (Level of Evidence = IIb)
Elevated plantar pressure is a significant risk factor for foot complications (Lavery, Armstrong, Wunderlich, Tredwell, & Boulton, 2003). The plantar surface of the forefoot is the most common location for foot ulcer development (CDA CPG Expert Committee, 2008;IWGDF, 2011). People with severe neuropathy may exhibit increased forefoot-to-rearfoot plantar pressure ratios, suggesting an imbalance in pressure distribution, which may predispose them to foot ulceration.
Pressure mapping is a technique that measures foot pressures in standing and walking positions. A cohort study by Giacomozzi and Martelli (2006) found that screening a person's peak pressure curve may be an effective method to detect risk of foot ulceration in diabetic clients. Similarly, using an F-Scan mat G system,  found that foot pressures greater than 6 kg/cm placed people at an increased risk for foot ulceration. Lavery et al. (1998) also identified a significant association between high plantar pressure (65 N/cm 2 and presence of foot ulceration.
Pressure over bony prominences can lead to callus formation and predispose the skin to break down (ACDS, 2001;Hutchinson et al., 2000). Calluses may act as a foreign body, elevating plantar pressures; therefore, callus removal or reduction often results in a significant reduction in foot pressure (Boulton, Meneses, & Ennis, 1999;Murray, Young, Hollis, & Boulton, 1996;Pataky et al., 2002;Young et al., 1992).
It is also important to ensure that dressings and offloading devices are used effectively, and that they are not contributing to increased pressure either around the ulcer or on other parts of the foot and leg.

# Structural Deformities (Level of Evidence = III)
Physical examination of a person with diabetes should include an assessment for foot deformities (IWGDF, 2011;Royal Melbourne Hospital, 2002). Foot deformities include hammer toe, claw toe, hallux deformity G pes planus, pes cavus and charcot arthropathy. These structural foot deformities alter the gait or mechanics of walking, and can result in abnormal forces on the foot, poor shock absorption, and shearing and stress to soft tissues (RNAO, 2007;Shaw & Boulton, 1997). Furthermore, the risk for elevated plantar pressure is directly associated with the number of foot deformities (Lavery et al., 2003).
See Appendix H for descriptions of each type of foot deformity.
Any deformity of the foot should be referred to a specialist (podiatrist/chiropodist) for further evaluation.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Ability to Exercise (Level of Evidence = IV)
Exercise may help people with diabetes to achieve a variety of health goals, including improved glycemic control (CDA CPG Expert Committee, 2008;SIGN, 2010). Limited joint mobility as a result of peri-articular limitations (e.g., muscle, tendon, joint capsule, ligament and skin) can be effectively treated with exercise-based interventions, including stretching and strength training (Allet et al., 2010).
It is important to note that people with diabetes-associated complications, including ulceration, should be carefully assessed and supervised when undertaking an exercise program. Referral to an exercise specialist, such as a physical therapist, may be indicated to address health and safety concerns.

# Gait Abnormality (Level of Evidence = III)
Gait is the manner or style of walking. Neurodegenerative processes are accelerated in diabetes, often resulting in abnormal weight bearing, unstable posture and a decline in motor control (Mason et al., 1999b;Meier, Desrosiers, Bourassa, & Blaszczyk, 2001). Alterations in gait, balance and mobility in a client may also be caused by sensory ataxia, poor vision, debilitation and/or neuropathy secondary to the diabetes disease process (Sinacore & Mueller, 2000).
Assessment of gait is important in order to establish a person's risk of falling and injury. Sinacore and Mueller (2000) found that the risk of falling was 15 times greater in people with diabetic neuropathy than in people with diabetes without neuropathy. Abnormal gait patterns that may be observed in a person with diabetes include: ataxic (unsteady, uncoordinated, employing a wide base of support), steppage (lifting the foot higher to accommodate for foot drop and/or poor ankle-joint mobility) and antalgic (limping, usually signifying discomfort).
Referral to a physical therapist may be indicated if gait abnormalities are noted.

# Ill-fitting Footwear and Offloading Devices (Level of Evidence = Ia)
Clients should be assessed for knowledge and understanding of the importance of proper footwear and offloading device use to reduce plantar pressures. Education regarding proper fit and use of footwear and devices should be provided if knowledge gaps or learning needs are identified.
In a large prospective study, Abbott and colleagues (2002) found that 55% of ulcerations assessed were attributed to pressure from footwear. Foot ulceration has been associated with constant or repetitive pressure from tight shoes over bony prominences on the dorsum of the lesser toes, at the medial aspect of the first metatarsal head G and the lateral aspect of the fifth metatarsal (Lavery et al., 1998).
It is imperative that people with diabetic foot ulcers see a foot-or health-care specialist regularly for the assessment of their feet, footwear and other devices associated with ambulation (American Diabetes Association (ADA), 2001; Campbell et al., 2000;CDA CPG Expert Committee, 2008;Hunt, 2001;Hutchinson et al., 2000; Institute for Clinical Systems Improvement (ICSI), 2000; Lavery & Gazewood, 2000;Maciejewski et al., 2004;McCabe, Stevenson & Dolan, 1998;New Zealand Guidelines Group (NZGG), 2000;Rizzo et al., 2012;Smieja et al., 1999;Zangaro & Hull, 1999).
See Appendix L for suggestions in assessing and selecting shoes and socks.

# Offloading Devices
Offloading devices, such as foot orthoses, aid in reducing plantar pressure in the diabetic foot. Foot orthoses are custom-made shoe inserts that serve to correct or relieve misalignment and/or pressure areas of the foot. A systematic review by Spencer (2004) found that in-shoe custom orthoses were effective at relieving foot pressure and resolving calluses in people with diabetes.
See Appendix M for selection of offloading devices.

# RECOMMENDATION 1.7:
Document characteristics of foot ulcer(s) after each assessment including location, classification and any abnormal findings.

# Level of Evidence = IV

# Discussion of Evidence:
Documentation is used to monitor a client's progress and communicate with other health-care providers (College of Nurses of Ontario (CNO), 2009a). Good record-keeping using common language and objective descriptors such as wound measurements and ulcer grading can increase clarity and improve outcomes. Careful monitoring of wound healing through consistent and thorough documentation is as important as initial assessment and treatment in influencing healing outcomes (Krasner, 1998).
The RNAO expert panel recommends using an interprofessional assessment tool to document assessment results. See Appendix N for an example of an assessment tool that may be used by an interprofessional team.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# PLANNING RECOMMENDATION 2.0:
Determine the potential of the foot ulcer(s) to heal and ensure interventions to optimize healing have been explored.

# Level of Evidence = IV

# Discussion of Evidence:
The healing potential of a wound must be taken into consideration when developing a plan of care. Factors affecting the healing potential of a diabetic foot ulcer may be grouped into three categories: local, host and environment. The RNAO expert panel has summarized these factors in   (Falanga, 2005;)
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition Moist wound care is not recommended in wounds where complete healing is not the goal. Use a dry dressing to keep the wound bed dry.
If infection is present and the client cannot fight infection, the moist wound will become a breeding ground for infection. Using a topical, cost-effective antiseptic G such as povidone iodine should be considered when the risk of infection outweighs the healing potential.

# RECOMMENDATION 2.1:
Develop a plan of care incorporating goals mutually agreed upon by the client and health-care professionals to manage diabetic foot ulcer(s).

# Level of Evidence = IV

# Discussion of Evidence:
Proper goal-setting enables the team to closely monitor the effectiveness of interventions, continuing those that are successful and discontinuing those that are unsuccessful.
Ideally, the primary goal in the treatment of diabetic foot ulcers is to obtain wound closure as expeditiously as possible. The resolution of foot ulcers and decreasing the rate of re-occurrence can lower the probability of lower extremity amputation for clients with diabetes. However, it should not be expected that all diabetic foot ulcers will have wound closure as a primary outcome. Wounds that are unlikely to heal should have alternative goals such as:
 Wound stabilization;  Reduced pain;  Reduced bacterial load; and  Decreased dressing changes.
Beyond tracking progress, goals can also motivate the client, ensure the team is working toward a common end and ensure important actions are not overlooked. Frequent re-evaluation of goals and the overall plan of care is essential as the circumstances affecting wound care may change (Sibbald et al., 2011).
The plan of care should be developed by the client and the interprofessional team, based on client-centred care approaches (RNAO, 2006a;Sibbald et al., 2011). Client-centred care involves collaborative care-planning and an interprofessional team approach to assessing, planning, implementing, monitoring and evaluating care with the client taking a key role. The plan of care for all clients with diabetic foot ulcers should include improving function and quality of life, maintaining health status and controlling costs. The plan of care should also include strategies to prevent deconditioning, which has many detrimental side effects, including psychosocial dysfunction.
In a client-centred model of care, diabetic foot ulcers are managed through a holistic approach where interprofessional team members synchronize activities to ensure the client receives the appropriate treatment from experts of each discipline (Schoen, Balchin & Thompson, 2010). Team members should advocate, collaborate and facilitate the process of goal-directed care to manage foot ulcers for people with diabetes. Fragmentation of care may lead to conflicting advice for the client, wasted time and unnecessary effort, and subsequent protracted wound healing.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# RECOMMENDATION 2.2:
Collaborate with the client/family and interprofessional team to explore other treatment options if healing has not occurred at the expected rate.

# Level of Evidence = IV
Discussion of Evidence:
Diabetic foot ulcers that have not healed at the expected rate, where potential causative factors have been addressed, may require the use of alternative treatment modalities, such as biological agents, adjunctive therapies or surgery.
See Appendix O for specific treatment options. These treatment methods often involve the cooperation and coordination of various members of the interprofessional team. Nurses should collaborate with the client and interprofessional team to explore treatment options, determine the best course of action for treatment and implement a revised plan of care.

# RECOMMENDATION 2.3:
Collaborate with client/family and the interprofessional team to establish mutually agreed upon goals to improve quality of life if factors affecting poor healing have been addressed and complete wound closure is unlikely.

# Level of Evidence = IV

# Discussion of Evidence:
The RNAO expert panel has summarized various factors that can contribute to poor healing of chronic wounds: If factors affecting poor healing of chronic wounds have been addressed and complete wound closure is unlikely, the client and the health-care team should mutually agree upon a plan of care to improve the quality of life for the client (Enoch & Price, 2004). To improve quality of life, the significance of managing exudate, controlling infection, relieving pain and minimizing odour in a non-healing wound must be established and accepted as legitimate goals by the client and the health-care team (Enoch & Price, 2004).
Major or minor amputation may be the most reasonable intervention for clients with complex or life-threatening situations. However, amputation should be a mutual decision between the client and the health-care team.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# IMPLEMENTATION RECOMMENDATION 3.0:
Implement a plan of care to mitigate risk factors that can influence wound healing.

# Level of Evidence = IV
Discussion of Evidence:
People with diabetes often have a combination of risk factors that may influence the condition of their skin and wounds. Based on a review of the literature, the RNAO expert panel identified risk factors that may affect wound healing. See Table 5 for a summary of these risk factors.

# RECOMMENDATION 3.1:
Provide wound care consisting of debridement, infection control and moisture balance where appropriate.

# Level of Evidence = Ia -IV

# Discussion of Evidence:
Local wound care is a significant component of the pathway to prevent and manage diabetic foot ulcers (refer to Figure 2). Wounds have the greatest potential for healing with care that includes:
- Debridement; 2. Infection control; and 3. Moisture balance.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition If healing potential is not established, aggressive debridement and moist interactive healing is not recommended.

# Debridement (Level of Evidence = Ia)
Debridement is the process of removing necrotic or foreign tissue from a wound to promote healing. Studies have shown that debridement of diabetic foot ulcers increases the rate of healing (Edwards & Stapley, 2010;Inlow et al., 2000;Rodeheaver, 2001). In an extensive review of clinical evidence to determine the utility of debridement, Cardinal et al. (2009) found that frequent or serial debridement of diabetic foot ulcers promoted wound healing and increased wound closure rates. Moreover, Steed, Donohoe, Webster and Lindsley (1996) found that lower rates of healing were correlated with less frequent debridement practices. Frequency of debridement should be based on clinical judgment and correspond to the client's care plan (Inlow et al., 2000). See Appendix P for a decision-making algorithm for debridement.
Several methods of debridement are available for varying stages of ulcers. The clinical use of enzymatic and biologic methods of debridement was not included as part of the literature base used for this BPG. This guideline will focus on the three most common methods of debridement for diabetic foot ulcers:
 Autolytic;  Mechanical; and  Surgical/Sharp.
Autolytic debridement uses the body's own natural enzymes to break down and digest necrotic tissue. Autolytic debridement also involves the use of moisture in semi-occlusive or occlusive dressings to aid in the efficiency of liquefying devitalized tissue. Dressings for autolytic debridement include hydrocolloids, hydrogels and films (Inlow et al., 2000). In a Cochrane review to determine the effectiveness of debridement methods for diabetic foot ulcers, Edwards and Stapely (2010) found that hydrogels were significantly more effective than gauze dressings or standard care in healing diabetic foot ulcers.
Mechanical debridement involves manually removing necrotic tissue and debris from a wound bed, using wet-to-dry dressings, saline irrigation or pulsed lavage. Mechanical debridement may be indicated in wounds with moderate levels of necrotic tissue (Enoch & Harding, 2003).
Surgical or sharp debridement G involves the use of a medical instrument such as a scalpel to excise necrotic tissue. Surgical debridement is often performed in wounds with large volumes of necrotic and infected tissue.
In a prospective trial, sharp debridement was associated with greater wound closure in people with diabetic foot ulcers (Saap & Falanga, 2002).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition
It should be noted, however, that clinical trials on surgical debridement are inadequately powered. More research is needed to evaluate the methods and effects of all types of debridement (Edwards & Stapley, 2010;Shannon et al., 2010).
Sharp debridement is a high-risk procedure and should be undertaken with caution.
It is a procedure that must only be performed by trained and experienced health-care professionals, within the policies of the organization.
Performing a procedure below the dermis is a controlled act that must be carried out by an authorized health-care professional. Health-care professionals should be aware of their professional scope of practice as well as the policies and procedures within their organization.

# Callus Reduction
In addition to wound debridement, callus debridement may also assist in the prevention and management of foot ulcers. Reducing a callus often involves surgical or sharp debridement, and has been demonstrated to significantly reduce pressure at the callus site by approximately 30% (Armstrong, Lavery, Vazquez, Nixon, & Boulton, 2002;Pitei, Foster & Edmonds, 1999;Young et al., 1992). Callus debridement is within the scope of practice for certain health-care professionals, and may be performed by those with the appropriate knowledge, skills and judgment about the procedure.

# Infection Control (Level of Evidence = III)
Preventing or controlling infection in diabetic foot ulcers is essential to prevent complications such as osteomyelitis (bone infection) or amputation. Infection often results when the number of bacterial organisms exceeds the capacity of local tissue defenses (Peacock & Van Winkle, 1976). Polymicrobial infection should be anticipated in people with diabetic foot ulcers, with a variety of grampositive cocci, gram-negative rods and anaerobic organisms predominating. Antibiotic G therapy typically involves broad-spectrum coverage for these organisms and should be initiated based on properly acquired wound cultures (Anti-infective Review Panel, 2010;Lipsky et al., 2012). Appendix J provides details of proper swabbing for wound cultures. Table 6 illustrates treatment options recommended by the RNAO expert panel for superficial infection, deep wound infection and systemic infection.
Once wound culture results are obtained, antimicrobial G therapy may be tailored to provide specific coverage or therapy against resistant organisms. Antibiotic-resistant organisms, such as methicillin-resistant staphylococcus aureus (MRSA) G are an increasing issue with infections in diabetic foot ulcers (Lipsky et al., 2012). Specifically, the prevalence of MRSA in diabetic foot ulcers ranges from 5 to 30% (Lipsky et al., 2012). Infections involving antibioticresistant organisms require targeted antibiotic therapy. If infection persists while the client is on antibiotic therapy, surgical assessment and wound culture should be considered.
Moreover, methods to enhance the client's immunity to infections should be considered, which may involve examining co-morbidities, glycemic control, nutritional needs and sleep-wake cycles.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Non-limb-threatening Infections
A non-limb-threatening infection is a superficial infection that can result from scratches, nail trauma, or heel fissures. These mild-to-moderate infections may be managed on an outpatient basis with close supervision by the health-care professional. Topical antimicrobial medicine may be used to reduce bacterial burden in superficial infections. See Appendix Q for a list of Topical Antimicrobial Agents.
There is, however, mixed evidence on the use of antimicrobial agents, specifically, when used with silver-based dressings. In a systematic review of 26 trials comparing silver-containing dressings, creams compared to dressings and creams that did not contain silver, Storm-Versloot, Vos, Ubbink and Vermeulen (2010) concluded that there was insufficient evidence to establish whether silver-containing dressings or topical agents promoted wound healing or prevented wound infections. More research is required, specifically related to diabetic foot ulcers.
If topical antimicrobial agents are used, and increased superficial bacterial burden or delayed healing are noted, treatment should be supplemented with debridement and moisture balance. If deep infection is present, or if the wound fails to heal within 2 weeks of topical antimicrobials, systemic antibiotic therapy should be considered. Systemic antibiotic medication may be prescribed by the appropriate health-care professional according to the Anti-Infective Guidelines for Community-acquired Infections (Anti-infective Review Panel, 2010).

# Limb-Threatening Infections
Inappropriately managed infections in diabetic foot ulcers can lead to life-or limb-threatening consequences. These infections may present with cellulitis extending greater than 2 cm beyond the wound border and cardinal signs of infection, such as fever, edema, lymphangitis, hyperglycemia, leukocytosis and/or ischemia.
A diabetic foot ulcer presenting with wet gangrene, deep abscesses and advancing cellulitis must be transferred to a medical facility for urgent care.
Hospitalization is required to treat the deep infection and associated systemic effects. Limb-threatening infections require immediate surgical attention, which should not be delayed while waiting for radiologic or medical workup of other co-morbid conditions Weir, 2010). Although many wound care procedures can be done at the bedside for people with diabetic foot ulcers, limb-threatening infections will require thorough debridement in the operating room. Individuals presenting with limb-threatening infections should be considered for emergent incision, drainage and debridement procedures.
An ulcer that probes to the bone or joint is indicative of osteomyelitis and may require a bone biopsy for microbiological and histopathological evaluation Grayson et al., 1995). If the affected bone is resected or amputated, the infection may be treated as a soft-tissue infection. If residual bone is in the wound, however, the client will require 4 to 8 weeks of antibiotic therapy, based on wound culture results IWGDF, 2011). Intravenous or oral agents may also be used, depending on the microbial isolates and infection severity.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Moisture Balance (Level of Evidence = III)
The type of dressing selected for the foot ulcer should promote a moist wound environment that minimizes trauma and risk of infection. Specifically, dressing selection should be based on its ability to provide local moisture balance for the wound to heal. Modern, moisture-promoting dressings used for diabetic foot ulcers include foams (high absorbency), calcium alginates (absorbent, hemostasis), hydrogels (moisture balance), hydrocolloids (occlusion) and adhesive membranes (protection) (Inlow et al., 2000). Consideration should be given to the following when choosing a moist wound dressing for a diabetic foot ulcer (Sibbald et al., 2000):
 Assess the wound bed for bacterial balance, exudate level and the need for debridement;  Select a dressing or combination of dressings that can manage and/or control the environment above the wound;  Use a dressing that will keep the wound bed continuously moist and the peri-wound skin dry;  Choose a dressing that controls exudate but does not dry the ulcer bed;  Consider the amount of professional caregiver time needed to apply and change dressing(s);  Eliminate wound dead space by loosely filling all cavities with dressing material;  Ensure that the dressing does not become a source of increased pressure to the affected area;  Confirm that the person with a diabetic foot ulcer is aware of the need to reduce pressure to the affected area; and  Evaluate the wound as prescribed to determine effectiveness of the treatment plan.
Application of moisture retentive dressings in the presence of ischemia and/or dry gangrene can result in a serious limb-threatening infection. In the presence of ischemia and/or dry gangrene, apply a drying antimicrobial, such as povidone iodine, a protective dry dressing and ensure proper off-loading.
There is mixed comparative evidence on the effectiveness of any particular dressing type to heal diabetic foot ulcers (Hinchcliffe et al. 2008). For a list of common products and more information on their use, see Appendix R.

# RECOMMENDATION 3.2:
Redistribute pressure applied to foot ulcer(s) by the use of offloading devices.

# Level of Evidence = Ia
Discussion of Evidence:
Ninety-four percent of diabetic foot ulcers occur at areas of increased pressure.
Calluses from repeated friction and contact due to increased plantar pressures can predispose the skin to ulceration. Thus, pressure alleviation is integral to prevent the formation of calluses and to promote ulcer wound healing. Pressure alleviation can be accomplished by redistributing pressure over a larger surface area through the application of external pressure offloading devices. A health-care professional skilled in the fabrication and modification of offloading devices, such as a chiropodist or podiatrist, should be consulted when providing pressure redistribution.
See Appendix M for a list of offloading devices and selection considerations.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition Various effective footwear and offloading devices are available that redistribute foot pressures. A systematic review by Bus et al. (2008) evaluating the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic clients reported that 73 to 100% of wounds healed when a total contact cast (TCC) was applied. The healing period ranged between 30 to 63 days. All other casting modalities, such as fiberglass cast shoes, Scotch-cast boots, window casts and custom splints, also reported positive healing rates between 70 to 91%, within a period of 34 to 300 days (Bus et al., 2008).
Surgery may be considered if pressure redistributing devices are ineffective or not a viable option. Several surgical procedures were identified for wounds that have not healed at the expected rate (refer to Recommendation 2.2 and Appendix O for specific treatment options).

# RECOMMENDATION 3.3:
Provide health education to optimize diabetes management, foot care and ulcer care.

# Level of Evidence = Ia
Discussion of Evidence:
Health education and its reinforcement is an essential intervention for clients with diabetic foot ulcers. Nurses, as the single largest group of health-care professionals working in a range of settings, are in a pivotal position to provide and reinforce health education related to diabetes management and foot and ulcer care. They may act as the primary diabetes foot care educator, as a link between clients and their primary care providers, or within specialized diabetes care teams (RNAO, 2007). Historically, diabetes education was didactic, but in recent years it has become more participative to address individual variables in the learning process (Whittemore, 2000).
Clients with diabetes who are at a high risk for foot ulceration benefit from diabetes health education and its regular reinforcement (ADA, 2001;CDA CPG Expert Committee, 2008;Mason et al., 1999a;NZGG, 2000; The University of York -NHS Centre for Reviews and Dissemination, 1999;Valk, Kriegsman, & Assendelft, 2004). Health education interventions result in short-term improvement in the knowledge and self-care behaviours of people with diabetes (Hutchinson et al., 2000;Valk, Kriegsman, & Assendelft, 2002). Diabetes self-care behaviours influence blood glucose control which, when improved, facilitate healing of foot ulcers. These behaviours also prevent or delay diabetes-related complications such as peripheral neuropathies and reduced circulation in lower extremities (IWGDF, 2011;RNAO, 2007;UKPDS Group 33, 1998). Furthermore, health education in a group setting and sustained long-term follow-up have both been shown to enhance knowledge and produce positive outcomes, such as improved glycemic control in type 2 diabetes (CDA CPG Expert Committee, 2008).
Although health education seems to have a positive impact on clients' foot and ulcer care knowledge and behaviours, it is uncertain whether it can prevent foot ulceration and amputation. In a Cochrane review of randomized controlled trials evaluating the impact of client education on diabetic foot ulceration, Dorresteijn, Kriegsman, Assendelft and Valk (2010) concluded that there is insufficient evidence to ascertain whether client education, without additional preventative measures, reduces ulcer incidence. It should be noted, however, that the methodology of inquiry must be in keeping with the research question and that randomized controlled trials may not always be the appropriate design for every question.
See Appendix S for a client handout on diabetic foot care.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# RECOMMENDATION 3.4:
Facilitate client-centred learning based on individual needs to prevent or reduce complications.

# Level of Evidence = III

# Discussion of Evidence:
Diabetic foot care education may support health promotion G strategies when presented in a way that is meaningful and easily understood by the client (Schoen et al., 2010). Conducting a learning needs assessment prior to delivering diabetic foot care education helps tailor the learning session to help the client receive and understand the information presented to him/her (RNAO, 2012a). This assessment should include the client's learning preferences, individual characteristics and relevant social determinants of health.

# Learning Preferences
Clients have diverse learning preferences that may or may not align with the health-care professional's personal teaching style. Every client should be given the opportunity to learn in his/her preferred manner (RNAO, 2012a).
The health-care professional should adapt the learning session to meet the client's learning needs and preferences.

# Individual Characteristics
Personal attitudes, cultural beliefs, level of literacy, age and physical condition all influence an individual's ability to carry out the recommended regimen (American Association of Diabetes Educators, 1999; Canadian Diabetes Association -Diabetes Educator Section, 2000). Accounting for these individual characteristics prior to the learning session may optimize the diabetic foot care education plan.

# Social Determinants of Health
Key factors related to the conditions in which people live and that affect their general health are known as social determinants of health. These factors include: Assessing the relevant social determinants of health as part of the learning needs assessment may identify key issues that could impact on the client's ability to implement strategies to prevent or reduce complications.
For further discussion and more detailed information about client centred learning strategies, the reader is encouraged to consult the RNAO Nursing Best Practice Guideline Facilitating Client Centred Learning (2012).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# EVALUATION RECOMMENDATION 4.0:
Monitor the progress of wound healing on an ongoing basis using a consistent tool, and evaluate the percentage of wound closure at 4 weeks.

# Level of Evidence = Ib
Discussion of Evidence:
Wound management is a comprehensive process and should therefore include an evaluation of the care plan.
The RNAO expert panel suggests posing the questions below when evaluating outcomes of the treatment plan:
- How is wound healing evaluated? 2. Is wound healing progressing at the expected rate? 3. Is the treatment plan effective?
Wound healing progress should be evaluated on an on-going and systematic basis. In a prospective, randomized controlled trial, Sheehan et al. (2003) found that a 50% reduction in wound surface area at 4 weeks was a good predictor of wound healing at 12 weeks. This finding was further supported by other research evidence, which showed that poor wound healing at 4 weeks was a strong predictor for non-healing at 12 weeks (Flanagan, 2003;Warriner, Snyder, & Cardinal, 2011). Furthermore, in a recent retrospective analysis of two randomized controlled trials of diabetic foot ulcer healing,  identified that wound healing at 12 weeks was substantially greater in wounds demonstrating more than 90% wound closure at 8 weeks. Therefore, progress of wound healing at 4 and 8 weeks may be correlated with wound closure at 12 weeks.
Assessment tools should be consistently used when monitoring and evaluating the progress of foot ulcer healing. The Pressure Ulcer Scale for Healing tool (PUSH tool) measures wound size, exudates and tissue type, and has recently been validated for assessing diabetic foot ulcer healing (Gardner, Frantz, Bergquist, & Shin, 2005;Hon et al., 2010).
A lower PUSH score indicates greater wound closure, less exudate and healthier epithelial tissue. See Appendix T for the PUSH Tool.
Furthermore, if a diabetic foot ulcer does not achieve a 50% reduction in surface area at 4 weeks, a comprehensive re-assessment of the treatment plan should be conducted before advanced healing technologies are considered.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# RECOMMENDATION 4.1:
Reassess for additional correctable factors if healing does not occur at the expected rate.

# Level of Evidence = IV

# Discussion of Evidence:
Reassessing correctable factors for a wound that has not healed according to the care plan is integral to wound management. These correctable factors may include infection, poor glycemic control and inadequate pressure redistribution from prescribed devices. Revisiting the client's health history and co-morbidities may also provide useful information to identify potential barriers to wound healing (Collins & Toiba, 2010).
The most common reason for delayed wound healing in a diabetic foot ulcer is inadequate pressure offloading.
Inadequate pressure offloading can be due to poor client adherence to offloading devices or a lack of prescription for offloading devices. Poor client adherence to prescribed offloading devices may be due to a variety of reasons. Nurses should assess the client's knowledge about the benefits of pressure-reducing devices, encourage the communication of concerns and engage in health teaching. Identifying strategies that promote informed and engaged clients may be the most critical aspect of care-planning and to ensure adherence to offloading and pressure redistribution devices. If appropriate offloading is not prescribed, however, the person with the diabetic foot ulcer should be referred to a centre specializing in diabetic foot ulcer care.
Appropriate follow-up measures may be indicated for non-healing wounds where all possible correctable factors have been addressed. Several adjunctive approaches can be considered for persistent non-healing wounds (refer to Recommendation 2.2 and Appendix O for specific treatment options).

# Level of Evidence = IV

# Discussion of Evidence:
Assessment and treatment of people with diabetic foot ulcers is a complex and dynamic process that requires a team of health-care professionals with specialized knowledge and skills. The knowledge and skills necessary to assess and treat a person with a diabetic foot ulcer are not taught in an entry level program. Therefore, team members should participate in accredited continuing education opportunities to receive specific wound care training with appropriate provisions of time, access and funding from their health-care organization. The team should adopt a client-centred approach G and have a sound knowledge base enabling them to problem solve and ensure interventions are evidence based according to organizational policies and procedures.
Refer to Appendix U for a list of resources for diabetic foot ulcer information.

# RECOMMENDATION 5.1:
Educational institutions incorporate the RNAO Nursing Best Practice Guideline, Assessment and Management of Foot Ulcers for People with Diabetes (2 nd ed.), into basic registered nurse, registered practical nurse, doctor of medicine and interprofessional curricula to promote a culture of evidence-based practice.

# Level of Evidence = IV

# Discussion of Evidence:
Members of the interprofessional team play a vital role in the early detection and ongoing assessment of diabetic foot ulcers. They are also in a pivotal position to facilitate an evidence-based team approach to treatment IWGDF, 2011).
The RNAO expert panel suggests incorporating the RNAO Nursing Best Practice Guideline, Assessment and Management of Foot Ulcers for People with Diabetes (2 nd ed.), into interprofessional curricula to ensure health-care professionals are exposed to and provided with evidence-based knowledge, skills and tools that are needed to assist in assessing and managing people with diabetic foot ulcers.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition
Organization and Policy Recommendations RECOMMENDATION 6.0:
Use a systematic approach to implement the Assessment and Management of Foot Ulcers for People with Diabetes (2 nd ed.) clinical practice guideline and provide resources and organizational and administrative supports to facilitate clinician uptake.

# Level of Evidence = IV
Discussion of Evidence:.
An effective organizational plan for guideline implementation includes:
 An assessment of organizational readiness and barriers to implementation, taking into account local circumstances;  Involvement of all members (whether in a direct or indirect supportive function) in the implementation process;  Ongoing educational opportunities to reinforce the importance of best practices;  One or more qualified individual(s) to provide the support needed for the education and implementation process; and  Opportunities for reflection on personal and organizational experience in implementing guidelines.
Successful implementation of best practice guidelines requires the use of a structured, systematic planning process and strong leadership from nurses who are able to transform the evidence-based recommendations into policies, procedures and nursing-related practices that impact on care within the organization. The RNAO Toolkit: Implementation of Best Practice Guidelines (2 nd ed.) (2012b) provides a structured model for implementing practice change.
Refer to the Implementation Strategies section of this guideline and Appendix V for a description of the RNAO Toolkit: Implementation of Best Practice Guidelines (2 nd ed.) (2012b).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition RECOMMENDATION 6.1: Develop policies that acknowledge and designate human, material and fiscal resources to support the interprofessional team in diabetic foot ulcer management.

# Level of Evidence = IV RECOMMENDATION 6.2:
Establish and support an interprofessional, inter-agency team comprised of knowledgeable and interested persons to address and monitor quality improvement in the management of diabetic foot ulcers.

# Level of Evidence = IV RECOMMENDATION 6.3:
Develop processes to facilitate the referral of clients with diabetic foot ulcers to local diabetes resources and health-care professionals.

# Level of Evidence = IV

# Discussion of Evidence:
Organizations play a pivotal role in advocating and facilitating access to diabetic foot ulcer care services. This role includes advocating for increased availability of and accessibility to diabetic foot ulcer care. To achieve optimal outcomes for people with diabetic foot ulcers, emphasis should be placed on an interprofessional health-care team that can establish and sustain an effective communication network between the client and their immediate health-care system. Teams may collaborate virtually to coordinate efforts and ensure goals are consistently met (Inlow et al., 2000). Furthermore, interprofessional diabetes foot ulcer care should be community-based and considerate of age, gender, cultural beliefs and socioeconomic dispositions. Through a retrospective review of the literature, Frykberg (1998) reported a reduction in non-traumatic amputation rates ranging from 58 to 100% after the implementation of an interprofessional approach to foot care.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition Key members of the team, along with the client and their family, may include: Diabetes foot care services should be accessible, comprehensive and supported by evidence-based clinical practice guidelines. Within this mandate, the interprofessional team should be dedicated to both maintaining the overall well being of the person with diabetes and preserving the integrity of lower extremities affected by foot ulcer(s) (Inlow et al., 2000).

# RECOMMENDATION 6.4:
Advocate for strategies and ongoing funding to assist clients in obtaining appropriate pressure redistribution devices during and after ulcer closure.

# Level of Evidence = IV

# Discussion of Evidence:
An organizational commitment to provide care and make available pressure redistribution devices is required to ensure quality health outcomes in foot ulcer management. As offloading devices may vary greatly in cost, the selection and effectiveness of appropriate devices should be continually assessed on an individual basis to optimize quality care. While the costs of pressure redistribution devices are substantial, it is important that such costs are viewed in relation to the total cost of care for foot ulcer and increased risk of amputation (Bus et al., 2008). Nurses may advocate for strategies and ongoing funding that increase the accessibility of pressure redistribution devices for clients with foot ulcers in the hospital and community setting.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Research Gaps and Future Implications
The RNAO expert panel, in reviewing the evidence for this edition of the guideline, identified the following priority research areas, many of which were identified in the first edition. These areas have been broadly categorized into practice, outcomes and health system research (see Table 7).

# HEALTH SYSTEM RESEARCH
Health delivery issues (government support and funding of programs and treatment for diabetic foot ulcer management, cultural beliefs, high-risk patient populations)
Health economic evaluations of secondary and tertiary prevention strategies
The above table, although in no way exhaustive, is an attempt to identify and prioritize the critical amount of research that is needed in this area. Many of the recommendations in the guideline are based on quantitative and qualitative research evidence. Other recommendations are based on consensus or expert opinion. Further substantive research is required to validate the expert opinion. Increasing the research evidence can impact knowledge that will lead to improved practice and outcomes for people who experience diabetic foot ulcers.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Evaluation/Monitoring of Guideline
Organizations implementing the recommendations in this nursing BPG are advised to consider how their implementation, and their impact, will be monitored and evaluated. The impact of BPG implementation and sustained use of evidence-based practice can be evaluated objectively through regular review of the utilization of the Nursing Order Sets G and their effect on client health outcomes. Nursing Order Sets embedded within clinical information systems simplify this process by providing a mechanism for electronic data capture.  Cost related to implementing guideline:
 Education and access to on-the-job supports.
 New documentation systems.
 Support systems.
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Implementation Strategies
Guideline implementation at the point of care is multifaceted and challenging at all levels. The uptake of knowledge in any practice setting requires more than the awareness and distribution of guidelines. Application of the guideline in any practice setting requires adaptation for the local context. Adaptation must be systematic and participatory to ensure recommendations are customized to fit the local context (Straus, Tetroe, & Graham 2009). The Registered Nurses' Association of Ontario recommends the use of the Toolkit: Implementation of Best Practice Guidelines (2 nd ed.) (RNAO, 2012b), which provides an evidenced-informed process for a systematic, well-planned implementation.
The Toolkit is based on emerging evidence that the likelihood of achieving successful uptake of best practice in health care increases when:
 Leaders at all levels are committed to support facilitation of guideline implementation  Guidelines are selected for implementation through a systematic, participatory process  Stakeholders relevant to the focus of the guideline are identified, and engaged in the implementation process  An environmental readiness assessment for implementation is conducted for its impact on guideline uptake  The guideline is tailored to the local context  Barriers and facilitators to use of the guideline are assessed and addressed  Interventions are selected that promote guideline use  Guideline use is systematically monitored and sustained  Evaluation of the impacts of guideline use is embedded into the process  There are adequate resources to complete the activities related to all aspects of guideline implementation
The Toolkit uses the knowledge-to-action model that depicts the process of choosing a guideline in the centre triangle, and follows a detailed step-by-step direction for implementing guideline recommendations at the local level. These steps are illustrated in Figure 3: "Knowledge to Action" framework (RNAO, 2012b;Straus et al., 2009).
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition A full version of the Toolkit: Implementation of Best Practice Guidelines (2 nd ed.) is available in PDF format at the RNAO website, .
In addition, RNAO is committed to widespread deployment and implementation of the guidelines and utilizes a coordinated approach to dissemination incorporating a variety of strategies. Guideline implementation is facilitated through RNAO specific initiatives that include the Nursing Best Practice Champion Network, which serves to develop the capacity of individual nurses and foster awareness, engagement and adoption of BPGs; and the Best Practice Spotlight Organization (BPSO) Designation that supports BPG implementation at the organizational and system levels. BPSOs focus on developing evidence-based cultures with the specific mandate to implement, evaluate and sustain multiple RNAO clinical practice BPGs. In addition to these strategies, capacitybuilding learning institutes related to specific BPGs and their implementation are held annually. (RNAO, 2012b, p. 19-20).
Further information about each of these implementation strategies can be found at:  Process For Guideline Update/ Review of Guideline
The Registered Nurses' Association of Ontario (RNAO) commits to update its best practice guidelines (BPG) as follows:
- Each nursing BPG will be reviewed by a team of specialists (RNAO Expert Panel) in the topic area -to be completed every 5 years following publication of the last edition.
Best Practice Guideline (IaBPG) Centre staff will regularly monitor for new systematic reviews, randomized controlled trials, and other relevant literature in the field.
- Based on the results of this monitoring, RNAO IaBPG Centre staff may recommend an earlier revision period.
Appropriate consultation with a team of members comprised of original RNAO Expert Panel members and other specialists and experts in the field will help inform the decision to review and revise the guidelines earlier than the targeted milestone. Fife, C., Mader, J. T., Stone, J., Brill, L., Satterfield, K., Norfleet, A., et al. (2007). Thrombin peptide CHRYSALIN stimulates healing of diabetic foot ulcers in a placebo-controlled phase I/II study. Wound Repair & Regeneration, 15(1), 23-34. Finch, P. M. & Hyder, E. (1999). Treatment of diabetic ulceration using Dermagraft. The Foot, 1999(9), 156-163. Fisken, R. A. & Digby, M. (1996. Which dressing for diabetic foot ulcers? Practical Diabetes International, 13(4), 107-109. Malnutrition: State of nutritional insufficiency due to either inadequate dietary intake or defective assimilation or utilization of food ingested.

# Metatarsal Heads:
The "metatarsal region" of the foot is the area on the bottom of a foot just before the toes, more commonly referred to as the ball-of-the-foot.

# Methicillin-Resistant Staphylococcus Aureus (MRSA):
MRSA is a strain of the staphylococcus bacterium that is resistant to the main groups of antibiotics.
Nursing Order Set: A nursing order set is a group of evidence-based interventions that are specific to the domain of nursing; it is ordered independently by nurses (i.e., without a physician's signature) to standardize the care provided for a specific clinical condition (e.g. pressure ulcers).
Onychomycosis: Fungal infection in the toe nails. Nails may appear dry, thickened, white or yellow and flaky.
Organization and Policy Recommendations: Statements of conditions required for a practice setting that enables the successful implementation of the best practice guideline. The conditions for success are largely the responsibility of the organization, although they may have implications for policy at a broader government or societal level.
Pallor: White, pale, blanched colour of a limb when in the upright position.
Pes Cavus: A foot characterized by an abnormally high arch. Hyperextension of the toes may be present which can give the foot the appearance of a claw.

# Pes Planus:
A foot that has a fallen arch and appears abnormally flat or spread out.
Photoplethysmography: Photoplethysmography uses infrared light to assess changes in the blood volume in the micro-circulation.
Practice Recommendations: Statements of best practice directed at the practice of health-care professionals that are ideally evidence-based.

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition
The degrees to which health-care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (World Health Organization, 2009). Randomized Controlled Trials: Clinical trials that involve at least one test treatment and one control treatment, concurrent enrollment and follow-up of the test-and control-treated groups, and in which the treatments to be administered are selected by a random process.
Rubor: Dark purple to bright red colour of a limb when in a dependent position.
Sensory Ataxia: An impairment of one's sense of body position. It may be characterized by striking the ground forcibly with the bottom of the foot as well as a stiff fling of the leg with walking.
The chance of having a negative test result given that one does not have a disease.
The chance of having positive test result given that one does have a disease.

# Sharp Debridement (also known as Conservative Sharp Debridement):
The removal of dead or devitalised tissue from healthy tissue using a scalpel, scissors and forceps (Gray et al., 2011).
Stakeholder: An individual, group or organization with a vested interest in the decisions and actions of organizations and who may attempt to influence decisions and actions (Baker et al., 1999). Stakeholders include all individuals or groups who will be directly or indirectly affected by the change or solution to the problem.
Swabbing: Technique involving the use of a swab to remove bacteria from a wound and place them in a growth medium for propagation and identification.

# Systemic Infection:
A clinical infection that extends beyond the margins of the wound. Some systemic infectious complications of pressure ulcers include cellulitis, advancing cellulitis, osteomyelitis, meningitis, endocarditis, septic arthritis, bacteremia and sepsis.

# Systematic Review:
The Cochrane Collaboration (2011) states that, "a systematic review attempts to collate all empirical evidence that fits pre-specified eligibility criteria in order to answer a specific research question". A systematic review uses systematic, explicit and reproducible methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review (The Cochrane Collaboration, 2011).
Toe Pressure: See Photoplethysmography.

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition studies equally between the two RNAO BPG Program Research Associates (Fleiss, 2003). A final summary of literature findings was completed. The comprehensive data tables and summary were provided to all panel members. In September 2012, the RNAO expert panel convened to achieve consensus on the need to update the original guideline recommendations and discussion of evidence.
A review of the most recent literature and relevant guidelines published between 2004 and 2012 resulted in refinements to existing recommendations, as well as inclusion of stronger evidence for the recommendations. This second edition of the guideline is a culmination of the original work and the new literature. The following flow diagrams of the review process for guidelines and articles are presented according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Moher, Liberati, Ttzlaff, Altman & The PRISMA Group, 2009).   J.G. Fleishchli, 1998, Archives of Internal Medicine,158(2), p. 157-162. Reprinted with permission of Dr. D.G. Armstrong.  More frequent visits may be indicated for monitoring Note. From "Practical criteria for screening patients at high risk for diabetic foot ulceration," by L.A. Lavery, D.G. Armstrong, S.A. Vela, T.L. Quebedeau and J.G. Fleishchli, 1998, Archives of Internal Medicine,158(2), p. 157-162. Reprinted with permission of Dr. D.G. Armstrong.

# Guideline Review Process Flow Diagram

# A P P E N D I C E S

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition
Wound size (measured in square centimetres) should be determined after debridement, if possible. The outer border of the ulcer should be measured from the intact skin surrounding the ulcer. If wound healing is one of the end-points in a study, tracing of the wound, planimetry or the grid technique should be used for sequential measurements of the wound area. If, on the other hand, wound size is measured only at the time of recruitment into a study and intact skin is the primary end-point, the surface area can also be estimated by multiplying the largest diameter by the second largest diameter measured perpendicular to the first diameter. However, this technique is clearly less precise. The frequency distribution of the size of the ulcers should be reported in each study as quartiles.

# Depth/Tissue Loss
Depth is difficult to determine and relative; an ulcer which is only a few millimeters deep on a toe can penetrate into bone or a joint, but, in other regions, ulcers can be several centimeters deep without involvement of deeper structures. Therefore, ulcers are divided into lesions confined to the skin and those deeper than the skin. Even if an ulcer does not seem to penetrate below the skin, clinical infection in subcutaneous tissues (e.g., an abscess or osteomyelitis) means it is a "deep" ulcer. The extent of tissue loss should be evaluated after initial debridement, but this should be performed judiciously when critical limb ischemia (Grade 3) is suspected.

# GRADE 1
Superficial full thickness ulcer, not penetrating any structure deeper than the dermis.

# GRADE 2
Deep ulcer, penetrating below the dermis to subcutaneous structures, involving fascia, muscle, or tendon.

# GRADE 3
All subsequent layers of the foot involved, including bone and/or joint (exposed bone, probing to bone).
Infection of a diabetic foot ulcer is defined as invasion and multiplication of microorganisms in body tissues associated with tissue destruction or a host inflammatory response. Infection is defined clinically, by the symptoms and signs of inflammation as described below, regardless of the results of any wound culture.
Studies on accuracy and validity of different tests for diagnosing infection in diabetic foot disease are scarce. Therefore, the scheme described below is based mainly on expert opinion.
In grading infection, three parameters, in particular, are relevant to clinical management and possibly to outcome: the involvement of skin only; the involvement of deeper structures and the systemic inflammatory response of the patient. In daily practise the term a "limb-threatening" infection is also frequently used. However, this category is very difficult to define and overlaps with the other categories.

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition
No symptoms or signs of infection
Infection involving the skin and the subcutaneous tissue only (without involvement of deeper tissues and without systemic signs as described below). At least 2 of the following items are present:
 local swelling or induration;
 erythema > 0.5 to 2 cm around the ulcer;
 local tenderness or pain;
 local warmth; and/or  purulent discharge (thick, opaque to white or sanguineous secretion).
Other causes of an inflammatory response of the skin should be excluded (e.g., trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, venous stasis).
Erythema > 2 cm plus one of the items described above (swelling, tenderness, warmth, discharge) or Infection involving structures deeper than skin and subcutaneous tissues such as abscess, osteomyelitis, septic arthritis, fasciitis.
No systemic inflammatory response signs, as described below.
Any foot infection with the following signs of a systemic inflammatory response syndrome (SIRS). This response is manifested by two or more of the following conditions:
 Temperature > 38 or < 36 Celsius;
 Heart rate > 90 beats/min;
 Respiratory rate > 20 breaths/min;  PaCO2 < 32 mmHg;
 White blood cell count > 12.000 or < 4.000/cu mm; and/or  10% immature (band) forms.

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition
The system categorizes patients as having present or absent protective sensation in the affected foot. The system does not categorise patients as having (diabetic) polyneuropathy, and additional information is needed for this diagnosis. Moreover, it does not provide information on the cause of the loss of protective sensation, nor is the severity of the sensory loss graded. Both pressure and vibration sensation should be determined in each patient.

# GRADE 1
No loss of protective sensation on the affected foot detected, defined as the presence of sensory modalities described below.

# GRADE 2
Loss of protective sensation on the affected foot is defined as the absence of perception of the one of the following tests in the affected foot:
 Absent pressure sensation, determined with a 10 gram Monofilament, on 2 out of 3 sites on the plantar side of the foot, as described in the International Consensus on the Diabetic Foot; and/or  Absent vibration sensation, (determined with a 128 Hz tuning fork) or vibration threshold > 25 V, (using semi-quantitative techniques), both tested on the hallux.
Note. From "Classification of diabetic foot ulcers for research purposes," by N.C. Schaper, 2004, Diabetes/Metabolism Research and Reviews, 20(Suppl 1), S90-S95. Reprinted with permission.  (Ledoux et al., 2003). There are many reasons for this condition, the first of which is heredity.

# A P P E N D I C E S
Many have this condition and never experience problems of any kind.
However, others will have this condition created through years in soft, unsupportive shoes on hard surfaces, injury, pregnancy, or other factors.
A broad band of fibrous connective tissue, called the longitudinal ligament, causes the arch in the foot. A ligament is nothing more than connective tissue that connects bone to bone. The longitudinal ligament connects the metatarsal phalangeal joints to the os calcis or heel bone. Like a string on a bow, they hold the two ends together and create an arch. This arch is a shock absorption structure and it also helps to maintain all the tarsals in proper erect anatomic position. As this arch decreases, impact from the concrete becomes worse.
When the arch ligament stretches or tears, the arch falls. If it falls far enough, the tarsals may begin to shift to the inside or create pronation or a valgus (greater than 90 degree erect) position at the ankle. This can cause problems in the origin area (the metatarsals) or in the heel.
It also may cause pressure on the medial (inner) knee and perhaps the hip and back. It is like pulling the string on a marionette too tight, the result is a kinked mass on one side. The human body is much the same; place too much tension on major muscle groups and the joints kink and yell back.

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# DEFORMITY DESCRIPTION
Pes Cavus (vs normal arch):
In pes cavus, the arch is abnormally high on weight bearing. The heel is often tilted inwards at the ankle (but not always). In many, the toes will appear clawed. When not standing, the front half of the foot (forefoot) will appear to be dropped below the level of the rear foot. Ledoux et al. (2003) identified biomechanical differences among pes planus and pes cavus feet in persons with diabetes. They found pes cavus feet had more prominent metatarsal heads, bony prominences, hammer/claw toes, increased hallux dorsiflexion and pes cavus decreased hallux plantarflexion.

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# DEFORMITY DESCRIPTION
Charcot Arthropathy (vs normal arch): One in 680 people with diabetes develop Charcot joint with an incidence of 9 to 12% individuals with documented diabetic peripheral neuropathy (Royal Melbourne Hospital, 2002). Charcot joint is a form of neuroarthropathy that occurs most often in the foot. Nerve damage from diabetes causes decreased sensation, muscle and ligamental atrophy and subsequent joint instability. The charcot joint process can affect many areas of the foot. Most commonly it affects the Lisfranc joint (tarsometatarsal) region. The deformity in this area manifests as the typical rocker bottom type foot. The second most commonly affected area is the rear foot, or the talar-navicular region. The ankle joint and forefoot are more rarely involved.
It is also important to note that charcot may affect more than one region of the foot, and these different areas may each be at a different stage of the progression of the deformity. Walking on this insensitive and weakened joint can cause even more damage to the foot structure.
In the acute stage there is inflammation and bone reabsorption that destroys the bone. In later stages, the arch falls and the foot may develop a rocker bottom appearance. Weight distribution of the sole is altered causing deformities leading to pressure points that enhance ulcer development. Signs of charcot arthopathy include swelling of the foot and leg, changes in the shape of the foot or ankle, feeling of instability, crunching feelings or sounds, and marked increase in temperature of the foot. Symptoms include pain or discomfort, pain at rest and burning sensations. It is important that the charcot foot is recognized early so that appropriate treatment of the foot can be provided to prevent further injury and promote a stable foot (Lavery et al., 1998).
For patient information on charcot arthropathy, visit 

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# DEFORMITY DESCRIPTION
Limited Joint Mobility Progressive stiffening of collagen-containing tissues leads to thickening of the skin, loss of joint mobility, and potential fixed flexor deformity. Up to 30% of people with diabetes may have limited joint mobility. Reduction in mobility of the ankle joint may cause increased plantar pressure when walking and be a major risk factor in the pathogenesis of diabetic foot ulcers (Fernando, Masson, Veves & Boulton, 1991;Zimny, Schatz & Pfohl, 2004). Achilles tendon contracture is a common cause of limited joint mobility causing increased pressure on the forefoot during ambulation (Armstrong, Lavery & Bushman, 1998;Mueller, Sinacore, Hastings, Strube & Johnson, 2004).  Measures absolute oxygen partial pressure in the dermis. According to T c pO 2 less than 20 mmHg gives a guarded prognosis for healing.
 40 mmHg is a good indication for healing.
 T c pO 2 should be measured on upper leg and dorsum of the foot for best results.
 Areas of callus, edema or bony prominences produce inaccurate results.
 Valuable for evaluating perfusion and is a good predictor of amputation in the lower limbs Mayfield, Reiber, Sanders, Janisse & Pogach, 1998;).
 T c pO 2 < 30 mmHg was an independent predictor of diabetic foot ulceration.

# Toe and Ankle Pressures
 Systolic toe and ankle pressures are measured with a fitted occluding cuff placed most often around the base of the first toe and around both ankles.
 Toe pressure of > 45 mmHg is necessary for optimal healing (Apelqvist, Castenfors, Larsson, Stenstrom & Agardh, 1989;.
 Most patients with toe blood pressures > 30mmHg healed with conservative management Royal Melbourne Hospital, 2002).
 With ankle pressures < 80mmHg, most patients had an amputation or died before healing occurred.
  suggests a cut-off of 25mmHg for T c pO 2 and 30mmHg for toe blood pressure as predictors of wound healing, with T c pO 2 being the better predictor in patients with diabetes and chronic foot ulcers. Toe pressures, however, may be more technically and economically feasible.
 Toe pressures for persons with diabetes were more reliable than persons with false negative ABPI's and lower limb neuropathy (Cao et al., 2011).

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# DIAGNOSTIC TEST DESCRIPTION
Ankle-Brachial Pressure Index (ABPI)
 ABPI or ratio of systolic blood pressure in the lower extremity to blood pressure in the arm is a common clinical measure of reduced circulation Cao et al., 2011).
 First line of assessment for diagnosing vascular status though insensitive to determine the extent of occlusive disease compared to angiography (Cao et al., 2011).
 This should not be the sole diagnostic test performed (Cao et al., 2011).  In the diabetic population, ABPI results can be unreliable (falsely negative; for example ABPI > 1.2) due to calcification of the arterial vessels Cao et al., 2011).
This should not be the sole diagnostic test performed.
 In persons with diabetes, ABPI results can be unreliable (falsely negative) due to calcification of the arterial vessels Cao et al., 2011). Sensitivity (63-100%) and specificity (85-97%) were reported for persons with diabetes (Cao et al., 2011).
 Sensitivity (92-98%) and specificity (88-98%) is high for all 3 types of angiography (Cao et al., 2011).
 Diagnosing magnetic resonance angiography (MRA) Contraindicated for persons with metal foreign implants (ie. pacemaker, aneurism clips, orthopedic screws, pin, etc.)
 Computed tomography, angiography (CTA) Exposure to nephrotoxic contrast medium (Cao et al., 2011).
 Digital subtraction angiography (DSA) Gold standard and traditional diagnostic tool. Potential for catheter puncture complications though risk is low -0.7% risk (Cao et al., 2011). Note. From "Interprofessional Diabetes Foot Ulcer Team Foot specific Initial Assessment Form," by R. Ogrin and Interprofessional Diabetes Foot Ulcer Team, 2009. Reprinted with permission.

# A P P E N D I C E S

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# BIOLOGIC AGENTS DESCRIPTION AND EVIDENCE IMMUNOKINE (WF10)
 Immunokine, or WF10, is an aqueous solution of the chlorite drug OXO-K993 given intravenously to treat chronic inflammatory disorders (Yingsakmongkol, Maraprygsavan & Sukosit, 2011).
 Topical application of WF10 has been shown to improve wound healing and enhance granulation tissue formation in various types of wounds (Yingsakmongkol et al., 2011). et al. (2011) conducted a randomized controlled trial to evaluate the effect of WF10 as an adjunct to the standard treatment of diabetic foot ulcers. The addition of WF10 to standard wound care significantly enhanced the formation of granulation tissue, and reduced infection, inflammation, necrotic tissue, and overall wound severity score (Yingsakmongkol et al., 2011).

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# TYPE OF ADJUNCTIVE THERAPY DESCRIPTION AND EVIDENCE
Negative Pressure Wound Therapy (NPWT)
 Subatmospheric pressure is delivered to the wound by a dressing covered with a clear membrane.
 The dressing is attached to a pump that delivers intermittent or continuous suction within a prescribed range of settings.
The RNAO expert panel reached consensus to support the Health Quality Ontario: Ontario Health Technology Advisory Committee (OHTAC, 2010) in recommending NPWT as an effective treatment option in the management of diabetic foot ulcers. The OHTAC (2010) review of randomized controlled trials found evidence that:
 The proportion of clients who achieved complete wound closure was significantly higher in the NPWT group than the control group.
 The duration of therapy and median time to complete ulcer closure was shorter in the NPWT group than the control group.
 The decrease in wound area from baseline was significantly greater in the NPWT group than the control group.

# A P P E N D I C E S
Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition

# Surgeries and Associated Evidence

# SURGERY DESCRIPTION AND EVIDENCE

# Achilles Tendon Lengthening
 Achilles Tendon Lengthening is a surgical procedure that involves lengthening the tendon or attached calf muscle to reduce stress on the foot.
 This procedure is effective at reducing ulcer recurrence in people with diabetes, peripheral neuropathy and a plantar ulcer (Mueller et al., 2004).
In a randomized clinical trial, Mueller et al. (2004) compared the effect of total contact casting alone to total contact casting combined with Achilles tendon lengthening in clients with diabetic foot ulcers. Outcome measures included healing rates and ulcer re-occurrence at the 7-month and 2-year follow-up. Although initial wound healing outcomes were similar, a significant reduction in ulcer re-occurrence was noted in the group with Achilles tendon lengthening at subsequent follow-up visits.

# Other surgical procedures
 Surgery for foot deformities in clients with diabetes can be beneficial in preventing the re-occurrence of ulcers.
 Options include: arthroplasty, digital amputation, bunionectomy, metatarsal osteotomy, ray resection, tendon tenotomy or skin grafting.
 Surgery may not be a viable option for select populations with impaired vascular supply.
To date, only anecdotal results are available. Note. From "Special considerations in wound bed preparation 2011: An update (Part 2)," by R.G. Sibbald, L. Goodman, K.Y. Woo, D. Krassner and H. Smart, 2012, Wound Care Canada, 10(3), p. 25-33. Reprinted with permission.
Appendix A: Glossary of Terms A1c (also known as Glycated Hemoglobin or HbA1c): The A1c test measures average blood glucose level over the preceding 2 to 3 months and, thus, assesses glycemic control. When the A1c is done every 3 months, it can detect whether glycemic control has been reached and maintained within the target range and also reflects departures from the target range.
Evidence: Evidence is information that comes closest to the facts of a matter. The form it takes depends on context. The findings of high-quality, methodologically appropriate research provides the most accurate evidence. As research is often incomplete and sometimes contradictory or unavailable, other kinds of information are necessary supplements to, or stand-ins for research. The evidence base for a decision involves combining the multiple forms of evidence and balancing rigor with expedience, privileging the former over the latter (Canadian Health Services Research Foundation, 2006).
Fissures: A long, narrow opening or gap that can extend into other cavities or areas of the body.
Foot Ulcer: A full thickness wound below the ankle in a diabetic patient, irrespective of duration.
Skin necrosis and gangrene are also included as ulcers (IWGDF, 2011).
Friable Granulation Tissue: Granulation tissue that bleeds easily with minimal stimulation. Normal healthy tissue is not friable.

# F-Scan Mat:
Measures dynamic plantar pressures (foot pressure in standing and walking positions). This device measures peak pressures under the forefoot and the rear foot and is used to assist health-care professionals in reducing pressure areas to the foot.
Hallux Deformity: A deformity of the great toe.
Hammer Toes: Middle joint is bent down, which may cause severe pressure and pain. The ligaments and tendons that have tightened cause the toe's joints to curl downwards and may occur in any toe except the great toe.
Health Promotion: A process of enabling people to increase control over and improve their health (WHO, 1986).
The presence of bacteria or other micro-organisms in sufficient quantity to damage tissue or impair healing. Clinical experience has indicated that wounds can be classified as infected when the wound tissue contains 105 or greater micro-organisms per gram of tissue. Clinical signs of infection may not be present, especially in the immuno-compromised client or the client with a chronic wound.
Insensate: A word that describes a region of the body where the person cannot feel a stimulus. As an example, if a monofilament is applied using proper technique, and the person does not feel the filament, that area of the foot is described as insensate.

# Intermittent claudication:
The reproducible cramping, aching, fatigue, weakness and/or frank pain in the buttock, thigh or calf muscles (rarely the foot) occurring after exercise and quickly relieved with 10 minutes of rest (Bonham & Flemister, 2008).

# Appendix B: Guideline Development Process
The Registered Nurses' Association of Ontario (RNAO) has made a commitment to ensure that this nursing best practice guideline is based on best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline every 5 years.
For this edition of the guideline, RNAO assembled an expert panel of health-care professionals comprised of members from the previous development panel as well as other recommended individuals with particular expertise in this practice area. A systematic review of the evidence based on the scope of the original guideline and supported by four clinical questions was conducted to capture the relevant literature and guidelines published between 2004 and 2012. The following research questions were established to guide the systematic review:
- What are the most effective methods for the assessment of foot ulcer in clients with diabetes?
- What are the most effective interventions to manage foot ulcers and prevent re-ulceration in clients with diabetes?
- What health-care professional education and training is required to ensure the provision of effective diabetic foot ulcer care?
- How do health-care organizations support and promote optimal assessment and management of foot ulcers in clients with diabetes?
The RNAO expert panel members were given a mandate to review the original guideline (March 2005) in light of the new evidence, specifically to ensure the validity, appropriateness and safety of the guideline recommendations.
Where necessary, sections of the guideline have been updated based on new evidence. This current edition (2013) is the culmination of the RNAO expert panel's work in integrating the most current and best evidence to update the guideline recommendations and supporting evidence from the first edition.

# Appendix C: Process for Systematic Review/Search Strategy

# Guideline Review
A member of the RNAO guideline development team (project coordinator) searched an established list of websites for guidelines and other relevant content published between 2004 and 2012. This list was compiled based on existing knowledge of evidence-based practice websites and recommendations from the literature. Detailed information about the search strategy for existing guidelines, including the list of websites searched and inclusion criteria, is available online at www.RNAO.ca. Guidelines were also identified by members of the RNAO expert panel.
Members of the panel critically appraised nine international guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument II (Brouwers et al., 2010). From this review, the following four guidelines were selected to inform the review process:
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Clinical practice guidelines for the prevention and management of diabetes in Canada. Canadian Journal of Diabetes, 32(suppl 1), S1-S201. The 2011 International Consensus on the Diabetic Foot & Practical and Specific Guidelines on the Management and Prevention of the Diabetic Foot continues to support the use of the PEDIS system as a diabetic foot ulcer classification system. For each category within this system, a grading system is provided, describing the severity within each category.

# GRADE 1 No symptoms or signs of PAD in the affected foot, in combination with:
 Palpable dorsal pedal and posterior tibial artery or  Ankle Brachial Index 0.9 to 1.10 or  Toe Brachial Index > 0.6 or  Transcutaneous oxygen pressure (TcPo2) > 60 mmHg

# GRADE 2 Symptoms or signs of PAD, but not of critical limb ischemia (CLI)
 Presence of intermittent claudication, as defined in the document of the International Consensus on the Diabetic Foot or  Ankle Brachial Index  50 mmHg or  Toe Brachial Index  30 mmHg or  TcPo2 30 -60 mmHg or  Other abnormalities on non-invasive testing, compatible with PAD (but not with CLI).
Note: If tests other than ankle or toe pressure or TcPo2 are performed, they should be specified in each study.

# GRADE 3 Critical limb ischemia, as defined by:
 Systolic ankle blood pressure < 50 mmHg or  Systolic toe blood pressure < 30 mmHg or  TcPo2 < 30 mmHg

# Appendix H: Description of Foot Deformities
The following table provides the description for several foot deformities: hammer toe, claw toe, hallux deformity, pes planus, pes cavus and charcot arthropathy.

# DEFORMITY DESCRIPTION
Hammer Toe -bent middle joint With atrophy of the intrinsic muscles of the foot, especially the toe plantar flexors, the flexor/ extensor balance at the metatarso-phalangeal joints is altered. This causes clawing at the toe and possible subluxation of the metatarsophalangeal joints. As a result, the submetatarsal fat pads are displaced and there is reduced pressure absorbing subcutaneous tissue at the metatarsal heads. In addition, glycosalation of collagen from hyperglycemia results in thickened, waxy skin that affects joint mobility. All these factors contribute to foot deformity and ulcer risk (Bennett, Stocks & Whittam, 1996;Shaw & Boulton, 1997).
Claw Toe -joint at base of toe is bent up and middle joint is bent down Appendix I: Diagnostic Tests to Determine Vascular Supply DIAGNOSTIC TEST

# Arterial Duplex Scan
 Non-invasive ultrasound test that can identify macro-and microvascular changes in the arterial tree.
 Used to diagnose aneurysm and large vessel stenosis >50%.
 Patients with suspected superficial artery stenosis and claudication may undergo duplex scanning to identify a lesion that is amenable to angioplasty, before subjected to angiogram Cao et al., 2011).
 Non-invasive arterial duplex scan as having sensitivity G and specificity rates greater than 90%.

# Continuous Wave Doppler
 Old technology. It is highly recommended to use in conjunction with duplex imaging to visualize the arteries (Cao et al., 2011).
Plethysmography  Records the "pulse volume recording" -another old tool that can establish diagnosis with limited accuracy (Cao et al., 2011).
 May be a initial diagnostic tool for persons with diabetes that do not have compressible arteries but should be used in conjuction with duplex scan (Cao et al., 2011).

# Appendix J: Wound Swabbing Technique
Collecting swab specimens using Levine's technique provides a reasonably accurate measure of wound bioburden (Gardner et al., 2006). Obtain a wound culture when clinical signs and symptoms of infection are present.
 Use sterile cotton-tipped swab and culture medium in a pre-packaged collection and transport system. Community nurses should not allow transport medium to freeze or become overheated in the car before using it.
 Thoroughly rinse wound with normal saline (non-bacteristatic).
 Do not swab pus, exudate, hard eschar or necrotic tissue.
 Rotate the swab tip in a 1cm 2 area of clean granulation tissue for a period of 5 seconds, using enough pressure to release tissue exudate. This may be painful so warn the patient of the possibility of pain and pre-medicate with analgesia if possible.
 Remove protective cap from culture medium and insert cotton-tipped applicator into the culture medium without contaminating the applicator.
 Transport to the laboratory at room temperature within 24 hours. 2. Show the monofilament to the client. Place the end of the monofilament on his/her hand or arm to show that the testing procedure will not hurt. 3. Ask the client to turn his/her head and close his/her eyes or look at the ceiling. 4. Hold the monofilament perpendicular to the skin. 5. Place the end of the monofilament on the sole of the foot. Ask the client to say 'yes' when he/she feels you touching his/her foot with the monofilament. DO NOT ASK THE CLIENT "did you feel that?" If the client does not say 'yes' when you touch a given testing site, continue on to another site. When you have completed the sequence, RETEST the area(s) where the client did not feel monofilament. 6. Push the monofilament until it bends, then hold for 1 to 3 seconds. 7. Lift the monofilament from the skin. Do not brush or slide along the skin. 8. Repeat the sequence randomly at each testing site on the foot (see pictures below).

# Sites on the sole of the foot for monofilament testing
Loss of protective sensation = absent sensation at one or more sites