best practice guidelines: wound management in diabetic foot ulcers

ASSESSING DFUsAssessing DFUsPatients with a DFU need to be assessed holistically and intrinsic and extrinsicfactors consideredFor the non-specialist practitioner, the key skillrequired is knowing when and how to refer apatient with a DFU to the multidisciplinary footcareteam (MDFT; see page 19). Patients witha DFU should be assessed by the team withinone working day of presentation — or soonerin the presence of severe infection 22,36,37 . Inmany places, however, MDFTs do not exist andpractitioners instead work as individuals. Inthese situations, the patient’s prognosis oftendepends on a particular practitioner’s knowledgeand interest in the diabetic foot.Patients with a DFU need to be assessed holisticallyto identify intrinsic and extrinsic factors.This should encompass a full patient historyincluding medication, comorbidities and diabetesstatus 38 . It should also take into considerationthe history of the wound, previous DFUs oramputations and any symptoms suggestive ofneuropathy or PAD 28 .EXAMINATION OF THE ULCERA physical examination should determine: Is the wound predominantly neuropathic,ischaemic or neuroischaemic? If ischaemic, is there critical limb ischaemia? Are there any musculoskeletal deformities? What is the size/depth/location of thewound? What is the colour/status of the woundbed?— Black (necrosis)— Yellow, red, pink Is there any exposed bone? Is there any necrosis or gangrene? Is the wound infected? If so, are theresystemic signs and symptoms of infection(such as fevers, chills, rigors, metabolicinstability and confusion)? Is there any malodour? Is there local pain? Is there any exudate? What is the level ofproduction (high, moderate, low, none),colour and consistency of exudate, and is itpurulent? What is the status of the wound edge(callus, maceration, erythema, oedema,undermining)?Documenting ulcer characteristicsRecording the size, depth, appearance and locationof the DFU will help to establish a baselinefor treatment, develop a treatment plan andmonitor any response to interventions. It isimportant also to assess the area around thewound: erythema and maceration indicateadditional complications that may hinderwound healing 38 .Digitally photographing DFUs at the firstconsultation and periodically thereafterto document progress is helpful 39 . This isparticularly useful for ensuring consistencyof care among healthcare practitioners,facilitating telehealth in remote areas andillustrating improvement to the patient.TESTING FOR LOSS OF SENSATIONTwo simple and effective tests for peripheralneuropathy are commonly used: 10g (Semmes-Weinstein) monofilament Standard 128Hz tuning fork.The 10g monofilament is the most frequentlyused screening tool to determine the presenceof neuropathy in patients with diabetes 28 . Itshould be applied at various sites along theplantar aspect of the foot. Guidelines vary in thenumber of sites advocated, but the internationalconsensus is to test at three sites (see Figure5) 7 . A positive result is the inability to feel themonofilament when it is pressed against thefoot with enough force to bend it 40 .Neuropathy is also demonstrated by an inabilityto sense vibration from a standard tuning fork.Other tests are available, such as the biothesiometerand neurothesiometer, which are morecomplex handheld devices for assessing theperception of vibration.Do not test for neuropathy in areas of callusas this can mask feeling from any of theneuropathy testing devices and may give afalse-positive result.Be aware that patients with small nerve fibredamage and intact sensory nerves may have34 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS