The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Patient Empowerment and Education
Recommendation 1.0
All patients with diabetic foot ulcer(s) (PWDFU) or caregivers should have an understanding of their condition and the resources available to optimize their general health, diabetes management, and ulcer care.
(Level of Evidence = Ia)
Recommendation 1.1
Education is essential as an empowerment strategy for diabetes self-management and prevention or reduction of complications.
(Level of Evidence = IV)
Recommendation 1.2
Education is based on identified individual needs, risk factors, ulcer status, available resources, and ability to heal.
(Level of Evidence = IV)
Holistic Assessment
Recommendation 2.0
Complete and document a health history, including diabetes management, allergies, medications, functional assessment, and physical examination (vascular status, infection, callus, neuropathy, foot deformity/pressure, ulcer).
(Level of Evidence = Ib-IV)
Vascular Status
Recommendation 2.1
Clinically assess bilateral lower extremities for vascular supply and facilitate appropriate diagnostic testing.
(Level of Evidence = IIb-IV)
Infection
Recommendation 2.2
Assess all patients with diabetic foot ulcers for signs and symptoms of infection and facilitate appropriate diagnostic testing and treatment.
(Level of Evidence = IIa)
Neuropathy
Recommendation 2.3
Identify peripheral neuropathy by assessing for sensory, autonomic, and motor (S.A.M.) changes.
(Level of Evidence = II-IV)
Foot Deformity and Pressure
Recommendation 2.4
Assess for foot pressure, deformity, gait, footwear, and devices. Facilitate appropriate referrals.
(Level of Evidence = Ia-IV)
Foot Ulcer Assessment
Recommendation 3.0
Describe and document the ulcer characteristics.
(Level of Evidence = IV)
Recommendation 3.1
Identify the location, length, width, depth and classify the ulcer(s).
(Level of Evidence = Ia-IV)
Recommendation 3.2
Assess ulcer bed, exudate, odour, and peri-ulcer skin.
(Level of Evidence = IV)
Goals of Care
Recommendation 4.0
Define goals based on clinical findings, expert opinion, and patient preference.
(Level of Evidence = IV)
Recommendation 4.1
Determine the potential of the ulcer to heal.
(Level of Evidence = IV)
Recommendation 4.2
Develop goals mutually agreed upon by the patient and health care professionals.
(Level of Evidence = IV)
Management
Recommendation 5.0
Identify and optimize systemic, local, and extrinsic factors that can influence wound healing.
(Level of Evidence = IV)
Systemic Factors
Recommendation 5.1
Modify systemic factors and co-factors that may interfere with or impact on healing.
(Level of Evidence = IV)
Local Factors
Recommendation 5.2
Provide local wound care considering debridement, infection control, and a moist wound environment.
(Level of Evidence = Ia-III)
Extrinsic Factors
Recommendation 5.3
Provide pressure redistribution.
(Level of Evidence = IIa)
Non-Healing Diabetic Foot Wounds
Recommendation 5.4
Evaluate and implement treatment options for non-healable wounds.
(Level of Evidence = IV)
Evaluation
Recommendation 6.0
Evaluate the impact and effectiveness of the treatment plan.
(Level of Evidence = IV)
Reassess
Recommendation 6.1
Reassess for additional correctable factors if healing does not occur at the expected rate.
(Level of Evidence = III - IV)
Other Therapies
Recommendation 6.2
Consider the use of biological agents, adjunctive therapies, and/or surgery if healing has not occurred at the expected rate. Review each specific modality for recommendations.
(Level of Evidence = Ia-IV)
Education Recommendations
Continuing Professional Development
Recommendation 7.0
Nurses and other members of the interdisciplinary team need specific knowledge and skills in order to competently assess and participate in the treatment of diabetic foot ulcers.
(Level of Evidence = IV)
Curriculum Support and Resources
Recommendation 8.0
Educational institutions are encouraged to incorporate the Registered Nurses Association of Ontario (RNAO) Nursing Best Practice Guideline Assessment and Management of Foot Ulcers for People with Diabetes into basic RN, RPN, MD and allied health professional curricula.
(Level of Evidence = IV)
Organization & Policy Recommendations
System Support
Recommendation 9.0
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Dedication of qualified individual(s) to provide the support needed for the development and implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Opportunities for reflection on personal and organizational experience in implementing guidelines
In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines, based on available evidence, theoretical perspectives and consensus. The RNAO strongly recommends the use of this Toolkit for guiding the implementation of the best practice guideline on Assessment and Management of Foot Ulcers for People with Diabetes.
(Level of Evidence = IV)
Resources
Recommendation 9.1
Organizations are encouraged to develop policies that acknowledge and designate human, material, and fiscal resources to support the nurse and the interdisciplinary team in diabetic foot ulcer management.
(Level of Evidence = IV)
Team Development
Recommendation 9.2
Organizations are encouraged to establish and support an interdisciplinary, inter-agency team comprised of interested and knowledgeable persons to address and monitor quality improvement in the management of diabetic foot ulcers.
(Level of Evidence = IV)
Partnerships
Recommendation 9.3
Organizations are encouraged to work with community and other partners to develop a process to facilitate patient referral and access to local diabetes resources and health professionals with specialized knowledge in diabetic foot ulcer management.
(Level of Evidence = IV)
Financial Support
Recommendation 9.4
Organizations are encouraged to advocate for strategies and funding to assist patients in obtaining appropriate pressure redistribution devices.
(Level of Evidence = IV)
Advocacy
Recommendation 9.5
Organizations are encouraged to advocate for an increase in the availability and accessibility of diabetic foot ulcer care for all residents of Ontario.
(Level of Evidence = IV)
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities