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4.2 Presence of Superficial Bacteria

i. Assess for Infection

Diabetic ulcers, like most chronic wounds, can become infected with superficial or spreading bacteria and/or biofilm. The validated mnemonics “NERDS” and “STONEES” classify the signs and symptoms of localized infection (NERDS) and spreading infection (STONEES). Increased localized pain is a significant predictor of deep compartment infection.

Presence of Superficial Bacteria

  • N - Non-healing wound
  • E - Exudate increased
  • R - Red friable (fragile tissue that bleeds easily)
  • D - Debris (presence of necrotic tissue (eschar/slough)) in wound
  • S - Smell

Presence of Spreading Bacteria (< 3 low bacteria count, >3 high bacteria count)

  • S - Size increasing
  • T - Temperature increased ( >4 degrees F / >2.2 degrees C difference using infrared thermometer)
  • O - Os (probes to bone or bone is increased)
  • N - New areas of breakdown
  • E - Exudate present
  • E - Erythema and/or Edema
  • S - Smell

j. Relief of Pressure and Protection of Ulcer

(Level A: RNAO’s Assessment and Management of Diabetic Foot Ulcers 1)

Offloading is for LIFE!


The International Working Group Diabetic Foot Ulcers outlines the importance of offloading to enhance wound healing:

  • This is a cornerstone in treating an ulcer associated with increased biomechanical stress
  • The preferred treatment for a neuropathic plantar ulcer is a non-removable knee-high offloading device, either total contact cast (TCC) or removable walker rendered irremovable
  • When a non-removable TCC or walker is contra-indicated or not tolerated, use a removable device
  • When these devices are contra-indicated, use footwear that best offloads the ulcer
  • In non-plantar ulcers, consider offloading with shoe-modifications, temporary footwear, toe-spacers or orthoses
  • If other forms of biomechanical relief are not available, consider felted foam, in combination with appropriate footwear
  • Instruct the patient to limit standing and walking, and to use crutches or wheelchair if necessary

Total Contact Cast or Prefabricated Removable Walking Casts (rendered irremovable) is GOLD STANDARD of Care
Contraindications for Total Contact Casting (TCC)

  • Patients with documented lower-extremity arterial disease
  • Patients with an active wound infection or a sinus tract with deep extension into the foot which requires daily wound access for topical wound management
  • Patients with unstable gait
  • Patients with cast claustrophobia or previously known non-adherence to treatment plan
  • Patients with fluctuating leg edema or active skin disease
  • Inadequately trained clinical staff
  • Restless leg syndrome or conditions which cause leg tremors

Check for red marks, blisters, skin abrasion, etc. caused by offloading device. If found, send patient to treating practitioner immediately.

Ongoing Offloading Care (per Waterloo Wellington Pathway for Diabetic Foot Ulcer document)

  • Ensure appropriate footwear/offloading referrals have been arranged to a qualified offloading specialist (if patient does not have)
  • Review weartime of offloading device as per treating practitioner’s directions
  • Review adherence to using appropriate footwear and/or offloading device(s)
  • Assess barriers to appropriate offloading
  • Initial and ongoing callous reduction is part of offloading
  • Assess for secondary complications of offloading and refer concerns to dispensing practitioner
  1. look for redmarks, blisters, skin abrasions
  2. ask about knee, hip or back issues (including contralateral limb) due to height difference of offloading device
  3. check for unsafe gait (are they stable, using appropriate aids, etc)
  • Check gait aids such as walker, cane, crutches
  • Review long term goals of offloading (i.e. transition from cast to shoes, foot orthoses, etc.)
  • Teach patient to assess for secondary complications
  • Discuss winter footwear with appropriate offloading specialist
  • Check for availability for financial compensation (e.g. private insurance, Department of Veterans Affairs - DHA, Ontario Disability Support Program –ODSP, Assisted Devices, Non-Insured Health Benefits -NIHB and Southern Ontario Aboriginal Diabetes Initiative – SOADI for First Nations people and Inuit)

Offloading Chart

Offloading Device Advantages Disadvantages

A well-molded minimally padded cast that maintains contact with the entire aspect of the foot and lower leg
  • Highest healing rates (gold standard)
  • Distributes pressure ove rthe entire plantar surgace
  • Completely offloads
  • Protects foot from infection
  • Controls edema
  • Maintains patient adherence as it is non-removable
  • Requires trained technician
  • Cannot assess foot on a daily basis
  • Affects sleeping and bathing
  • Exacerbates postural instability or causes poor balance
  • Cannot use if wound is infected
  • Cannot be used in the neuro-ischemic limb

A commercially available removable boot that reduces plantar pressures
  • Easily removable allowing wound inspection and treatment
  • Allows more comfortable bathing and sleeping
  • Can be used for infected wounds and superficial ulcers
  • Can be made irremovable
  • Removable nature of cast reduces adherence
  • No clinical data to support its efficacy compared to TCC

Offers Support only under the rear and mid-foot
  • Inexpensive
  • Easy to apply
  • Less effective than TCC
  • Hampers gait
  • If used consistently will offload pressure
  • Rentable
  • Requires upper body strength and endurance
  • May not be used all the time
  • Difficulty in navigating indoors
  • Can increase pressures on contralateral side
  • Can be used in feet with severe Charcot deformity to accommodate rocker bottom foot
  • Costly
  • Removable
  • Requires physician/specialist to prescribe

k. Determine if the wound is “Healable, Maintenance or Non-Healable

Healable Wounds: Have sufficient vascular supply, underlying cause can be corrected, offloaded & health can be optimized
Goal: Principles of wound bed preparation and moist wound healing: treat the cause, debridement, bacterial balance, exudate control, protect peri-wound skin
Maintenance Wounds: have healing potential, but various patient factors are compromising wound healing at this time
Goal: Principles of wound bed preparation and moist wound healing: treat the cause, debridement, bacterial balance, exudate control and protect peri-wound skin. Avoid higher cost advanced wound treatments until factors compromising wound healing are resolved. Focus on quality of life issues, exudate and odour management
Non-healable/Palliative wounds: has no ability to heal due to untreatable causes such as terminal disease or end-of-life
Goal: Avoid higher cost advanced wound treatment and focus on exudate and odour management, quality of life issues.2

Provide Local Wound Care
  1. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  2. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.

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