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Wound care essentials summative assignment

Introduction

Section 1. Search strategy

Describe the strategy you used to retrieve the right resources to help you write your assignment. You must include the key words you used, the databases used and other sources of your literature such as websites, the years searched and the type of literature you were looking for.

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Approximate word count: 150-200

Your answer here:

Keywords used in the search engine are: diabetic, foot, ulceration, risk, prospective, aetiology, prevalence, cost, infection, dressing, treatment, amputation, wound, management, policy, guidelines, UK, Philippines, South Asia, Europe, which were consecutively joined together, using the Boolean Operation of adding AND and an asterisk to each terms. The main databases used were CINAHL plus and PubMed. Another source of evidence that the researcher used is the official website of the National Institute for Health and Clinical Excellence in which a clinical guideline was used deemed necessary for the said topic. The World Health Organization and the National Health Services websites were also used in collecting data for statistics as well as the Department of Health website in the Philippines. Peer reviewed articles have been searched using the said databases and have been sources of information. Limitations in this search have been identified. These are as follows:

The search has been limited for ten years only to make the search more manageable and clinically up to date while capturing key information.
The search is only applicable for humans aged 65 and up, regardless of gender. This bracket has been chosen because according to the World Health Organization (2006) diabetic foot ulceration is rampant in this age group.
The search is limited for peer reviewed journals only.
The search is not confined to the United Kingdom only; hence, statistics from Asia were also gathered.

Section 2. Wound aetiology

Select a common wound type (e.g. diabetic foot ulceration, pressure ulcer, leg ulcer, fungating wound, dehisced surgical wound.

Now explain and discuss:

What your chosen wound type is
How this type of wound develops (including contributory factors)
How this type of wound is recognised (common characteristics)
Who it affects
Prevalence in UK and home country (if known)

Approximate word count: 800-1000

Your answer here:

The type of wound that the author chose is diabetic foot ulceration. This was chosen because this type of wound is prevalent in the nursing home that the author is currently working at and Diabetes itself is a serious health issue worldwide. Consequently, diabetic foot ulceration is considered to be one of the most significant complications of diabetes, representing a worldwide issue of medical, social, and economic problem greatly affecting the patient’s quality of life. (World Health Organization, 2004) Earlier definitions of diabetic foot ulceration dated back to 1985 by the World Health Organization stating that it is an infection, ulceration, and/or destruction of deep tissue related with neurological abnormalities and various degrees of peripheral vascular disease in the lower extremities. This has been argued by Brownlee (2005) that the term ‘diabetic’ foot signifies that there are specific qualities about the feet of the individual with diabetes that sets this disease apart from other conditions that affect the lower extremities. However they added that anything which affects the foot in those with diabetes can also affect the foot in those without the disease. Thus the definition by De Heus-van Putten (1994) best neutralise those views, stating that diabetic foot ulcers is the many different lesions of the skin, nails, bone, and connective tissue in the foot which occur more often in diabetic patients than non-diabetic patients, such conditions like ulcers, neuropathic fractures, infections, gangrene, and amputation. This is supported by the contemporary study of Vileikyte (2001), presenting that the diabetic patients are statistically more likely to develop foot ulcer that usually leads to disablement and leg amputation. The aetiology of diabetic foot ulceration comprises many components. A multicentre study by Rathur and Boulton (2007) attributed 63% of diabetic foot ulcers to diabetic neuropathy and peripheral vascular disease to be the main causative factors of diabetic foot ulceration. Peripheral neuropathy is a complication of diabetes that is the result of overtime damage of the nerve due to high blood sugar levels (Jerosch-Herold, 2005). This complication consequently contribute to the cause of diabetic foot ulcer for the nerves that relay messages of pain and sensation to the lower limb are generally affected, leading to numbness or even complete loss of sensation in the legs and feet. Losing sensation would also mean not knowing if the feet are hurt or damage. This explains why diabetic patients are usually prone to problems like minor cuts, bruises and blisters without them feeling it.Furthermore, another risk factor is the peripheral vascular disease wherein there is narrowing of the arteries caused by fatty deposits that accumulate in the lining of the arteries resulting to poor blood circulation to the feet (Medina, Scott-Paul, Ghahary & Tredget-Edward, 2005). Inadequate blood supply to the wound means decrease healing and is likely to be damaged. This explains why even a mild injury like stepping in small object or a small scratch in bare foot can eventually become ulcer for a diabetic patient. Moreover, according to Veves, Giurini, and LoGerfo (2006), predisposing factors that may act in combination to the two main risk factors are the unrecognised trauma, the biomechanical abnormalities or deformity, the limited joint mobility, and the increased susceptibility to infection. Demographic factors also play an effect on diabetic foot ulceration, such as age, gender, ethnicity and lifestyle (Medina, Scott-Paul, Ghahary & Tredget-Edward, 2003). According to the World Health Organization (2004) Diabetic foot ulcerations are common on individuals who have Type 1 and Type 2 Diabetes and who are in the age bracket of 65 years old and above. This statistics is not only relevant here in the UK but also worldwide. People who have diabetes for a longer period or manage their diabetes less effectively are more likely to develop foot ulcers. Smoking, not taking exercise, being overweight and having high cholesterol or blood pressure can all increase diabetes foot ulcer risk (Diabetes UK, 2004). Previous foot ulcers and diabetes complications can increase foot ulcer likelihood, as can ill-fitting shoes or previous foot problems such as bunions, etc.

Diabetic foot ulceration usually located in increased pressure points on the bottom of the feet. However, ulcers related to trauma can occur anywhere on the foot (Diabetes UK, 2004) Anatomical distribution of diabetic foot ulceration comprises 50% of ulcers are on the toes; 30-40% are on the plantar metatarsal head; 10-15% are on the dorsum (sole) of the foot; 5-10% are on the ankle; and up to 10% are multiple ulcers (Department of Health, 2002). According to the National Diabetes Support Team (2006), the appearance of a diabetic foot ulcer generally has a base with pink/red or brown/black, depending on the patient’s blood circulations, and with a border of ‘punched-out’ like appearance while surrounded by callous skin. It has a bed with necrotic cap or ulcer (underlying tissues are exposed). Ulcers with a mainly neuropathic aetiology will have a healthy granulating bed whilst those with a significant arterial component will have a necrotic bed (Reiber, 2001). The International Diabetes Federation (2005) accounts that there are 170 million cases of diabetics reported worldwide. By 2025, this figure is expected to rise to 300 million. These diabetics patient have a 12-25% risk of suffering a foot ulcer at some time in their life. According to Reed (2004), elderly people with diabetics have twice the risk of developing foot ulcer, three times the risk of developing foot abscess and four times the risk of developing osteomyelitis. Similarly, diabetics were at greater risk of either local amputations or higher amputations (Hall & DeFrances, 2003). Since different regions of the world have populations that at variance in body builds, footwear, habits and lifestyles, the differences in the prevalence of diabetic foot ulceration is expected. Such differences are likely to be found in Asia, Africa and America for developing countries will experience the greatest rise in the prevalence of Type 2 diabetes in the next twenty years (Stanley & Collier, 2009). Thus, people living in these countries will be expected to have greater risks of ulceration in the later years. However, Abbott et al (2005) focused on Type 2 diabetics among migrant populations of South Asia and African-Carribean populations, compared with data from Europeans living in the UK, and revealed a three to four times higher incidence of ulceration in the Europeans. The lower risk of South Asians was attributed to the lower rates of foot deformity, peripheral vascular disease and neuropathy.

In the Philippines on the other hand, the author was not able to find statistics regarding the prevalence of diabetic foot ulcerations on individuals with either Type 1 or Type 2 Diabetes. Apparently, the Department of Health Philippines website does not have relevant statistics regarding the above matter however, according to the World Health Organization (2004), the prevalence of people having diabetes in Asia is fast rising and it may comprise to 75% of all diabetics in 2025 worldwide.

Section 3. Wound Assessment

Identify one feature of your chosen wound type that is commonly identified during the assessment process and critically discuss different ways of assessing this problem. Your discussion must make clear which aspect of wound assessment you have chosen e.g. exudate, odour, infection, and include an exploration of the different options available for measuring, describing and documenting it. You must link your discussion to the contemporary wound care literature.

Approximate word count: 800-1000

Your answer here:

When a diabetic patient develops an ulcer, it is very essential to know that the ulcer presents in the perspective of the diabetic. However, in the case of a diabetic patient, the skin usually in the feet does not heal efficiently and is prone to develop an ulcer as discussed on the previous section. This is what the writer believes to be the foremost feature of the diabetic foot ulceration that needs major consideration for it can eventually result to infection.

Assessing the delay wound healing of a diabetic foot and its relation to the aspect of infection involves thorough evaluation, thus, a general assessment by the multidisciplinary care approach of the patient with diabetic foot ulcer is fundamental. This includes evaluating for evidence of retinal and cerebro-vascular pathology that could relate to foot and ankle problem (Pham et al, 2000). The said evidence can play a part to falls, traumatic injury and poor foot hygiene of the patient and can aid in appropriate treatment of the wound. The renal and cardiac disease evaluation is another pathological assessment that can contribute to the evaluation of poor healing potential (Stanley & Collier, 2009). The standard observations of blood pressure, heart rate and temperature are also requisite assessment for these can reveal overriding features of sepsis such as pyrexia, tachycardia and general malaise (Costigan, Thordarson & Debnath, 2007). Stanley and Collier (2009) also added that inspection of the diabetic foot such as the characteristics of the skin, nails, and web spaces, is important for it can reveal pathology of the nails (Paronychia) or the cause of the spread of infection. Generally, limb-threatening infections can be defined by cellulitis extending 2cm from the ulcer perimeter, as well as deep abscess, osteomyelitis or critical ischemia (Frykberg et al, 2002). The existence of odor and exudates, and extent of cellulitis should be properly noted for these are indicative of osteomylitis which could indicate infection (Frykberg et al, 2002). In the case of neurological assessment, Jerosch-Herold ‘s (2005) assessment review stated that Semmes-Weinstein monofilament is considered to be the most reliable test for evaluating any loss of protective sensation done in the sole of the feet. The test is not only relevant in assessing loss of sensation; it also evaluates foot deformity, risk for ulceration and signs of infection.

Moreover, a vital part in this assessment is the classification of diabetic foot ulcer itself. This is supported by Frykberg et al (2002) stating that classifying ulcer is important in order to facilitate a logical approach to treatment and aid in the prediction of outcome.

In line with that, there are several wound classification guidelines used universally to assess the diabetic foot ulcer. One of this is the Wagner ulcer classification system (1987) is the most widely accepted descriptive classification of diabetic foot ulcerations. It categorises wound depth according to 6 wound grades. These include: grade 0 (intact skin), grade 1 (superficial ulcer), grade 2 (deep ulcer that includes tendon, bone, or joint), grade 3 (deep ulcer with abscess or osteomyelitis), grade 4 (forefoot gangrene) and lastly grade 5 (whole foot gangrene). However, the downside of the Wagner classification system is that it does not specifically address the aspect of infection and circulation problem, which are actually the important parameters of diabetic foot ulceration. However, this method is not really very reliable in assessing ischemia and infection because only useful guidance in the management of each class of ulcer is provided. Nonetheless, a more comprehensive scale has been developed at the University of Texas, which includes risk stratification and expresses tissue breakdown, infection and gangrene separately. According to Abbott et al (2005), this system is generally predictive of the outcome for it uses four grades of ulcer depth (0 to 3) and then stages them into four stages (A to D) basing on the presence or absence of ischemia and infection. The classification system assesses the depth of ulcer penetration, the presence of wound infection, and the presence of clinical signs of lower-extremity ischemia. Similarly, the International Working Group on the Diabetic Foot (2004) has proposed the PEDIS classification which grades the wound on a 5-feature basis: Perfusion (arterial supply), Extent (area), Depth, Infection, and Sensation. Finally, according to the Infectious Diseases Society of America guidelines (2004), the infected diabetic foot is sub-classified into the categories of mild (restricted involvement of only skin and subcutaneous tissues), moderate (more extensive or affecting deeper tissues), and severe (accompanied by systemic signs of infection or metabolic instability).

In addition to that, another form of assessment for infection is the surface swab. But according to Bowker and Pfiefer (2001), it is inadequate for identifying the type of bacteria causing limb-threatening deep infection. The most accurate and reliable technique involves removing exudates from the ulcer, getting a little tissue biopsy from the base of the ulcer and sending the sample to the laboratory in appropriate aerobic and anaerobic culture material. Plain film radiographs should also be obtained to look for tissue, gas and foreign bodies and to evaluate the infected ulcer for bone involvement. (Sutter & Shelton, 2006) Probing to bone using aseptic technique is also done to find out if osteomyelitis is present.

Section 4. Wound Management

Using the same wound feature that you identified in Section 3; critically discuss the different ways there are of managing this problem.

Your discussion must include:

The different types of wound care dressings, products and treatments that could be used to manage this problem
Other appropriate/related aspects of patient care such as nutrition and positioning
How the patient experience can be improved

Approximate word count: 800-1000

Your answer here:

After a comprehensive assessment, an ulcer management plan must be developed to direct treatment goals. In the treatment of diabetic foot ulceration, the primary goal is to attain wound closure and to control infection (Frykberg et al, 2002). In order to achieve this goal good wound care techniques are required. Part of this wound technique are dressings. Wound dressings represent a part of the management of diabetic foot ulceration. Ideally, dressings should alleviate symptoms, provide protection for the wound and promote healing. (Hilton, Williams, Beuker, Miller & Harding, 2002) In line with that, the NHS (2002) released a guide for useful dressings which included dressings for infected diabetic wound. Dressings that are low or non-adhering must be used on infected diabetic wounds with daily dressing changes. According to Foster, Greenhill, and Edmonds (2007), the ideal dressing for infected diabetic foot ulcers are those that fit in the shoes and does not take up too much room, it could withstand shear forces and carry out properly in an enclosed environment, does not increase the risk of infection, absorbs exudates suitably as well as allow drainage and it can be changed frequently and can be removed easily. Hydrocolloids are the best example of such dressings. They contain gel-forming agents, such as gelatin, so when the dressing comes into contact with wound exudate it absorbs ?uid and forms a gel which creates a moist healing environment (Heenan, 2008). According to Pudner (2001), it is advisable to use hydrocolloids in a diabetic foot ulcer as they absorb exudates and can give a visual indication of the need to change dressing. This kind of dressing can be easily removed by gently lifting an edge of the dressing and pulling carefully upwards to reduce the seal of the dressing on the skin and thus minimise trauma to the wound bed and surrounding skin. (Pudner, 2001) Regular dressing changes are done to monitor deterioration of the ulcer. Dressings with Inadine, Iodoflex or Iodosorb are also used to reduce bacterial inhabitation in the ulceration. Daily Flamazine dressings are also recommended for the treatment of Pseudomonas infection. (Sibbald et al, 2003) When the infected diabetic wound become heavily exudated, foams and alginate may be used because they are highly absorbent. Hydrogels facilitate autolysis and may be beneficial in managing ulcers containing necrotic tissue. Dressings containing Inadine and Silver may aid in managing wound infection. Occlusive dressings should be avoided for infected wounds. All dressings require frequent change for wound inspection. (Armstrong, Lavery & Harkless, 2003)

Another management is debridement. The purpose of this is to remove dead or devitalised tissue. (Bowker & Pfeifer, 2004) It is also recognised as one of the most important methods of wound bed preparation because it promotes the release of growth factors which contribute to progressive wound healing. (Leaper, 2002) Ulcer debridement is performed to remove unhealthy tissues such as necrotic, callus and fibrous tissue and recondition them back to bleeding tissues in order to facilitate full image of the extent of the ulcer and its underlying problems like abscesses or osteomyelitis (National Diabetes Support Team, 2006). Offloading must also be part of the management plan for the infected diabetic foot ulcers to relieve pressure from the wound to allow healing to take place. (Doupis & Vevies, 2008) However, offloading devices might be impractical for diabetic individuals who are frail or susceptible to falls, and a disadvantage of devices that cannot be removed is interference with bathing and showering. (Caravaggi, Faglia, & De Giglio, 2000)

In addition to the management stated above, antibiotic treatment is also necessary. The antibiotic regimen should be based on the anticipated spectrum of infecting organisms. (Chantelau, Tanudjaja & Altenhofer, 2006) The combination of an aminopenicillin and a penicillinase inhibitor has the required activity but other options include a quinolone plus either metronidazole or clindamycin. (Tentolouris, Jude & Smirnoff, 2003) In addition to antibiotic therapy, It may also be necessary to promote non weight bearing strategies such as bed rest and or use of wheelchair, crutches, walker, or cane. Diabetic individuals may also be advised to replace or modify their footwear. The lack of sensation associated with neuropathy can result in the tendency to buy shoes that are too small or too tight. It is necessary to accommodate any foot changes or deformities. Orthoses or custom-made shoe inserts may be required for pressure reduction. (Armstrong, Lavery, Harkless, 2003) In selecting devices, the ability of a device to remove or redistribute pressure, the ease of application, cost-effectiveness, and ability to gain compliance must be taken into consideration.

Proper footcare and general skincare must also be implemented. Feet should be checked daily for further cuts, sores, blisters, bruises or dry skin to prevent further ulcer formation. Bringing blood glucose levels within normal range is essential. (International Diabetes Federation, 2009) Strictly managing diabetes is the first stage in treating all the other complications and even the condition itself. Diet and exercise will almost certainly play a role in preventing as well as treating diabetes. (Embil, 2003)

Section 5.

Identify a contemporary source of evidence based guidance (i.e. a clinical guideline) which could be used as a basis for providing a high standard of care to patients with this type of wound. Critically discuss how the guidance given in this document might influence your nursing practice including whether you believe there are any omissions or recommendations made that would be difficult to manage in your own placement. Please also comment on whether the Guideline recommendations could be implemented in your home country e.g. Philippines, Sri Lanka, Malaysia, China.

You must clearly state the title your chosen guideline document and link your work to other healthcare literature where appropriate.

Approximate word count: 400-500

Please start this section by stating the name of your chosen Clinical Guideline.

Name of Guideline: Clinical Guidelines for Type 2 Diabetes Prevention and management of foot problems

A very crucial statement in the guideline states that diabetic individuals should have their feet and legs examined for specific problems at least once a year. This is highly recommended and should be implemented. Diabetic individuals need help to detect problems when they develop neuropathy and lack of protective pain sensation. If this is carried out, prevalence of infection and other diabetic complications will surely go down.

With regards to the whole healthcare setting, the NICE guideline recommends that health care professionals who carry out examinations must be properly trained but specific details of the training are not given. Nurses as well as other members of the healthcare team would need specific trainings most especially on handling equipments as well as imparting management to the affected individuals.

It was also mentioned that diabetic individuals with active problems will be seen by the multidisciplinary foot care team that consists of highly trained podiatrists and orthotists, nurses with training in dressing diabetic foot wounds and diabetes specialists with expertise in lower limb complications. However, there is currently a shortage of podiatrists, nurses and other specialised members of the healthcare team. Lack of clarity about the membership of the multidisciplinary team may affect in the implementation of the guideline.

Regarding ulcer management, there is a further problem with the section in the NICE guidelines on how ulcers should be managed. One or more interventions are suggested, including dressings, antibiotics to treat infection, and pressure relief by the use of special shoes or total contact casts. However, there is little guidance as to which intervention should be chosen and in which circumstance. Unfortunately, this could lead to a reinforcement of current practice where many patients with diabetic foot ulcers have dressings applied to their ulcers with no further interventions until the ulcer deteriorates. (Rathur & Boulton, 2007) Nurses caring for patients with diabetic foot ulcers should understand that, in addition to dressings, patients need effective pressure relief and management of infection.

As with regards to the author’s workplace which is a nursing home, although the guideline is flawed, as all guidelines are, the author believes that it will be really helpful in the management of diabetic foot problems since almost all of the residents who have diabetes are experiencing foot problems already. However, it will be better if the guideline made recommendations regarding services exclusive to nursing homes to address to the specific needs of the diabetic residents.

The author believes that this guideline is not achievable to the Philippines. In view of the current health care setting of the country, it will be very had to implement the guideline due mainly to lack of funding and a huge shortage of specialist health care professionals. The Philippines is one of the countries in South East Asia that prevalence rate of diabetic foot ulcerations and infections are fast rising (WHO,2004) but unfortunately, the country is also understaffed and underfunded.

The author believes that for the NICE guidelines to be implemented whether in the placement or for the whole healthcare setting, it will be necessary to recruit and train a lot of diabetic foot professionals or better yet, educate existing health care professionals. Careful monitoring of the diabetic individuals will be essential as well as imparting proper lifestyle change and management.

Reference List

Abbot, C.A, Carrington, A.L., Ash, H., Bath, S., Every, L.C., Griffiths, J., et al. (2002). The Northwest diabetes foot care study: incidence of and risk factors for new diabetic foot ulceration in a community based cohort. Wiley.19(5). 377-384.

Abbott, C.A., Garrow, A.P., Carrington, A.L., Morris, J., Van Ross, E.R. & Boulton, A.J. (2005). Foot ulcer risk is lower in South-Asian and African-Caribbean compared with European diabetic patients in the UK. The North-West Diabetes Foot Care Study, Diabetes Care, 28(8), 1869–1875.

Armstrong, P.G., Lavery, L.A., & Harkless, L.B. (2003). Validation of a wound classification system. Diabetes Care. 21 (5). 855-859.

Brownlee, M. (2005). The pathology of diabetic complications. Diabetes. 54. 1615-1625.

Bowker, J.H., & Pfeifer, M.A. (2001). The Diabetic Foot. 6th edition. St. Louis: Mosby

Caravaggi, C., Faglia, E., De Giglio, R., Mantero, M., Quarantello, A., Sommaria, E., et al. (2000). Effectiveness and safety of non removable fibreglass off-bearing cast versus a thereapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. Diabetes Care. (12). 1746-1751.

Chantelau, E., Tanudjaja, T. & Altenhofer, F. (2006). Antibiotic treatment for uncomplicated neuropathic foot ulcers in diabetes: a controlled trial. Diabetic Medicine. 13. 156-159.

Costigan, W., Thordarson, D.B., & Debnath, U.K. (2007). Operative management of ankle fractures in patients with diabetes mellitus, Foot and Ankle International, 28(1), 32–37.

De Heus-van Putten, M.A. (1994). The role of the Dutch podiatrist m the treatment of diabetic feet. Journal of British Podiatric Medicine,49(42), 161-164.

Department of Health. (2002). National service framework for diabetes. London: HSMO.

Diabetes UK. (2004). Epedimiology and Statistics. London: HSMO

Doupies, J., & Vevis, A. (2008). Classification, diagnosis, and treatment of diabetic foot ulcers. Retrieved March 30, 2009, from http://www.woundresearch.com/article/8706.

Embil, J. (2003). Getting to the bottom of the diabetic foot. The Canadian Journal of CME. 3:76-86.

Foster, A.V.M., Greenhill, M.T., & Edmonds, M.E. (2004). Comparing two dressings in the treatment of diabetic foot ulcers. J Wound Care. 3: 224-228.

Frykberg, R.G., Armstrong, D.G., Gurini, J., Edwards, H., Kraviette, M., Kavitz, S., et al. (2002). Diabetic foot disorders: a clinical practice guideline. The Journal of Foot and Ankle Surgery. 39(5).

Hall, M.J. & DeFrances, C.J. (2001). National Hospital Discharge Survey. Advance data from vital and health statistics; No: 332, National Center for Health Statistics:Hyattsville.

Heenan, A. (2008). Frequently asked questions: hydrocolloid dressings. Retrieved February 2007 from www.worldwidewounds.com/1998/april/Hydrocolloid-FAQ/hydrocolloid-questions.html

Hilton, J.R., Williams, B.T., Beuker, B.M., & Harding, K.G. (2004). Wound dressings in diabetic foot disease. Medline. 1:39, 100-103.

International Diabetes Federation. Diabetes. (2009). atlas 2nd edition. Brussels.

Leaper, D. (2002). Sharp technique for wound debridement. Retrieved December 15, 2005 from www.worldwidewounds.com/2002/december/leaper/sharp-debridement.html

Medina, A,, Scott Paul, G., Ghahary, A. & Tredget Edward, E. (2005). Pathophysiology of chronic nonhealing wounds, Burn Care Rehabilitation, 26(4), 306–319.

.National Diabetes Support Team. (2006). Diabetic foot guide, NHS Clinical Governance Support Team. London: NHS.

National Health Service . (2002). Diabetic Foot Ulcer Dressings Guidance and Referral Advice. Leicester.

National Institute for Clinical Excellence. (2004). Prevention and Management of foot problems in people with type 2 diabetes. Retrived January 2002 from http://www.nice.org.uk/nicemedia/live/10934/29246/29246.pdf

Pham, H., Armstrong, D.G, Harvey, C., Harkless, L.B., Giurini, J.M. & Veves, A. (2000). Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial, Diabetes Care, 23(5), 606–611.

Pudner, R. (2001). Hydrocolloid dressings in wound management. Retrieved February 2007 from www.jcn.co.uk/journal.asp?MonthNum=048

Rathur, H.M & Boulton, A.J. (2007). The diabetic foot. Clinics in Dermatology, 25(1),109-201.

Reed, J.F. (2004). An audit of lower extremity complications in octogenarian patients with diabetes mellitus, International Journal of Lower Extremity Wounds, 3 (3), 161–164.

Reiber, G.E., Smith, D.G., & Wallace., C.,(2002). Effect of therapeutic footwear on ulceration in patients with diabetes. Journal of the American Medicine Association. 287: 2552-2558.

Sibbald, R.G., Williams, D., Orstead, H.R., Campbell, K., Keart, D., Krasner, D. et al. (2003). Preparing the wound bed: Focus on infection and inflammation. Ostomy/Wound Management. 49 (11). 24-51.

Sutter, J.H., & Shelton, D.K. (2006). Three phase bone scan in osteomyelitis and other musculoskeletal disorders. Diabetes Medicine. 24 (12). 93-98.

Tentolouris, N., Jude, E.B., & Smirnoff, I. (2003). Methicillin resistant Staphylococcus Aureus, an increasing problem in the diabetic foot clinic: a worsening problem. Diabetic Medicine. 20 (2). 159-161.

Veves, A., Giurini, J. & LoGerfo, F. (2006). The Diabetic Foot: Medical and Surgical Management. Totowa, NJ: Humana Press.

Vileikyte, L. (2001). Diabetic foot ulcers: a quality of life issue. Diabetes Metabolism Research and Review,17(4), 46–249.

Wagner, F.W. (1987). The diabetic foot. Orthopedics, 10, 163–72.

World Health Organization. (2004). Adherence to Long term Therapies in Diabetes. Geneva.

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