Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Background
  • Diabetes is a disorder manifested by high blood glucose levels that result from defective insulin secretion or insulin action or a combination of both of these problems.
  • There are two major classifications of diabetes. Type 1 diabetes, which is primarily a result of the inability to produce insulin due to beta cell destruction in the pancreas. Type 2 diabetes, which results from a combination of insufficient insulin production and/or resistance of the cells of the body to the actions of insulin (CDA, 1998; 2003).
  • Regardless of the diabetes type, over time, failure to achieve optimal glycemic control can cause damage to the body’s small and large blood vessels and nerves.
  • Diabetes is a major cause of coronary artery disease, and is the leading cause of new cases of blindness and kidney disease (CDA, 1998; 2003).
  • Abbott et al. (2002) found that the incidence of foot ulcers in people with diabetes was 2.2% annually, and that past history of foot ulcers or history of amputation was strongly related to future ulcer risk.
  • In Ontario, the adjusted rates of lower extremity amputation are approximately 20 times higher for people with diabetes than in persons without diabetes (Institute for Clinical Evaluative Sciences, 2003).
  • The sequence of events leading to lower extremity ulceration and amputation in diabetes is a complex process with many factors combining to increase the likelihood that a foot injury or infection will occur and healing will be delayed. In the presence of reduced circulation (peripheral vascular disease) and loss of protective sensation (neuropathy), even minor foot trauma or unusual pressures on the foot may be sufficient to cause ulceration and eventual amputation.
  • The prevention of such traumatic “pivotal” events, together with the early identification and prompt treatment of foot problems can reduce the incidence of foot ulceration and amputation.
  • This can be achieved through a program of risk assessment, self-care education and regular reinforcement of self-care (Mayfield et al., 1998).