Diabetic Foot — Advanced Nursing Guide

Review: Annually

Annual foot exam, GP/practice nurse

Review: 3–6 Monthly

Podiatry referral recommended

Review: 1–3 Monthly

MDT foot clinic, specialist podiatry

MDT within 24 hours

Emergency referral — consider admission

SKIN

STRUCTURE

NAILS

FOOTWEAR

Perfusion — grade 1–3 (normal→critical ischaemia)

Extent/size — wound area in cm²

Depth/tissue loss — grade 1–3 (superficial→bone)

Infection — IDSA grades 1–4

Sensation — neuropathy absent/present

T

I

M

E

Total Contact Cast (TCC)

Gold standard for plantar neuropathic ulcers. Distributes load across entire plantar surface. Non-removable preferred — improves compliance. Changes every 1–2 weeks.

CONTRAINDICATED: ischaemic ulcers, deep infection, uncontrolled oedema

Scotchcast Boot

Removable below-knee cast. Less effective than TCC due to compliance issues (removes at night). Can be made irremovable by adding fibreglass overwrap.

Removable Cast Walker (RCW)

Commercially available. Effective when made irremovable. Inferior to TCC for plantar forefoot ulcers when used removably. Instant TCC = RCW wrapped in fibreglass.

Therapeutic Footwear

Depth-inlay shoes, custom orthotics, toe box modifications. For healed ulcers to prevent recurrence. Inadequate for active ulcer offloading unless very superficial.

Mild Infection (Grade 2)

First line: Flucloxacillin 500mg–1g QDS oral
Penicillin allergy: Co-trimoxazole or clindamycin
Alternative: Co-amoxiclav 625mg TDS (gram-negative coverage)

Moderate Infection (Grade 3)

IV: Co-amoxiclav 1.2g TDS IV
MRSA risk: Add vancomycin or teicoplanin
Pseudomonas risk (warm climate/moist): Consider piperacillin-tazobactam

Severe Infection (Grade 4)

Broad spectrum IV: Piperacillin-tazobactam 4.5g TDS
+ MRSA cover: Vancomycin (trough monitoring required)
Metronidazole if anaerobic coverage needed (necrosis)

MRSA Coverage Indications

Revascularisation First

For ischaemic/mixed ulcers — angioplasty (endovascular) or bypass surgery. Limb salvage intent. Assess with duplex USS, CTA, or angiography. Best chance of healing with adequate perfusion restored first.

Minor Amputation

Toe amputation or ray resection (toe + metatarsal head). Preserves foot function. Preferred approach when infection contained to digit. Must have adequate perfusion for healing.

Major Amputation — Below Knee (BK)

Trans-tibial amputation. Preferred over AK — better prosthetic outcome and energy expenditure. Requires adequate knee function. 70–80% of major amputees rehabilitate with prosthesis.

Major Amputation — Above Knee (AK)

Trans-femoral. Reserved for extensive disease, knee joint involvement, or failed BK. Higher energy expenditure, lower prosthetic use rate. MDT decision involving patient and family.

25–40%

Adult diabetes prevalence in GCC — among highest globally

#1

Diabetic foot — leading cause of non-traumatic amputations in GCC region

Barefoot Walking Risks

Hot sand on beaches and outdoor areas can cause thermal burns in neuropathic feet (patient cannot feel heat). Prayer mat walking (barefoot for Salah) — repeated friction trauma on neuropathic plantar surfaces. Sandals and open footwear widely worn — inadequate pressure distribution and no toe protection.

Climate & Environment

Extreme heat (45–50°C ambient) accelerates infection in wounds. Dehydration impairs tissue perfusion and healing. Humidity in Gulf summer — maceration risk between toes. Air conditioning — dry skin, heel cracking.

Hajj Risk — Diabetic Pilgrims

Tawaf and Sa'i require walking vast distances (10–20km/day) in heat. Neuropathic diabetics cannot feel developing blisters or ulcers. Overcrowding delays medical attention. Footwear frequently removed for prayer. Pre-Hajj foot screening critical — must be classified and counselled before travel. Saudi MOH Hajj health protocols address diabetic foot specifically.

DHA (Dubai Health Authority)

CBAHI Accreditation Requirements

SCFHS Diabetes Nursing Exam Topics