Archive for the ‘Diabetic Wound Management’ Category

Diabetic Toenails: Watch for Change

Tuesday, March 21st, 2023

Changes in the diabetic foot can happen fast: here are the signs and types clinicians in wound care need to look for. As a wound care professional, chances are you’ve treated a number of nail conditions and abnormalities that occur among the general population.

But when you’re working with diabetic patients, noticing and identifying variations is even more crucial. This is because change can happen more rapidly in the diabetic foot, and pathologies in diabetic toenails can ultimately lead to skin breakdown, foot ulcerations and infection.

So, what causes the nails to change? What exactly should you look for? We’ve got you covered.


Diabetes Wounds: Caring for Foot Ulcers and Other Wounds

Wednesday, November 16th, 2022

Diabetes wounds can be some of the most challenging to treat, even for the most experienced wound care professionals. As the prevalence of diabetes continues to grow, with 38% of U.S. adults having prediabetes, whether you are new to wound care or a seasoned professional, you will most likely encounter patients with diabetes on an increasing basis.

The American Diabetes Association recognizes November as American Diabetes Month, and as of 2022, diabetes has affected 37.3 million people in the United States. Having diabetes can complicate and delay the healing process of any type of wound, including pressure injuries, venous ulcers, arterial ulcers, or trauma wounds.

However, diabetes wounds can be especially pervasive, as they are known to be slow to heal, and there are numerous reasons why. One reason is that the cells most responsible for healing cannot correctly function when the patient has elevated blood sugars or has developed hyperglycemia with an increased risk for arterial disease.


A Look at the UT and Wagner Scale Diabetic Foot Ulcer Classification Systems

Thursday, August 19th, 2021

Given the fact that DFUs occur in approximately 15% of patients with diabetes and there are more than 34 million people in the U.S. with diabetes, using a relevant diabetic foot ulcer classification system for patients is essential.

There are several diabetic wound classification systems. But how do you choose which one to use?

This decision generally involves clinician preference along with the organization’s policy.

Two wound care specialists provide an overview of two systems for DFU classification: The Wagner Scale and the University of Texas (UT) Diabetic Wound Classification System.


Hyperbaric Oxygen Therapy Fundamentals in Wound Care

Thursday, August 27th, 2020

When you hear the words hyperbaric oxygen, you probably think of a troubled scuba diver with decompression sickness in need of immediate live-saving medical care.

But hyperbaric oxygen therapy — HBOT for short — is also a go-to therapy routinely used in wound care.

To learn the basics about HBOT, we spoke with wound care experts in the U.S. and abroad.


Decoding Foot Wounds: Pressure Injury Vs. Diabetic Foot Ulcer (DFU)

Wednesday, August 5th, 2020

How often have you found yourself in the conundrum of deciding whether a wound on the foot of a diabetic patient is a diabetic foot ulcer or a pressure injury? 

Probably more than once. This is a hotly debated issue among wound care clinicians.

In this post, we’ll dissect the facts and provide a clear understanding of how to differentiate the two types of foot wounds.


How to Treat Diabetic Foot Ulcers with a Total Contact Cast

Thursday, October 10th, 2019

There are times when clinicians and patients have done all they can to prevent diabetic foot ulcers, and they still develop.

“The patients who develop a diabetic foot ulcer are the ones who fell through the cracks,” said Don Wollheim, MD, FAPWCA, WCC, DWC, a board-certified surgeon of the American Board of Surgery.

Wollheim has 25 years of experience in general/vascular surgery and 13 years as a wound care specialist and educator. He also is a medical-legal consultant, college science instructor and clinical instructor for the Wound Care Education Institute.

“Once a diabetic foot ulcer develops, it’s essential it is treated aggressively with proven, standardized methods, as 85% of the amputations performed on diabetic patients began as a diabetic foot ulcer,” Wollheim said.


Learn about the Cause and Prevention of Diabetic Foot Ulcers

Tuesday, July 2nd, 2019

With more than 30 million people in the U.S. afflicted with diabetes, clinicians are very likely to encounter diabetic patients.

Carole Jakucs

By Carole Jakucs, MSN, RN, PHN

Diabetic foot ulcers occur in approximately 15% of diabetic patients. And if you’re a wound care clinician, you’ll likely find yourself caring for patients with diabetic foot ulcers more often than not.

To learn more about the causes and how to prevent diabetic foot ulcers, we spoke with Don Wollheim, MD, FAPWCA, WCC, DWC, a board-certified surgeon of the American Board of Surgery.

He has 25 years of experience in general/vascular surgery and 13 years of experience as a wound care specialist and educator. Wollheim is also a medical-legal consultant, college science instructor and clinical instructor at the Wound Care Education Institute (WCEI).


How to Pick the Best Wound Care Certification to Fit Your Role

Tuesday, April 16th, 2019

If you’re working in wound care and seeking to earn wound care certification, kudos because your skills are in great demand.

“The wound care industry in general lacks enough knowledgeable clinicians to handle the challenges of chronic wounds, as rarely is comprehensive wound care training included during college training of all disciplines, this includes MDs, NPs, PAs, RNs, PTs, OTs and LVNs,” said Bill Richlen, PT, WCC, DWC, one of our clinical wound care instructors.

The lack of standardized, pervasive wound care training for clinicians, sets the foundation for why clinicians working with wound patients on a routine basis, may want to get certified in wound care, said Richlen, who also owns Infinitus LLC, in Santa Claus, Ind., a wound care instruction and consulting company.

If you’re having difficulty trying to decide which wound care certification to start with, the info below may be just what you’re looking for to help you decide which certification route to go.


Lower Extremity Ulcers and the Toe Brachial Pressure Index

Friday, January 19th, 2018

To treat patients with lower extremity ulcers, you need to find out if there’s impaired arterial blood flow. For some patients, however, the standard Ankle Brachial Index (ABI) yields misleading results. Fortunately, there’s an easy alternative: the Toe Brachial Pressure Index (TBPI).  Here’s when and how to perform this simple test.

When confronting a lower extremity ulcer, we know that the usual wound assessment isn’t enough. Standards of care guide us to perform an Ankle Brachial Index (ABI) to calculate blood flow. By doing so, you can rule out significant arterial disease and determine the amount of venous compression you can safely apply.

The ABI compares the systolic blood pressure of the ankle to that of the arm (brachial) with the following formula:


Calculating Ankle Brachial Index


Values between 0.41-0.91 represent peripheral arterial disease (PAD) sufficient to cause claudication. Meanwhile, values of 0.00-0.40 reflect severe PAD sufficient to cause resting pain or gangrene. Refer the patient to a vascular specialist for further assessment.

When the ABI Falls Short:  Hardened Arteries

If your patient has a long history of diabetes, severe neuropathy, or kidney disease, the ABI diagnostic may yield misleading results because of calcified arteries.  In other words, If the blood pressure cuff cannot adequately compress the arteries, your ABI will be falsely inflated.

If you already know your that your patient has calcified arteries or an ABI comes back with an abnormally high value (>1.3), you need an alternative approach.  That’s where the Toe Brachial Pressure Index (TBPI) enters the picture.

How to Perform a Toe Brachial Pressure Index

The Toe Brachial Pressure Index is a non-invasive method of determining blood flow through the arteries in the feet and toes, which seldom calcify. The procedure resembles the more familiar ABI. If you have solid blood pressure skills, you will master the TBPI with ease.

TBPI Equipment

First, gather the items you’ll need on hand to complete the TBPI measurements:

  • A blood pressure meter with an arm cuff and toe cuff
  • A handheld Doppler ultrasound device
  • Ultrasound transmission gel
  • Tissue or gauze
  • Damp cloth or alcohol wipes

Measuring Brachial Systolic Pressure

  1. Have the patient remove shoes and stockings and lie down for at least 10 minutes prior to obtaining blood pressure measurement.
  2. Apply the blood pressure cuff snugly on the upper arm with the lower edge of the cuff 1 inch above the antecubital fossa (pit of the elbow) and palpate for the brachial pulse.
  3. Apply conductivity gel over the brachial artery. Turn on the Doppler device and place the tip of the probe at the antecubital area at approximately a 60-degree angle to the surface of the skin.
  4. Move the probe around until you hear the clearest arterial pulse sounds. Keep the probe at that position.
  5. Inflate the blood pressure cuff to approximately 20mm Hg above the numerical reading where the pulse sounds cease.
  6. Slowly deflate the cuff at a rate of 2 mm Hg per second until you hear the first arterial pulse sound. When this number is determined, deflate the cuff completely and record this systolic reading.
  7. Remove the gel from the patient’s skin with a tissue or gauze
  8. Repeat the procedure in the other arm and record the reading.

Measuring Toe Systolic Pressure

  1. Place the toe cuff around the base of the great toe. Use the second toe if the great toe can’t be used.
  2. Palpate the pulse signal on the toe’s distal pad area. Apply transmission gel to the pulse site.
  3. Place the tip of the Doppler probe onto the gel at a 45-degree angle to the skin surface. Direct the probe toward the patient’s head to detect the pulse signal.
  4. Slowly inflate the toe cuff until you no longer hear the pulse signal (to a maximum of 200 mm Hg). A partial squeeze should adequately inflate the cuff.
  5. Slowly deflate the toe cuff until the point at which the pulse signal returns. This is the toe’s systolic pressure.
  6. Remove the toe cuff. Use tissue or gauze to remove the leftover gel from the patient’s skin and from the Doppler probe. Gently clean the Doppler probe with a damp cloth or alcohol wipe.
  7. Calculate and document the results with the Toe Brachial Pressure Index formula, using the brachial systolic pressure in the arm with the highest pressure:


Calculating Toe Brachial Index


Understanding Toe Brachial Index Results

How do you interpret the number that results from your measurements and calculation?

TBPI > 0.7    Normal, suggests no arterial disease

TBPI = 0.64 – 0.7   Borderline

TBPI < 0.64    Abnormal, suggests arterial disease

If the absolute Toe Pressure (mm Hg) ≤30, this indicates Lower Extremity Arterial Disease and predicts a failure to heal.

Do you already see widespread adoption of the ABI and the TBPI in your facility? If so, do you have any handy tips for your fellow clinicians? Can you offer recommendations for your favorite equipment? We welcome you to share your knowledge and help elevate the skills of your fellow healers.


Wound Care Education Institute® provides online and onsite courses in Skin, WoundDiabetic and Ostomy Management. Eligible clinicians may sit for the prestigious WCC®, DWC® and OMS national board certification exams through the National Alliance of Wound Care and Ostomy®(NAWCO®). For details, see

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to the care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.


8 Reasons to Get Diabetes Under Control Now!

Friday, January 12th, 2018

Patients with diabetes are more likely to suffer many serious health issues besides foot wounds and amputations. This makes it imperative that they resolve to get their blood glucose levels under control.

All of the lawsuits I review have a common theme. The plaintiff suffers from a chronic wound and some degree of malnutrition and/or dehydration. I have started to notice that in addition to these problems, the plaintiff also quite often has diabetes. This trifecta of problems leads to pain, suffering, disability, and discontent.

People with diabetes are 10 to 20 times more likely to have a lower extremity amputation than those without diabetes.1 This is a scary statistic compounded by the fact that people with diabetes may not even notice a foot wound developing because they cannot feel it because of neuropathy. A foot ulcer is the initial event in more than 85% of major amputations that are performed on people with diabetes.2 Knowing this should provide enough motivation for patients to get their diabetes under control, but some people need even more reasons. Here are eight more consequences you can discuss with your patients. Hopefully, one will hit home.