Article
The assessment and management of foot ulcers
for people with diabetes nursing order set:
Expediting knowledge translation
Rita Wilson, Irmajean Bajnok, Tanya Costa
Citation: Wilson R, Baknok I,
Costa T (2014) The assessment
and management of foot
ulcers for people with diabetes
nursing order set: Expediting
knowledge translation Diabetic
Foot Canada 2: 16–20
Article points
1.An “order set” is a standardized
list of interventions commonly
used in the management of
a particular condition.
2.The nursing order set for
diabetic foot ulcer care can be
used to generate an evidencebased plan of care and reduce
variation in nursing practice.
3.Nursing order sets can be used
to simplify the introduction
of best practice guidelines.
Key words
- Evidence-based practice
- Knowledge translation
- Nursing
- Order set
Authors
Rita Wilson, eHealth Program
Manager, International Affairs and
Best Practice Guidelines Centre,
Registered Nurses’ Association
of Ontario; Irmajean Bajnok,
Director, International Affairs and
Best Practice Guidelines Centre,
Registered Nurses’ Association
of Ontario; Tanya Costa, eHealth
Project Coordinator, International
Affairs and Best Practice
Guidelines Centre, Registered
Nurses’ Association of Ontario.
16
The healthcare costs associated with the treatment of foot ulcers among Canadians
living with diabetes is approximately $150 million annually and growing. As a mitigation
strategy, the Canadian Council of the Federation’s Health Care Innovation Working
Group is promoting the widespread adoption of two clinical practice guidelines across
the country. One of these guidelines is the Registered Nurses’ Association of Ontario
(RNAO) Best Practice Guideline Assessment and Management of Foot Ulcers for
People with Diabetes. Implementing a best practice guideline can be a daunting task.
The RNAO Assessment and Management of Foot Ulcers for People with Diabetes
Nursing Order Set was developed to simplify this process and to expedite the transfer of
evidence into practice. This article provides a comprehensive overview of this nursing
order set and discusses the implications for nursing practice, research and policy.
B
y 2020, it is estimated that 3.7 million
Canadians will be living with diabetes
(Canadian Diabetes Association [CDA],
2012). The cost to the Canadian healthcare system
is expected to be $16.9 billion annually (CDA,
2012). Fifteen per cent of Canadians with diabetes
will develop foot ulcers in their lifetime (Canadian
Association of Wound Care, 2014). The cost to
treat diabetic foot ulcers is more than $150 million
a year, and growing (Health Care Innovation
Working Group [HCIWG], 2012).
In 2012, the Canadian Council of Federation’s
Healthcare Innovation Working Group, which
is comprised of the Canadian territorial and
provincial leaders (excluding Quebec), developed
a mitigation strategy to address the escalating
healthcare costs (HCIWG, 2012). One particular
area of focus was the cost associated with the
treatment of foot ulcers among Canadians with
diabetes (HCIWG, 2012). This mitigation strategy
includes the nationwide adoption of the Registered
Nurses’ Association of Ontario’s (RNAO)
Best Practice Guideline (BPG) Assessment and
Management of Foot Ulcers for People with Diabetes
(RNAO, 2013a). Through this approach, the
territorial and provincial leaders hope to decrease
costs by increasing access to the highest quality
evidence-based healthcare.
On average, it takes 17 years for research findings
to become ingrained in clinical practice (Balas,
2001). The RNAO’s International Affairs and Best
Practice Guideline Centre aims to expedite this
transition through its focus on the implementation
of its BPGs through a variety of channels including
the RNAO Guideline Implementation Toolkit
(RNAO, 2012), the Best Practice Spotlight
Organization Program® (BPSO) (Di Constanzo,
2013), the BPG Champion Network (Ploeg, 2010)
and BPG-based nursing order sets (RNAO, 2014).
The RNAO Assessment and Management of Foot
Ulcers for People with Diabetes Nursing Order Set
was developed to facilitate the transfer of evidence
into practice and assist healthcare organizations
in their efforts to implement the RNAO BPG
recommended by the HIWG for nation-wide
adoption (RNAO, 2014).
What is a nursing order set?
In healthcare, the term “order set” refers to a
standardized list of interventions commonly used
Diabetic Foot Canada Volume 2 No 1 2014
The assessment and management of foot ulcers for people with diabetes nursing order set: Expediting knowledge translation
Table 1. Practice recommendations converted to action-oriented interventions
Assessment & Management of Foot Ulcers Best Practice
Guideline Practice Recommendations
Assessment & Management of Foot Ulcers Nursing
Order Set Action-Oriented Nursing Interventions
1.1 Identify the location and classification of foot
ulcer(s) and measure length, width and depth of wound
bed.
• Assess foot ulcer(s) using a validated tool on admission
or initial contact.
• Identify the location and classification of the foot
ulcer(s).
• Measure the length, width and depth of the wound
bed using a consistent tool.
4.0 Monitor the progress of wound healing on an
ongoing basis using a consistent tool, and evaluate the
percentage of wound closure at 4 weeks.
• Observe and measure pressure ulcer(s) on an ongoing
basis using the PUSH Tool.
• Evaluate the percentage of wound healing at 4 weeks.
If a 50% reduction in surface area is not achieved
in 4 weeks, a comprehensive reassessment of the
client and treatment plan should be conducted before
advanced healing technologies are considered.
in the management of a particular condition
(Sheff, 2014). Order sets were initially developed
for physicians’ interventions (Wilson, 2013). More
recently, order sets for other healthcare providers,
including nurses, are growing in popularity
(Wilson, 2013).
RNAO’s nursing order sets are actionable
evidence-based nursing interventions derived
from the corresponding RNAO BPG (Wilson,
2013). They can be used as a paper-based tool or
integrated within an electronic medical record or
clinical decision support system, irrespective of
the vendor (Wilson, 2013). Once implemented,
nursing practice will be aligned with the best
available evidence (Ballard et al, 2008).
The nursing order set for diabetic foot ulcer
care was derived from the evidence-based practice
recommendations published in the RNAO BPG
Assessment and Management of Foot Ulcers for People
with Diabetes. Table 1 shows two of these practice
recommendations from the RNAO BPG that have
been converted to action-oriented interventions in
the corresponding nursing order set. As shown, the
order set provides the specific nursing interventions
required and tells the nurse when and how they
should be implemented. Therefore, the nursing
order set for diabetic foot ulcer care can be used to
generate an evidence-based plan of care and reduce
variation in nursing practice (Ballard et al, 2008).
Diabetic Foot Canada Volume 2 No 1 2014
“The nursing order set
for diabetic foot ulcer
care can be used to
generate an evidencebased plan of care and
reduce variation in
nursing practice”
Key features of the nursing order set
for diabetic foot ulcer care
The use of standardized terminology in the design
of order sets is strongly recommended (Institute
for Safe Medication Practice, 2010). Standardized
terminology allows electronic medical records
and clinical decision support systems to identify
different terms used to describe similar conditions
(e.g. decubitus ulcer, pressure ulcer, and bed sore)
as synonyms, and to assign the same numerical
code to each of these terms. This process is more
commonly referred to as mapping (Wieteck, 2008).
The use of standardized terminology facilitates the
extraction of more accurate and rich data to support
nursing practice, research and policy. It also enables
comparative analyses across healthcare organizations
and geographical locations to examine trends. The
rich data that the use of standardized terminology
affords also helps to better understand the impact of
specific interventions on health outcomes.
Each intervention in the nursing order set
for diabetic foot ulcer care was formulated by
experienced nursing informaticians in compliance
with two international nursing-specific standards:
1.Integration of a Reference Terminology Model
for Nursing (ISO 18104:2003) which is
published by the International Organization for
Standardization (ISO).
2.International Classification of Nursing Practice
17
The assessment and management of foot ulcers for people with diabetes nursing order set: Expediting knowledge translation
“The nursing order set
for diabetic foot ulcer
care incorporates many
other features that
increase its utility for
nurses.”
Figure 1. Subset of assessment and management of foot ulcers for people with diabetes nursing order set
Assessment and Management of Foot Ulcers for People with Diabetes Nursing Order Set
PR#
See Associated Document for Practice Recommendations (PR)
The interventions displayed in bold are supported by the strongest evidence.
Assessment
 Obtain a comprehensive health history on admission or initial contact.
• A comprehensive health history is required for all clients who present with diabetic foot
ulceration.
1.0
• Includes a history of presenting illness, past medical history, glycemic control, nutritional
status, allergies, medications, family history and psychological well-being.
• Obtain consult for Dietitian to see, if nutritional deficits identified.
Associated Documents: Comprehensive Health History Considerations; Risk Factors for
Amputation; Risk Factors for Ulceration.
Alert: People with diabetic foot ulcers should be identified as high risk for amputation.
Perform physical examination of affected limb(s) on admission or initial contact.
 Assess foot ulcer(s) using a validated tool on admission or initial contact
• Identify the location and classification of the foot ulcer(s).

• Measure the length, width and depth of the wound bed using a consistent tool.
1.0
1.1
1.1
1.1
1.2
• Assess bed of foot ulcer(s) for exudate, odour, condition of peri-ulcer skin and pain.
Associated Documents: University of Texas Diabetic Wound Classification System; PEDIS:
Diabetic Foot Ulcer Classification System; Clinical Assessment Tool
Planning
Collaborate with the interprofessional team to determine the potential of the foot ulcer(s) to
heal and ensure interventions to optimize healing have been explored.
Alert: Moist wound care is not recommended in wounds where complete healing is not the
goal. Use a dry dressing to keep the wound bed dry. If infection is present and the client cannot
fight infection, the moist wound will become a breeding ground for infection. Using a topical,
cost-effective antiseptic such as povidone iodine should be considered when the risk of infection
outweighs the healing potential.
Associated Documents: Factors Associated With Poor Healing of Chronic Wounds; Factors
Affecting Healing Potential

(ICNP) 7-Axis Model which was developed
by the International Council of Nurses (ICN)
(ISO, 2013; ICN, 2009).
Plans are also underway to map each intervention
to the ICNP and Systematized Nomenclature of
Medicine Clinical Terms (SNOMED CT).
ICNP is the standardized terminology
language developed by the International Council
of Nurses to describe the work that nurses do
(Coenen and Kim, 2010). SNOMED CT is the
standardized terminology language developed
by the International Health Terminology
Standards Development Organization (IHTSDO).
SNOMED CT is the most comprehensive
terminology language available (IHTSDO, 2013).
18
2.0
It is used globally to facilitate the exchange of
health information (IHTSDO, 2013).
The nursing order set for diabetic foot ulcer care
incorporates many other features that increase its
utility for nurses. For example, the interventions
in the nursing order set for diabetic foot ulcer
care are aligned with each of the four elements
of the nursing process: assessment, planning,
implementation and evaluation. The American
Nurses Association (2013) recognizes the nursing
process as “the common thread uniting different
types of nurses who work in varied areas”. By
design, no interventions are pre-selected to ensure
that the order set is used to support rather than
replace nurses’ critical thinking.
Diabetic Foot Canada Volume 2 No 1 2014
The assessment and management of foot ulcers for people with diabetes nursing order set: Expediting knowledge translation
To facilitate ease of access to the supporting
evidence, the nursing order set clearly delineates
the practice recommendations from which each
intervention is derived. Figure 1 shows a subset of
the nursing order set for diabetic foot ulcer care. The
numbers displayed to the right of each intervention,
under the sub-heading PR# (i.e. Practice
Recommendation Number), provide the link to the
supporting evidence in the related RNAO BPG. For
example, the interventions “Obtain a comprehensive
health history on admission or initial contact” and
“Perform physical examination of affected limb(s)
on admission or initial contact” were derived from
Practice Recommendation 1.0. in the BPG. It is
important to note that both of these interventions
are displayed using bold font. This signifies that
they are both supported by the strongest possible
evidence (e.g. meta-analyses, systematic reviews
of randomized controlled trials or at least one
randomized controlled trial).
Quite often practice recommendations contain
important instructions for nurses that further
explain the required interventions. These are
displayed as sub-bullet points in the subset of
the nursing order set for diabetic foot ulcer
care provided in Figure 1. A case in point is the
instruction to the nurse to obtain a consult for
the dietitian to see if the comprehensive health
history completed on admission or initial contact
reveals nutritional deficits. Additional instructions
for the nurse performing the intervention at the
point-of-care are also included in the order set
as associated documents. These are pertinent
clinical decision support resources derived from
the BPGs that may be made accessible to the nurse
using hyperlinks. There are several examples of
these in Figure 1, including the Risk Factors for
Amputation and the University of Texas Diabetic
Wound Classification System (Armstrong et al,
1998). There are many other types of clinical
decision support resources embedded within
the nursing order set for diabetic foot ulcer
care such as the Pathway to the Prevention and
Management of Diabetic Foot Ulcer (Botros et
al, 2010), Assessment and Diagnostic Tests to
Determine Vascular Supply (“Appendix I” as cited
in RNAO, 2013, p. 126) and Wound Swabbing
Technique, (“Appendix J” as cited in RNAO,
2013, p. 127).
Diabetic Foot Canada Volume 2 No 1 2014
“Alerts” are an integral feature of the nursing
order set for diabetic foot ulcer care. Alerts are short
statements that provide important information to
nurses at the point of care related to specific risk
factors or non-evidence-based practices that might
jeopardize patient safety. In the nursing order set for
diabetic foot ulcer care, alerts are displayed using
red font to increase their visibility. Two alerts are
shown in Figure 1, one of which is “Moist wound
care is not recommended in wounds where complete
healing is not the goal”. This information is vitally
important to communicate to nurses caring for
people with foot ulcers where complete healing
is not the expected outcome; in which case moist
wound care increases the risk of wound infection.
“Alerts are short
statements that provide
important information
to nurses at the point of
care related to specific
risk factors or nonevidence-based practices
that might jeopardize
patient safety”
Link between the nursing order set for
diabetic foot ulcer care and outcome
evaluation
Outcome evaluation is another important aspect of
BPG implementations. RNAO’s Nursing Quality
Indicators for Reporting and Evaluation (NQuIRE®)
is an international repository of quality indicators
designed to measure the impact of implementing
BPGs in terms of the structure, processes and
outcomes (Lloyd et al, 2013). Six quality indicators
have been developed for the Assessment and
Management of Foot Ulcers for People with Diabetes
guideline (Lloyd et al, 2013). The process indicators
(i.e. the nursing care provided) have been aligned
with the interventions in the complementary nursing
order set for diabetic foot ulcer care and with the
outcome indicators which reflect the expected patient
outcomes. BPSOs that have entered into a formal
agreement with RNAO to implement the Assessment
and Management of Foot Ulcers for People with
Diabetes BPG and are also participating in RNAO’s
NQuIRE initiative will find the nursing order set for
diabetic foot ulcer care particularly useful.
Accessing the nursing order set for
diabetic foot ulcer care
The nursing order set for diabetic foot ulcer care
may be incorporated into an existing electronic
medical record, clinical decision support system
or be integrated within the clinical context
as a paper-based tool. RNAO has partnered
with PatientOrderSets.com to support the
implementation process.
19
The assessment and management of foot ulcers for people with diabetes nursing order set: Expediting knowledge translation
“Embedding the nursing
order set for diabetic
foot ulcer care within
an existing electronic
system has many
benefits.”
PatientOrderSets.com is a leader in order set
development and deployment with a customer base
of over 270 Canadian healthcare organizations
(PatientOrderSets.com, 2014). They provide two
web-based applications to support organizations
interested in implementing the nursing
order set for diabetic foot ulcer care, namely:
TxConnect and EntryPoint (PatientOrderSets.
com, 2014). TxConnect is an order set library
and content management system that facilitates
the customization of order sets to suit the
organization’s clinical context. Customized order
sets can be printed as needed for inclusion in a
paper-based health record (PatientOrderSets.com,
2014). EntryPoint allows organizations to complete
their customized order sets electronically using a
desktop computer or mobile device such as a tablet
(PatientOrderSets.com, 2014).
PatientOrderSets.com
offers
a
third
implementation option – support for healthcare
organizations wishing to embed the nursing order
set for diabetic foot ulcer care within their own
electronic system (Wilson, 2013). Embedding the
nursing order set for diabetic foot ulcer care within
an existing electronic system has many benefits
beyond those previously mentioned. It supports the
integration and sharing of pertinent information
among healthcare providers and improves the
patient’s healthcare experience. An integrated
health record also increases the visibility of the
nurses’ contributions to the patient outcomes.
Healthcare organizations across the spectrum
of care will undoubtedly derive many benefits
from implementing the RNAO Assessment and
Management of Foot Ulcers for People with Diabetes
Nursing Order Set. A licensing fee is required for
access. For more information, visit www.RNAO.ca
or contact [email protected]
n
Source of support
Funding for this initiative was provided by eHealth
Ontario.
Conflict of interest
The author has no personal conflict of interest to
declare. The Registered Nurses’ Association of Ontario
has partnered with PatientOrderSets.com to disseminate
nursing order sets for a fee.
20
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Diabetic Foot Canada Volume 2 No 1 2014