Diabetic-foot-ulcer Presentation MUST 22

8/13/2019 Diabetic-foot-ulcer Presentation MUST 22

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Pressure Ulcers


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Pressure Ulcers

Definition and Location

Classification

Risk Factors

Prevention

Treatment

Pressure Ulcers treatment for each stage Complications


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What is a Pressure Ulcer?

Definition: A pressure ulcer is a localized injuryto the skin or underlying tissue, usually over a bony

prominence, that is a result of pressure or of

pressure combined with shear or friction.

Reported prevalence rates have ranged

from 2.3 percent to 28 percent and reported

incidence rates from 2.2 percent to 23.9percent


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What is a Pressure Ulcer?

95% of pressure ulcers develop on the lower body

(about 65% in the pelvic area and 30% in the lower

extremities) 2-6 times greater mortality risk

Effective pressure ulcer treatment best

achieved through interdisciplinary teamapproach


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Pressure Ulcers

Location

Pressure ulcers commonly occur over the :

Sacrum

Greater trochanter Ischial tuberosity

Malleolus

Heel

Fibular head

Scapula


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Areas of pressure


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Pressure UlcersRisk Factors

Spinal cord injuries

Traumatic brain injury

Neuromuscular disorders Immobility

Malnutrition

Fecal and urinary

incontinence Altered level of

consciousness

Chronic systemic illness

Fractures

Aging skin decreased epidermal

turnover

dermoepidermal junction

flattens

fewer blood vessels

Decreased pain perception


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Contributory factors:

Internal/patient-related factors: Systemic disease: metabolic, neurological,

vascular, terminal illness

Reduced mobility or immobility

Sensory impairment

Psychological e.g. depression

Anaemia

Malnutrition

Level of consciousness

Extremes of age

Previous history of pressure damage or poor

skin condition Acute or chronic oedema

Dehydration/fluid status- sweat, incontinence

External factors:Pressure - support surfaces, change of

position

Shear- positioning, mobility

Friction- moving and handling

techniques, patient education,

splinting, casts, positioning

Other factors

- Moisture - incontinence, sweating,

pyrexia, wound exudate

- Medication


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Guidelines for Pressure Ulcers

Care

Recognition

Assessment Diagnosis Prevention and Treatment

Monitoring


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Recognition Steps

Examine the patients skin thoroughly to

identify existing pressure ulcers

Identify risk factors for developing pressureulcers

Review records/resident interview to

identify previous history of pressure ulcers


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Ulcer Type Pathophysiology Location

Diabetic Peripheral neuropathy secondary to

small or large vessel disease in

chronic, uncontrolled diabetes

Usually lower extremities

Ischemic Reduction in blood flow to tissuescaused by coronary artery

disease, diabetes mellitus,

hypertension, hyperlipidemia,

peripheral arterial disease, or

smoking

Usually distal lower extremitiesTips of toes

Pressure Unrelieved pressure resulting in

damage to skin or underlying

tissue

Usually over bony prominences (e.g.,

buttocks, elbows, heels, ischium,

medial and lateral malleolus,sacrum, trochanters)

Venous Venous hypertension resulting from

incompetence of venous valves, post-

phlebitic syndrome, or venous

insufficiency. Tend to be

irregularly shaped

Usually lower leg region

Distinguishing Features of Common

Types of Ulcers


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Risk Assessment and Evaluation

Braden Scale

Push Tool


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Braden Scale

Sensory Perception 1-4

Moisture 1-4

Physical Activity 1-4 Mobility 1-4

Nutrition 1-4

Friction & Shear 1-3 Score 18+ Low risk

15-18 Mild risk, 13-14 Moderate risk, 10-12

High risk, below 10 Very High Risk


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Prevention

Aims

Reduce Pressure and Shearing effects

Reduce Moisture

General Skin Care

Nutrition Co-morbidities

Involve patient, family, caregivers


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Prevention Daily skin inspection

Bathing and skin cleaning frequency

Moisturize skin; avoid hot water or harsh

solutions Assess and treat incontinence; use topical barriers

or absorbent padding when needed

Proper re-positioning frequently; q2hrly for thosebed-bound, q1hrly for those in wheelchairs; selfre-positioning every 15 minutes for those inwheelchairs

Avoid manipulating bony prominences


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Prevention Practice proper positioning, transferring and turning

techniques to avoid friction and shearing forces; lift

dont shift

Use dry lubricants (cornstarch) or protectivecoverings to reduce friction injury

Institute a rehabilitation program to maintain or

improve mobility/activity status

Consider nutritional supplementation/support for

nutritionally compromised persons


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Prevention

Use adjunct devices (air mattresses, limb

padding) where necessary

Use pillows or padding to avoid bony

prominences such as knees from having direct

contact

Elevate the head of the bed no more than 30

unless absolutely necessary

Monitor and document interventions and

outcomes

Have a fixed re ositionin schedule


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Staging of pressure ulcers

Suspected deep tissue injury Purple or maroon localized area of

discolored intact skin or blood-filled

blister due to damage of underlyingsoft tissue from pressure and/orshear*. The area may be preceded by

tissue that is painful, firm, mushy,boggy, warmer or cooler ascompared to adjacent tissue.


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Suspected Deep Tissue Injury

Purple or maroon localized area of discolored

intact skin or blood-filled blister due to

damage of underlying soft tissue from pressure

and/or shear.


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Deep Tissue Injury


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Pressure Ulcers on Mucous

Membranes Pressure ulcers can develop on mucous

membranes from pressure exerted by a

medical device in use at the location of theulcer.


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LAYERS:

g = epitheliumf = lamina propria

e = muscularis mucosa

c = smooth muscle (location specific

presence )


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Stage I

Intact skin with non blanchable

redness of a localized area, usuallyover a bony prominence. Darkly

pigmented skin may not have visible

blanching; its color may differ fromthe surrounding area.


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Stage 1


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STAGE I


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Stage 1 pressure ulcer on the

foot.


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Stage II

Partial thickness loss of dermis

presenting as a shallow open ulcer with ared pink ulcer bed, without slough*. May

also present as an intact or

open/ruptured serum-filled blister.


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STAGE II


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Stage 2 pressure ulcer on the ear.


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Staging of pressure ulcersStage III

Full thickness tissue loss. Subcutaneous fat may be visible but bone,tendon or muscle are not exposed. Slough may be present but does notobscure the depth of tissue loss. May include undermining* andtunneling*.


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STAGE III


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STAGE III


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Stage IV

Full thickness tissue loss with

exposed bone, tendon or muscle.Slough or eschar may be presenton some parts of the ulcer bed.

Often include undermining andtunneling..


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Grade 4


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Unstageable

Full thickness tissue loss in which

the base of the ulcer is covered byslough (yellow, tan, gray, green or

brown) and/or eschar (tan, brown

or black) in the ulcer bed.


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UNSTAGEABLE


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Pressure Ulcer Prevention Plan,

Documentation and Education of Patient

and CaregiversThe prevention of pressure ulcers incorporates

the interventions below:

I. Minimize or eliminate friction and shear

II. Minimize pressure (off-loading)

III.Support surfaces

IV.Manage moisture

V. Maintain adequate nutrition/hydration


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Treatment


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Assessment

History and Physical Examination

Assessing Complications

Nutritional Assessment and Management

Pain Assessment and Management

Psychosocial Assessment and Management


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Pressure UlcersUlcer care

The four basic components

1. debridement of necrotic tissue as needed on initial and

subsequent assessments

2. cleansing the wound initially and with each dressingchange

3. prevention, diagnosis, and treatment of infection

4. using a dressing that keeps the ulcer bed moist andthe surrounding intact tissue dry


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Debridement

Moist, devitalized tissue supports the growth of

pathological organisms.

Therefore, the removal of such tissue favorablyalters the healing environment of a wound.

Removal of devitalized tissue is considered

necessary for wound healing


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Adjunctive Therapies

The therapies included :

electrical stimulation

hyperbaric oxygen infrared and ultraviolet light

low-energy laser irradiation

ultrasound

miscellaneous topical agents (including cytokinegrowth factors)

systemic drugs other than antibiotics


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Wound Cleansing

Remove necrotic tissue, exudate, and metabolicwastes from the wound.

Minimum of chemical and mechanical trauma. .

Cleanse wounds initially and at each dressingchange

Do not clean ulcer wounds with skin cleansers or

antiseptics Use normal saline for cleansing

Consider whirlpool treatment for ulcers thatcontain thick exudate, slough, or necrotic tissue.


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Dressings

Keep the ulcer bed continuously moist.

Wet-to-dry dressings should be used only

for debridement

No differences in pressure ulcer healing

outcomes with diverse dressings

Keep the surrounding intact (periulcer) skindry while keeping the ulcer bed moist.


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Dressings

Control exudate but do not desiccate the

ulcer bed.

Consider caregiver time

Eliminate wound dead space by loosely

filling all cavities with dressing material.

Avoid overpacking the wound.

Monitor dressings applied near the anus


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Pressure Ulcers

Treatment for each stage


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Stage 1

Intensive implementation of preventive measuresas usual

Polyurethane dressings (transparent) applied every1 to 10 days (Tegaderm)

They are semipermeable films, permeable to watervapor, oxygen and other gases and impermeable towater and bacteria

Most lesions can be expected to heal by 2 weeks


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Stage 2

The same as for stage I but

Wound should be inspected for signs of

infection Polyurethane dressings are more effective

and less costly than wet-to-dry dressings(Tegaderm or thin Duoderm )

Wet-to-dry dressings are rarely indicated atthis stage


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Stage 3

Remove necrotic material

Small eschar:

Debridement by experienced PCP

Topical application of enzymatic debriding agents

Eschar should be scored

Enzymes must not touch surrounding areas

Large eschar: Surgical consultation


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Stage 3

Loose material can be debrided with wet-to-dry

dressings every 8 hours

Polyurethane and hydrocolloid dressings(Duoderm) are more effective

Hydrocolloids are impermeable to gas and

moisture and are changed every 1-4 days

Deeper stage 3 or 4: Wounds need to be packed

with material depending on exudate


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Stage 3

Hydrocolloid dressings are not appropriate

Dry wounds:less absorptive Hydrogels or

moist soaks with normal saline

Exudative wounds:Absorptive dressings such

as Hydrophilic foam alginates (Kaltostat ) or

saline impregnated gauze

Packings are changed daily


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Stage 3

Consider specialized beds:

air fluidized beds

low-air-loss beds They should be used for at least 60 days

Patients with large defects: surgery consult

Patients with large defects in the sacral area and

urinary incontinence may require catheterization


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Stage 4

They require surgical intervention for initialdebridement

Wet-to-dry dressings may help Whirlpool baths may facilitate debridement

Clean deep ulcers require packing

Consider grafting procedures Always keep in mind the goals of the

patient

D i


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DressingsDressing Type Description Indication Brand Names

Transparent Film Adhesive, semi-

permeable, allows

vaporization

Stage I and II with

light or no exudates

Opsite, Tegaderm

Hydrogel Water/Glycerin based

gels on gauze ordressings

Stage II, III, IV; deep

ulcers; necrosis &slough

Acryderm, Flexigel,

Intrasite

Alginate From Seaweed Stage III, IV with

moderate to heavy

exudate

Algicell, Algisite,

Tegagen

Foam Moist, thermal

Insulation

Stage II to IV with

varying drainage

Hydrocell, Polyderm

Hydrocolloid Occlusive or

semiocclusive;

gelatin and pectin

Stage II to IV with

sough and necrosis

Dermafilm,

Tegaderm

Moistened Gauze Gauze in saline Stage III to IV

Managing Bacterial Colonization and


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Infection

Stage 2, 3 and 4 pressure ulcers are invariably

colonized with bacteria.

In most cases, adequate cleansing and debridementprevent bacterial colonization from proceeding to

the point of clinical infection

If purulence or foul odor is present, more frequent

cleansing and possibly debridement are required.


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Infected Pressure Sore



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Infection

Do not use swab cultures to diagnose woundinfection (colonization)

Consider 2-week trial of topical antibiotics forclean pressure ulcers that are not healing or

producing exudate

Effective against gram negative, positive, andanaerobes

Perform quantitative bacterial cultures of softtissue and evaluate for osteomyelitis when ulcerdoes not respond to topical antibiotic therapy.



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Infection

Systemic antibiotic therapy for patients withbacteremia, sepsis, advancing cellulitis, orosteomyelitis.

Do not use topical antiseptics (povidone iodine,iodophor, Dakins solution, hydrogen peroxide,acetic acid) to reduce bacteria in wound tissue.

Systemic antibiotics are not required for pressureulcers with signs of local infection.

Protect pressure ulcers from exogenous sources ofcontamination


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Infection Control

Follow body substance isolation precautions or anequivalent system.

Use clean gloves for each patient.

When treating multiple ulcers on the same patient,attend to the most contaminated ulcer last

Use sterile instruments to debride ulcers

Use clean dressings, rather than sterile ones, totreat pressure ulcers.


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Operative Repair of Pressure Ulcers

Operative procedures to repair pressureulcers include one or more of the following:

Direct closureSkin grafting

Skin flaps

Musculocutaneous flapsFree flaps.


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Operative Repair of Pressure Ulcers

Consider for operative repair when clean StageIII-IV do not respond to optimal patient care

Candidates are medically stable, well nourishedand can tolerate operative blood loss and postopimmobility.

Correct factors that may be associated withimpaired healing (smoking, spasticity, levels of

bacterial colonization, incontinence, and UTI)

Minimize pressure to the operative site by use ofspecial beds


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Assessment of Ulcer Healing

Evaluate at least weekly

If general condition deteriorates, the ulcer shouldbe reassessed promptly

Evaluate using size, depth, presence of exudate,epithelialization, granulation tissue, necrotictissue, sinus tracts, undermining, tunneling,

purulent drainage or signs of infection.

A clean pressure ulcer with adequate innervationand blood supply should show progress towardhealing in 2 to 4 weeks


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Monitoring

Healing ulcers should be assessed regularly

Monitor the individual's general health, nutritional

status, psychosocial support, pain level and bealert to signs of complications

The frequency of monitoring should be

determined by the clinician based on the condition

of the patient, ulcer, rate of healing, and the healthcare setting.


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Complications


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Pressure Ulcers

Complications Amyloidosis

Endocarditis

Heterotopic bone

formation

Maggot infestation

Meningitis

Perineal-urethral fistula

Pseudoaneurysm

Septic arthritis

Sinus tract or abscess

Squamous cell carcinoma

in the ulcer

Systemic complications of

topical treatment

Osteomyelitis

Bacteremia

Advancing cellulitis


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Case review

Adult male presented with a Sacral pressure

ulcer, bilateral superficial trochanteric ulcers.

he was manged in a single stage by ulcer

excision and bilateral superior gluteusmaximus V-Y advancement flap coverage. his

post operative period was uneventful.


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P Ul S i Q i


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Pressure Ulcer Staging Quiz

The test is comprised of 12 pictures of pressure

ulcers.

Question 1


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Question 1

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV

Unstageable/Unclassified

Deep Tissue Injury

Question 2


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Ques o

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q ti 3


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Question 3

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury


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Question 4

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q ti 4


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Question 4

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q ti 5


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Question 5

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q ti 6


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Question 6

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q ti 7


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Question 7

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q ti 8


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Question 8

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q ti 9


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Question 9

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Q estion 10


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Question 10

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Question 10


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Question 10

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Question 11


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Question 11

Category/Stage I

Category/Stage II

Category/Stage III

Category/Stage IV


Deep Tissue Injury

Question 12


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Question 12


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DIABETIC FOOT ULCERS

Dr Sedaka Donaldson


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CASE M M C


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CASE: Mr. M.C.

64 yr-old obese white male, not seen x 12 mo Type 2 DM (15 yrs)

BP (18 yrs)

Dyslipidemia (18 yrs)

CABG (10 yrs ago)

Claudication (today; 25 yds)

Insulin/Metformin/Statin/ARB/Hctz/CCB/ASA

Sore on my left foot, Doc


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CASE: Mr. M.C.

Clinical evaluation of heel ulcer:

Probe reached bone

Extensive subcutaneous abscess

MRI: extensive osteomyelitis

ABI: 0.2

Angiography: severe infrapopliteal, suprapopliteal obstruction

Not amenable to revascularization Uncontrolled infection despite antibiotics/drainage


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AMPUTATIONS IN DIABETES


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Common: Worldwideamputation 2to diabetes q 30 sec.

U.S.A.80,000 amputations/y (2002) Higher rates in men, racial/ethnic minorities

Costly:

$60,000/amputation

$2 billion/y total costs

Lancet 2005; 366:1719 Diabetes Care 2004; 27:1598 Diabetes Care 2003;26:495


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Tragic: Rule of 50

50% of amputations transfemoral/transtibial level

50% of patients 2ndamputation in 5y

50% of patients Die in

5y

Clinical Care of the Diabetic Foot, 2005


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FOOT ULCERS IN DIABETES

Precipitate 85% of amputations: Rule of 15

15% of diabetes patients Foot ulcer in lifetime

15% of foot ulcers Osteomyelitis

15% of foot ulcers Amputation

Clinical Care of the Diabetic Foot, 2005



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Costly: $30,000/ulcer

$9 billion/y total costs

Tragic:

Quality of life: ulcer patient amputation patient Burden of non-weight-bearing as ulcer heals

Lifetime behavioral adaptations to prevent recurrence Fear of recurrent ulcer/amputation

70% ulcer recurrence in 3y

Foot Ankle Int 2005; 26:32, 128 Clin Infect Dis 2004; 39(Suppl 2):S129

S i A i A

PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION


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Sensory Joint Motor Autonomic PAD

Neuropathy Mobility Neuropathy Neuropathy

Protective Muscle atrophy and Sweating Ischemia

sensation 2foot deformities 2dry skin

Foot pressure Foot pressure Fissure Healing

Minor trauma esp. overrecognition bony prominences

Callus Pre-ulcer ULCER Infection AMPUTATION

Minor Trauma: Interdigital Maceration

Mechanical (Moisture, Fungus)

Chemical

Thermal


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OTHER RISKS FOR ULCER/AMPUTATION

Failure to adequately care for the feet:

Inadequate patient education

Inadequate patient motivation

Depression, anxiety, anger more common in diabetes

Physical disability

Cannot see feet 2to retinopathy

Cannot reach feet 2to obesity, age (?50% of patients)Limited access to medical services

Age Ageing 1992; 21:333 Diabetes Care 2003; 29:495 Diab Metab Res Rev 2004; 20(Suppl 1):S13

CAUSAL PATHWAYS FOR FOOT ULCERS% Causal Pathways


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% Causal Pathways

NEUROPATHY Neuropathy: 78%

Minor trauma: 79%DEFORMITY Deformity: 63%

Behavioral issues ?

MINOR TRAUMA

- Mechanical (shoes) POOR SELF-

- Thermal FOOT CARE

- Chemical

ULCER

Diabetes Care 1999; 22:157

DETECTING FEET-AT-RISK History:


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History: Prior amputation

Prior foot ulcer PAD: known or claudication at < 1 block

Exam:

Insensate to 5.07/10g monofilament Major foot deformities

PAD Absent DP and PT pulses

Prolonged venous filling time Reduced Ankle-Brachial Index (ABI)

Pre-ulcerative cutaneous pathologyArch Intern Med 1998; 158:157


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PHYSICAL EXAMINATION OF THE FEET

IN PERSONS WITH DIABETES


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SENSORY NEUROPATHY IN DIABETES

Loss of protective sensation in feet

Sensory loss sufficient to allow painless skin injury

Major risk factor for foot ulcer in diabetes

Detect with 5.07/10g Semmes-Weinstein monofilament

Prevalence of insensate feet to 10g monofilament: Age > 40y: 30% of diabetic patients

Age > 60y: 50% of diabetic patients

Up to 50% have no neuropathic symptoms

Diabetes Care 2006; 29(Suppl 1):S24 Diabetes Care 2004; 27:1591


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UTILITY OF MONOFILAMENT TESTING


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UTILITY OF MONOFILAMENT TESTING

Predicts ulcer/amputation in 5 prospective studies:

NPV (normal sensing) = 90-98%

PPV (fail to sense) = 18-36%

Prospective 32 mo observational study: 80% of ulcers/100% of amputations in insensate feet

Superior predictive value to other tests: Pin prick, cotton wisp, symptoms

? 128 Hz tuning fork? ADA recommendation, 2006: also test vibration

Diabetes Care 2006; 29(Suppl 1):S25 J Fam Pract 2000; 49:S30 Diabetes Care 1992; 15:1386

USING THE 5.07/10gm MF (Tool-Kit)


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Demonstrate sensation on

the forearm or hand Place monofilament

perpendicular to test site

Bow into C-shape for onesecond

Test four sites/foot: Predicts95% of ulcer formers vs. 8sites

Heel testing does not

discriminate ulcer formers Avoid calluses, scars, and

ulcers

USING THE 5.07/10g MF (Tool-Kit)


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US G . 7/ g ( oo )

Minimize bias: Test sites in random sequences

Test each site X3, sham test as 1 of 3

Do you feel it? Yes or No?

Retest site if patient fails (misses 2/3 responses)

Insensate at 1 site = insensate feet

Falsely insensate with edema, cold feet

Test annually when sensation normal Use < 100x/d; replace if bent; replace q 3 mo.

Purchase calibrated MF (See Tool-Kit)

PAD IN DIABETES

P l (ABI < 0 9) 20 30%


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Prevalence(ABI < 0.9): 20-30%

10-20% in type 2 diabetes at Dx

30% in diabetics age 50y

40-60% in diabetics with foot ulcer

Complications: Claudication and functional disability

Increases risk for concurrent CAD and CVD

Delays ulcer healing

Increases amputation risk

Not increase foot ulcer risk

JACC 2006; 47:921 Diabet Med 2005; 22:1310 Diabetes Care 2003; 26:3333

HX TO DETECT PAD IN DIABETES


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HX TO DETECT PAD IN DIABETES

Claudication at < 1 block suggests severe ischemiaVascular Level Site of Pain

Aorto-iliac Buttocks/Thigh

Femoral CalfTibioperoneal Foot/Ankle

Rest pain indicates critical ischemia

Toes and forefoot

Difficult to distinguish from neuropathic pain

INTERPRETATION OF THE ABI


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ABINormal 0.91-1.30

Mild obstruction 0.71-0.90

*Moderate obstruction 0.41-0.70

*Severe obstruction 0.40

**Poorly compressible >1.30

2to medial Ca++

*Poor ulcer healing with ABI 0.50

**Further vascular evaluation needed


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MOTOR NEUROPATHY AND FOOT DEFORMITIES

Hammer toes

Claw toes

Prominent metatarsal heads

Hallux valgus

Collapsed plantar arch

Hammer

Toes


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From Levin and Pfeifer, The Uncomplicated Guide

to Diabetes Complications, 2002

Toes

Claw Toes


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From Levin and Pfeifer, The Uncomplicated

Guide to Diabetes Complications, 2002

HalluxValgus


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From Boulton, et al Diabetic Medicine 1998, 15:508

PRE-ULCER CUTANEOUS PATHOLOGY


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PRE ULCER CUTANEOUS PATHOLOGY

Neuropathy inappropriate footwear: Persistent erythema after shoe removal

Callus

Callus with subcutaneous hemorrhage: pre-ulcer

Autonomic neuropathy and secondary dry skin:

Fissure ulceration

Augment callus formation

Poor self-care of the feet:

Interdigital maceration with fungal infection

Nail pathology


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RISK-STRATIFIED FOOTCARE

MANAGEMENT FOR DIABETES PATIENTS


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HIGH RISK: CATEGORY 1-3 PATIENTS

A l h i f t


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Annual comprehensive foot exam

Inspect feet at every office visit

Podiatry care stratified to risk level

Intensive patient education

Detect/manage barriers to foot care

Therapeutic footwear, if needed

HIGH RISK: CATEGORY 1 3 PATIENTS


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Nursing tasks to facilitate foot exams:

High Risk Feet stickers to each chart (Tool-Kit)

Remove patients shoes/socks

Increases % of foot exams in observational studies

Determine that patient can reach/see soles of feet

Stock 10g monofilament in each room

Consider training to perform 10g monofilament exam

Provide patient education forms

Literacy/language appropriate

Diabetes Care 1983; 6:499 J Gen Intern Med 2003; 18:258


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Regular prophylactic podiatry care:

Provide nail and skin care

Assess footwear needs

RCT: 48% RRR for recurrent ulceration

Optimal visit frequency not evidence-based:

Category 1 q 3-6 mo

Category 2 q 2-3 mo

Category 3 q 1-2 mo

Diabetes Care 2003; 26:1691 J Fam Practice 2000; 49(Suppl):S30



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Intensive patient education:

1care clinician, podiatrist, educator contribute

Reinforce frequentlylow retention documentedPatient to demonstrate self-care knowledge

Questionnaires, tests are available (see Tool-Kit)

Utility:

? Reduced foot ulcer/amputation rates?

Cochrane Database Syst Rev 2005 Jan 25;(1)CD001488 Foot Ankle Int 2005; 26:38

BASIC FOOT CARE CONCEPTS


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Daily foot inspection

May require mirror, magnification, or caregiver

Educate patient to recognize/report ASAP: Persistent erythema

Enlarging callus

Pre-ulcer (callus with hemorrhage)



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Commitment to self-care:

Wash/dry daily

Avoid hot water; dry thoroughly between toes

Lubricate daily (not between toes)

Debride callus/corn to reduce plantar pressure 25%

Avoid sharp instruments, corn plasters

No self-cutting of nails if:

Neuropathy, PAD, poor vision



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Protective behaviors:

Avoid temperature extremes

No walking barefoot/stocking-footedAppropriate exercise if sensory neuropathy

Bicycle/swim > walking/treadmill

Inspect shoes for foreign objects

Optimal footwear at all times

FOOT CARE EDUCATION TOOLS


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FOOT CARE EDUCATION TOOLS

Diabetic Foot Care

American Orthopedic Foot and Ankle Society

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EDUCATIONAL DEFICIENCIES:HIGH RISK PATIENTS

558 high risk patients:


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558 high risk patients:

Deficiency % DeficientNot inspect feet regularly 50%

Walk barefoot/stockings 62%

Seldom/never test water temp. 40%Trim callus with sharp object 48%

Not know to call ASAP for foot ulcer 58%

Not know how to select footwear 57%

From GE Reiber, 2003

BASIC FOOTWEAR EDUCATION


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Avoid:Pointed-toes

Slip-ons

Open-toes

High heels

Plastic

Black color

Too small

Favor:Broad-round toes

Adjustable (laces, buckles,Velcro)

Athletic shoes, walking shoesLeather, canvas

White/light colors

between longest toe and

end of shoe

Diabetes Self-Management 2005; 22:33

THERAPEUTIC FOOTWEAR: GOALS


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THERAPEUTIC FOOTWEAR: GOALS

Inappropriate footwear:

Contributes to 21-76% of ulcers/amputations

Optimal footwear should:

Protect feet from external injury

Reduce plantar pressure, shock and shear forces

Accommodate, stabilize, support deformities

Suitable for occupation, home, leisure

Diabetes Care 2004; 27:1832 Diab Metab Res Rev 2004; 20(Suppl1):S51

THERAPEUTIC FOOTWEAR: COMPONENTS


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Padded socks(eg. CoolMax, Duraspun, others)

Cushion metatarsal heads, heels, and decrease plantarpressure

White, seamless, absorbent acrylic fibers

Shoe inserts/insoles(closed-cell foam, viscoelastic)

Off-the-shelf

Custom-molded

Therapeutic shoes

Extra-depth extra-width

Rigid rocker outsoles

Custom-molded

FOOTWEAR RECOMMENDATIONS BY RISK LEVEL


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Low Risk (0) Proper style/fit, cushioned stock shoes

Sensation (1) Deep toe box shoes, cushioned insoles

Callosities, ulcer Hx Extra-depth stock shoes, custom-molded insole

Severe deformities Custom-molded extra-depth shoes and insoles,

rigid rocker outsoles

Modified from The Foot in Diabetes, 2000, p.136

THERAPEUTIC FOOTWEAR: EFFICACY


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THERAPEUTIC FOOTWEAR: EFFICACY

Decreases plantar pressure 50-70%

Uncertain reduction in ulcer rate:

1prevention: no data

2prevention: controversial reduction of ulcer recurrence

Analytic/descriptive studies decreases ulcers 50-75%

2 RCTs no benefit

Benefits vary with footwear use, risk level?

Severe foot deformity, prior toe/ray amputation?

Diabetes Care 2004; 27:1774


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THANK YOU

Diabetic-foot-ulcer Presentation MUST 22

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