Slides current until 2008 Diabetic neuropathy Wound healing.
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Transcript of Slides current until 2008 Diabetic neuropathy Wound healing.
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 2 of 31
Slides current until 2008
The diabetic foot
• Neuropathy – principal problem
• Vascular disease – secondary
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 3 of 31
Slides current until 2008
Four types of ulcers
• Neuropathic ulcers
• Ischaemic ulcers
• Neuroischaemic ulcers
• Venous ulcers
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 4 of 31
Slides current until 2008
Determine aetiology
• Neuropathic?
• Vascular?
• Mixed? predominant pathology?
• Determine wound management
• Act quickly
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 5 of 31
Slides current until 2008
Neuropathic ulcers
• Area of pressure
• Callus
• Red granulating base
• Low-to-moderately exudative
• Bounding pulses
• Painless
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 6 of 31
Slides current until 2008
Intrinsic – biomechanical
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 7 of 31
Slides current until 2008
Extrinsic – thermal
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 8 of 31
Slides current until 2008
Extrinsic – footwear
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 9 of 31
Slides current until 2008
Extrinsic – chemical
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 10 of 31
Slides current until 2008
Management of neuropathic ulcers
• Treat infection
• Debridement of callus
• Reduce pressure
• Restrict walking
• Dressings
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 11 of 31
Slides current until 2008
Pre- and post-debridement
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 12 of 31
Slides current until 2008
Felt deflection
• Reduces pressure by 61%
• Simple and cheap
• Replace weekly
• Impractical for exudating ulcers
• Risk of tinea/skin tears
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 13 of 31
Slides current until 2008
Ulcer healing with felt deflective padding
Week 1: pre-debridement Week 1: post-debridement
Week 3 Week 6: healed
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 14 of 31
Slides current until 2008
Pre-fabricated casts
• Simple to use
• Will not fit all feet
• Removable
• Less effective in maintaining foot shape
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 15 of 31
Slides current until 2008
Ischaemic ulcer
• On toes and foot margins
• Pale granulation, sloughy tissue or eschar
• Dry with irregular borders
• Painful
• Pulses weak or impalpable
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 16 of 31
Slides current until 2008
Management of ischaemic ulcers
• Vascular assessment and treatment
• Treat infection
• Pain management
• Dressings
• Avoid compression/bandaging
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 17 of 31
Slides current until 2008
Treatment goals
• Control infection
• Improve blood supply
• Optimize wound healing environment
• Protect wound from trauma
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 18 of 31
Slides current until 2008
Neuro-ischaemic ulcer
• Mixed neuropathic and vascular processes
• One process more dominant
• Need to assess
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 19 of 31
Slides current until 2008
Practice tips: neuropathic ulcers
• Foams 2 cm larger than the wound
• Use gels sparingly
• Keep foot dry – wash separately
• Do not use occlusive dressings
• Extra pads increase pressure and occlude the wound
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 20 of 31
Slides current until 2008
Practice tips: ischaemic ulcers
• Gels contraindicated in the presence of ischaemia
• Do not debride
• Do not use compression
• Keep foot dry in shower and wash separately
• Be very careful with tapes to prevent skin tears
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 21 of 31
Slides current until 2008
Foot infection
• Swelling, redness, heat
• Odour from ulcer
• Increase in exudate
• Failure to heal
• Elevated blood glucose levels
Pain may not be present if the person has loss of sensation. Signs of inflammation may be absent in people with severe ischaemia.
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 22 of 31
Slides current until 2008
In diabetes, clinical signs may
be masked leading to delayed
diagnosis of infection.
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 23 of 31
Slides current until 2008
Do not withhold antibiotics until results
of culture available
Rely on clinical judgement
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 24 of 31
Slides current until 2008
Antibiotic treatment is an essential aspect of treating diabetic foot ulcers – maintain until ulcer has healed.
Depending on clinical response, frequent changes and long-term antibiotics may be required.
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 25 of 31
Slides current until 2008
Foot infection
• Ulcer = risk of infection
• Osteomyelitis (sausage toe)
• Amputation
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 26 of 31
Slides current until 2008
Treatment of osteomyelitis
• Antibiotics
– minimum of 3 months until
there is evidence of healing on
x-ray or scan
• Infected bones may need to be
removed surgically
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 27 of 31
Slides current until 2008
Prevention of the diabetic foot disease
Primary prevention
• No successful clinical trials
• Metabolic control
• Smoking cessation
Secondary prevention
• Identify high risk feet
• Foot education
• Foot care
• Management of active foot problems (ulceration)
Diabetic neuropathyWound healing
Curriculum Module III-7CSlide 28 of 31
Slides current until 2008
Key points
• Assess
• Determine aetiology
• Arrange appropriate wound management
Diabetic neuropathyWound healing
Curriculum Module III-7cSlide 29 of 31
ACTIVITY
Slides current until 2008
Case study
• 70-year old man
• Type 2 diabetes
• Diabetes for 35 years
• Smoker for 35 years
Diabetic neuropathyWound healing
Curriculum Module III-7cSlide 30 of 31
ACTIVITY
Slides current until 2008
Case study
• Pulses absent
• ABI’s
Left - 0.69
Right - 0.71
• Left 1st MPJ ulcer
• Right hallux (great toe) ulcer – had bypass now ABI improved to 1.00