MANAGEMENT OF THE DIABETIC FOOT

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MANAGEMENT OF THE DIABETIC FOOT
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NURSING CARE OF THE DIABETIC FOOT

• Perspective of the body
• As seen by the Podiatrist

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NURSING CARE OF THE DIABETIC FOOT

• Perspectives of the body
• The Body as seen by a Nurse/Doctor

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MANAGEMENT OF THE DIABETIC FOOT

• The Diabetic Foot may be defined as a group of
  syndromes in which neuropathy, ischaemia, and
  infection lead to tissue breakdown resulting in
  morbidity and possible amputation
• ( WHO 1995 )

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MANAGEMENT OF THE DIABETIC FOOT

• Epidemiology
• 50 of all lower limb amputations are diabetes
  related
• 70 of lower limb amputations are preceded by a
  foot ulcer
• 3-10 of those with diabetes have a foot ulcer
• 15 of those with diabetes will, during their
  lifetime develop an ulcer ( at any one time 20
  of inpatients at SOH have diabetes )

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MANAGEMENT OF THE DIABETIC FOOT

• 80 of foot ulcers are precipitated by external
  trauma
• Diabetic patients are 15x at risk of BKA than
  general population
• Up to 50 of patients who receive a BKA undergo a
  contralateral amputation within 1-3 years
• 3 year mortalilty after amputation is 20-50
• In no trauma related lower limb amputations foot
  ulcers precede 84 of amputations and 50 of
  such amputations will be in patients with
  diabetes

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MANAGEMENT OF THE DIABETIC FOOT

• RENAL DISEASE
• Diabetic nephropathy is the leading cause of ESRD
  in many countries and is increasing
• All stages of diabetic nephropathy are associated
  with increased risk of foot ulceration
• The rate of lower limb amputation in patients is
  higher after initiating dialysis
• Rate of lower limb amputation among diabetic
  patients with ESRD is 10x that of the general
  diabetic population
• 2/3 of patients with diabetes ESRD who have
  lower limb amputations die within 2 years

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MANAGEMENT OF THE DIABETIC FOOT

• Cost
• Financial - to NHS 251.5 m( annual cost of
  diabetic peripheral neuropathy its
  complications )
• - to family ?
• Psychological hidden
• Litigation

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MANAGEMENT OF THE DIABETIC FOOT

• Impact of diabetes on the foot
• How to manage the non ulcerated/ulcerated foot
  role of podiatrist
• Dressings

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MANAGEMENT OF THE DIABETIC FOOT

• Predisposing factors
• Precipitating factors
• Perpetuating factors

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MANAGEMENT OF THE DIABETIC FOOT

• Predisposing factors
• Peripheral Neuropathy
• Peripheral Vascular Disease

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MANAGEMENT OF THE DIABETIC FOOT

• Peripheral Neuropathy
• Sensory
• Motor
• Autonomic

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MANAGEMENT OF THE DIABETIC FOOT

• Chronic sensorimotor neuropathy the presence
  of symptoms and/or signs of peripheral nerve
  dysfunction in people with diabetes after
  exclusion of other causes
• 22-41 prevalence.
• Increases with age duration of diabetes

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MANAGEMENT OF THE DIABETIC FOOT

• The Gift of Pain
• Pain The gift nobody wants .
• Paul Brand

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MANAGEMENT OF THE DIABETIC FOOT

• Typical neuropathic foot

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MANAGEMENT OF THE DIABETIC FOOT

• Motor changes

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MANAGEMENT OF THE DIABETIC FOOT

• Sympathetic autonomic neuropathy
• Reduce sweating dry skin/fissuring
• Increased blood flow A/V shunting
• Studies indicate neuropathy present in 90 of
  foot ulcers

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MANAGEMENT OF THE DIABETIC FOOT

• Charcot foot
• Acute or subacute inflammation of all or part of
  the foot in people with diabetes complicated by
  distal symmetrical neuropathy, accompanying
  fracture or dislocation that cannot be explained
  by recent trauma, and without preceding
  ulceration of the surrounding skin
• (Jeffcoate 2004)

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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT

• Peripheral Vascular Disease
• Chronic limb ischaemia
• Grade 0 Mild claudication Acutely presenting
• Grade 1 Moderate to severe diabetic foot may
  be
• claudication without associated with any
• tissue loss or degree of chronic
• ischaemic rest pain limb ischaemia.
• Chronic critical ischaemia Ischaemia may be
  critical
• Grade 2 ischaemic rest pain or insignificant
  in the
• Grade 3 Tissue loss due to aetiology of
  ulceration
• Ischaemic ulceration or infection tissue
• gangrene necrosis

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MANAGEMENT OF THE DIABETIC FOOT

• Precipitating Factors
• Trauma
• puncture/thermal/stress/footwear
• Tinea

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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT

• Mechanisms of injury that destroy the foot
• Direct mechanical disruption. eg puncture wound
• Small amount of force sustained over time leading
  to ischaemia
• Moderate amount of force repeated over over
  leading to inflammation and enzymatic autolysis
  of tissues
• Continuous amount of force
• Infection

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MANAGEMENT OF THE DIABETIC FOOT

• Perpetuating factors
• Factors that delay healing
• Impaired wound healing
• Delays in primary care
• Delays in secondary care
• Patient factors

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MANAGEMENT OF THE DIABETIC FOOT

• Inflammmatory phase- neutrophil function is
  impaired(migration/chemotaxis,cytokine release,
  bacteriocidal activity
• In proliferation phase- lymphocyte response may
  be impaired
• Immune system changes manifest themselves not
  only as delayed response to injury but also as an
  increased tendency of diabetic patients to
  develop wound infections

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MANAGEMENT OF THE DIABETIC FOOT

• Hyperglycaemia produces non-enzymatic
  glycosolation of keratin/collagen making it more
  rigid inflexible
• These changes put the foot at increased risk of
  tissue breakdown through the reduced ability to
  withstand shear forces

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MANAGEMENT OF THE DIABETIC FOOT

• 5 cornerstones of management
• Identification of the foot at risk
• Education of patient, family, and healthcare
  providers
• Appropriate footwear
• Management of non ulcerative pathology
• Regular inspection and examination of foot at
  risk
• --------------------------------------------------
  ------------
• Management of ulcerative pathology
• International Working group on the diabetic foot
  1999

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MANAGEMENT OF THE DIABETIC FOOT

• Examination identification of the foot at
  risk
• History
• Neuropathy
• Vascular state
• Skin
• Bones/joints
• Footwear

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MANAGEMENT OF THE DIABETIC FOOT

• N I C E
• Prevention management of foot problems
• 4 categories of patient groups
• Care of people at low risk of foot ulcers (
  normal sensation, palpable pulses)
• Agree a management plan including foot care
  education with each person

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MANAGEMENT OF THE DIABETIC FOOT

• Care of people at increases risk of foot ulcers (
  neuropathy or absent pulses or other risk
  factors.
• arrange regular review 3-6monthy by foot
  protection team
• at each review
• -inspect patients feet
• -consider need for vascular assessment
• -evaluate footwear
• -enhance footcare education
• NB, if patient has had previous ulcer or
  deformity or skin changes manage as high risk

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MANAGEMENT OF THE DIABETIC FOOT

• Care of people at high risk of foot ulcers (
  neuropathy or absent pulses plus deformity or
  skin changes or previous ulcer.
• arrange frequent review 1-3 monthly
• at each review
• -inspect patients feet
• -Consider need for vascular assessment
• -evaluate ensure the appropriate provision of
• Intensified foot care education
• Specialist footwear and insoles
• Skin nailcare

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MANAGEMENT OF THE DIABETIC FOOT

• Care of people with footcare emergencies and foot
  ulcers
• footcare emergency ( new ulceration, swelling,
  discoloration) REFER to multidisciplinary
  footcare team within 24 hours
• Expect that team as a minimum to
• Investigate treat vascular insufficiency
• Initiate supervise wound management
• use dressing debridement as indicated
• use systemic antibiotic therapy for cellulitis
  or bone infection as indicated
• Ensure an effective means of distributing foot
  pressures
• including specialist footwear orthotics casts
• Try to achieve optimal glucose levels control
  of cardiovascular risk factors

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MANAGEMENT OF THE DIABETIC FOOT

• MANAGEMENT OF NON ULCERATIVE PATHOLOGY
• In high risk patients , callous and nails
  pathologies should receive regular treatment
• Site of callous is 90 more likely to ulcerate
• Haemorrhage in callous is pre-ulcerous in 50 of
  patients

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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT

• MANAGEMENT OF DIABETIC ULCERS
• 1ST Identify the cause
• Do not ignore the contra-lateral foot
• Delayed referral results in crisis management

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MANAGEMENT OF THE DIABETIC FOOT

• ULCER TYPES
• Neuropathic
• Ischaemic
• Over 50 of ulcers are mixed aetiology-
  neuroischaemic

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MANAGEMENT OF THE DIABETIC FOOT

• Principles of Foot ulcer management
• Infection Control
• Offloading
• Vascular assessment
• Wound care

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MANAGEMENT OF THE DIABETIC FOOT

• Infection Control
• Foot infections are a major cause of morbidity.
• Foot infections are the most common cause of
  admission to hospital for patients with diabetes
• Infection is a precursor to amputation in many
  cases
• Treat aggressively
• Do not wait for swab result
• Classical signs not always present

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MANAGEMENT OF THE DIABETIC FOOT

• Sampling by sterile swabs misses important
  pathogens
• True bacteriological yield is obtained from deep
  tissue samples
• Need to treat aggressively
• IF INFECTION SUSPECTED DO NOT WAIT FOR SWAB
  RESULTS

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MANAGEMENT OF THE DIABETIC FOOT

• Offloading
• Remove pressure from the affected site is
  essential
• How ?

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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT

• Footwear
• Specialised offloading devices

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MANAGEMENT OF THE DIABETIC FOOT

• Footwear
• Good shoes are integral to good foot health

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MANAGEMENT OF THE DIABETIC FOOT

• Vascular assessment
• ABPI
• Duplex
• Surgical revascularisation

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MANAGEMENT OF THE DIABETIC FOOT

• Wound care
• Determine cause
• Wound assessment

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MANAGEMENT OF THE DIABETIC FOOT

• Debridement

• The removal of foreign material and dead or
  contaminated tissue from ( or adjacent to) a
  traumatic or infected lesion in order to expose
  healthy tissue.
• If not removed it provides a medium for bacterial
  growth and a physical barrier to normal wound
  healing

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MANAGEMENT OF THE DIABETIC FOOT

• Surgical
• Sharp
• Dressings
• Larvae

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MANAGEMENT OF THE DIABETIC FOOT

• Dressings

• The foot is complicated to dress, there is no
  point in applying a dressing if -
• It moves
• Its the wrong one
• Its on upside down
• Its causing harm
• Its not working
• Footwear
• Bandaging

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MANAGEMENT OF THE DIABETIC FOOT

• What type?
• New developments
• Frequency of dressing changes
• Can you get it in the shoe
• Holidays

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MANAGEMENT OF THE DIABETIC FOOT

• Team Approach
• Diabetologist
• Diabetes Nurse Specialist
• General Practitioner
• Podiatrist PATIENT
• Orthotist
• Primary care Nurse
• Vascular Surgeon
• Dietician

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MANAGEMENT OF THE DIABETIC FOOT

• Take the diabetic foot seriously
• Ensure referrals are timely and appropriate
• ALL PATIENTS WITH DIABETIC FOOT ULCERS SHOULD BE
  REFERRED ON FOR SPECIALIST CARE

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MANAGEMENT OF THE DIABETIC FOOT

• The pathway to amputation
• Is littered with bandages and dressings which
  have deceived both the doctor and patient into
  thinking that by dressing an ulcer they were
  curing it
• Paul brand