Support Staff Education for Diabetes Management

1
Support Staff Education for Diabetes Management

• Introduction
• Module 1 Diabetes Overview
• Module 2 Foot Care Competency
• Module 3 Glucose Monitor Competency
• Module 4 Order Entry / Standing Orders
• Appendix

2
NavMed Policy 06-011

• To ensure effective care of diabetic patients,
  improve health outcomes and reduce cost within
  Navy Medicine.
• Standards
• ID enrolled patients diagnosed with Diabetes (Pop
  Health Navigator)
• Implement CPG (clinical practice guidelines)
• Re-engineer disease management

3
Standards.. (cont)

• Train all members of the healthcare team on their
  roles and responsibilities.
• Conduct initial and ongoing training on basic
  skill competencies for team members.
• Provide comprehensive Patient Education
• Maintain Metrics
• Maintain a Diabetes Champion Toolkit

4
Questions?

• What are Clinical Practice Guidelines (CPGs)?
• Why do we need them?
• How are CPGs going to improve patient care?
• How will they affect my current responsibilities?
• What can I do to help?

5
Clinical Practice Guidelines

• systematically developed statements to assist
  provider and patient decisions about appropriate
  health care services for specific clinical
  circumstances.
• Institute of Medicine (1992)

6
Why do we need them?

• Decrease variation in practice
• Care is based on research
• Increase appropriateness of care
• Decrease errors in healthcare

7
CPGs (cont.)

• Diagnosis, education, preventive screenings, risk
  reduction, and pharmaceutical treatment of
  diabetic complications occurs mostly in
  outpatient primary care settings.
• CPGs encompass the critical factors in diabetic
  patient care management
• Glycemic control
• Foot and Eye evaluations
• ID and treatment of complications (HTN,
  hyperlipidemia, renal disease)
• It also incorporates flexible use of referrals
  Diabetic Educator, Optometry, Ophthalmology,
  Podiatry, Nephrology, Endocrinology

8
How will they improve patient care?

• Evidence-based practice
• Provides a way to measure outcomes (metrics)
• Did what was suppose to happen really happen?
• Are we meeting our performance standards?

9
Diabetes Performance Gaps
FY99 Subvention Study
10
CPG Population Level Metrics

• A1c
• Lipids
• Microalbumin
• Dilated eye exams
• Comprehensive foot exams
• BPlt130/80 mm Hg
• Screened tobacco use
• Evidence-based
• Practice

11
What will you have to do?

• Become educated to the use of CPGs.
• Keep informed as the program progresses new
  forms, new data entry requirements, etc.
• Follow the guidelines for care at each level
  lab, exams, patient teaching, etc.
• Remain current in CPGs.
• Inform patients of available resources and
  updates.

12
Questions?
13
Staff Education Module 1

• Key Elements in the Care of Patients with
  Diabetes

14
Learning Objectives Upon completion of this
module the learner will be able to

• Distinguish between Type I, Type 2 and
  Gestational Diabetes.
• Identify characteristics of hypoglycemia and
  hyperglycemia.
• Identify current guidelines for diabetes care,
  goals of therapy and treatment guidelines.
• Identify the roles and responsibilities of staff
  in the management of the diabetic patient.
• Utilize assessment tools in the assessment of the
  diabetic patient.
• Implement diabetes education as an integral
  component of the patients self-management plan.
• Identify the need for referrals and specialty
  follow up.

15
What is Diabetes?

• Diabetes is a disease in which the body does not
  produce or properly use insulin.
• Insulin is a hormone produced by the pancreas.
• Insulin is essential for the utilization of
  glucose (fuel) for cellular metabolism as well as
  protein and fat metabolism.
• Glucose is the fuel our body needs to function
  properly.
• We get glucose from the foods we eat.
• Without insulin, the body can not use glucose,
  plasma glucose levels rise (normal BS
  70-110mm/dl) and glycosuria (glucose in the
  urine) results.

16

• Both genetics and environmental factors such as
  obesity and lack of exercise play a role in the
  development of diabetes.
• Types of diabetes Type 1, Type 2, and
  Gestational
• Pre-diabetes is a condition in which blood
  glucose levels are higher than normal but are not
  high enough to be diagnostic of diabetes.

17
Type 1 Diabetes

• Formerly called juvenile diabetes, is usually
  diagnosed in childhood / young adulthood.
• The beta cells of the pancreas no longer produce
  enough insulin.
• It may be an auto-immune disorder or idiopathic
  (no known cause).
• Treatment includes injectable insulin, or insulin
  pump, diet modifications, exercise, controlling
  BP and cholesterol.

18
Type 2 Diabetes

• Formerly called adult onset or Non Insulin
  Dependent Diabetes Mellitus (NIDDM).
• Most common form of the disease.
• Can develop at any age, even childhood.
• Unlike Type 1, the pancreas still produces
  insulin, but it either is not enough or the cells
  are resistant to it, and dont respond
  effectively.
• Risk Factors heredity, obesity, and inactive
  lifestyle
• Treatment Medication, diet modifications,
  exercise, weight loss, ASA, controlling BP and
  cholesterol.

19
Gestational Diabetes

• Any degree of glucose intolerance with onset
  during pregnancy.
• Due to hormonal changes or a shortage of
  insulin.
• Risk Factors overweight / obesity, parent or
  sibling with diabetes, inactivity, hypertension,
  elevated cholesterol or triglycerides, elevated
  glucose in past.
• Usually resolves after delivery.
• Increased risk of developing Type 2 diabetes
  later in life.

20
Symptoms (characteristics) of Diabetes

• Frequent thirst
• Frequent urination
• Feeling hungry
• Losing weight without dieting
• Slow wound healing
• Dry, itchy skin
• Numbness, tingling in feet
• Blurry eyesight

21
How is Diabetes Diagnosed?

• There are several ways to diagnose diabetes.
• 1. Symptoms of diabetes and plasma glucose
  gt200mg/dl.
• 2. Fasting Plasma Glucose (FPG) gt126 mg/dl on 2
  separate occasions.
• 3. 2 hr plasma glucose (PG) gt200mg/dl after
  75gms of oral glucose.

22
Hyperglycemia (glucosegt160 some use 275 mm/dl)

• Due to too much exercise, not taking diabetes
  medications, eating too much, medication
  interactions, stress, illness.
• S/sx thirst, blurred vision, frequent urination,
  fatigue, n/v, muscle cramps, ketoacidosis
• TX diabetic medications, fluids, follow meal
  plan, exercise plan

23
Hypoglycemia (Blood glucose 70 mg/dl or less)

• Due to skipping or delaying meals or snacks,
  increasing activity, or increasing insulin /
  diabetes medications
• Symptoms
• Shakiness
• Sweating
• Rapid heart rate
• Hunger
• Irritability
• Lightheadedness
• May progress to inability to concentrate,
  confusion, slurred speech, blurred vision,
  fatigue.
• If glucose continues to drop, seizures loss of
  consciousness can occur

24
Know the difference

• Hypoglycemia low blood glucose give glucose
• Hyperglycemia high blood glucose give insulin
• S/Sx very similar, treatment very different

25
Treatment of Hypoglycemia

• 15 grams of quick carbohydrate (CHO), (airheads)
• Recheck glucose in 10-15 min
• If lt 70 repeat 15 grams CHO

26
Chronic Complications of Diabetes (related to
prolonged hyperglycemia)

• Macrovascular
• Cerebrovascular Disease
• Coronary Artery Disease
• Microvascular
• Retinopathy
• Nephropathy
• Peripheral Neuropathy

27
General Overview of Complications

• Cerebrovascular Diseasehypertension,elevated
  lipids,and uncontrolled glucose increase risk of
  stroke and transient ischemic attack.
• Coronary Artery Disease atherosclerosis and
  vessel damage increase risk of heart attack.
• Retinopathy appearance of hemorrhages and damage
  to the retina, leads to blurred vision,
  floaters, flashing lights.
• Nephropathy thickening of the glomerular
  membranes and renal vessel sclerosis leads to
  diminished renal function.
• Peripheral Neuropathy decreased sensitivity of
  the feet to touch,vibration,and temperature.

28
Desired Outcomes for the Patient with Diabetes
(metrics)

• Blood glucose Level 70-100 mg/dl
• A1c lt7
• Blood Pressure lt130/80
• Urine microalbumin lt30 mg/24hr
• Cholesterol lt200 mg/dl
• Triglycerides lt150 mg/dl
• LDL-cholesterol lt100 mg/dl
• HDL-cholesterol gt45 mg/dl
• 
  

29
Goals of Therapy

• The patient will achieve and maintain a
• Healthy weight.
• Good quality of life
• Exercise program
• Management plan acceptable to the patient and
  health care team.

30
Medications

• Oral Agents for patients producing insulin
• Insulin Preparations for patients unable to
  produce insulin or not producing enough. Type 1
  diabetics require insulin. Many with Type 2
  require insulin. (competency check)
• Insulin pumps insulin delivered under the skin
  via needle
• Some patients use a combination of oral
  preparations, some use oral meds with insulin,
  some use insulin alone.
• See VA/DoD CPG Table G4, G5, G6

31
Glucose Monitoring

• NHCH uses the Precision Xtra Glucose Monitor.
  (competency check)
• Please refer to the Quick Reference Guide for
  glucose and ketone calibration and testing.
• Instructional Video (Module 3)
• Demonstration / Practice (Module 3)
• Familiarize self with Living Well with Diabetes,
  A guide for Staying Healthy

32
Diet

• Focus on lifestyle changes not just weight loss.
• CHO 60-70 carbs and monounsaturated fat.
• Protein 15-20 diet
• FAT 10 saturated fat, 10 polyunsaturated fat
• Fiber 20-35 grams
• Limit alcohol (1 drink /day (f) , 2 drinks/day
  (m)
• Refer to Diabetes Class
• Resources Survival Skills for the Person with
  Diabetes, Food Pyramid, Your Guide to
  diabetes.., Carb Counting

33
Exercise

• Moderate sustained exercise may help regulate
  glucose.
• Before starting an exercise program, patients
  over 35 with diabetes should have a physical
  exam.
• Patients should be instructed in proper
  shoes/foot care
• Instructed in effects of exercise and insulin
  need, CHO intake
• See guideline for Making Food Adjustments for
  Exercise handout.

34
Sick Day Management

• Common illness, such as the flu or a cold, can
  cause serious problems for the person with
  diabetes.
• Education includes
• Medication dosage variation
• Monitor blood glucose more often (q4hrs)
• Increase liquids, especially with a fever
• May need to check urine for ketones
• See Survival Skillsfor the Person with
  diabetes and Your Guide to Diabetes, Type 1 and
  2

35
Roles of the Healthcare Team Staff

• Diabetic education is key to a successful
  diabetes management plan.
• The overall plan should include
• Smoking cessation plan (if applicable)
• Exercise plan
• Glycemic control (ideally A1c lt7)
• Lipid management
• Blood pressure management

36
Clinic visit

• Physical examination includes
• Blood pressure
• Foot exams
• Weight
• Eye exam with dilation (annually)
• Lipid profile
• Patient Education
• Medication
• Glucose monitoring
• Diet / exercise
• Foot care
• When to seek treatment
• Sick day management

37

• While diabetes is a serious, common, and costly
  disease, it is controllable.
• There are many things people with diabetes can do
  to control symptoms and prevent complications.
• That is why patient education is crucial to
  successful diabetes management.
• And that is where YOU come in.

38
The staffs role in patient education

• Provide culturally competent care keep in mind
  the patients cultural, religious, educational,
  and developmental needs.
• Be respectful.
• Be prepared have all that you need.
• Ask for feedback from the patient. Did they
  understand?

39
Staff role (cont)

• Give handouts / resource materials as
  reinforcers.
• Use referrals ie Diabetes Education Classes
• Podiatry
• Fitness Trainers

40
Access to information

• Kiosk www.tricareonline.com
• Written patient education materials pamphlets,
  books, videos, charts, handouts, etc.
• CPG

41
Diabetes Control Network(pfizer)

• Disease Management Program helps patients face
  the challenges in managing their diabetes.
• Patient Education Materials
• Monthly Newsletters
• Daily Journals
• Scorecards/checklists to bring to clinic
• Rewards (pedometer, T-shirts)
• Tools for the Provider

42
Staff Education Module 2

• Diabetic Foot Care Competency

43
FOOT CARE COMPETENCY TRAINING FOR SUPPORT
PERSONNEL

• VICKIE R. DRIVER, DPM, MS, FACFAS
• CHIEF, LIMB PRESERVATION SERVICE
• DEPARTMENT OF ORTHOPAEDICS
• MADIGAN ARMY MEDICAL CENTER
• March, 2004 (modified May 05)

44
Foot Care Competency Guideline

• Introduction
• The purpose of this training is to provide
  support personnel with a specialized, three tier
  program of instruction in providing foot care to
  patients with diabetes and assisting health care
  providers who care for them.

45
Foot Care Competency Guideline

• The training advances with a higher level of
  specialized and detailed training as you move
  from basic to intermediate to advanced foot care.
• Training includes formal lectures and hands on
  experience.

46
Foot Care Competency Guidelines

• Developed in a three tier program for foot care
• Basic
• Intermediate
• Advanced
• Note pages
• Clinical supervision

47
Foot Care Competency Guidelines

• Evaluations
• Direct observed performance
• Competency training check list

48
Foot Care Competency Guidelines

• Management Plan
• Self-management education
• Diagnostic studies if required
• Foot wear recommendations, orthotic prescription
  if required
• Nail, skin and ulcer care
• Follow-up dates
• Low Risk 1 year
• High Risk 4 weeks

49
FOOT CARE COMPETENCY

• The purpose of this teaching plan is to provide
  clinical and didactic understanding to providers
  that directly correlate to the foot care
  competency level achieved.

50
Foot Care Competencies

• More complex foot care skills are designated
  medical acts and licensed nursing personnel are
  advised to follow the guidance of the facilitys
  locally approved foot care protocols
• Facility privileges are required for advanced
  foot care skills

51
Foot Risk CategoriesThe level of foot care
skills depends on the foot risk category of the
patient and on the type of foot exam being done.

• Low Risk Category
• Intact protective sensation
• No history of foot ulcer
• No history of amputation
• Intact pulses
• Absence of foot deformities

• High Risk Category
• Absence of sensation AND/OR absence of pulses
• History of foot ulcer
• History of amputation
• Presence or absence of foot deformities

52
Foot Care Competencies

• A visual foot exam is recommended at every visit
  with patients in the low risk category.
• A more comprehensive foot assessment including
  foot structure, skin integrity, vascular status
  and protective sensation is performed annually
  with patients considered to be low risk and as
  indicated with patients in the high risk category.

53
BASIC FOOT CARE

• WHY IS BASIC FOOT CARE IMPORTANT?
• There were an estimated 86,000 diabetes-related
  lower extremity amputations (LEA) in 2002 (1)
• Approximately 85 of LEAs are preceded by foot
  ulcers (2,3)
• The leading cause of amputations is diabetes

54
Basic Foot Care

• The goal of basic foot care is to prepare
  patients in the low risk category for a visual or
  more thorough examination.

55
Basic Foot CareLimb at Risk Factors

• A history of diabetic foot ulcer (DFU) or partial
  foot/toe amputation
• History of Charcot Foot
• Foot deformity
• Neuropathy
• Peripheral vascular disease (PVD)
• Compromised skin integrity
• Compromised nutritional status
• Sacral decubitus ulcer
• Lower extremity cellulitis
• Poor glycemic control, A1C gt 8

56
Basic Foot CareLimb at Risk Factors

• Rheumatoid with difficulty ambulating
• Neuro-muscular disease, e.g. Spina Bifida
• Auto-immune diseases
• End stage renal disease
• Scleraderma
• Post burn
• Post-surgical sites of lower extremity, e.g.
  venous harvest site
• Deep vein thrombosis (DVT) history
• Symptoms of claudication

57
Basic Foot CarePatient History

• Cover wide range of patient information including
• Walking difficulties
• Shoe problems
• Pain
• Social issues (e.g. smoking, alcohol use)
• Age
• Sex
• Weight
• Ethnicity
• Glycosylated hemoglobin level

58
Basic Foot CareFoot Evaluation

• Protective sensation
• Musculoskeletal deformities
• Vascular status
• Skin and nail condition
• Pedal pulses
• Sensory and motor foot exam
• Gait evaluation

59
Basic Foot CareSkin Assessment

• Why is checking the skin so important?
• First line of defense against infection
• Provides sensory perception
• It is important to look at the skin for any
  redness, swelling, sores, corns, calluses,
  ulcers, fissures and drainage
• The most important skill is having the patient
  remove their shoes and socks

60
Basic Foot CareSkin Assessment

• Why is skin temperature important?
• Skin temperature ranges from cool to warm to the
  touch
• At best, touching is a rough estimate of skin
  temperature but look for bilateral symmetry of
  skin temperature
• Environmental conditions will affect skin
  temperature
• A variance of 2-3 degrees may indicate infection
  and/or fracture
• Using an Infrared Temperature Scanner for
  accurate assessment of temperature is invaluable

61
Basic Foot CarePeripheral Vascular Assessment

• Skin
• Does the skin look pink or dusky?
• Is there hair on the toes?
• Are the toenails brittle and thick?
• May indicate poor circulation. Brittle and
  thick toenails can be seen as a normal part of
  aging. Yellow discoloration occurs with fungal
  infections.

62
Basic Foot CarePeripheral Vascular Assessment

• Pulses should be palpated but can be difficult to
  find.
• Palpate the dorsalis pedis (Medial side of dorsum
  of foot with foot slightly dorsiflexed)
• Palpate the posterior tibialis (Behind and
  slightly inferior to medial malleolus of ankle)

63
Basic Foot CareVascular Assessment (cont.)

• Notify the clinic nurse or PCM if pulses cannot
  be felt.
• Nurse or PCM may then use a Doppler to assess
  pedal pulses
• Using the Doppler, note whether pulses are
  monophasic, biphasic or triphasic

64
Basic Foot CareNeurological Assessment

• The monofilament exam is done using a 5.07/10gm
  monofilament.
• Hold the monofilament by the handle
• Use a smooth motion to touch the skin on the foot
  for 1-2 seconds
• Touch along side of and not directly on any
  ulcer, callous or scar

65
Basic Foot CareNeurological Assessment (cont.)

• Touch the foot to make the monofilament bend.
  Touch only once and do not drag the monofilament
  along the skin.
• Repeat the test if patient does not feel the
  monofilament.

66
Basic Foot CareNeurological Assessment

• Place a () in the circle if the patient can feel
  the monofilament at that site and a (-) if the
  patient cannot feel the filament at that site.
  (see chart)

67
Basic Foot CareNeurological Assessment

• Notify the nurse or PCM if the patient cannot
  feel the filament at any site.
• Give patients a basic instruction sheet which
  describes daily inspection of feet, proper
  hygiene practices, exercise, proper footwear,
  review of lifestyle habits such as tobacco
  cessation and when to report problems.
• Report any abnormal findings to the nurse or PCM

68
Basic Foot CarePatient Education

• Examples of basic foot instruction can be found
  in the VA/DoD tool kit.
• Example can be found at http//www.ndep.nih.gov/d
  iabetes/pubs/feet_broch_Eng.pdf
• Notify nurse or PCM if patient has any concerns
  regarding proper foot care.

69
Intermediate Foot Care

• The goal of intermediate foot care is to assess
  patients more thoroughly for early detection of
  problems and to implement foot care maintenance
  and education.

70
Intermediate Foot CareSkin, Nails and Foot
Anatomy

• Skin
• Protect against infection
• Provide sensory perception
• Repair surface wounds
• Has three layers epidermis, dermis and
  hypodermis
• Nails
• Epidermal cells converted to hard plates of
  keratin

71
Intermediate Foot CareSkin, Nails and Foot
Anatomy

• Foot
• Tibiotalar joint consists of the articulation of
  the tibia, fibula and talus
• Protected by ligaments on the medial and lateral
  surfaces
• Tibiotalar joint permits flexion and extension
• Talocalcaneal (subtalar) joint and transverse
  tarsal joint permits pivot or rotation movement.

72
Intermediate Foot Care

• Conduct an assessment of the feet to include
• History of Present Problem
• Any changes in the feet since last diabetes
  visit?
• Any changes in the skin of the feet such as
  dryness, itching, sores, ulcers, corns, calluses,
  swelling, redness, or drainage?

73
Intermediate Foot Care

• History of Present Problem
• Any leg pain or cramps?
• Does it occur with rest or activity? With
  elevation of legs? What makes it better or
  worse?
• Any burning in feet? Is it continuous, induced
  by activity?
• Any pain? Onset, location, duration, what makes
  it better or worse?

74
Intermediate Foot Care

• History of Present Problem cont.
• Any skin changes, cold skin, hair loss or pallor?
• Any history of injury or trauma?
• Any history of ulcers?
• Past Medical History
• Any past medical history of ulcers, changes in
  skin sensitivity?

75
Intermediate Foot Care

• Past Medical History (cont.)
• Any history of diminished sensitivity?
• Any systemic problems such as thyroid disorders
  or skin problems?
• History of chronic diseases (hypertension,
  coronary artery disease, thyroid?)
• Any history of skeletal deformities or congenital
  anomalies?
• Any surgeries?

76
Intermediate Foot Care

• Past Medical History
• Any change in activities of daily living or in
  the ability to walk?
• Family History
• Any familial hair loss or coloration patterns?
• Any family history of skin disorders?
• History of chronic diseases (diabetes,
  hypertension, hyperlipidemia, heart disease or
  thyroid disease?)

77
Intermediate Foot Care

• Family History (cont.)
• Any family history of weakness or gait disorders?
• Personal/Social History
• Skin care habits (kinds of soap and lotions used,
  home remedies)
• Skin self-examination
• Any difficulty trimming nails?

78
Intermediate Foot Care

• Personal/Social History cont.
• Any exposure to sun, chemicals?
• What type of work is done, physical demands
  involving the feet?
• Functional ability to walk, bath, dress, climb
  stairs, care for others, shop or fulfill work
  expectations?
• Any use of mood-altering drugs?

79
Intermediate Foot Care

• Personal/Social History cont.
• Tobacco use? What type, how often, cessation
  attempts?
• Alcohol use? What type, how often?
• Exercise? What type, how often, what intensity
  and for how long?
• Nutrition
• Type of diet
• Weight gain or loss

80
Intermediate Foot Care

• Personal/Social History (cont.)
• Any recent psychologic or physiologic stress?
• Sleep pattern?

81
Intermediate Foot Care

• Observe gait
• How does the patient walk, sit down, rise from
  sitting position, takes off coat, respond to
  directions?
• Is there any limping, shuffling, staggering or
  foot dragging?
• Observe for joint symmetry and alignment
• Inspection of the feet to include
• Shoes for rough spots, foreign objects or tears

82
Intermediate Foot Care

• Inspection of the feet to include (cont.)
• Soles of shoes for worn down heels gt30
• Socks or stockings for holes or pressure points
• Skin of legs and feet for sores, calluses,
  ulcers, lesions, redness, drainage, edema, or
  dryness (to include between the toes, heels and
  bottom of feet)

83
Intermediate Foot Care

• Inspection of the feet to include cont.
• Toenails for length, thickness and fungal
  infection
• Feet and toes for deformities or bunions
• Amputation
• Palpation
• Palpate the right and left posterior tibialis and
  dorsalis pedis pulses

84
Intermediate Foot Care

• Palpation (cont.)
• Use Doppler to identify an arterial signal and
  measure ankle brachial index (ABI)
• Skin temperature
• Edema
• Nails for capillary refill time

85
Intermediate Foot Care

• Sensory Exam to include
• DTRs
• Vibration
• Position sense of toes
• Monofilament exam
• See previous slide for instruction on
  monofilament exam

86
Intermediate Foot Care

• Interventions
• Hygiene
• Moisturizers
• What to use and what not to use
• Buffing and padding
• Lecture and demonstration
• Trimming and nail debridement
• Lecture and demonstration
• Use of rotary tool or electric grinder

87
Intermediate Foot Care

• Documentation
• Use of SF600 or AHLTA
• Patient Teaching
• Build on basic instruction sheet
• Educate in self-care and when to report problems
• Discuss lifestyle habits such as tobacco cessation

88
Intermediate Foot Care

• Follow-up/Referral
• Refer patient with abnormal findings to a foot
  care specialist if they are at risk for
  complications or functional impairments (see DM
  CPG for high risk foot)
• Refer for individual or comprehensive diabetes
  education

89
Advanced Foot Care

• The goal of advanced foot care is to provide
  prompt interventions for specific foot problems
  until the problem is resolved
• Clinical supervision of 120 hours or as
  determined by governing/hospital body
• Interventions governed by locally approved
  protocols
• Facility privileges required

90
Advanced Foot Care

• Must demonstrate has basic and intermediate foot
  care skills to include a comprehensive history
• Diabetes foot complications
• Pathophysiology of diabetes
• Pathophysiology of foot complications
• Corns, calluses and ingrown toenails
• PVD
• Infections
• Ulcers

91
Advanced Foot Care

• Principles of Infection Control
• Corns and Callous Debridement
• Wound Care Principles
• Wound Classification System
• Dressing and Dressing Changes
• Use of antibiotics and antifungals
• Topicals and Oral agents

92
Advanced Foot Care

• Anesthetic Administration
• Anesthetic symptoms, complications and
  contraindications
• Digital Blocks
• Understanding anatomy
• Protocols
• Therapy options
• Indications and contraindications
• Complications
• Post-procedure therapy plan

93
Advanced Foot Care

• Anesthetic Administration
• Oralets for administering treatments
• Debridement
• Biopsy
• Nail Removal

94
Advanced Foot Care

• Other issues related to the foot
• Understanding strains and sprains of the ankle
• Shoes
• Socks
• Whats supportive and whats not

95
Advanced Foot Care

• Diagnostic Studies
• X-rays
• Noninvasive vascular studies
• Bone scans
• Cultures
• Labs

96
Advanced Foot Care

• Documentation using SF600 or AHLTA
• Patient Education
• Specialty Referrals

97
References

• Center for Disease Control and Prevention (CDCP),
  National Center for Chronic Disease Prevention
  and Health Promotion. The Burden of Heart
  Disease, Stroke, Cancer, and Diabetes, United
  States. In The Burden of Chronic Diseases and
  Their Risk Factors. National and State
  Perspectives 2002. http//www.cdc.gov/nccdphp/burd
  enbook2002/02_diabetes.htm
• Pecoraro RE, Reiber GE, Burgess EM. Pathways to
  diabetic limb amputation. Basis for prevention.
  Diabetes Care 13 513-52, 1990.
• Larsson J, Agardh C, Apleqvist J, Stenstrom A
  Long term prognosis after healed amputations in
  patients with diabetes. Clin Orthop 1998
  350149-158.

98
VA/DoD Clinical Practice GuidelineWebsites
http//www.qmo.amedd.army.mil/http//www.
oqp.med.va.gov/cpg/DM/DM_base/htmFor online
information of clinical practice guidelines
99
QUESTIONS?
100
Staff Education Module 3

• Learning Objectives upon completion of this
  training session which includes handouts, and
  training video, the learner will be able to
• Complete the competency tasks and correctly use
  the Medisense Precision PCx glucose monitoring
  system.
• Instruct the patient in the use of the Medisense
  Precision PCx glucose monitoring system.

101
Glucometer Training

• Precision Xtra Instructional video
• Hands on demonstration

102
Staff Education Module 4

• Order Entry
• Using Standing Orders

103
Learning Objectives

• Upon completion of this module, the learner will
  be able to
• Determine the roles and responsibilities of the
  HM/LPN and clerical staff.
• Discuss phone call protocols and appropriate
  follow up.
• Determine patient needs according to clinic
  visit.
• Use standing order form to prepare patient for
  PCM visit.
• Verbalize key elements in the Care of Patients
  with diabetes.

104
Front line contact

• Phone call protocols What, When, Where and Who?
• What needs to be evaluated?
• When does the patient need to be evaluated?
• Where should the patient go first?
• Who does the patient need to be evaluated by?

105
Initial Visit following Diagnosis

• Comprehensive Patient Education
• Meds
• Importance of Diet, Exercise, Foot Care
• Tracking Blood Glucose
• When to call for advise / help
• Influenza Vaccine (in season)

106
Each Routine Primary Visit

• Visual foot Inspection ( especially if high risk
  patient)
• Tobacco Cessation and counseling/referral
• BP
• Self BGM results

107
Quarterly to annually

• A1c measurement and risk assessment
• If A1c is not on target education reinforcement
  (diet, exercise, meds)

108
Annually

• Dilated eye exam (make appt for optometry)
• Microalbuminuria screening
• Lipid Profile (make appt for lab)
• Visual inspection, documented foot risk
  assessment and education
• Flu vaccine (in season)
• Pneumonia vaccine (if indicated)