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MANAGEMENT OF THE DIABETIC FOOT

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Title: MANAGEMENT OF THE DIABETIC FOOT


1
MANAGEMENT OF THE DIABETIC FOOT
2
NURSING CARE OF THE DIABETIC FOOT
  • Perspective of the body
  • As seen by the Podiatrist

3
NURSING CARE OF THE DIABETIC FOOT
  • Perspectives of the body
  • The Body as seen by a Nurse/Doctor

4
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 )

5
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 )

6
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

7
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

8
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

9
MANAGEMENT OF THE DIABETIC FOOT
  • Impact of diabetes on the foot
  • How to manage the non ulcerated/ulcerated foot
    role of podiatrist
  • Dressings

10
MANAGEMENT OF THE DIABETIC FOOT
  • Predisposing factors
  • Precipitating factors
  • Perpetuating factors

11
MANAGEMENT OF THE DIABETIC FOOT
  • Predisposing factors
  • Peripheral Neuropathy
  • Peripheral Vascular Disease

12
MANAGEMENT OF THE DIABETIC FOOT
  • Peripheral Neuropathy
  • Sensory
  • Motor
  • Autonomic

13
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

14
MANAGEMENT OF THE DIABETIC FOOT
  • The Gift of Pain
  • Pain The gift nobody wants .
  • Paul Brand

15
MANAGEMENT OF THE DIABETIC FOOT
  • Typical neuropathic foot

16
MANAGEMENT OF THE DIABETIC FOOT
  • Motor changes

17
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

18
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

23
MANAGEMENT OF THE DIABETIC FOOT
  • Precipitating Factors
  • Trauma
  • puncture/thermal/stress/footwear
  • Tinea

24
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

26
MANAGEMENT OF THE DIABETIC FOOT
  • Perpetuating factors
  • Factors that delay healing
  • Impaired wound healing
  • Delays in primary care
  • Delays in secondary care
  • Patient factors

27
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

28
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

29
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

30
MANAGEMENT OF THE DIABETIC FOOT
  • Examination identification of the foot at
    risk
  • History
  • Neuropathy
  • Vascular state
  • Skin
  • Bones/joints
  • Footwear

31
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

32
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

33
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

34
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

35
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

36
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
  • MANAGEMENT OF DIABETIC ULCERS
  • 1ST Identify the cause
  • Do not ignore the contra-lateral foot
  • Delayed referral results in crisis management

40
MANAGEMENT OF THE DIABETIC FOOT
  • ULCER TYPES
  • Neuropathic
  • Ischaemic
  • Over 50 of ulcers are mixed aetiology-
    neuroischaemic

41
MANAGEMENT OF THE DIABETIC FOOT
  • Principles of Foot ulcer management
  • Infection Control
  • Offloading
  • Vascular assessment
  • Wound care

42
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

43
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

44
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
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MANAGEMENT OF THE DIABETIC FOOT
  • Offloading
  • Remove pressure from the affected site is
    essential
  • How ?

49
MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
  • Footwear
  • Specialised offloading devices

51
MANAGEMENT OF THE DIABETIC FOOT
  • Footwear
  • Good shoes are integral to good foot health

52
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
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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
  • Vascular assessment
  • ABPI
  • Duplex
  • Surgical revascularisation

58
MANAGEMENT OF THE DIABETIC FOOT
  • Wound care
  • Determine cause
  • Wound assessment

59
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

60
MANAGEMENT OF THE DIABETIC FOOT
  • Surgical
  • Sharp
  • Dressings
  • Larvae

61
MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
64
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

65
MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
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MANAGEMENT OF THE DIABETIC FOOT
68
MANAGEMENT OF THE DIABETIC FOOT
  • What type?
  • New developments
  • Frequency of dressing changes
  • Can you get it in the shoe
  • Holidays

69
MANAGEMENT OF THE DIABETIC FOOT
  • Team Approach
  • Diabetologist
  • Diabetes Nurse Specialist
  • General Practitioner
  • Podiatrist PATIENT
  • Orthotist
  • Primary care Nurse
  • Vascular Surgeon
  • Dietician

70
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

71
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
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