reducing foot complications for people with diabetes – champion training

Reducing Foot Complications for People with Diabetes – Champion Training

Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga

Mississauga Hospital100 Queensway West, Mississauga

Queensway Health Centre150 Sherway Drive, Toronto

Agenda

• Welcome

• Diabetic Foot assessment program background

• Diabetic neuropathy 101

• Diabetic foot assessment and documentation

• Hands on foot assessment

2




Background

• Diabetes is a common, serious, lifelong condition in more than 1 million Canadians

• Foot complications account for 20% of diabetes related hospital admissions.

• 15% of people with diabetics will develop a foot ulcer.

• 85% of lower extremity amputations are preceded by a non-healing ulcer

3




Big Picture

• We want to decrease the number of diabetics that develop foot problems . These problems are likely to result in ulcers but may take other forms of problems from poor management of diabetes and foot care.

• RNAO – Best Practice Guideline Assessment and Management of Foot ulcer for people with diabetes.

4




• Health- care professionals evidence based team approach to initiative.

• Participation in continuing education to enhance knowledge and skills to competency.

• Utilizing Best Practice Guideline as a structured model for implementing practice change.

5




Nurses role in prevention

1. Conduct and document a foot assessment for patients with known diabetes.

2. Patient education to promote the maintenance of healthy feet.

3. Identify patients at risk for developing foot ulcers and /or amputation.

4. Refer high risk individuals for specialized care.

6




7

Complete the Diabetic-Foot Risk Assessment Form in SCM on all persons with diabetes over 15 years of age (excluded are women with Gestational Diabetes, Psychiatric, Emergency and Pediatric populations) within 24-48 hours of admission to the hospital. The Diabetic-Foot Risk Assessment Form has 5 factors to be assessed; skin; circulation/vascular; sensation (monofilament); structural abnormalities and self-care knowledge and behaviour.

High Risk: If any one of the following is assessed -current ulcer; signs of infection – elevated temperature, swelling, inflammation, discharge, pain; no palpable pedal pulses; presence of leg muscle pain or fatigue on walking that relieved by rest; dependent rubor; delayed capillary refill - then the person is at HIGH Risk. This increases potential for the development of infectious disease (e.g. cellulitis, gangrene) and/or need for surgical intervention (e.g. amputation, femoral bypass).

Low Risk: If no potential factors are identified, the level of risk is considered “lower”. Reinforce the benefits of yearly foot exam and preventive self-care actions.

Foot Risk Assessment Algorithm and Risk Reduction GuidelinesStep #1: Assessment

Step #2: Identify Level of Risk




Basic foot education

• Awareness of personal risk factors

• Importance of at least annual inspection of feet by health care professional.

• Daily self inspection of feet

• Proper nail and skin care

• Injury prevention

• Check for the wear and tear of footwear

• When to seek help or specialized referral8




Five key risk factors for developing foot ulcers and amputation

1. Ulcers / Skin Assessment2. Circulation3. Sensation4. Structural abnormalities5. Self-care knowledge and behaviour

9




1. Skin Assessment

• Visually inspect the top & bottom of both feet

• Assess for signs of dry or sweaty feet

• Look for any corns, calluses, fissures or cracks, maceration and other skin abnormalities

• Check between the toes for soft corns or any sign if skin breakdown

• Be alert for signs of infection such as elevated skin temperature, swelling, inflammation, discharge, and pain




1. Skin Assessment

• Check skin temperature by running the back of your hand down the leg from the below the knee to the dorsum of the digits

• Ask about previous ulcers• Be alert to any signs of foot

trauma

• Inspect the toenails to see if thickened, discolored, deformed or ingrown – may indicate vascular or fungal disease




Ulcers / Skin Assessment

People with Diabetes may not feel trauma1.Acute Trauma – abrasions and burns occur often due to the absence of nociception. Poor wound healing makes ulcerations more likely to occur

2.Chronic trauma – reduced motor function results in a high arch. Together with decreased proprioception, this creates classical deformed foot shapes. These result in bony prominence which, in turn, when coupled with high mechanical pressure on the overlying skin, results in ulceration.

12




Circulation / Vascular Assessment

• Peripheral Arterial Disease is 4-7 times more prevalent in diabetics than non-diabetics

• Atherosclerosis causes a progressive blocking of the arteries as a result of a build up of fatty plaque

• The delivery of essential nutrients and oxygen to the foot is compromised leading to anaerobic infections and tissue necrosis.

13

Posterior Tibial pulse Dorsalis Pedis pulse




Peripheral Arterial Disease

• Thin, fragile, shiny skin• Absence of hair growth• Cool/cold skin• Pallor on elevation of foot• Dependent rubor (dusky /

bluish / cyanotic• Delayed capillary refill (> 3-4

sec)

• Check for edema (evidence of poor venous return

• Intermittent claudication: Leg muscle pain or fatigue on walking that is relieved by rest




Loss of SensationNumbness

TinglingPain

Lack of feeling

• Peripheral neuropathy (nerve damage) occurs because of duration and severity of hyperglycemia to the distal part of the axons of the nerve. This causes dying back and dysfunction of the nerves.

Three types of neuropathy1. Autonomic2. Motor3. Sensory

15




Autonomic Neuropathy

Symptoms are:•Reduced sweating results in dry cracked skin, dry toenails predisposing skin to damage & infection•Increases blood flow leading to a warm foot•Bounding pulse and dilated dorsal veins

16




Sensory neuropathy

Symptoms are: •Burning•Numbness and Tingling •Pain•Lack of feelingLoss of protective sensation is associated with an increased risk of amputation.

17




Steps for Monofilament Test for Neuropathy:

Check for sensory intactness, using a 10 gram monofilament1.Show and touch monofilament to patient’s arm or upper leg.2.Ask the patient to close their eyes and say yes when they feel the monofilament.3.Touch monofilament until filament bends in a letter “c” shape, assessing all 10 areas on diagram (Do not test over calluses, scars or ulcers)4.Lack of feeling (4 or more out of 10) - indicates a negative reaction = Neuropathy = “YES” on screening tool

18




Motor Neuropathy

Includes; •Limited joint mobility •Foot deformities develop such as Charcot foot / Hammer toes / Clawed toes •Pressure points over the plantar forefoot •Altered gait/tripping

19




Diabetic foot

20




Pathophysiology of Diabetic Foot Ulcer

2 Major components1. Peripheral neuropathy- 2/3 of patients with

ulcers occurs due to prolonged glucose elevation.

2. Peripheral vascular disease- 1/3 of patients will also have atherosclerosis of the large limb vessels and not from micro vascular disease. It is usually symmetrical in both limbs, long segments below the knees.

21




Self Care Knowledge & Behaviors

• Poor foot hygiene, inability to perform self-care and routine inspection of the feet and inappropriate footwear are common contributors to diabetic foot problems.

• Inspect the feet for signs of poor foot hygiene – dirty, long or poorly shaped nails

• Can the patient see the bottom of feet and/or are they able to reach the bottom of feet? Ask if foot care assistance is required for hygiene and for performing daily

foot inspections

• If assistance required find out why – poor vision decreased mobility etc.

22




5. Self Care Knowledge & Behaviors

Check

• Does the Patient report foot problems to health care provider, e.g. ask, “What would you do if you found a blister on your foot?”

• Check your feet every day for cuts, cracks, bruises, sores, infections or unusual markings

• Use a mirror to see the bottom of your feet if you can’t lift them up

Check

• Does the Patient take steps to reduce risk of injury, e.g. ask if patient walks bare foot in/outdoors, checks for foreign objects in shoes before wearing them, checks water temperature before entering a bath, etc.




5. Self Care Knowledge & Behaviors- the Do’s & Don’ts

Do…• Check the color of your legs

and feet. Is there is swelling, warmth or redness or if you have pain, see your doctor or foot specialist right away

• Clean a cut or scratch with a mild soap and water and cover with a dry dressing for sensitive skin

Don’t…• Use over- the -counter

medications to treat corns and warts. They are dangerous for people with diabetes

• Apply heat to your feet with a hot water bottle or electric blanket. You could burn your feet without realizing it





Do…• Trim your nails straight across.

Get help to cut your nails if needed

• Wash and dry your feet every day, especially between the toes

• Apply a good skin lotion every day on your heels and soles. Wipe off any excess lotion

Don’t…• Soak your feet

• Take very hot baths

• Use lotion between your toes

• Walk barefoot inside or outside





Do…

• Change your socks every day• Always wear a good supportive

shoe• Always wear professional fitted

shoes from a reputable store. Professionally fitted orthotics may help

• Exercise

Don’t…

• Wear tight socks, garters or elastics or knee highs

• Wear over the counter insoles – they can cause blisters if they are not right for your feet

• Sit for long periods of time• Never try to treat your own

feet if there are sores. Always seek professional help




Education Resources

1. Have patient watch DVD on hospital TV’s “Preventing Diabetic Foot Ulcers: The 3 Step Program”

2. Provide each patient a resource package containing:

• Brochure “Diabetes Foot Care Do’s and Don’ts”

• Coloplast Diabetic Foot Care Brochure

• Brochure “Diabetes, Healthy Feet and You” (CAWC)

• Resource list of foot clinics

• Products: Sample of foot cream (Atrac-tain cream- Coloplast) and Mirror to check the bottom of their feet.

3. Reinforce need to notify family physician about risk factor(s)

27




28




29




30




31




32




33




Mentors role

• To facilitate and implement guidelines of the THP policies and systems.

• To increase awareness of nurses and other health care professionals on significance of foot care assessment on diabetic patients.

• To encourage participation of other colleagues in completing foot assessment and accurate documentation.

• To review and audit data result and outcomes of this initiative.

34

reducing foot complications for people with diabetes – champion training

Documents

eglinton avenue west

foot care

foot problems

foot ulcers

management of foot ulcer

known diabetes

gestational diabetes

poor management of diabetes