wellone primary medical care program for medical clinical staff diabetic foot screening click here...

WellOne Primary Medical CareProgram for Medical Clinical Staff

DIABETIC FOOT SCREENING

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Diabetes and Amputation

Diabetes is the cause of over 50% of all the non-traumatic amputations in the United States.

The risk of ulcers or amputations is increased in people who have had diabetes >10 years, are male, have poor glucose control, or have cardiovascular, retinal, or renal complications.

The loss of a lower extremity, or even part of a lower extremity, significantly impacts quality of life


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True of False: Diabetes is the cause of over 50% of all the non-traumatic amputations in the United

States.

True

False

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The correct answer is

TRUE

5-15% with diabetes will undergo amputation in lifetime

That’s up to 30 amputations in 200 patientsAbout 84,000 people with diabetes have lower

extremity amputations each year (Centers for Disease Control and

Prevention. Diabetes: disabling, deadly and on the rise, 2004..)


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Diabetes and Amputation

Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday..."

- Lancet. 2005;366:1674


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Risk Factors: Peripheral Neuropathy (PN)

High levels of glucose are toxic to the nerves

Peripheral neuropathy (PN) is damage to the nerves that connect the spinal cord to the arms and legs (the peripheral nerves)

PN is the # 1 risk factor for diabetic foot ulcer and amputation


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True of False: Peripheral Neuropathy is the #1 risk factor for foot ulcer and amputation.

True

False



answer

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The correct answer is

TRUEAbout 60% to 70% of all people with diabetes will

eventually develop peripheral neuropathy, although not all suffer pain. This leads to painless trauma, ulceration, infection, and finally amputation.

Because of the lack of pain, the diabetic with neuropathy is prone to foot trauma/injury unawareness. A lack of pain when an ulcer is noted may lull the patient into a false sense of security, perceiving the ulcer to be of little or no significance. Thus, the patient may neglect and/or delay appropriate treatment for their problem.


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PN: Symptoms

Symptoms can range from mild to severe and perhaps disabling.

Sometimes PN is present even without symptoms.

When people first get PN, they normally feel sensations like tingling, weakness, numbness, pinching, buzzing or stiffness in their toes and feet or fingers and hands.

As it gets worse, people report having a cramping, burning, throbbing or shooting pain.

Some refer to the pain as "frostbite", "pins and needles sticking in", "a lit match held to my foot" or "walking on broken glass". This could be so severe that wearing clothes or sleeping under blankets is painful.

Symptoms of PN vary from person to person. They can appear suddenly, come and go, or persist over time. They usually affect both sides of the body at the same time, and they may get worse at night.

When the nerves going into the feet are damaged, sensation is impaired

Normally pain is protective, letting us know there is a problem.

With PN there may be little to no pain when an injury has occurred Click here

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Peripheral Neuropathy


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PN: Physical Exam Findings

Decreased ability to feel pressure with monofilament testing

This is termed an “insensate foot”


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Risk Factors: Peripheral Arterial Disease

Arterial insufficiency refers to sluggish blood flow through the arteries.

In diabetes, this is usually due to atherosclerosis (plaques that line the blood vessels)

This results in reduced blood flow to the feet and extremitiesClick here

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Peripheral arterial disease is usually due to:

Peripheral neuropathy

Nerve damage

Atherosclerosis




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The correct answer is:

Peripheral neuropathy

Nerve damage

Atherosclerosis




answer

Click here to learn more;

select atherosclerosis from the drop down menu


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PAD: Symptoms

The reduced blood flow (and lack of oxygen to the tissues) leads to unhealthy tissues and poor wound healing

Many people with diabetes and PAD

do not have any symptoms. Somepeople may experience mild leg

painor trouble walking and believe thatit’s just a sign of getting older.

Othersmay have the following symptoms:

leg pain, particularly when walking or exercising, which disappears after a few minutes of rest (clinical term is intermittent claudication)

numbness, tingling, or coldness in the lower legs or feet

sores or infections on the feet or legs that heal slowly


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Peripheral arterial disease

Intermittent claudication


The clinical term for leg/calf pain that occurs with activity and disappears with rest is:


answerClick

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answerClick

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PAD: Physical exam findings

On physical exam, persons with peripheral arterial disease may have:

Weak or absent pulses in lower extremities (pedal pulse)

Coolness of the foot or leg

Shiny skin with or without stasis dermatitis

Hair loss (on the legs and toes)

Toe nail changes (brittle, thickened)

Red to brownish discoloration, known as stasis dermatitis.


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Stasis Dermatitis



A red/brown discoloration of the lower extremities that is seen with arterial disease is termed:


answer


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answerClick here


The correct answer is…….

Stasis dermatitis


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PAD: Risk Factors or developing

Smoking High blood pressure High cholesterol Overweight/Obesity Physical inactivity Poor control of blood glucose

All of these increase the risk of PAD


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Cool extremities

Diminished pedal pulses

Loss of sensation

Decreased hair growth

All of the following are signs of arterial disease except:





answerClick here


Cool extremitites

Diminished pedal pulses

Loss of sensation

Decreased hair growth

All of the following are signs of arterial disease except:

Cool

extrem

ities,

decrea

sed

hair

growth

and

diminis

hed

pedal

pulses

are

seen

with

PAD,

wherea

s loss

of

sensati

on

occurs

with

periph

eral

neurop

athy


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Risk Factor: Obesity

Obesity is a risk factor for diabetic foot disease because:

There is more weight and shear stress on the feet

Obese persons may have a difficult time inspecting and caring for their feet


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Risk Factor: Foot Deformity

Foot deformities, such as

bunions, hammer toes,claw toes, etc. lead to

areasof increased friction and

pressure

ULCERATION


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Additional Risk Factors

Impaired visionPoor glucose control Poor footwear Decreased mobilitySevere nail pathologyHistory of foot ulcers or amputation


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These nails are hypertrophied (thickened) from fungal infection in this patient with no prior access to podiatric care. Due to the increased pressure transmitted to underlying tissues, these nails can damage the nail bed which may then become secondarily infected and ulcerate.


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The Diabetic Foot Exam

Also known as the LEAP ExamLEAP is an acronym for:

Lower Extremity Amputation Prevention


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LEAP PROGRAM

The LEAP Program consists of five relatively simple activities:

Foot screeningPatient educationDaily self inspection of the footAppropriate footwear selectionManagement of simple foot problems


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The Bureau of Primary Health Care’s (BPHC) Lower Extremities Amputation Program (LEAP) recommend visual foot exams / inspections at each visit.

All patients with diabetes should have a monofilament test done at least annually.

Who should have a diabetic foot screening?

Click here to visit the BPHC/HRSA website


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True of False: A visual foot exam should be performed at every visit with a diabetic patient

True

False



answer

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The correct answer is……

True


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Level I Diabetic Foot Screening: Step I:Talk with the patient and document responses

Have there been any changes in your feet?

How often do you examine your feet for changes?

Any burning, numbness, tingling, or pain in your feet or calves?

Is there pain in the calf muscles when walking?

Do you smoke?


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Arterial Insufficiency

Diabetic nephropathy

Stasis Dermatitis

Burning, numbness and/or tingling in the feet may indicate:





answerClick here



Arterial Insufficiency

Diabetic nephropathy

Stasis Dermatitis



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Level I Diabetic Foot Screening: Step II: Perform a visual

screening of footwear and lower extremities

Explain to the patient that you will be performing a foot screening

Ask the patient to remove both the shoes and socks

Inspect the shoes for signs of excess wear and the presence of objects such as pebbles, sharp areas, etc

Visually inspect the lower extremities- paying particular attention to look between the toes and the back of the heal. Feel for the temperature and condition of the skin.

Note any deformities and skin problems

Redness and

pressure areas

Dry, cracked skin

Calloused areas

Deformity

Tight & Shiny Skin

Edema


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Footwear and socks

Areas between the toes

The heels of the feet

All of the above

The visual portion of the diabetic foot screening includes inspection of:





answerClick here



All of the above


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Level I Diabetic Foot Screening: Step III: Perform the monofilament screening

Explain exam and demonstrate on hand

Position for comfort

Have patient close their eyes. Ask patient to say “yes” when they feel filament

Touch monofilament to testing area, creating a C shaped bend and remove; avoid dragging; avoid calloused areas


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The Monofilament Screening

Is used to determine if there is loss of protective sensation (LOPS)

A lack of sensation in any area with monofilament screening means the patient is at increased risk of foot ulceration and this usually prompts the health care practitioner to refer the patient to a podiatrist


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Tell the patient to let you know when he/she feels the sensation

Ask the patient to blink 3 times when he/she feels the sensation

Ask the patient: “Do you feel this?”

What is the preferred way to establish if the patient feels the monofilament?


answer


answer


answer

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Tell the patient to let you know when he/she feels the sensation. This avoids the examiner “prodding” the patient to report the sensation. If the patient does not respond to the monofilament, the examiner should note negative sensation in the area and move on with the screening.


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True of False: The proper amount of pressure for monofilament testing is that which causes an indentation to be left in the skin.

True

False



answer

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The correct answer is…..

False……the correct pressure is applied by touching the monofilament to the testing area and creating a C shaped bend.


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MONOFILAMENT SCREENING

A simplified monofilament examination using only 4 sites per foot (total 8 sites) detected 90% of patients with an abnormal 16-site monofilament evaluation.

J Gen Intern Med. 1999 July; 14(7): 418–424. doi: 10.1046/j.1525-1497.1999.05208.x.


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The 4 test sites


Demonstrate themonofilament on thePatient’s hand or arm

Lubricate themonofilament

Prior to performing the monofilament screening, it is important that the examiner:


answer


answer

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The correct answer is……

………..Demonstrate the monofilament on the patient’s arm or hand

This lets the patient know that the monofilament does not hurt and what the monofilament is “suppose to” feel like.


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Throughout the screening and following the screening….Provide patient education

Awareness of personal risk factors Daily self inspection of feetProper nail and skin care Injury prevention When to seek help or specialized referral; For a foot finding call

immediately; do not delayNever walk barefootFor a foot finding call immediately; do not delaySmoking cessationCheck water temperature for bathingMoisturize but not between toesProper foot wear selection


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Education and Goal Setting Is Important

It is estimated that the risk of diabetes-related foot complications can be reduced by 49% to 85% by proper preventive measures, patient education, and foot self-care.

(Apelqvist J, Bakker K, van Houtum WH, Nabuurs-Franssen MH, Schaper NC. International consensus and practical guidelines on the management and the prevention of the diabetic foot. International Working Group on the Diabetic Foot. Diabetes Metab Res Rev. 2000;16:S84–S92.)


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Lastly, Be sure to…..

Document all findings and educationVerbally report findings to the PCP

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You have reached the end of this program…..

Once you are confident that you are comfortable with all the materials presented, proceed to the Diabetic Foot Screening post-test at http://www.classmarker.com/professional/

Your username is the first initial of your first name followed by your full last name. Your password is= nwhealth

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wellone primary medical care program for medical clinical staff diabetic foot screening click here...

Documents

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previous screendiabetes

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diabetic foot ulcer

lower extremity amputations

lack of pain

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peripheral nervespn