Transcript The Foot in Diabetes

The Foot in Diabetes
Nurse Education
Start
Feet in Diabetes
Economics of
Diabetes
NICE
Guidelines
Foot Assessments
Read Codes
for Foot
Assessments
Why worry about Diabetic Feet?
• Counting the cost of diabetes
• NHS expenditure on diabetes projected on the
basis of nine per cent (Currie CJ et al 1997) of
NHS costs in 2000 = £5,185,314,000
• This is equivalent to:
• £99,717,567 a week
• £14,245,367 a day
• £593,560 an hour
• £9,893 a minute
• £165 a second
Diabetic Feet
• Foot ulceration – 'diabetic foot' – is the
commonest reason for people with diabetes to
be admitted to hospital in the UK. (Young MJ et
al 1994) Diabetic Foot problems take up more
bed days than all the other complications put
together (Waugh NR 1988)
• It is a result of nerve damage (neuropathy) and
lack of blood supply (ischaemia). If an ulcer
becomes infected and gangrenous this can
necessitate amputation. According to one widely
cited study, people with diabetes are 15 times
more likely to need amputation than people
without the condition. (Bild DE et al 1989)
The NICE Guidelines
• The National Institute for Clinical
Excellence (NICE) has produced
guidelines to help prevent a person with
diabetes develop the complications that
can lead to amputation and hospitalisation
• A Foot assessment can also recognise the
complications affecting the feet and
establish protocols for education, review
and onward referral.
The NICE Guidelines
• A General Management approach
• Decision making shared between patient
and professionals
• Recall and annual review
• Feet Examination as part of Annual review
by trained personnel to assess risk
• Examination: Pulses; sensation; deformity
and footwear
• Classify Risk: low; increased; high; ulcer.
Low Risk Foot
• Foot Pulses are Present: so no Ischaemia
• No Loss of Sensation: so no Neuropathy
Increased Risk Foot
• Either Pulses are Absent
• Or there is Neuropathy
• Or there is Foot deformity
High Risk Foot
• Previous History of Foot Ulceration
• Or Pulses are Absent
• Or there is Neuropathy
• and there is Foot deformity, or other risk
factor
Read Codes used in Foot
Assessments
• Diabetic Foot Risk Assessment: 66AW
• Read Codes for Low Risk Feet
– Right Foot: 2G5E
– Left Foot: 2G5I
• Read Codes for Increased Risk Feet
– Right Foot: 2G5F
– Left Foot: 2G5J
• Read Codes for High Risk Feet
– Right Foot: 2G5G
– Left Foot: 2G5K
Foot Assessment
• The assessment is vital to establish a level
of risk in the Diabetic Foot
• This assessment is normally performed in
a primary care setting by Practice nurses,
but may also be performed by Podiatrists,
GPs and Consultant Physicians
Foot Assessment
• The risk groups the assessment is
designed to place people in are:
• Low Risk
• Increased Risk
• High Risk
• Ulcerated
(Ref: NICE Guidelines 2005)
Foot Assessment
•
The assessment can be divided into three
parts:
1. History
2. Examination
3. Investigations
•
Remember all these can be done at the same
time in a busy clinic otherwise you will run
behind and people will start getting annoyed
with you in the waiting room!
History
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Presenting complaint if there is one
Past Foot History
Diabetes History
Past Medical History
Family History
Drug History
Psychosocial History
Presenting Foot Complaint
• Foot problem could be:
– Skin breakdown; swelling; colour changes;
pain; callosity; toenail problem or footwear
problem
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Ask questions:
Where is the problem?
When did it start?
How did it start?
How has it been treated so far?
Presenting Foot Complaint
• Consider who is the best team member to
deal with the current problem and refer
when necessary.
• Pain as a symptom may be due to
localised trauma; infection; ischaemia or
neuropathy
• The next slide will help you distinguish
between pain from ischaemia and
neuropathy
Ischaemic or Neuropathic Pain?
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Ischaemic Pain
Persistent pain
Worse on elevation
Relieved by
dependency
• Pain in calf on
exercise
(claudication) relieved
by rest
• Neuropathic Pain
• Burning pains
• Contact pains due to
sheets or other touch
• Sharp short shooting
pains
• Pain relieved by cold
• Pain worse during
rest
Past Foot History
• Note previous ulceration and treatments
• Note any previous amputations
– Major
– Minor
– Reasons for amputations:
• Osteomyelitis; Necrosis; Trauma
• Peripheral Angioplasties
• Peripheral Arterial Bypasses
Diabetes History
• Type of Diabetes
– Type 1
– Type 2
• Duration of Diabetes
• Treatment of Diabetes
– Insulin
– Oral Hypoglycaemics
Diabetes History
• Complications
– Retinopathy
– Nephropathy
– Cardiovascular
• Angina, Heart Failure, Myocardial Infarction
• Coronary artery angioplasty or bypass
– Cerebrovascular
• Transient Ischaemic attack (TIA)
• Stroke (CVA)
Past Medical History
• Severe systemic conditions
– Cancer, Rheumatoid Arthritis etc
– Neurological conditions
• Epilepsy, Parkinson’s disease etc
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Accidents
Injuries
Hospital Admissions
Operations
Drug History
• Present Medication
– Steroids, Anti-coagulants etc.
• Known Allergies or sensitivities
– Antibiotics
– Medications
– Dressings
– Adhesive dressings
Family History
• Familial History of Diabetes
• Other serious illness
• Cause of death of near relatives
• Obesity
Psychosocial History
• Occupation
• Smoker?
– Number of cigarettes smoked daily
• Drink Alcohol?
– Number of units drunk daily
• Psychiatric illness
• Home circumstance
– Type of accommodation; Lives alone?;
Foot Examination
• Explain what you are doing for each test
• Look at the feet and legs from a distance away
and note any differences between the right and
left in terms of: Deformity, Colour and Volume
• Ask the patient whether they have any worries
about their feet
• Take a short history of any relevant operations,
injuries, medication, that may impact on their
feet. (See History)
Foot Examination
• Feel with the back of the hand the temperature
of the skin surface from the distal part of the foot
up the leg and then compare to the other foot
and leg.
• Are there any differences? Cold spots or areas
of heat? (May lead you to think about ischaemia
or infection)
• Note the absence of hair growth on the toes and
legs (non conclusive sign of ischaemia)
Foot Examination
• Note any colour differences
• Redness (erythema) may lead to conclusions
about presence of infection.
• Oedema may or may not be present in infection
dependant on how ischaemic the foot is.
• Any suspicion of infection should be referred on
to an appropriate team member to decide on the
necessity for antibiotic therapy
• Now go on to check the foot pulses
Check the Foot Pulses
• Dorsalis Pedis Pulse
– Use index, middle and ring fingers together
and palpate the dorsum of the foot over the
bony prominence of the tarsal bones 4-5 cm
proximal to the space between the first and
second toe just lateral to the Extensor
Hallucis longus tendon
• Posterior Tibial Pulse
– Found below and behind the medial malleolus
Check the Foot Pulses
• If you palpate either of these pulses it is unlikely
there is any significant ischaemia in the foot
• If both pulses are not palpable then check the
popliteal and femoral pulses
• ABPI (Ankle Brachial Pressure Index) can be
undertaken but calcification of arteries in
Diabetes can lead to falsely high ABPI readings
so toe pressures could be undertaken (TBPI)
Check for Neuropathy
• The method of choice is the 10gm monofilament
applied perpendicular to the foot and pressure
applied until it bends
• Sites to test:
– Apex of first, third, and fifth toes and the ball of the
foot (MTP joints) of the same toes, dorsum of foot and
heel
• Vibration sense tested on dorsum of first toe and
a site further proximal such as the lateral
malleolus using a 128-Hz tuning fork
Check for Neuropathy
• When testing get the person to close their
eyes
• Repeat the test three times at each site
• One of those three tests should be a non
test where the foot is not touched
• This is to ascertain whether the person
being tested is telling you what they “feel”
you want to hear
Foot Examination
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Next examine each foot more closely
Check each toe and in between each toe
Check the Toenails
Check the skin
Check for areas of deformity or swelling
Check joint mobility
Check colour signs of necrosis or ischaemia
Check Footwear
Toes
• Toes should be
checked for shoe
pressures and
callosities
• Toes should be
checked for
deformities and
advice given as
appropriate on
footwear
Toenails
• Toenails should be
checked for infections
– Fungal Nail infections
• Toenails should be
checked for ulceration
– Ulceration under the
nail
– (sub ungual ulceration)
Toenails
• Toenails should be
checked for
thickening
(Onychogryphosis)
• Check for ingrown
Toenails
Skin
• Skin should be
checked for any
wounds or entry
points for infections
• Skin should be
checked for callosity
and signs of pressure
Deformity and Oedema
• Check deformities are
not under pressure
from footwear
• Be aware of any
oedema and its
possible causes:
– venous insufficiency
– infection
Joint Mobility
• Check joint mobility
as this may impact on
possible pressure
points
• Other conditions
complicating Diabetes
such as Rheumatoid
arthritis can result in
poor joint mobility and
gross deformity
Necrosis and Ischaemia
• Buergers Test:
– Elevate the limb above heart
level: Turns White
– Then lower the limb to
dependency: Turns Purple
– Is a Indicator for Ischaemia
• Find Pulse with doppler then
raise leg if pulse sound
reduces or stops then
ischaemia is indicated
Necrosis and Ischaemia
• Wet necrosis
– Usually appears as
yellow/grey slough with
grey/pale pink base
• Dry Necrotic Lesions
should be noted and left
dry but monitor
demarcation lines for
signs of infection
Examine Footwear
• Check Footwear for:
– Length, width & depth
– Template Test
– Internal seams or rough edges
• Fastenings:
– Fastenings to keep shoe on
– No fastenings means shoe is
too tight or person has to claw
toes to keep shoes on
• Heels:
– Wide stable heel
– Not higher than 2.5cm
Footwear: Template Test
• To check for length and
width:
– Place foot on thin card (cereal
pack will do)
– Draw around barefoot
– Cut out template
– Place inside shoes
– This will show if any edges of
the template need to deform to
get the shoe on
– Repeat for the other foot
– Show the person your findings
Stages of Diabetic Foot
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Stage 1: Normal or Low Risk Foot
Stage 2: High-Risk Foot
Stage 3: Ulcerated Foot
Stage 4: Infected Foot
Stage 5: Necrotic Foot
Stage 6: Unsalvageable Foot
(Stages of Diabetic Foot: Ref: Edmonds, Foster, Sanders 2004)
Normal Foot
• No risk factors present
– Foot sensation good
– Foot pulses palpable
– No foot deformities
– No pathological callus
– No swelling
• Foot Assessment
High Risk Foot
• Neuropathy and Ischaemia
– are the main risk factors for ulceration.
• Deformity, oedema and callus
– are risk factors that will not necessarily lead to
ulceration unless either or both of the main
risk factors are present
High Risk Foot
•
1.
2.
3.
4.
5.
The Foot has developed one or more or
the following risk factors for ulceration:
Neuropathy
Ischaemia
Deformity
Oedema
Callus
Ulcerated Foot
• Foot ulcers can be
less than 1mm or
cover most of the foot
surface
• But all foot ulcers
large or small should
be taken very
seriously
• As they can
deteriorate rapidly
Infected Foot
• Managing Infection is
a vital in treating foot
ulceration
• Tissue samples are
better than swabs to
send for culture and
sensitivity, but if
swabs are used take
from the base of the
ulcer.
Spreading erythema from L/4th
toe would strongly suggest
infection
Necrotic Foot
• Necrosis can be wet
or dry
• Wet Necrosis has
slough which is soft,
yellow or grey in
colour
• Dry Necrosis has
slough which is hard
and black
Wet Necrotic Slough
Dry Necrotic Slough
Unsalvageable Foot
• Sometimes when
there is a great risk of
Spreading
Osteomyelitis and or
necrosis or the
patients life is in
danger from
Septicaemia then
Amputation is the only
recourse
Ulcer probes to bone
Necrosis and
osteomyelitis present
Amputation
was
performed
within days
Investigations
• Laboratory Tests:
• Full Blood Count (FBC) to detect anaemia or
polycythaemia
• Serum Electrolytes, urea and creatinine to assess
Renal function
• Serum bilirubin, alkaline phosphatase, gamma
glutamyl transferase, and aspartame transaminase
to assess Liver function
• Blood Glucose & HbA1c to assess diabetes control
• Serum cholesterol and triglycerides to assess
arterial disease risk factors
Investigations
• Radiological: determined by clinical
presentation and not always necessary
• X-ray to detect
– Osteomyelitis
– Fracture
– Charcot Foot
– Gas in soft tissues
– Foreign Body
Investigations
• Foot Pressures:
– These techniques measure pressure
distributions of the foot either out of shoe by
walking across pressure plates or by “in shoe”
pressure templates which are placed in the
shoes and then foot pressures recorded over
time.
– See www.
Foot Risk Factors
Neuropathy
Ischaemia
Callus
• Callus is an indication that an area of skin
is working harder than it is designed for.
• In poor tissue viability the callus can
ulcerate.
• Try to remove the causes of the callus
• Footwear can be a major cause of callus
• So can deformities or poor gait patterns
Foot Deformity
One month later ulcer
improved and infection
treated with antibiotics
Ulcer over exostosis
deformity with infection
Foot or Toe Deformities
• Deformities under the foot can add to pressures
when the patient is ambulant
• Deformities to the top or the sides of the foot can
add to pressures from footwear
• If surgical treatment of the deformity is unwanted
then accommodate the deformity by referring for
therapeutic footwear
Oedema
This patients
Lymphoedema has
caused pressure
from footwear on
the lateral border of
the foot
Foot Ulceration
Ischaemia
• Ischaemia is the
result of poor arterial
supply to the foot and
leg.
• Without a good blood
supply skin will not
heal well and can
lead to necrosis
(gangrene)
Necrosis of the apex of toe
Foot Health Education
Self Assessment Tests
• Are you ready to take a self assessment
test of this module?
• If not then press the button to go back to
review the material again
• However if you feel ready to be questioned
then press this button instead
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Neuropathy
• Diabetic Peripheral Neuropathy is the presence
of symptoms and/or signs of peripheral nerve
dysfunction in people with diabetes, after
exclusion of other causes e.g. Multiple Sclerosis
(Boulton et al 1998)
• This can be sub divided into
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Motor Neuropathy
Painful Neuropathy
Autonomic Neuropathy
Sensory Neuropathy
Charcot Neuroarthropathy
Motor Neuropathy
• Diabetic amyotrophy
– This is a rare and unusual manifestation
which results in poor motor control of the leg
muscles usually bilateral leading to muscle
weakness and muscle wasting
– Usually affects the quadriceps (anterior thigh)
– May also affect hamstrings (posterior thigh)
– Not always associated with sensory loss
(Ref: Kaplan & Abourizk 1981)
Painful Neuropathy
• A small number of people with diabetes
complain of:
– Burning pains or Shooting pains in the legs
– Sensation of overtight skin
– Toes can feel larger than they actually are
– Heightened awareness of sensations
– Feeling of walking on stones
– Warm/cold sensations in the feet
Painful Neuropathy
• This is a nasty complication of diabetes
that can be underestimated by healthcare
professionals as it presents with little sign
that anything is wrong.
• However patients in pain do not sleep well
become disturbed, confused and
depressed as constant unexplained pain
can be miserable to bear.
Painful Neuropathy
• Can be provoked when insulin is first
started and gradually improves if tight
blood sugars are maintained
• Distribution usually bilateral (both legs)
• Usually worse at night and is not improved
with foot dependency unlike ischaemic
rest pain which is improved if the foot is
lowered out of the bed
Painful Neuropathy
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•
Management is reassurance as this
condition usually resolves within 2 years
but may be replaced with numbness
Therapies include:
1.
2.
3.
4.
Topical therapy
Glycaemic control
Drug therapy
Physical treatments
Painful Neuropathy
• Topical Therapy
• Some patients find relief from burning
pains or contact dysaesthesia with opsite
film dressings or opsite sprays though
clingfilm worn on the unbroken skin of the
legs at night may be an alternative.
• Capsaicin applied as a cream
Painful Neuropathy
• Glycaemic Control
• High blood sugars (Hyperglycaemia) is
known to lower the threshold for pain
• So with diabetic painful neuropathy due
regard should be taken to HbA1c levels
noting the normal range to be 3.8 to 6.4
• Diabetic therapies should then be
optimised
Painful Neuropathy
• Drug Therapy
• This consists of analgesics, hypnotics,
tricyclic antidepressants, anticonvulsants
and antiarrythmics (used rarely)
• Burning pain: Tricyclic antidepressants
e.g. Amitriptyline or Imipramine (but be
aware of postural hypotension)
• Anticonvulsants: e.g. Gabapentin
Painful Neuropathy
• Physical Therapy
• Transcutaneous electrical nerve
stimulation; TENS
– Can be used to block the pain stimulus with
electrodes either side of painful area
• Acupuncture
– Anecdotally reported as useful
Autonomic Neuropathy
• This is very common in the diabetic foot as
the autonomic nervous system controls
the sweat glands.
• This type of neuropathy produces dry skin
which is liable to fissure and could lead to
infections and/or ulceration
Autonomic Neuropathy
• As we can see from this picture of a heel, dry
skin can easily lead to fissuring and ulceration
Autonomic Neuropathy
• So people with autonomic neuropathy
should be encouraged to use emollients
on a daily basis
• A small amount daily is much better than a
big dollop once a week
• Aqueous Cream B.P. is very good and
generally more affordable that “branded”
products such as E45,Vaseline Intensive
Care or Atrixo
Sensory Neuropathy
• This is the most common form of
Neuropathy in diabetes.
• Leads to a numb, painless foot insensitive
to one or all of:
– light touch; deep touch; heat and cold; pain
sensation and vibration sensation
• This can lead to problems of patients
being unaware of trauma to the feet.
Sensory Neuropathy
•
This type of neuropathy can lead to
problems of ulceration caused by:
1. Mechanical Trauma
2. Chemical Trauma
3. Thermal Injury
Sensory Neuropathy
• Mechanical Trauma
• Skin can be subject to
shearing and
compressive
mechanical stresses
leading to corns or
callus
• Further stresses can
then lead to tissue
breakdown under the
callosity
Sensory Neuropathy
• Mechanical Trauma
• The pain and/or
pressure response is
absent and the
pressure causing the
lesions continues
without rest and leads
to ulceration beneath
the callosity
Sensory Neuropathy
• Chemical Trauma
• People are tempted to
use medicated corn and
callus plasters which
contain salicylic acid
which breaks down the
keratin molecules within
the skin and theoretically
softening the callosity
unfortunately this acid
varies in concentration
and can lead to ulceration
Sensory Neuropathy
• Thermal Injury
• This example is of a person
with diabetic sensory
neuropathy who burnt his
toe on the metal side of a
radiant heater.
• As he felt no pain he did not
realise the damage that
was occurring. So as he
watched television the skin
was burnt then blistered
and took 7 months to heal
Sensory Neuropathy
• Sensory Neuropathy when recognised as
present in a person with diabetes should
lead to an education of that person by
healthcare professionals in how to care for
themselves.
• The main point of that education is DAILY
FOOT EXAMINATIONS by the patient or
their carer.
Sensory Neuropathy
• Prevention and recognition of any foot problem is the
primary responsibility of the person with diabetes and
their carers.
• The daily foot examination is vital in the high risk foot as
injuries may have occurred without the patient realising
so they must look for any wounds, injuries or blistering
which may give an access point to opportunist infections.
• Then a immediate regime of antiseptic dressings should
be instituted by the patient or carer with daily wound
checking
• If any sign of infection is present or if the wound is large
an immediate GP appointment should be sought for
antibiotic therapy with support from the community
nursing team instituted
Foot Risk Factors
Neuropathy
Deformity
Ischaemia
Callus
Economics of Diabetes