Transcript File

Reducing Foot Complications for People
with Diabetes – Champion Training
Agenda
• Welcome
• Diabetic Foot assessment program
background
• Diabetic neuropathy 101
• Diabetic foot assessment and documentation
• Hands on foot assessment
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
6
Foot Risk Assessment Algorithm and Risk Reduction Guidelines
Step #1: Assessment
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.
Step #2: Identify Level of Risk
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.
Step #3: Education Intervention
(For both low and high risk persons with diabetes)

Step #4: Follow up
• Notify and confirm that MRP is aware of HIGH Risk factors.
• Notify and confirm that Wound Care Team is aware of
current/new ulcer and care plan is in effect.
Step #5: Potential Resources Available in the community and
or Hospital
Wound Care Team

OT/PT

Chiropodist

Orthotist

CCAC/Wound Clinic

Diabetes Centre (for uncontrolled and unmanaged blood
sugars)

Vascular Surgeon (referral by MRP)
Credit Valley Hospital

Dermatology and Plastics (referral
MRP)
2200by
Eglinton
Avenue West, Mississauga






Provide person with the education brochures; “Diabetes and Foot Care –
Do’s and Don’ts & Diabetes, Healthy Feet and You.
Provide person with foot care products.
Provide self-care education: level of personal risk, inspection by self or
caregiver, wearing protective footwear, general nail and skin care.
Provide education regarding when to seek resources; see resource
listings.
Encourage person to watch the “Preventing Diabetic Foot Ulcers” DVD
video on the THC channel.
If person requires more detailed education materials, please provide
them with the Ministry of Health’s “Diabetes and You” information
package.
Reinforce the importance of notifying their family practitioner regarding
their risk factors.
Mississauga Hospital
Queensway Health Centre
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
7
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 referral
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
8
Five key risk factors for developing foot
ulcers and amputation
1.
2.
3.
4.
5.
Ulcers / Skin Assessment
Circulation
Sensation
Structural abnormalities
Self-care knowledge and behaviour
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
Ulcers / Skin Assessment
People with Diabetes may not feel trauma
1. 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.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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.
Posterior Tibial pulse
Dorsalis Pedis pulse
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
13
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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
Loss of Sensation
• Peripheral neuropathy (nerve damage) occurs
Numbness
Tingling
because of duration and severity of
Pain
hyperglycemia to the distal part of the axons
Lack of feeling
of the nerve. This causes dying back and
dysfunction of the nerves.
Three types of neuropathy
1. Autonomic
2. Motor
3. Sensory
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
16
Sensory neuropathy
Symptoms are:
• Burning
• Numbness and
Tingling
• Pain
• Lack of feeling
Loss of protective
sensation is associated
with an increased risk
of amputation.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
17
Steps for Monofilament Test for
Neuropathy:
Check for sensory intactness, using a
10 gram monofilament
1. 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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
19
Diabetic foot
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
20
Pathophysiology of Diabetic Foot Ulcer
2 Major components
1. 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.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
22
5. Self Care Knowledge & Behaviors
Check
Check
• Does the Patient report foot
• Does the Patient take steps to
problems to health care
reduce risk of injury, e.g. ask if
provider, e.g. ask,
patient walks bare foot
“What would you do if you
in/outdoors, checks for foreign
found a blister on your foot?”
objects in shoes before
wearing them, checks water
• Check your feet every day for
temperature before entering a
cuts, cracks, bruises, sores,
bath, etc.
infections or unusual markings
• Use a mirror to see the bottom
of your feet if you can’t lift
them up
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
5. Self Care Knowledge & Behaviorsthe Do’s & Don’ts
Do…
Don’t…
• Soak your feet
• Trim your nails straight across.
Get help to cut your nails if
needed
• Take very hot baths
• Wash and dry your feet every
day, especially between the toes
• Use lotion between your toes
• Apply a good skin lotion every
day on your heels and soles.
Wipe off any excess lotion
• Walk barefoot inside or
outside
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
5. Self Care Knowledge & Behaviorsthe Do’s & Don’ts
Do…
Don’t…
• 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
• 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
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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)
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
27
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
28
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
29
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
30
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
31
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
32
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
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.
Credit Valley Hospital
Mississauga Hospital
Queensway Health Centre
2200 Eglinton Avenue West, Mississauga
100 Queensway West, Mississauga
150 Sherway Drive, Toronto
34