Diabetes Flashcards
What are the stages of development for a Diabetic Foot Ulcer (DFU)
Pain - first symptom Callus Numbness Deformity Ulcers Gangrene - treated with amputation
What are two causes of DFU
Reduced blood flow and Damaged Nerves
- Diabetes makes it worse
- Macrovascular diseases
- Microvascular diseases
Microvascular disease leads to which 3 things?
Nephropathy, Neuropathy, Retinopathy
-As blood vessels in the nerves dwindle, the nerves also become affected (myelin sheath)
How many patients have neuropathy as the time of DM diagnosis?
10%
50% will develop neuropathy within 25 years of initial Diabetes diagnosis
What % of neuropathies are assoicated w/ pain?
25-33%
Pain can vary
How do calluses form?
Repeated friction leads to thicken skin - precursor to DFU
What are sensory issues that come with neuropathy?
Loss of feeling –> loss of protective sensation, ulcers.
Loss of proprioception –> poor balance
-Also leads to loss of sweat –> dry, cracked skin (breeding ground for bacteria
Motor neuropathy can lead to foot drop and deformities
What happens when gastroc get tight in motor neuropathy?
foot stuck in PF, mid foot collapses.
1st MT elevates, inc. pressure on 2-4 MT.
MUST STRETCH!
Check balance
REverse callus formation
*bad shoes can lead to callus on tip of toes
What a bad place for those with sensory neuropathy?
The beach - can eb disasterous.
Do 5.07g monofilament testing at 7 spots.
How to check for autonomic neuropathy?
Take off socks and shoes - look at the skin
Get an XRay to look for undiagnosed fracture
What is the pathophysiology of DFUs?
Inc Glucose over the long-term
Inc glycation of lipids and proteins
Both cause molecular re-arrangement
Accelerated production of advanced glycated end products (AGEs) - leads to modifications of extracellular structural proteins
What does increased AGE production lead to?
Accelerated production of advanced glycated end products (AGEs) - leads to modifications of extracellular structural proteins
- Tissue destructive Matrix Metalloproteinases
- Fibroblasts unable to produce normal levels of Vascular Endothelial Growth Factor (VEGF) - dec collagen!!!
- Dec NO production in DM –> dec platelet derived growth factor (dec collagen) –> dec tissue strength!!!!!!!!!!
What do you want blood work to look like with DM?
FSBG less than 110
HgA1C less than 6.5 for wound healing (7 otherwise)
BUN - normal 5-20
Creatine - normal 0.5-1.2
Albumin - higher than 3.0
Pre-Albumin - higher than 17 is wanted, but anything below 14 is bad for wound healing
Smoking status - none. 0 ppd. (O2 cut in half after just one cig)
Clinical Assessment for DFU?
Pulses, ABI, Diagnostics
Monofilament, tuning fork
Deformities, Pressures, footwear
Where are the Top 3 locations for DFUs?
Heel, Hallux, and lateral foot due to Abnormal Lateral Loading (ALL) - check w/ Harris Mat and outline shoe
What’s bad about heels?
Pressure on met heads
No ankle support
Dennis is pissed.
What’s bad about flip flops
Diabetics don’t have feeling and will wear them in the snow
Do diabetics like tight shoes?
Yes
How can you revascularize with DFU?
Angioplasty (balloon)
Stenting
Bypass
Amputation
What to do first when you see wound (review from lecture 1)?
Check for infection and pulses
Non-audible: ABI (if above thershold, treat as audible pulse)
Audible: debride if > 50%, modalities if less
What do you do if the wound bed is dry?
Add/retain moisture
What do you do if the wound bed is wet?
Absorb moisture
See PPT for different dressings and topical agents
Way too many to list here
What’s bad about REGRANEX Gel? (Promotes angiogenesis and granulation tissue formation)
Increased rate of mortality secondary to malignancy in pts that used 3+ tubes. Only use if benefits outweight the large risks
What is a Ground Reaction Force (GRF) perpendicular to the foot?
Vertical Stress
What is a Ground Reaction Force (GRF) parallel to the foot?
Shear stress
ulcers may form when forces working together repetitively overtime
What % of the time is a person in unilateral stance during the gait cycle?
23%
Heel is in contact for the first 64% of the phase and the forefoot is in contact for the last 59% of the phase
-Pressure can be 1.2-1.5 BW (bad for bigger people)
What is the goal of offloading modality?
Redistributing plantar pressure from one specific area to a broad area. YOU WANT TO KEEP PATIENTS AMBULATORY
What can you use to keep patients ambulatory with a healing DFU?
AD on affective limb Post-op/wooden surgical shoes -Darco -Carville -The Dutch Approach Wedge healing shoes Removable cast walkers (RCW) Charcot Restraint Orthotic Walker (CROW) brace Total Contact Cast (TCC)
What is the gold standard for DFU off-loading?
TCC - Total Contact Cast
What are indications for a Total Contact Cast (TCC)?
Plantar Foot Ulcer
Free of infection
Good arterial inflow
Good standard wound care
Drainage can be controlled over multiple days
Cognition and compliance are good
Balance deficits are managed appropriately
What are things for patients to consider while using TCC?
Do not get the cast wet
Do not place anything into/under the cast
No driving if on the right foot
Wear PJ bottoms over the cast in bed
Consider the side or not sleeping with significant other in the same bed
When does the TCC come off?
7 days, no longer than 14 days if an open wound
Take it off if there are cracks, dents, or tightness from edema or other damage
Also take it off if there is drainage, odor, or pain
-Bivalve the TCC for assistance with transition to diabetic footwear when wound is closed
What are good shoe features?
Laces can provide support, velcro if dexterity is a problem - use caution to not pull too tight
-Toe box with 1/2 inch space in front of the toes
-An arch shape that supports your foot
No more than 1.5 inch heels
Smooth lining and no rough seams
A good tread to prevent slipping
Have both feet measured in STANDING when you buy new shoes
Have someone trace the outline of your foot in standing
Men’s shoes tend to cause more blisters, corns, and calluses
Women’s shoes tend to increase pressure from higher heels are more pointed toes
When during the day should you buy shoes?
Later in the day
Do not expect shoes to break in
Try on both shoes, buy the larger one
What modalities are available for DFUs?
e-stim NPWT (VAC) Pulsed Lavage w/ suction (PLWS) Ultrasound - KHz Pneumatic pump HBO
Old:
- Ultrasound - Mhz
- Whirlpool
- Anodyne (MIRE)
How do you use US?
1.0 Mhz for deep tissues (3-5cm), 3.0 MHz for superficial (
Indications for US?
Less than 50% necrosis in the wound base
Stage II, III or IV (Medicare guideline)
Conventional therapy failure (Medicare guideline) in 30 days of treatment
US no longer reimburseable for wound care under Medicare!!!!!!!!!!!!!!!!!!!!!!!! (Lisa Travis seconds that)
In which phase of healing can US be used
All 3
Inflammatory:
-Stimulates release of histamine
-Attracts neutrophils and monocytes
-Monocytes develop into macrophages
-Macrophages and neutrophils remove debris and pathogenic organisms
Proliferative:
-Stimulates fibroblasts to secrete more collagen
Remodeling phase:
-Presumed to improve mechanical properties of mature scar tissue
(studies only done in animals; can’t be extrapolated to humans)
When would you choose Whirlpool? (Level C evidence)
To reduce wound contamination and infection by softening and removal of debris and exudate
Increase local tissue perfusion
-Increase O2 transport
-Increase nutrient transport
-Remove waste products
Stimulate cellular activities for regeneration to facilitate neuronal mechanisms for analgesia for pain relief and increased mobility
Utilized to treat multiple wound sites at one time
Contraindications for Whirlpool?
Moderate to severe extremity edema Lethargy Unresponsiveness Maceration Febrile conditions Traction Casted extremities ICU Obesity Compromised CV or pulmonary function Acute Plebitis Dry gangrene Incontinence Contractures IV placements Combativeness/restraints
Precautions for Whirlpool? Things a patient might have that would make you reconsider using this modality…
Clean granulating wounds Epithelializing wounds New skin grafts New tissue grafts Non-necrotic diabetic ulcers Edematous limbs
Standard temp and time for whirlpool?
102-104 degrees
15-20 mins
Things for you to consider when using the Whirlpool?
Infection control! Time - set up, procedure, take down Disadvantages of soaking, dependent position, transporting patient off IP units Tank size Too much necrotic tissue Reimbursement issues
Is Anodyne reimburseable? (increases vasodilation via NO)
Usually not.
Pt education for DFU?
Regular exercise
Inspect skin daily - especially the bottom of the foot
Cleansing products
-mild, fragrant-free soap
-avoid astringents - many are alcohol-based and will dry/irritate the skin
Avoid exposure to hot water (scald burns can occur at lower temps in diabetics)
Avoid bath tubs and soaking the feet
Dry between the toes, but don’t put moisturizer there
Turn down heat as much as possible; use humidifiers
Don’t smoke
Sleep 7-9 hours per night
In 60 second DFU monofilament test, how many negatives do you need for it to be a positive test?
4 or more
10 total spots
So 6/10 or less
