Diabetic Foot Care Flashcards
How does diabetes affect the feet?
4
Nerve Damage (Neuropathy)
Peripheral Vascular Disease(?)
Musculoskeletal deformities
Infections
Pathophysiology of Neuropathy
7
- Accumulation of advanced glycosylation end products
- Accumulation of sorbitol
- Disruption of the hexosamine pathway
- Disruption of the protein kinase C pathway
- Activation of the poly (ADP-ribose) polymerase pathway
- Increased oxidative stress
- Nerve ischemia
PREVENTION of neuropathy?
Tight glycemic control
What is Sensory Neuropathy?
Nerve Damage with symptoms of numbness, burning, tingling, pins and needles
What is Motor Neuropathy?
Nerve Damage leading to musculoskeletal deformities
What is Autonomic Neuropathy?
Nerve Damage to autonomic nervous system (symptoms?)
Decreases body’s ability to fight infection and to heal wounds in the foot. What habit would compound this?
Smoking = more peripheral vascular disease
Patient History / Subjective Evaluation
7
- Previous diabetic education
- Diabetic Peripheral
- Neuropathy
- Peripheral vascular disease
- Skin condition
- Musculoskeletal deformities
- Footwear
Visual Inspection – Objective Exam
10
- Color of skin
- Type of skin—dry, thin, hair?
- Trauma/ulceration
- Callus
- Swelling
- Nail deformities
- Signs of pressure!
- Musculoskeletal
- Deformities
- General hygiene/self care!!
What are the nail deformities that we shouuld look for?
Onychomycosis - Most common deformity of the nail
Onychocryptosis – Ingrown toenails
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Subungual ulcertion
Bilateral foot problems indicates what?
this indicates cardiac failure, renal impairment, venous insufficiency and rarely neuropathy when linked to ateriovenous shunting
Unilateral foot problems indicate what?
local pathology of foot or leg e.g. infection, charcot foot, gout, trauma, dvt, venous insufficiency, lymphoedema secondary to malignancy
How to do Sensory Testing?
4
- Use a 10g Semmes Weinstein monofilament – effective for 10 patients
- Perpendicular to the foot
- Not over areas of callus or broken skin
- 2-3 seconds after monofilament buckles
WHat makes the sensory testing/ monofilament test postive?
Significant for neuropathy if unable to feel more than 6 sites
How many sites with the vibratory exam/tuning fork indicate positive neuropathy?
Two or more sites unfelt indicate neuropathy
Vascular Testing – Objective Exam. Four things to look for?
4
What is the most common form of vascular foot problems?
- Palpation of foot pulses – Dorsalis Pedis and Posterior Tibialis arteries
- Capillary Refill Testing in digits
- Doppler Testing
- Edematous Changes
foot ulcerations
Signs of Arterial Disease
4
- Intermittent claudication (but be aware of lack of pain due to neuropathy! )
- Thin, shiny skin with lack of hair
- Lack of subcutaneous “padding”
- Dusky red/cyanotic/grey color
Signs of Venous Stasis Changes
5
- Poor tissue viability
- Skin is atrophic
- Appears shiny and thin
- Change of colour
- Nail condition
Musculoskeletal Deformities
that occur in the diabetic foot?
6
- High arch feet (Pes Cavus)
- Bunions
- Claw and hammer toes
- Deformities due to past trauma/surgery
- Past ulceration sites
- Charcot foot
Areas of concern for Musculoskeletal Deformities
that occur in the diabetic?
4
- Plantar feet
- Pes Planus (middle of arch at risk)
- Pes cavus (ball of foot and upper toe at risk)
- Interdigital pressure
What is the most common problem in people who have diabetes?
Why is this difficult to treat?
Diabetic Foot Infections
Often multi-bacterial infections present
–Usually caused by Group A & B Strep, & S. Aureus
Can’t feel it and its on the foot. pressure all the time
Deep Skin & Soft Tissue Infections lab considerations?
4
How should we treat cellulitis?
If they have an infection where will their blood sugars go?
- Deep Wound Culture
- CBC, ESR
- systemic signs of infection, blood cultures
- blood sugars
antibiotics Cephalosporins, Clindamycin
TRACE IT
UP
Deep Skin & Soft Tissue Infection Treatment Guidelines:
4
- Antibiotics:
- -Start with Broad Spectrum
- -Specify with Culture Results
- -Multi organisms may be present. - Debridement & flushing
- Offloading
- Dressing Changes
What is an infection all the way down to the bone?
Whats the usual cause?
What lab considerations?
4
Acute Osteomyelitis
S. Aureus is the usual cause
Watch for MRSA
Consider:
- Systemic symptoms
- Blood Sugars,
- CBC, Culture, ESR
- Diagnostic studies
Acute Osteomyelitis
treatment?
4
- Antibiotic Therapy: Start Broad and then get specific with culture results
- Debridement and Wash out
- Infectious Disease consultation
- Ortho consult if needed
What is charcot foot?
2
Most commonly involves what joints?
- Destructive Arthropathy resulting from impaired pain perception and increased bone blood flow
- Bone becomes washed out & weak resulting in small periarticular fractures until joints become destroyed
Most commonly involves the midfoot joints
Signs of charcot foot?
Usually the result of what?
Who are the most common pts for this?
Treatment?
Painless swelling is hallmark sign
Painful foot when normally neuropathic
Bounding pulses
Usually the result of trauma and impaired sensation caused by neuropathy
Diabetes is most common cause, but can be seen in other conditions causing neuropathy
Treatment: Immobilization!!! Get them off the foot!!!
What should the heel height be for people with diabtes?
under 5 cm
Patient Education points?
6
- Check your feet daily. Report any changes IMMEDIATELY!
- Remember to run your hands inside any footwear before putting them on
- Pay close attention to the fit and style of your shoes
- Don’t remove hard skin or loose skin yourself!
- Have your feet checked by a health care professional as often as advised
- DO NOT SMOKE! (WHY?)
- Don’t go barefoot, even at home
- Check the temperature of the bathwater before stepping in
- Avoid the use of heating pads and hot water bottles on the feet
- Wear socks and change daily
- Trim toenails in shape of nail, do not trim cuticles—if you are unable to cut nails easily have it done at a diabetic clinic or podiatrist
Diabetic Foot Risk Classification
1. “ Low current risk”
- “Increased risk”
- “High risk”
- “Ulcerated foot/foot care emergency”
- – normal sensation, pulses palpable
- – neuropathy or absent pulses
- – neuropathy or absent pulses plus other risk factors
- – ulcer present or sign of infection/charcot foot development.
When to Refer for diabetic foot? Which classes?
4
- 1
- 1
- 2
- 1
- Low risk category – annual review by trained practice staff
- Increased risk – refer to a orthopedist or podiatrist
- High risk – refer to a podiatrist and if ischemia found consider vascular referral, Infectious Disease
- Ulcerated/foot care emergency – immediate referral to ED/Hospital
