Diabetic Foot Care

Question 1

How does diabetes affect the feet?

4

Answer 1

Nerve Damage (Neuropathy)

Peripheral Vascular Disease(?)

Musculoskeletal deformities

Infections

Question 2

Pathophysiology of Neuropathy

7

Answer 2

1. Accumulation of advanced glycosylation end products
2. Accumulation of sorbitol
3. Disruption of the hexosamine pathway
4. Disruption of the protein kinase C pathway
5. Activation of the poly (ADP-ribose) polymerase pathway
6. Increased oxidative stress
7. Nerve ischemia

Question 3

PREVENTION of neuropathy?

Answer 3

Tight glycemic control

Question 4

What is Sensory Neuropathy?

Answer 4

Nerve Damage with symptoms of numbness, burning, tingling, pins and needles

Question 5

What is Motor Neuropathy?

Answer 5

Nerve Damage leading to musculoskeletal deformities

Question 6

What is Autonomic Neuropathy?

Answer 6

Nerve Damage to autonomic nervous system (symptoms?)

Question 7

Decreases body’s ability to fight infection and to heal wounds in the foot. What habit would compound this?

Answer 7

Smoking = more peripheral vascular disease

Question 8

Patient History / Subjective Evaluation

7

Answer 8

1. Previous diabetic education
2. Diabetic Peripheral
3. Neuropathy
4. Peripheral vascular disease
5. Skin condition
6. Musculoskeletal deformities
7. Footwear

Question 9

Visual Inspection – Objective Exam

10

Answer 9

1. Color of skin
2. Type of skin—dry, thin, hair?
3. Trauma/ulceration
4. Callus
5. Swelling
6. Nail deformities
7. Signs of pressure!
8. Musculoskeletal
9. Deformities
10. General hygiene/self care!!

Question 10

What are the nail deformities that we shouuld look for?

Answer 10

Onychomycosis - Most common deformity of the nail

Onychocryptosis – Ingrown toenails
\
Subungual ulcertion

Question 11

Bilateral foot problems indicates what?

Answer 11

this indicates cardiac failure, renal impairment, venous insufficiency and rarely neuropathy when linked to ateriovenous shunting

Question 12

Unilateral foot problems indicate what?

Answer 12

local pathology of foot or leg e.g. infection, charcot foot, gout, trauma, dvt, venous insufficiency, lymphoedema secondary to malignancy

Question 13

How to do Sensory Testing?

4

Answer 13

1. Use a 10g Semmes Weinstein monofilament – effective for 10 patients
2. Perpendicular to the foot
3. Not over areas of callus or broken skin
4. 2-3 seconds after monofilament buckles

Question 14

WHat makes the sensory testing/ monofilament test postive?

Answer 14

Significant for neuropathy if unable to feel more than 6 sites

Question 15

How many sites with the vibratory exam/tuning fork indicate positive neuropathy?

Answer 15

Two or more sites unfelt indicate neuropathy

Question 16

Vascular Testing – Objective Exam. Four things to look for?
4

What is the most common form of vascular foot problems?

Answer 16

1. Palpation of foot pulses – Dorsalis Pedis and Posterior Tibialis arteries
2. Capillary Refill Testing in digits
3. Doppler Testing
4. Edematous Changes

foot ulcerations

Question 17

Signs of Arterial Disease

4

Answer 17

1. Intermittent claudication (but be aware of lack of pain due to neuropathy! )
2. Thin, shiny skin with lack of hair
3. Lack of subcutaneous “padding”
4. Dusky red/cyanotic/grey color

Question 18

Signs of Venous Stasis Changes

5

Answer 18

1. Poor tissue viability
2. Skin is atrophic
3. Appears shiny and thin
4. Change of colour
5. Nail condition

Question 19

Musculoskeletal Deformities
that occur in the diabetic foot?
6

Answer 19

1. High arch feet (Pes Cavus)
2. Bunions
3. Claw and hammer toes
4. Deformities due to past trauma/surgery
5. Past ulceration sites
6. Charcot foot

Question 20

Areas of concern for Musculoskeletal Deformities
that occur in the diabetic?
4

Answer 20

1. Plantar feet
2. Pes Planus (middle of arch at risk)
3. Pes cavus (ball of foot and upper toe at risk)
4. Interdigital pressure

Question 21

What is the most common problem in people who have diabetes?

Why is this difficult to treat?

Answer 21

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

Question 22

Deep Skin & Soft Tissue Infections lab considerations?
4

How should we treat cellulitis?

If they have an infection where will their blood sugars go?

Answer 22

1. Deep Wound Culture
2. CBC, ESR
3. systemic signs of infection, blood cultures
4. blood sugars

antibiotics Cephalosporins, Clindamycin
TRACE IT

UP

Question 23

Deep Skin & Soft Tissue Infection Treatment Guidelines:

4

Answer 23

1. Antibiotics:
   - -Start with Broad Spectrum
   - -Specify with Culture Results
   - -Multi organisms may be present.
2. Debridement & flushing
3. Offloading
4. Dressing Changes

Question 24

What is an infection all the way down to the bone?

Whats the usual cause?

What lab considerations?
4

Answer 24

Acute Osteomyelitis

S. Aureus is the usual cause
Watch for MRSA

Consider:

1. Systemic symptoms
2. Blood Sugars,
3. CBC, Culture, ESR
4. Diagnostic studies

Question 25

Acute Osteomyelitis treatment? 4

Answer 25

1. Antibiotic Therapy: Start Broad and then get specific with culture results 2. Debridement and Wash out 3. Infectious Disease consultation 4. Ortho consult if needed

Question 26

What is charcot foot? 2 Most commonly involves what joints?

Answer 26

1. Destructive Arthropathy resulting from impaired pain perception and increased bone blood flow 2. Bone becomes washed out & weak resulting in small periarticular fractures until joints become destroyed Most commonly involves the midfoot joints

Question 27

Signs of charcot foot? Usually the result of what? Who are the most common pts for this? Treatment?

Answer 27

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!!!

Question 28

What should the heel height be for people with diabtes?

Answer 28

under 5 cm

Question 29

Patient Education points? | 6

Answer 29

1. Check your feet daily. Report any changes IMMEDIATELY! 2. Remember to run your hands inside any footwear before putting them on 3. Pay close attention to the fit and style of your shoes 4. Don’t remove hard skin or loose skin yourself! 5. Have your feet checked by a health care professional as often as advised 6. DO NOT SMOKE! (WHY?) 7. Don’t go barefoot, even at home 8. Check the temperature of the bathwater before stepping in 9. Avoid the use of heating pads and hot water bottles on the feet 10. Wear socks and change daily 11. 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

Question 30

Diabetic Foot Risk Classification 1. “ Low current risk” 2. “Increased risk” 3. “High risk” 4. “Ulcerated foot/foot care emergency”

Answer 30

1. – normal sensation, pulses palpable 2. – neuropathy or absent pulses 3. – neuropathy or absent pulses plus other risk factors 4. – ulcer present or sign of infection/charcot foot development.

Question 31

When to Refer for diabetic foot? Which classes? 4 1. 1 2. 1 3. 2 4. 1

Answer 31

1. Low risk category – annual review by trained practice staff 2. Increased risk – refer to a orthopedist or podiatrist 3. High risk – refer to a podiatrist and if ischemia found consider vascular referral, Infectious Disease 4. Ulcerated/foot care emergency – immediate referral to ED/Hospital