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Endocrinology > Diabetic foot care > Flashcards

Diabetic foot care Flashcards

1
Q

Why is foot care so impt in diabetic pts?

A
  • 15-25% of people with type 1 and type 11 diabetes will develop one or more foot ulcers in their lifetime
  • 18% of these will go on to have major lower limb amputation
  • of all non traumatic lower limb amputations 85% are due to diabetic foot ulcerations
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2
Q

Most common cause for hospitilizations for diabetics?

A
  • problems with diabetic foot

- annual health care cost over $148 billion

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3
Q

What are the principal pathogenic mechanisms of diabetic foot problems?

A
  • neuropathy, PVD, and infection
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4
Q

How does diabetes affect the feet?

A
  • nerve damage (neuropathy)
  • PVD
  • musculoskeletal deformities
  • infections
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5
Q

pathophysiology of neuropathy?

A
  • accumulation of advanced glycosylation end products
  • accumulation of sorbitol
  • disruption of hexosamine pathway
  • disruption of protein kinase C pathway
  • activation of poly (ADP-ribose) polymerase pathway
  • increased oxidative stress
  • nerve ischemia
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6
Q

Pathophys of neuropathy?

A
  • hyperglycemia!!!
  • 80% of pts with foot ulcers have neuropathy
  • prevention: tight glycemic control
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7
Q

Different types of peripheral neuropathy?

A
  • sensory neuropathy: nerve damage with sxs of numbness, burning, tingling, pins and needles
  • motor neuropathy: nerve damage leading to musculoskeletal deformities
  • autonomic neuropathy: nerve damage to autonomic nervous system (absence of pressures, impaired blood flow regulation: lead to dry skin fissures and dilated foot veins - dry foot - lead to foot ulcers)
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8
Q

PVD?

A
  • decreases body’s ability to fight infection and to heal wounds in the footm not getting enough blood flow to foot.
  • Smoking would compound this
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9
Q

How do you approach the diabetic foot?

A
  • annual foot exam (always look at the feet)
  • ask them about their feet
  • visual and hands on inspection
  • tx: education and recommendations
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10
Q

Pt history and subjective eval?

A
  • previous diabetic education
  • diabetic peripheral neuropathy
  • PVD
  • skin condition
  • musculoskeletal deformities
  • footwear
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11
Q

Visual inspection: objective exam?

A
  • color of skin
  • type of skin: dry, thin, hair present?
  • callus
  • trauma, ulceration
  • swelling
  • nail deformities
  • signs of pressure
  • musculoskeletal deformities
  • general hygiene/self care
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12
Q

Nail deformities?

A
  • onychomycosis: most common deformity of nail (fungal infection)
  • onychocryptosis: ingrown toenails
  • subungual ulceration
  • may refer to a foot specialist if severe problems
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13
Q

How do you perform sensory testing on a diabetic pt?

A
  • use 10 g semmes weinstein monofilament: effective for 10 pts
  • perpendicular to foot
  • not over areas of callus or broken skin
  • 2-3 seconds after monofilament buckles
  • sig. for neuropathy if unable to feel 6 or more sites out of the 10 spots
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14
Q

Vibratory exam - tuning fork?

A
  • let pt know how it feels by placing on wrist or elbow
  • have pt close their eyes
  • aply fork to bony part of distal hallux
  • repeat testing 2x
  • test is positive for feeling if pt correctly answered at least 2 out of 3 applications (work from distal to proximal)
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15
Q

Vascular testing -objective testing?

A
  • palpation of foot pulses
  • dorsalis pedis and posterior tibialis arteries
  • capillary refill testing in digits
  • doppler testing if you can’t palpate pulses (can’t get on doppler: worried about PAD)
  • edematous changes
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16
Q

What are signs of arterial disease?

A
  • intermittent claudication (may have lack of pain due to neuropathy)
  • thin, shiny skin with lack of hair
  • lack of subq padding
  • dusky red/cyanotic/grey color
17
Q

What kind of venous stasis changes might you see?

A
  • decreased venous return will lead to bronzing pigmentation on outside of leg
  • get the pt ambulating if able
18
Q

What kind of musculoskeletal deformities may a diabetic pt have?

A
  • high arch feet (Pes Cavus)
  • bunions
  • claw and hammer toes
  • deformities due to past trauma/surgery
  • past ulceration sites
  • charcot foot
  • ** all of these can result in pressure ulcers
19
Q

Diabetic foot infections?

A
  • most common problem in people with diabetes
  • range from superficial cellulitis infections, to deep soft tissue infections to chronic bone infections
  • difficult to tx because most are staph infections and
    often multi-bacterial infections present
20
Q

Cellulitis pathogens and tx?

A
  • superficial skin infection
  • usually caused by Group A and B strep and S. Aureus
  • tx: antibiotics: cephalosporins, clindamycin
21
Q

What should you suspect and consider when you see a full thickness ulceration?

A
  • that multi-organisms: may include both gram + and - and anaerobes
  • consider: a deep wound culture, a CBC, ESR, systemic signs of infection, blood cultures, blood sugars
22
Q

Tx guidelines of deep skin and soft tissue infection?

A
  • abx: start broad, specify with culture results
  • multi organisms may be present
  • debridement and flushing
  • offloading
  • dressing changes
23
Q

What is acute osteomyelitis? usual cause?

A
  • osteomyelitis: infection down to the bone
  • S. Aureus is usual cause
  • watch for MRSA
  • consider: systemic sxs, blood sugars, CBC, dx studies
24
Q

What is the tx for acute osteomyelitis?

A
  • abx therapy, start borad then get specific with culture results
  • debridement and wash out
  • infectious disease consult
  • ortho consult if needed
25
Q

What is charcot foot?

A
  • destructive arthropathy resulting from impaired pain perception and increased bone blood flow
  • bone becomes washed out and weak resulting in small periarticular fractures until joints become destroyed
  • most commonly involves midfoot joints
26
Q

Signs and tx of charcot foot?

A
  • signs: painless swelling is hallmark sign
    painful foot when normally neuropathic, and bounding pulses
  • usually the result of trauma and impaired sensation caused by neuropathy
  • neuropathy can cause foot ulcerations
  • diabetes is most common cause, but can be seen in other conditions causing neuropathy
  • tx: immobilization
27
Q

footwear for diabetics?

A
  • sufficient room: depth, length, and width to accomodate toes
  • fastening: lace or velcro
  • hell height: under 5 cm
  • smooth seamless lining
  • wear socks or stockings
  • medicare will pay for 1 pair of diabetic extra depth shoes per year, 3 pairs of diabetic inserts/arch supports
  • This is preventative medicine
28
Q

Pt education?

A
  • check your feet daily for changes in color, swelling, discharge, hot spots and report any changes immediately
  • remember to run your hands inside any footwear before putting them on
  • pay close attention to fit and style of shoes
  • don’t remove hard skin or loose skin yourself
  • have your feet checked by health care professional as often as advised
  • don’t smoke - vasoconstriction
  • don’t go barefoot even at home
  • check temp of bathwater with elbow
  • avoid use of heating pads and hot water bottles on feet
  • wear socks and change daily
  • trim toenails in shape of nail, don’t trim cuticles, if you are unable to trim nails easily have it done at diabetic clinic or podiatrist
29
Q

Diabetic foot risk classification?

A
  • low current risk: normal sensation, pulses are palpable
  • increased risk: neuropathy or absent pulses
  • high risk: neuropathy or absent pulses plus other risk factors
  • ulcerated foot/foot care emergency: ulcer present or sign of infection/charcot foot development
30
Q

When should you refer?

A
  • low risk category: annual review by trained practice staff
  • increased risk: refer to orthopedist or podiatrist
  • high risk: refer to podiatrist and if ischemia found consider vascular referral, infectious disease
  • ulcerated/foot care emergency: immediate referral ot ED/hospital *ulcers, charcot)

Endocrinology (22 decks)

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