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DQA Focus 2017: The Challenges of Diabetic Foot Ulcers · PDF file Hammer or claw toes Toe...

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  • 05/02/2018

    1

    Christine Berke MSN APRN-NP CWOCN-AP AGPCNP-BC [email protected]

     No Conflicts of Interest No off label recommendations  Unless I tell you 

    Objectives:  Recognize the correct assessment for diabetic

    neuropathy & it’s implications for risk of a foot ulcer.  Educate the patient with diabetes regarding life style

    changes necessary to prevent foot ulcers and decrease risk for amputation(s).

     Identify current Evidence for treatment of foot and/or leg ulcers with a primary etiology of neuropathy and/or peripheral vascular disease.

    HouseKeeping

     Centers for Disease Control (CDC)  2015:  30.3 million U.S. have Diabetes Mellitus

     9.4% of population  7.2 million undiagnosed

     1 in 4 don’t know they have it  84 million over age 20 have pre diabetes  90-95% of Diabetes disease is Type 2  Incident increases with age; 25%over age 65

    Statistics

    https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

  • 05/02/2018

    2

      15-25% of people with diabetes will develop tissue

    loss on their feet⁵  60% of diabetic foot ulcer (DFU) progress to

    infection⁵  20% of those DFU lead to some form of amputation

     80% of DFU that present to emergency department are admitted to the hospital for treatment/surgery⁵

     30-80% of people with previous DFU (healed/amputated) will experience recurrence ~1yr⁵

    Mortality rates for patients with amputations related to DFU: 20-60% 5 year survival rate⁵

    Statistics

     One of several complications of Diabetes Mellitus¹²  Contributing causes for DFU:  Diabetic Peripheral Neuropathy (DPN)  Peripheral Arterial Disease (PAD)  Immunosuppression

     Strongest predictor of DFU ⁶  Chronic callus  Foot structure changes  DPN  PAD  Previous DFU

    Diabetic Foot Ulcers

     Hyperglycemia⁷  Oxidative stress on nerve cells Neuropathy  Deposits of glucose in the nerve cells Nerve conduction  Tightens ligaments in the foot  Injures the nerves  Constricts arteries Ischemia, decreases blood flow

     Neuropathy⁷  Motor – imbalance of flexors/extensors – foot structure changes  Autonomic – impairs sweat gland function – dry skin, fissures  Sensory – peripheral sensation impaired

     Repetitive Trauma  Immune response changes⁷  Increased T lymphocyte apoptosis, inhibits healing

    Pathology

  • 05/02/2018

    3

      Type 1 DM – after 5 years of diagnosis, annually  Type 2 DM – at initial diagnosis, annually  Symptoms vary based on sensory fibers involved  Small fibers – pain & dysesthesias (burning, tingling)  Large fibers – loss of protective sensation (LOPS)  Positive test indicates polyneuropathy with motor loss

     Small fiber tests: pinprick, temperature  Large fiber tests: vibration, monofilament, ankle

    reflexes Consider other causes of peripheral neuropathy

    Testing for DPN⁷`⁸

      10-g (5.07) monofilament  Eyes closed, resting quietly with feet exposed  4-10 sites – 1st, 3rd, 5th metatarsal heads, plantar hallux  Include reference sites to verify sensation detection  Test both feet  Results can vary between feet  Good time to examine for callus & deformities  Document Results!

    Monofilament Testing⁷

  • 05/02/2018

    4

    Monofilament 5.07

    https://www.hrsa.gov/sites/default/files/hansensdisease/pdfs/leapfilament.pdf

    https://youtu.be/ZzP_gijk6TA

      128-Hz tuning fork  Close eyes, touch base of vibrating fork to bony

    surface of each toe in succession, ask when vibration begins and ends with each toe

     Pinprick test  Just proximal to toenail of the dorsal aspect  Blunt tip, don’t draw blood, test arm first  1st toe – L4; 2nd/3rd toes – L5; 5th toe – S1

    Ankle reflex test  Achilles tendon tested, patient sitting with foot

    neutral, strike tendon and watch/feel for plantar flex

    Other Tests⁷

      Patient history  Cardiac  Kidney  Tobacco use

     Evaluate Limbs  Peripheral pulses  Palpate (bounding ≠ adequate flow)  Doppler (hand held versus laboratory)  ABI/TBI and/or duplex  Transcutaneous oxygen

    DM and PVD¹⁻³

  • 05/02/2018

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      Evaluate limb volume  Edema  Varicosities  Compression & or elevation use/tolerance

     Skin exam  Moisture  Hair growth  Texture  Nails and Calluses  Temperature

    DM & PVD (continued)

      Foot Exam  Clinician should be knowledgeable in DM foot

    exam/care  Education (alone is not enough)  Patient and significant other(s)  Repeat each visit  Callus - often heralding lesion/risk for DFU⁹

     Self Exam of Feet  Daily or more (evaluate patient’s activity level)  After episodes of intense/unusual activity  Long handled mirror

    Prevention of DFU¹⁻³

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     Foot Care  Cleaning – no soaking  Socks - compression  Lotions versus creams  Nail care  Fungal dermatitis

     Foot wear (protect, protect, protect)  Bare or stocking footed walking  Open toe shoes/sandals/Crocs™/flip flops/slippers  Shoe style, inserts, supports, replacement frequency  Must be worn in the house (only 15%compliance⁹)

     At night?  Escalating shoe wear

     Inserts – standard versus molded  Standard shoe versus custom made

    Prevention (continued)

    Maguire, J. 2012 http://www.podiatrytoday.com/transitioning-open-wound-final-footwear- offloading-diabetic-foot Accessed 10/2/17

  • 05/02/2018

    7

      Toe contracture  Hammer or claw toes

     Toe diversion  Hallux valgus

    Arch  Lifting/Flattening

    Ankle immobility  Foot drop  Gait changes

    Charcot deformity  Acute versus Chronic

    Structural Foot Changes

     Toe Contractures

     Toe Diversion

  • 05/02/2018

    8

    Charcot

    https://www.ncbi.nlm.nih.gov/books/NBK409609/ Accessed 10/2/17

      Treat/Control Systemic Conditions that Affect Wound

    Healing  Manage co-morbid conditions/diseases

    Offloading (can’t be stressed enough)  Protect the Wound from Trauma

    Control Edema  Know Vascular Status

    Use Evidence Based Topical Therapy  Promote a Clean Wound Base  Maintain a Moist Wound Environment  Control Bacteria/Treat Infection

    Wound Care Focus

    Bryant, R.A., Nix, D.P. Acute & Chronic Wounds: Current management concepts, 4th Ed. Mosby; St. Louis, 2012.

  • 05/02/2018

    9

      Identify and manage co-morbid conditions  Diabetes – Capillary BG, foot checks, footwear, nocturia  HTN, CAD, PAD – perfusion, edema, medications  Kidney disease  Obesity &/or malnutrition – weight loss & wound healing,

    nutrition, fluids  Anemia  Sleep apnea

     Lifestyle choices – smoking, alcohol, drugs (OTC, prescribed, recreational)  Immunosuppression –  Cancer, organ transplant, Autoimmune disorders

     Interdisciplinary Team - Critical

    Systemic conditions

      Wound Culture  Quantitative versus Qualitative

     Vascular studies  Arterial duplex, ABI/TBI, TcPO2  Venous duplex – standing to look for reflux

     Labs  CBC, Sed rate, CRP, Hgb A1C, BMP/CMP

     Xray versus MRI  Osteomyelitis

     Nutritional parameters  Weight, height, meal &/or fluid diaries/recall

     Vital signs

    Diagnostic considerations

      Causes of Edema

     Venous insufficiency  Heart failure  Renal disease  Lymphedema

     http://www.lymphedemablog.com/  Lipedema

     Compression  Wraps  Stockings

     Electric pumps  Arterial  Venous  Lymphatic

     Elevation

    Edema Management

  • 05/02/2018

    10

    Offloading

     Gold Standard for treatment of DFU  Redistributes plantar pressure over a larger surface

    area Assess patient risks  Mobility/Falls

     Inability to examine wound as frequently Neuropathy can interfere with recognition of

    complications from the TCC

    Total Contact Casting ¹⁻³·¹⁰·¹¹

    https://www.youtube.com/watch?v=jtapSDECeG4

     Wound Exam

     Comprehensive & regular wound assessments  Measurements, wound tissue, color, edges, exudate, odor,

    peri-wound skin  Photos for documentation  Address pain  Quickly identify wounds that are not healing or are

    actively deteriorating  No progress for 2 consecutive weeks  Review entire care plan  Consider referral to specialist

     Consider palliative care if healing not realistic  patient focused care

  • 05/02/2018

    11

     Debride - if appropriate  Methods:  Autolytic, chemical*, enzymatic, biologic, surgical  Mechanical  Wet to dry dressings  F-tag 314 – limited situations, removes healthy tissue, increases

    pain  Whirlpool  Pulse lavage

     Wound cleansers vs. Skin cleansers  Chlorhexidine  Dakin

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