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Christine Berke MSN APRN-NP CWOCN-AP [email protected]
No Conflicts of InterestNo 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
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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
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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
reflexesConsider 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
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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
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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-footAccessed 10/2/17
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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
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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.
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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
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Offloading
Gold Standard for treatment of DFU Redistributes plantar pressure over a larger surface
areaAssess patient risks Mobility/Falls
Inability to examine wound as frequentlyNeuropathy 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
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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’s solution* Saline Soap & water (potable)
Clean versus Sterile wound care
Wound Bed Preparation
Provide an optimal healing environment No one dressing is appropriate for all wounds nor all phases of
healing A wound may require more than 1 type of dressing in the course of
healing The choice of a wound dressing is dependent on:
Etiology Phase of wound healing (Inflammatory, Proliferative, Regenerative) Presence/absence of infection Wound size and location Wound drainage Ease of use Patient acceptance Cost – reimbursement Availability Goal of care
Wound Healing Strategy
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Home Health Home bound requirement 60 day episode of care- services/DME bundled- case mix Maintenance care may not be covered
Nursing Facility Medicare allowable for DME (dressings) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4121050/
Compression stocking reimbursement Orthotic Shoes/Inserts
Reimbursement for Wound Care
http://www.woundsource.com/blog/navigating-reimbursement-wound-care-dressings
Moist wound healing Dr. George Winter - Formation of the scab and the rate
of epithelisation of superficial wounds in the skin of the young domestic pig (Nature 1962; 193:293)
Hinman & Maibach - Effect of air exposure and occlusion on experimental human skin wounds. (Nature 1963; 200:377)
Moist Wound Healing
Dry Stable Eschar
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Hyperbaric Oxygen
8 general categories: Gauze Clear/transparent film Hydrogel Foam/sponge Absorptive fillers Hydrocolloid Specialty dressings Contact layers Collagen Bactericidal/Bacteriostatic
NPWT
Wound Dressings
Requires 4 weeks of standard careChronic wounds – decreased GF, abnormal ECM,
poor blood supply, increased inflammatory cytokines
3 types of CTPs Scaffolds – biologic matrix or processed matrix Cells – epidermal or combination epiderm./dermal Growth Factors
Biologic Actions Temporary, Semi-permanent, Permanent
Coverage varies, expensive products Assure good wound bed preparation
Cellular Tissue Products (CTP)¹³
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Moyassar B. H. Al‐Shaibani, Xiao‐nong Wang, Penny E. Lovat andAnne M. Dickinson (2016). Cellular Therapy for Wounds: Applications of Mesenchymal Stem Cells in Wound Healing, Wound Healing - New insights into Ancient Challenges, Dr. Vlad Alexandrescu (Ed.), InTech, DOI: 10.5772/63963. Available from: https://www.intechopen.com/books/wound-healing-new-insights-into-ancient-challenges/cellular-therapy-for-wounds-applications-of-mesenchymal-stem-cells-in-wound-healing
Three Pronged Treatment Plan for DFU
1. Manage/Control DiabetesIdentify/Treat Infection
2. Improve/Support NutritionSupplements
3. Evidenced Based Wound CareVascular StatusOffload the Foot
Summary
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