Diabetic Foot Ulcers (DFU) Diabetic Foot Ulcers (DFU)

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Diabetic Foot Ulcers (DFU) Diabetic Foot Ulcers (DFU)

Regional Skin Integrity & Wound Management Steering Committee &

Diabetic Foot Ulcer Education Shared Work Team

Fraser Health Fraser Health Regional Wound Education Regional Wound Education

A Person’s Life Experience A Person’s Life Experience

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Diabetic Foot Ulcers 2006 Revised: 2012

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Vision Vision

To reduce the prevalence and incidence of

diabetic foot ulcers with a person-centered and a team approach

Mission Mission

Establish a team approach to identify clients at risk for diabetic foot ulcer, to implement

prevention and management strategies in a timely manner by:

1. Utilizing the appropriate tools/resources

2. Identifying interdisciplinary team members’ roles

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Diabetic Foot Ulcers

2006 Revised: 2012 4

Ice Breaker / Pre-test

Ice Breaker / Pre-test

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Objectives Objectives

Describe the etiology & predisposing risk factors of Diabetes (DM)

Describe the strategies in the prevention and management of DFU with an interprofessional team approach

Describe the components of a vascular and neurological assessment of the foot

Perform foot inspection, foot wear

assessment & identify interventions used to reduce pressure

Select local wound care interventions

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Diabetic Foot Ulcers 2006 Revised: 2012

Diabetes (DM) Pandemic Diabetes (DM) Pandemic

The 6th leading cause of death in Canada in 2008

Every hour/every day, >20 Canadians are diagnosed with DM

2 million (6.4%) Canadians have DM in 2010, and projected to be 3.5 millions (9.9%) in 2020

Aboriginal populations are more at risk by 3-5 times

Rising obesity, sedentary lifestyles, aging population, and changes in ethnic mix attribute to increasing

prevalence and incidence

Source:

1.An economic tsunami: the cost of diabetes in Canada, Canadian Diabetes Association (Dec 2009

2.Statistic Canada (2010) & An economic tsunami: the cost of diabetes in Canada, Canadian Diabetes Association (Dec 2009)

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An Economic Tsunami:

An Economic Tsunami:

The Cost of Diabetes in Canada The Cost of Diabetes in Canada

 Economic burden of diabetes in Canada was projected to be about $12.2 billion in 2010; nearly double its level in 2000

 Cost of diabetes is expected to be $17 billion in 2020

 Direct cost of diabetes accounts for 3.5%

of public healthcare spending and is likely to continue rising

Source: An economic tsunami: the cost of diabetes in Canada, Canadian Diabetes

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Persons with Diabetes Mellitus Persons with Diabetes Mellitus

(DM) (DM)

15% of individuals with DM will develop foot ulcers (DFUs) during the course of the illness

50% of DFUs that heal re-occur

DFU accounts for 50% of lower limb amputations

50% of persons with an amputation will have a contralateral amputation within 3-5 years

The 3-year survival rates after DM-related

lower extremity amputation are 50% with the major cause of death being cardiovascular

disease

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Age Offload

Family Physician

SAM/LOPS Lifestyle

Sam, our client newly diagnosed with DM Sam, our client newly diagnosed with DM

A Team approach to Optimizing Health Status A Team approach to Optimizing Health Status

Footcare

Dietitian Nurses/CM

RCA/PCA/CHW Food Services

OT/PT/Rehab

Pharmacist Social Worker

Specialists

Recreation

Psychosocial Spiritual

Volunteers Management

Sam/Family

DM Educator

DM Control

Orthotist/Pedorthotist

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Risk Factors For Ulcerations Risk Factors For Ulcerations

Age

Obesity

Duration and control of diabetes

Nephropathy

Retinopathy

Prior foot ulcers or amputations

Peripheral NeuropathyPeripheral Neuropathy

Peripheral Vascular Peripheral Vascular Disease

Disease

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3 ABCs ABCs ...of Optimizing Diabetes ...of Optimizing Diabetes

A1C - greater than 9% will affect

wound healing.

Recommended is less than 7%

Blood Pressure

Cholesterol

Diet

Exercise

Foot care-

Check both feet at each appointment

Shoes should be professionally fitted

Smoking

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Feet for

Feet for L.I.F.E. L.I.F.E.

Lifestyle choices

Inspect your feet and footwear

Find professional assistance

Expect your feet to last a life time

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Diabetic Educators can Diabetic Educators can

help:

help:

Foot Care for Prevention

Wash feet daily + dry well

Avoid excessive heat – water, heating pads, etc.

Apply moisturizer (NOT between toes)

Cut toes nails straight across

Do NOT self treat corns, warts, etc.

Avoid bare feet + wear shoes that fit well

Seamless socks, no tight band

Check footwear for foreign objects

(Source: FH Diabetic Education Center)

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Client Education: Early Detection Client Education: Early Detection

 Inspect your feet daily

 Check the bottoms of your feet

 If needed ask your family to help or use a mirror

 Be aware of signs of infection

Redness

Swelling

Warmer than surrounding skin

Discharge

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Client Education: Prompt Client Education: Prompt

Treatment Treatment

See your doctor for uninfected sores that don’t improve in 2-3 days

If signs of infection are present, seek medical attention immediately

Infection can raise blood sugar

Infection can move 2-3 times faster when blood sugar is high

Pain of an injury may not be felt

Follow treatment advice of your health care provider

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Diabetes & Healthy Feet Diabetes & Healthy Feet

Canadian Association of Wound Care (CAWC) Public Information http://www.cawc.net/

An interactive public site that allows client to identify:

Personal self management plan

Questions to ask your doctor

Personal foot care team

Personal foot care plan

How to assess your feet

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Prevention & Treatment of DFUs Prevention & Treatment of DFUs

 Take a careful history to determine general health, diabetic control, and complications

 Ensure that the client is aware of the risks to feet associated with diabetes

 Recognize that loss of protective

sensation (LOPS) is the greatest risk factor for the development of plantar ulcers

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3 Components of Foot Assessment Components of Foot Assessment

History:__________

Foot appearance &

structure: observe foot shape and any deformities

Gait: walking, ROM, balance

Neurologic:

sensation, tenderness, signs of hyperesthesia, paresthesia

Circulation: skin temp, pulses, cap refill,

Doppler, ABI (ankle brachial index)

Skin condition:

hydrated, dry,

macerated, fissures, cracks, edema

Infection

Footwear: indoor &

outdoor

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Diabetic Foot Ulcers 2006 Revised: 2012

Seconds Questions Physical Exam First 15

seconds

Are your feet ever numb?

*Look at the feet/shoes

*Visually examine the foot for skin condition, colour, calluses, toenail condition and structural deformities

Next 15

seconds Do they ever

tingle? *Palpate the foot for

temperature and ROM in general, but the big toe specifically

Final 30

seconds Do they ever burn?

Do they feel like insects crawling on them?

Check for sensory intactness, especially light tough using a 10-gram monofilament

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Sixty Second Foot Exam Sixty Second Foot Exam

Shane Inlow, 2004 Shane Inlow, 2004

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Peripheral

Peripheral

Neuropathy Neuropathy

 Metabolic origin

 Possible theory

High blood sugars results in demyelination and subsequent lower conduction speed in the peripheral nerves

Type 1 diabetes: Rare in first 5 years of diagnosis

Type 2 diabetes: 8% have neuropathy at diagnosis

40% have neuropathy after 20 years diagnosis

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Neuropathy Neuropathy

3 different types of neuropathy

Causatives of problems with diabetic foot

S ensory

A utonomic

M otor

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3 S S ensory Neuropathy ( ensory Neuropathy ( S S .A.M.) .A.M.)

Signs & Symptoms

Burning, tingling, numbness cramps

Paresthesia, hyperesthesia,

Loss of vibratory sensation

Loss of Protective Sensation (LOPS) can cause trauma:

Chemical trauma

Mechanical trauma

Thermal trauma

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S S ensory Neuropathy & ensory Neuropathy & LOPS LOPS

L oss O f

P rotective

S ensation

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Why Why L L

ossoss

O O

ff

P P

rotective rotective

S S

ensationnsation

causes causes ulceration

ulceration

Poorly fitted shoes

Undetected foreign bodies

Improper nail trimming

Burns from hot water & heat appliances

Frostbite

Walking on structures and tissues that are destroyed

Self callous removal

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Un-trimmed Nail Causing Pressure

Un-trimmed Nail Causing Pressure

( ( S S .A.M.) .A.M.)

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3 Monofilament Testing Monofilament Testing

Conducted with clients who have:

Diagnosis of diabetes and/ or diabetic foot ulcer

Numbness tingling, burning or a “crawling” sensation in either foot

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Monofilament Testing

Monofilament Testing

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3 A A utonomic Neuropathy (S. utonomic Neuropathy (S. A A .M.) .M.)

Signs & Symptoms

Dry skin and/or sweaty feet leads to:

Fissures

Fungal infections

Poor skin integrity and increased entry for

infection

Hot or cold sensations in the feet

Diminished reflexes

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Xerosis/Anhydrosis Fissures

A A utonomic Neuropathy (S. utonomic Neuropathy (S. A A .M.) .M.)

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Moisturizers to Protect Skin Moisturizers to Protect Skin

(S. (S. A A .M.) .M.)

Classified as:

Emollient – mixture of water and oil

Humectant – additives that attract and hold water (lactic acid, urea)

Occlusion – physical covering of the skin preventing water loss

Good moisturizer should?

Combine occlusion and humectant properties

e.g. Atractain

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M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)

 Neuropathy of the innervating motor neurons of the lower extremities

 Distal to proximal cell death pattern

 Intrinsic muscles of the foot are primarily involved

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Intrinsic muscle weakness:

Physical deformity of the foot

New pressure areas form

Altered gait

M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)

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Hammer Toe

Claw Toe

M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)

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Claw Toe Hammer Toe

M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)

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Diabetic Foot Ulcers 2006 Revised: 2012

Fat Pad Migration

Fat Pad Migration (S.A. (S.A. M M .) .)

Clawing of the toes pulls the fat pads towards the toes

Uncovers the heads of the metatarsal bones

This removes the protective padding for the skin and

subcutaneous tissue

Pressure Pressure

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Intrinsic muscle

imbalance in the foot can cause the medial

longitudinal arch to increase

M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)

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The transverse arch of the forefoot can collapse, creating new pressure areas

1 2

2

M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)

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How How M M otor Deformity otor Deformity Contributed To Ulcer?

Contributed To Ulcer?

1. Clawing of the foot / toes 2. Collapse of the arches

3. Migration of the fat pads All adds up to pressure

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Deformities In The Foot:

Deformities In The Foot:

Where do you see the problem?

Where do you see the problem?

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Address Client Concerns Address Client Concerns

Related to

Related to SAM SAM

 Activity of daily living (ADL)

 Life styles

 Diet

 Work

 Psychosocial/financial/emotional issues

 Supports family, community, etc

 Environmental issues

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Self Management Self Management

Previous education

Foot care/footwear

Knowledge of

Personal risk factors and harm reduction

How to avoid foot trauma

When to access medical care

Behaviour

Adherence to diet, blood glucose monitoring, healthy lifestyle

choices

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3 Nutrition Nutrition

Optimal glycemic control

Adequate calories

Protein requirements 2-3 times normal

Supplement with multi- vitamins and minerals

Adequate hydration

Referral to dietitian

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Role of Dietitian (RD) Role of Dietitian (RD)

Determines macro-/micro-nutrient needs

Modifies diet and/or recommend supplements if required

Provides education for optimizing glycemic control

Blood sugar / A1C

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3 Dietitian Referral Dietitian Referral

Diabetes Services

Clinics across Fraser Health, contact information and referral form available on

http://www.fraserhealth.ca/find_us/services/our_services?

&program_id=9557

Home Health Dietitian

Only available in Fraser North and East

Very limited access

Home visits only available to homebound clients who receive Home Health/Nursing Care

HealthLink BC

8-1-1

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One Day, One Day,

Sam was surprised that...

Sam was surprised that...

His right foot was red, swollen, hot, and very painful

His GP referred him to ER suspecting of cellulitis or deep vein thrombosis

From his medical history, physical examination,

and lab/x-ray results, Sam was admitted for …

Charcot FootCharcot Foot

Fracture caused by decreased structural

integrity of the bone as a result of hypervascularity of the mid foot osseous structures

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Age

Offload

Physician

VIP SAM/LOPS

Lifestyle

A Team Approach to Support Sam with A Team Approach to Support Sam with

CC

harcot Foot harcot Foot

Footcare

Dietitian Nurses/CM

RCA/PCA/CHW Food Services

OT/PT/Rehab

Pharmacist Social Worker

Specialists

Recreation

Psychosocial Spiritual

Volunteers Management

Sam/Family

DM Educator

DM Control

Charcot Foot

WCC/ET/WOCN

Orthotist/Pedorthotist

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Risk Factors for Charcot Foot Risk Factors for Charcot Foot

1 in 680 person with diabetes (0.15%)

Many go undetected when clients do not

experience pain due to neuropathy

Risk factors :

Peripheral sensory neuropathy

Normal circulation

Preceding trauma, often minor, e.g.

sprains or contusions

Foot deformities, prior amputations, joint

infections or surgical trauma disease

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Stages of Charcot Foot

Stages of Charcot Foot

BPR update 2010BPR update 2010

Stage Description

0 Prodromal period: dermal flush/redness,

increase skin temperature, with or without local edema & bounding pulses. Evidence of foot

instability. X-ray evidence may be seen

1 Developmental stage: An acute destructive period that is induced by minor trauma resulting in fragmentation of bone and joint

dislocation/subluxation

2 Coalescence stage: Lessening of edema and healing of fractures

3 Reconstruction: Healing of bone and

remodeling on X-ray, and evidence of deformity

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Charcot Foot With Ulceration Charcot Foot With Ulceration

Acute Charcot is a medical emergency

High risk for ulceration with re-occurrence

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Age

Offload

Physician

VIP SAM/LOPS

Lifestyle

A Team Approach to Support Sam

A Team Approach to Support Sam withwith

Diabetic Foot Ulcers (DFUs) Diabetic Foot Ulcers (DFUs)

Footcare

Dietitian Nurses/CM

RCA/PCA/CHW Food Services

OT/PT/Rehab

Pharmacist Social Worker

Specialists

Recreation

Psychosocial Spiritual

Volunteers Management

Sam/Family

DM Educator

DM Control

DFU

WCC/ET/WOCN

Orthotist/Pedorthotist

Prosthetics

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Pathway To Assessment and Treatment Pathway To Assessment and Treatment

Of Person With Diabetic Foot Ulcers Of Person With Diabetic Foot Ulcers

Best Practice Recommendations for the Prevention and Treatment of Diabetic Foot Ulcers: Update 2006 - Heather L. Orsted, Gordon Searles, Heather Trowell, Leah Shapera, Pat Miller and John Rahman

Person with Diabetic Foot Ulcer

Treat the Cause

Vascular flow

Awareness of neuropathic changes

Pressure redistribution

Glycemic control

Lipid control

Client-centered Concerns

Adherence to plan of care

Quality-of-life issues related to lifestyle changes

Local Wound Care

Debridement

Callus and necrotic tissue Moisture Balance

Control exudate Inflammation/

Infection Control

Rule out/treat osteomyelitis

Edge of the Wound

Biological dressings

Adjunctive therapies

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Risk Factors Affecting DFU Healing Risk Factors Affecting DFU Healing

Nutrition

Ulcer history

Co-morbidities

Oxygenation

Smoking

COPD

Glucose Control

Hx of Diabetes>10yr

AIC greater than 9%

Foot care

Ability to assess feet

Footwear

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Diabetic Foot Ulcer Assessment Diabetic Foot Ulcer Assessment

Address underlying cause and establish goal of treatment

VIP – 3 major components of assessment

V ascular Supply

I nfection

P ressure

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V V ascular Supply I I nfection P P ressure

15% of DFUs are related to peripheral vascular supply (Vascular supply)

Poor vascular supply and pressure often exist together to varying degrees within the ulcer etiology

V

ascular Supply

I

nfection

P

ressure

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VIP V : : V V ascular Supply ascular Supply

Compromised Arterial Flow Leads To Ulcerations

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3 The Vascular Assessment: The Vascular Assessment:

Thin atrophied skin

Loss of hair on the foot and ankle

Temperature of skin, feet

Thickened nails

Decreased or absent DP and PT pulses

Claudication

Pallor with elevation

Intolerance of elevation

Dependent rubour

Slow capillary re-fill (greater than 4

seconds)

But there is the catch……..

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The catch The catch

with a Person With Diabetes…

with a Person With Diabetes…

Intermittent claudication/rest pain may be absent

Palpable pedal pulse is a poor indicator of vascular status due to vessel calcification

Toe pressures or transcutaneous oxygen are the gold standard for determining the quality of peripheral arterial circulation of a person with diabetes

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3 V V ascular Supply ascular Supply

Occlusion of blood vessels can progress rapidly due to:

hyperlipidemia

hypertension

insulin resistance

hyperglycemia

increases in plaque formation and

coagulation

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Review Vascular Disease (V.I.P) Review Vascular Disease (V.I.P)

How do we assess the foot and the limb?

 Pedal pulse

 Skin

 Temp

 Colour

 Hair

 Nails

 Pain

 Claudication

 Rest Pain

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3 V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure

Infection makes healing

of an ulcer difficult or may be a causative factor in ulceration

Dry skin can lead to

infection and ulceration

What Signs and Symptoms Of Infection Do You See Here?

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3 Increased Bacterial Burden Increased Bacterial Burden

 Non healing

 Non-granulation

 Friable or

hypergranulation

 Slough

↑Exudate

 Serous to purulent

 Odour after cleansing

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Localized Infection Localized Infection

Pain or wound pain

Induration>=2cm

↑Erythema>=2cm

↑Warmth

Wound deterioration

Purulent exudate

Wound may probe to bone

↑Spasticity/Dysreflex in persons with SCI

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3 Systemic Systemic I I nfection nfection

 General Malaise

 Fever

 Rigor/Chills

 Change in Behaviour

 Change in Cognition

 Unexplained elevation of blood sugars

 Septic shock, multi-organ failure

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V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure

Beware!

Symptoms of infection may be masked by decreased immune response common in diabetes

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Key features of diabetic foot infection:

History of worsening glucose control without explanation

New local pain

Increased WBC

V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure

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Neuropathic changes result in gait changes &

callous formations causing Pressure

Pressure is the primary cause of 85% of diabetic foot

V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure

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3 P P ressure Related Forces ressure Related Forces

 Compression – perpendicular force to the tissue

 Friction – superficial transverse force between skin and contact surface

 Shear – deeper transverse force between superficial and subcutaneous tissue

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Braden Scale Braden Scale

Can be a useful tool to identify at risk client

1. Sensory Perception 2. Moisture

3. Activity 4. Mobility 5. Nutrition

6. Friction & shear

70

(71)

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3 P P ressure ressure

Pressure highest between soft tissue &

bony prominences

Plantar Metatarsophalangeal joints

Plantar 1st toe

Perimeter and plantar heel

Plantar, Dorsal and lateral surfaces of the digits and foot

New areas caused by deformity

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“Off-Loading the Diabetic Foot for Ulcer, Prevention and Healing”; P.R.

Cavanagh, S.A. Bus; Plast. Reconstr. Surg. 127 (Suppl.):248S, 2011.

A. Bare foot B. Flat insole C. Custom moulded insole

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3 P P ressure and Callous ressure and Callous

Long term or repetitive pressure, not high enough to cause immediate cell death, can result in the formation of callous

Callous increases the pressure directly to the underlying tissues, creating more callous, and leads to sufficient pressures to cause

ulceration

In the diabetic foot, callous increases the pressure directly to the underlying tissues, creating more callous, and leads to sufficient pressures to cause ulceration

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Footwear, Pressure, Footwear, Footwear, Pressure, Footwear, Pressure, Footwear, Pressure…

Pressure, Footwear, Pressure…

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Key Criteria Key Criteria

For Appropriate Footwear For Appropriate Footwear

A wide toe box

Sufficient depth

Good arch support

Good fit

Grip

Cushioning

Lacing

Durability

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Shoe Components Shoe Components

Toe Box

Arch Support Laces

Grip / Sole Foot Bed

Heel Counter

Seams / Ridges

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Activity: Foot Tracing

Activity: Foot Tracing

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Recommendations for Appropriate Recommendations for Appropriate

Footwear Footwear

Utilize skilled shoe fitters, if possible

Shop for shoes in afternoon when feet are largest

Bring orthotics with you, if you wear them

Wear socks you normally wear

Bring old shoes so fitter can see pattern of wear

Inspect and eliminate pressure lines, both lateral and plantar

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3 Appropriate Footwear Appropriate Footwear

Consider:

 Wound / ulcer location

 S.A.M., V.I.P., and other risk factors

 Environment of use

 Finances

 Compliance

 Cognition

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Coffee Break

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Managing Pressure Managing Pressure

Three Frameworks

1. Pressure Reduction – Immersion 2. Pressure Offloading – Non weight

bearing, cut outs, half shoes, crutches, etc

3. Alternating Pressure – powered or non powered surfaces, not applicable for plantar wounds

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3 OT Can Help OT Can Help

Assess pressure, shear, friction, positioning, and function

Recommendations for maximizing physical, cognitive, behavioral, environmental, and / or functional ability in relation to wound healing

Education on community resources (e.g.

specialized ped-orthosis providers)

Basic education on basic shoe fitting

Problem solving when lower income and lack of funding are barriers to care.

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Footwear / Offloading Options Footwear / Offloading Options

1. Total Contact Casts

2. Removable Cast Walkers 3. Half Shoes

4. Surgical Shoes 5. Healing Sandals

6. Over the Counter Orthopedic Shoes 7. Custom Made Shoes

8. Orthotics / Foot beds 9. Mobility Aides

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3 Total Contact Cast Total Contact Cast

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Total Contact Cast Total Contact Cast

Advantages

Uniform distribution

of pressure over entire foot surface

Permits mobility

Protects foot from infection

Controls edema

High degree of client adherence

Gold standard in research

Disadvantages

Requires highly trained technicians to apply

safely and effectively

Potential to cause skin irritation an/or ulceration

Unable to assess the foot regularly

Contraindicated

with infection or drainage

Minimal client acceptance

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3 Removable Cast Walkers Removable Cast Walkers

XP Diabetic Walker™ System DH Offloading Walker™

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Image of Pressure Mapping Image of Pressure Mapping Test Comparing a Patient’s Test Comparing a Patient’s

Own Footwear to a Own Footwear to a Removable Cast Walker Removable Cast Walker

Removable Air Cast / Cast Walkers Removable Air Cast / Cast Walkers

“Off-Loading the Diabetic Foot for Ulcer, Prevention and Healing”; P.R.

Cavanagh, S.A. Bus; Plast. Reconstr. Surg. 127 (Suppl.):248S, 2011.

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Removable Cast Walkers Removable Cast Walkers

Advantages

Allows for self-inspection and dressing changes

Improved comfort

Initial studies suggest close to TCC results

Can add custom foot bed to the boot

Disadvantages

Significant risk if over inflated- ischemia

Contraindicated for client’s with mobility and/or cognitive

impairments

Removable

Expensive

Contraindicated for heel ulcers

(90)

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Diabetic Foot Ulcers 2006 Revised: 2012

90

Half Shoes Half Shoes

Rear Foot Forefoot

DARCO HeelWedge™

DARCO OrthoWedge™

(91)

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3 Half Shoes Half Shoes

Advantages

Transfer pressure to mid and rear foot by eliminating prolusion

Low Cost

Disadvantages

Very unstable

High risk of falls

Does not fully offload or redistribute pressure

(92)

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Surgical Shoes Surgical Shoes

DH Offloading Post-Op Shoe

DARCO APB™ All Purpose Boot DARCO MedSurg™ Shoe

(93)

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Surgical Shoe Surgical Shoe

Advantages

Low Cost

Accommodates Edema

Good for short term management

Disadvantages

Offloading is limited

Requires an orthotic or cushioning foot bed to be effective

Limits mobility

(94)

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Healing Sandals Healing Sandals

DARCO Wound Care Shoe System™

Custom Sandal

(95)

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Healing Sandals Healing Sandals

Advantages

Moderate plantar pressure offloading

Complete pressure offloading of the top of the toes

Disadvantages

Require skilled and

experienced personnel to create and/or apply

Negative impact on mobility and balance

Limited durability

Expensive

Tall

(96)

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OTC Diabetic Orthopaedic Shoes OTC Diabetic Orthopaedic Shoes

DARCO Gentle Step™

Pedors Black Classic

Pedors Classic Max

Figure

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References

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