Você está na página 1de 6

To help protect y our priv acy , PowerPoint

prev ented this external picture from being


automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Objectives:

Wound Care:
The Patient with
Diabetic Foot

1. What is a diabetic foot ulcer.


2. Review the contributing factors causing a
diabetic foot ulcer.
3. Review the assessment and management
strategies for patients with diabetic feet based
on best practice documents.
4. Discuss the role of antimicrobial dressings to
assist in reducing the bacterial burden.
5. Discuss the role of the team in providing
support for the patients with diabetic ulcers

Sheila Moffatt RN BN IIWCC


Pressure Ulcer Prevention Coordinator
October 28, 2011

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Amputation

Diabetic foot ulcer

In industrialized countries, diabetes is the leading cause of


non-traumatic, lower extremity amputations (American
Diabetes Association (ADA), 1999; Foundation for
Accountability, 1996).
Approximately 15% of all persons with diabetes (PWD) will
develop a foot ulcer at some time during the course of their
disease (ADA, 1999).
Eighty-five percent of lower extremity amputations are
preceded by foot ulcers (Reiber, Boyko & Smith, 1995).
Of these, 14% to 24% will proceed to major amputation
(Ramsey, Newton, Blough, McCulloch, Sandhu, Reiber et al.,
1999).

A syndrome comprised of
neuropathy, peripheral arterial
disease and deformity. The end-stage
complications of this syndrome are
diabetic foot ulcerations.

Chronic Wound Care, 4th edition 2007, p549

RNAO. 2005

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Risk factors for vascular


disease
Diabetes
Smoking
Hyperlipidemia (above LDL below 2
mmol/L
Hypertension (BP more than 130/80)

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Pathway to Assessment/Treatment
Person with Diabetic Foot Ulcer
Treat the Cause
Vascular flow
Awareness of
neuropathic changes
Pressure redistribution
Glycemic control
Lipid control

Debridement

Local Wound
Care

Patient-centered
Concerns
Adherence to plan
of care
Quality of life
Caregiver/Family

Inflammation/Infection
Control

Moisture
Balance

Rule out/treat osteomylitis

Edge of the Wound


Active therapies
Biological agents
Adjunctive therapies

Adapted from Sibbald RG,


Orsted HL, Schultz GS, et
al, 2006

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

RNAO Principles for


Assessment and Management

Cardiovascular disease
Comorbidities
Diabetes/Glycemic control
Smoker
Obesity
Medications (steriods)
Nutrition
Adherence and Behavioural Choices (QoL)

V VASCULAR INSUFFICIENCY
I INFECTION
P - PRESSURE

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Assessment of Patients
Physical presentation

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

function, urinalysis, microalbumin, creatinine)

ECG, cardiac echo


Ankle Brachial Index (abnormal less than
0.8) , Transcutaneous oxygen levels
(abnormal less than 40mmHg, Systolic toe
pressures (abnormal less than 45mmHg)

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Dorsal Pedal Pulse

RNAO pictures

RNAO,
Posterior Pedal Pulse
(medial maleollus)

Assessment of Vascular
System
BP, Pedal pulses
Blood work (ESR, CRP, lytes, HbA1c, Cr, liver

visual vascular assessment (color,


temperature, edema)
sensation
structural deformities
pain (i.e. intermittent claudication)
footwear
infection
pressure

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Assessment of the
Patients History

Assessment of
Peripheral Neuropathy
Sensory- loss of first line of defense
against injury
Autonomic- improper vasoconstriction and
vasodilation (i.e.-the skin dries and
cracks and is more at risk for
trauma/damage)
Motor- nerve damage in muscle leads to
abnormal shape, bones are not held in
proper alignment

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Neuropathy (SAM)

Protective Sensation

Sensory

Autonomic

Motor

Heat intolerance
Mild edema
Excessive
moisture
or dry skin

Burning
Numbness
Tingling
Pain
Lack of
sensation

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

DCPNS

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

DCPNS

Perform a
ten point monofilament test
using a 10-gm Semmes-Weinstein Monofilament

Foot Drop
Tripping
Deformities
Changes in
gait

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

DCPNS

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

60 second assessment
The 60-second foot exam for people with diabetes
Questions

First 15 seconds Are your feet ever


numb?

Physical Exam
Look at the feet/shoes. Visually examine the
foot for skin condition, colour, calluses,
toenail condition and structure deformities.

Next 15
seconds

Do they ever tingle?

Palpate the foot for temperature and ROM in


general (but of the big toe specifically).

Final 30
seconds

Do they ever burn?


Do they ever feel like
insects are crawling on
them?

Check for sensory intactness, especially light


touch using a 10-gram monofilament,

The 60-second Foot Exam for People with


Diabetes, Wound Care Canada ( 2004, Inlow)

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Deformities/Mobility

Footwear Assessment

Callus
Hammer toes or claw toes
Arch deformity
Overlapping digits
Rigid digits (especially the great toe)
Bunion
Ingrown or fungal nails
Charcot foot
Gait changes

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Ensure footwear is part of your


assessment. Many times this is the
source of the trauma which leads to
the ulcer.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Orthotics Consult

Infection

Appropriate fitting shoe


Adjustment to shoes for deformity
Brace or cast to offload (ie. Total cast or
pneumatic walker)
Half shoes
Healing sandals (ie. Rocker bottom
sandles)

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Bedside assessments:
Probe to bone ?
NERDS and STONES?
Eyes and nose!

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

NERDS
Non-healing wounds
Exudative wound
Red and bleeding wound surface
granulation tissue

Debris (yellow or black necrotic tissue) on


the wound surface

Smell or unpleasant odor from the wound


Sibbald, Woo, Ayello
Wounds UK, 2007, Vol 3, No 2

For deep infection, think of


STONES:
Size is bigger
Temperature is increased
Os probe to or exposed bone
New or satellite areas of breakdown
Exudate, erythema, edema
Smell.
Sibbald, woo, Ayello
Wounds UK, 2007, Vol 3, No 2

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Diagnostic Tests

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Wound Cultures
C-Reative Protien
ESR
WBC
X-ray (cannot identify acute osteomylitis)
Bone/Gallium Scan
CT
Magnetic Resonance Imaging (MRI)

Dressings to fight
infection
Antimicrobials:
Silver (Ag)Cadexomer iodine-(Iodosrb)
Honey
AMD gauze or cling roll

Superior sensitivity and specificity

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Pressure

Most Common Ulcers


#1. Metatarsal head is the most common
site of ulceration (especially the first
and fifth)
#2. Midfoot collapse with loss of planter
arch

Intrinsic: Genetic / Structural


Extrinsic: Shoes / Trauma / Surgery
Behavioural: Poor choices of
footwear / walking patterns

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Self-care / Education
Check feet morning at night with a mirror
Moisturize dry and cracked skin (natural
oils decrease with age and disease)
Cut nails regularly straight across with
straight clippers
Ensure you check and dry between toes
Always wear footwear to protect your feet
Inspect your shoe prior to wearing
Buy sock that are not restricting circulation
or causing irritation from seams

Include the Team


Physician
Nurse
Foot Care Nurse
Diabetic Educator
Dietitian
Orthotics

Podiatrist
Endocrinologist
Vascular Surgeon
Smoking program
Vision screening
Daily Assistive Care

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Optimize the Patients


Status

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Pathway to Assessment/Treatment
Person with Diabetic Foot Ulcer

Ensure the patient has foot care ordered


by family doctor, if unable to perform by self
Ensure the patient is optimizing their
nutritional intake of protein
Encourage blood sugar control to optimize
healing
Involve orthotics to maintain foot structure
early, accommodate deformities and
offloading as ulcers develop.

Treat the Cause


Vascular flow
Awareness of
neuropathic changes
Pressure redistribution
Glycemic control
Lipid control

Debridement

Local Wound
Care

Patient-centered
Concerns
Adherence to plan
of care
Quality of life
Caregiver/Family

Inflammation/Infection
Control

Moisture
Balance

Rule out/treat osteomylitis

Edge of the Wound


Active therapies

Biological agents
Adjunctive therapies

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

RNAO
Recommendation 6.2

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Biologics/Modulators
Promogran /Prisma
Oasis

Consider the use of biological agents, adjunctive


therapies and/or surgery if healing has not
occurred at the expected rate. Consider use of:
J Biological agents
J Adjunctive therapies- Electric Stimulation,
Hyperbaric Oxygen, and NPWT
J Surgery (e.g., skin graft, Achilles tendon
lengthening, bony reconstruction)

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Adapted from Sibbald RG,


Orsted HL, Schultz GS, et
al, 2006

To help protect y our priv acy , PowerPoint


prev ented this external picture from being
automatically downloaded. To download
and display this picture, click Options in the
Message Bar, and then click Enable external
content.

Adjunctive Therapy
Hyperbaric oxygen therapy
Electrical modalities
Gene therapy
Human growth factors
Human skin equivalents
Laser
Negative Pressure Wound Therapy

Resource Material
RNAO- www.rnao.org
Reducing Foot Complications for People with Diabetes
Assessment and Management of Foot Ulcers for
People with Diabetes
CAWC- www.cawc.net
Best Practice for the Prevention, Diagnosis, and
Treatment of Diabetic Foot Ulcers
Monofilaments
DCPNS- www.diabetescareprogram.ns.ca
Diabetes Foot Inspection Tool
CDA- www.diabetes.ca
Clinical Practice Guideline