HouseKeeping. Statistics 10/30/2017. Christine Berke MSN APRN-NP CWOCN-AP AGPCNP-BC

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1 Christine Berke MSN APRN-NP CWOCN-AP AGPCNP-BC HouseKeeping 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. Statistics 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

2 Statistics 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 Diabetic Foot Ulcers 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 Pathology 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 2

3 Testing for DPN⁷`⁸ 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 Monofilament Testing⁷ 10-g (5.07) monofilament Eyes closed, resting quietly with feet exposed 4-10 sites 1 st, 3 rd, 5 th 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! 3

4 Monofilament Other Tests⁷ 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 1 st toe L4; 2 nd /3 rd toes L5; 5 th toe S1 Ankle reflex test Achilles tendon tested, patient sitting with foot neutral, strike tendon and watch/feel for plantar flex DM and PVD¹ ³ 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 4

5 DM & PVD (continued) Evaluate limb volume Edema Varicosities Compression & or elevation use/tolerance Skin exam Moisture Hair growth Texture Nails and Calluses Temperature Prevention of DFU¹ ³ 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 5

6 Prevention (continued) 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 Maguire, J Accessed 10/2/17 6

7 Structural Foot Changes Toe contracture Hammer or claw toes Toe diversion Hallux valgus Arch Lifting/Flattening Ankle immobility Foot drop Gait changes Charcot deformity Acute versus Chronic Toe Contractures Toe Diversion 7

8 Charcot Accessed 10/2/17 Wound Care Focus 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 Bryant, R.A., Nix, D.P. Acute & Chronic Wounds: Current management concepts, 4th Ed. Mosby; St. Louis,

9 Systemic conditions 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 Diagnostic considerations 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 Edema Management Causes of Edema Venous insufficiency Heart failure Renal disease Lymphedema Lipedema Compression Wraps Stockings Electric pumps Arterial Venous Lymphatic Elevation 9

10 Offloading Total Contact Casting ¹ ³ ¹⁰ ¹¹ 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 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 10

11 Wound Bed Preparation 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 Healing Strategy 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 11

12 Reimbursement for Wound Care 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) Compression stocking reimbursement Orthotic Shoes/Inserts Moist Wound Healing 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) Dry Stable Eschar 12

13 Hyperbaric Oxygen Wound Dressings 8 general categories: Gauze Clear/transparent film Hydrogel Foam/sponge Absorptive fillers Hydrocolloid Specialty dressings Contact layers Collagen Bactericidal/Bacteriostatic NPWT Cellular Tissue Products (CTP)¹³ Requires 4 weeks of standard care Chronic 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 13

14 Moyassar B. H. Al Shaibani, Xiao nong Wang, Penny E. Lovat and Anne 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: / Available from: Summary Three Pronged Treatment Plan for DFU 1. Manage/Control Diabetes Identify/Treat Infection 2. Improve/Support Nutrition Supplements 3. Evidenced Based Wound Care Vascular Status Offload the Foot References 14

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