The Diabetic Foot Screen and Management Foundation Series of Modules for Primary Care Anita Murray - Senior Podiatrist Diabetes, SCH
Learning Outcomes Knowledge of the Model of Care For The Diabetic Foot Understand how to do the Diabetic Foot Screen How to look out for Common Nail and Foot conditions that increase amputation risk How to access the Foot Protection Team
How Diabetes affects the feet The Stairway to Amputation, 2010
Model of Care For The Diabetic Foot (National Diabetes Programme 2011) Aims at highlighting foot complications associated with Diabetes with the aim of preventing ulceration and Limb Loss All people living with diabetes should have their feet assessed at least annually and their feet will be given a risk classification Low Risk Moderate Risk High Risk Active foot disease
Diabetic Foot Screen Assessment of the diabetic foot should include inspection, palpation & sensory testing. Record signs of neuropathy, ischemia, deformity, callus, swelling, ulceration, infection or necrosis should be recorded Each patient should be given a RISK STATUS and referred on if necessary SCH Records Audit : April 2016 72% August 2016: 88%
Tests Vascular exam Dorsalis Pedis Test
Tests Vascular exam Posterior tibial artery Palpate
Tests Vascular exam If pulses not palpable use doppler Monophasic Biphasic Triphasic
Signs and Symptoms of Vascular compromised foot Pain Claudication, night cramps, rest pain Pallor - white Pulselessness Parathesia Paralysis Pershing cold
Tests Neurological exam Tuning Fork To be tested initially on wrist to demonstrate sensation Should be used on a prominence i.e. 1 st Metatarsal head First stages on neuropathy
Tests Neurological exam 10g monofilament Sites
Observations of a neuropathic foot Dysfunction of motor, sensory and autonomic nerves Foot is warm, well perfused with bounding pulses What could it look like? Clawing of the toes Prominent metatarsal heads Possible rocker bottom deformity (charcot) High arch Callus formation
Foot Deformities Bunion joints Hammer toes Prominent Metatarsal Heads
Uncovering ulcers Ulcer underlying callus Ulcer post debridement Looks can be deceiving...
Status Pulses Vibration Sensation History of ulceration Low Risk All normal None Foot Deformity Visual Impairment Moderate Risk High Risk One of above abnormal None maybe All compromised Always maybe maybe
Review process
Initial Diabetic Foot Ulcer Management Begins with a comprehensive history and physical Thorough wound assessment, treatment and referral including: Management of peripheral arterial disease (PAD) referral to Vascular team? Infection control and management - eg. Culture and sensitivity, Antibiotic cover? Debridement and Off-loading necessary * referral to Podiatry* Maintaining a moist wound environment eg. sterile dry dressing and refer to Podiatry ***Timely wound healing is less likely without comprehensive management, including offloading, Vascular input and monitoring for infection***
Referral to Local Podiatry Services All referrals will be triaged by the Podiatrist or a member of the foot protection team. They will be prioritised as the following: Active diabetic foot ulcer (non infected): 1 day or next working day in SCH Infected diabetic foot ulcer with spreading cellulitis, Suspected Osteomyelitis: Attend ED at SVUH for admission on the Diabetic Foot Care Pathway At Risk Diabetic Foot Classification: Telephone review within 2 weeks, appointment date to be agreed for SCH or Primary Care Centre Request for Clarification of Risk Status/: Telephone review within 2 weeks, appointment to be made if required at SCH or Primary Care Centre
Podiatry Service Development Update Diabetic Foot Care pathway, SVUH Integrated pathway championed by Edel Kellegher, Clinical Specialist Podiatrist in conjunction with Vascular, Endocrinology, Opate team, In patient unit and Microbiology. Reduced hospital diabetes related amputation rates and cost to patients quality of life and to hospital bed stays Nominated for National Award for clinical excellence At Risk Foot Offloading and Orthoses Clinic Neuropathic Ulcer Prevention Care pathway, SCH and Primary Care Patient centred service across primary and secondary care setting. Podiatry lead Orthoses and footwear Service (including integrated clinic with Orthotist) so far reducing cost of orthoses by 63% and waiting times for orthoses from 9 months to six weeks.
DEMONSTRATION
Group Work Case Based learning and group feedback How would you describe the wound presentation? How would you assess this? (Observations, history tests) What about management? (Immediate Actions and referrals)