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Module 4.1.1. 'Best Feet Forward'. Workshop material developed by the The Alfred DPMI Workforce Development Team for the Central West Gippsland PCP Diabetes Prevention & Management Initiative. Acknowledgements.

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Module 4.1.1

'Best Feet Forward'

Workshop material developed by the

The Alfred DPMI Workforce Development Team

for the Central West Gippsland PCP

Diabetes Prevention & Management Initiative

Produced by The Alfred Workforce Development Team

on behalf of DHS Public Health -

Diabetes Prevention and Management Initiative

June 2005


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Acknowledgements

  • This resource was developed in consultation with the Central West Gippsland PCP: DPMI Technical Working Group.

  • The presentation has been adapted from the:

  • Footcare in Diabetes Workbook for Health Professionals. Australian Diabetes Educators Association

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Workshop purpose – Level 2

Target

  • Registered nurses involved in caring for people with diabetes i.e. those involved in community, home or acute nursing, general practitioner practice nurses.

    Objective

  • To provide training to increase skills in:

    • Appropriate foot assessment and documentation of assessment

    • Identification of foot at high risk of ulceration or amputation

    • Identification of active foot problems that require further assessment and/or treatment

    • Development of foot care action/care plans consistent with assessment findings.

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Best Feet Forward” Project

  • Aim

    • To decrease foot problems in people with diabetes

  • Objectives

    • Train health care providers in the assessment, classification and care of the diabetic foot

    • To support appropriate action planning and multidisciplinary care of diabetic foot problems

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Diabetes complications

  • Admission rates in the Central West Gippsland catchment are 2.5 times higher than the state

  • A large percentage of those admitted with complications occur below the knee

    Reference:

    Public Health Division, Department of Human Services, The Victorian Ambulatory Care Sensitive Conditions Study: Opportunities for Targeted Interventions, June 2002

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Why perform a foot assessment?

  • Prevention of:

    • foot ulceration gangrene

      amputation

  • Assist in the maintenance of:

    • Mobility

    • Independence

    • Healthy active lifestyle

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Function of the feet

  • To act as a stable base of support

  • To provide shock absorption with each step

  • To adapt to surface irregularities

  • To provide sensory feedback

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Peripheral vascular disease

  • Degenerative vascular disease

    • Most commonly it is seen as multiple occlusions of the popliteal artery and its branches

  • Risk factors

    • Hyperglycemia

    • Smoking

    • Hypertension

    • Hyperlipidemia

Normal Artery

Stenosed Artery

Fibrous and/or fatty plaques

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Peripheral neuropathy

  • Impairment of nerve function segmental demyelination

  • All nerve fibres can be affected

    • Sensory

    • Autonomic

    • Motor

Ne

r

V

e

Axon

Ne

r

V

e

Axon

Myelin Sheath necessary for normal impulse conduction

Demyelination of axon i.e. no impulse conduction

DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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Foot ulceration

  • Predisposing factors

    • Vascular Disease

    • Peripheral Neuropathy

    • Infection

    • Physical injury

  • Precipitating factors

    • Physical injury

    • Mechanical (pressure)

  • DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Foot ulceration

    Extrinsic Pressure

    Tissue Hypoxia

    Repetitive rubbing

    Footwear

    Intrinsic Pressure

    Limited joint mobility

    Callus Formation

    Altered tissue strength

    Foot deformity

    Irregular foot structure

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Foot ulceration-mechanism

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Diabetic Osteopathy (Charcot’s disease)

    • Presents as a warm swollen foot or ankle

      • Often misdiagnosed as cellulites

      • Affects ankle, subtalar and mid-tarsal joints

      • Severe peripheral neuropathy is nearly always present

    • Urgent orthopedic referral is required

    • Foot must be immobilised while inflammation present

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Diabetic Osteopathy (Charcot’s disease)

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Foot assessment

    • WHY?

      • Most foot problems are preventable when identified early, treated appropriately and when people are educated to avoid problems

    • GOAL

      • Prevent amputations

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Foot assessment

    • Aim to identify the high risk foot using as indicators

      • History of previous ulcer

      • Peripheral neuropathy

      • Peripheral vascular disease

      • Foot deformity

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Foot assessment

    • Aim to identify active foot problems check for:

      • Infection

      • Ulceration

      • Calluses or corns

      • Any skin breaks

      • Nail disorders

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005




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    General footcare

    • Feet clean

    • State of Skin – moist/ dry/shiny/hairless/thin

    • Interdigitial areas – macerated/ dry

    • Callus

      • Must be regarded as pre- ulcerative, esp in neuropathic foot.

      • Appears as yellow thickened skin

      • Occurs at pressure points

      • Early treatment and pressure relief prevents ulceration

    • Socks, pantyhose, shoes – appropriate, well fitting, provide adequate support

    • Orthotics/prosthesis

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    General footcare

    • Shoes

      • Appropriate, provide adequate support- general rule leather and lace are best

      • Good condition

      • Well fitting – shoes should fit three ways length/width/depth

    • Poorly fitting shoes can cause blisters and corns that may ulcerate

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    General footcare

    • Nails

      • Thickened

      • Fungal infection

      • Ingrown

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    General footcare

    • Note and draw on feet on assessment form

      • Ulceration- Non-healing wounds may occur anywhere on the feet, look particularly at pressure areas e.g. tops/tips of toes, ball of foot,heel, under callus.

        • May be painless

      • Infection- look forredness, warmth, discharge, swelling

        • Signs and symptoms may be masked byischemia or neuropathy

      • Deformities- such ascorns, callus, bunions, claw/hammer toes, heel cracks

        • These areas are more susceptible to pressure and require special attention to shoe fit

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Neurological status

    • Symptoms of neuropathy

      • Pain

      • Burning, numbness, pins & needles

        • Symptoms usually bilateral

        • Often worse at night

        • May be hypersensitive to touch

        • May be present when first diagnosed with diabetes

        • May worsen with unstable blood glucose levels

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Vascular assessment

    • Symptoms of intermittent claudication

      • Pain in calf muscle when walking, leg cramps

  • Pulses

    • Dorsalis Pedis

    • Posterior tibial

  • Ulcer

  • Gangrene

  • Amputation

  • DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Assess self care capability

    • Does/can the client:

      • Understand effects of diabetes on the feet

      • Identify appropriate foot care practices

      • Smoke

      • Able to adequately care for their feet

      • Have impaired vision/mobility

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Flow chart for diabetes foot exams

    Start

    Type 1 and Type 2 Diabetes: when diagnosed

    Annual Comprehensive Foot Exam and Risk Categorization

    By diabetes educator/podiatrist /general practitioner

    Include education for self care of the feet and reassess metabolic control

    Visually inspect feet 6 monthly

    Visually inspect feet at every visit

    Low

    Risk

    Feet

    High

    Risk

    Feet

    Action plan to support self care and identification of foot problems

    Action plan to restore and/or maintain integrity of the feet

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005

    Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program http://www.ndep.nih.gov/resources/health.htm


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    Risk categories

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005

    Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program http://www.ndep.nih.gov/resources/health.htm


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    Action Plan

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005

    Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program http://www.ndep.nih.gov/resources/health.htm


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    Case study one

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


    Case study two l.jpg
    Case study two

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


    Case study three l.jpg
    Case study three

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


    Case study four l.jpg
    Case study four

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


    Case study five l.jpg
    Case study five

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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    Diabetic Osteopathy (Charcot’s disease)

    DPMI Workforce Development – The Alfred Workforce Development Team June 2005


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