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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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slide1

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

acknowledgements
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

workshop purpose level 2
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

best feet forward project
“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

diabetes complications
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

why perform a foot assessment
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

function of the feet
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

peripheral vascular disease
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

peripheral neuropathy
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

foot ulceration
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

foot ulceration11
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

foot ulceration mechanism
Foot ulceration-mechanism

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

diabetic osteopathy charcot s disease
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

diabetic osteopathy charcot s disease14
Diabetic Osteopathy (Charcot’s disease)

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

foot assessment
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

foot assessment16
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

foot assessment17
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

general footcare
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

general footcare21
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

general footcare22
General footcare
  • Nails
    • Thickened
    • Fungal infection
    • Ingrown

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

general footcare23
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

neurological status
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

vascular assessment
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

assess self care capability
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

flow chart for diabetes foot exams
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

risk categories
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

action plan
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

case study one
Case study one

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

case study two
Case study two

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

case study three
Case study three

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

case study four
Case study four

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

case study five
Case study five

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

diabetic osteopathy charcot s disease35
Diabetic Osteopathy (Charcot’s disease)

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

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