The diabetic foot
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The Diabetic Foot. Angela Walker Diabetes Specialist Podiatrist. “Why Worry …?”. Approximately 15% of all people with diabetes will be affected by foot ulcer during their lifetime; 85% of diabetes-related amputations are preceded by foot ulcers (International Diabetes Federation) ;

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The Diabetic Foot

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The diabetic foot

The Diabetic Foot

Angela Walker

Diabetes Specialist Podiatrist


Why worry

“Why Worry …?”

  • Approximately 15% of all people with diabetes will be affected by foot ulcer during their lifetime;

  • 85% of diabetes-related amputations are preceded by foot ulcers (International Diabetes Federation) ;

  • Up to 70% of amputations are performed on people with Diabetes;

  • “Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday…”

    Lancet. 2005;366:1674


Multifactorial aetiology

Multifactorial Aetiology

  • Vascular: macro and microangiopathy results in poor skin quality, poor healing and potential for ulceration and amputation.

  • Neuropathy causes loss of sensation, potential for injury, infection, leading to ulceration and possible amputation.

  • Delayed immune response: any injury to the foot is a potential cause for concern.


Diabetic ischaemia

Diabetic Ischaemia

  • Micro-vascular and Macro-vascular

  • Pathology identical to non-diabetics

  • Earlier onset

  • Complications of high blood pressure, high

    cholesterol and smoking are all amplified by

    diabetes

  • 1 Cigarette reduces peripheral blood flow by 30% for

    1 hour.


The diabetic foot

Skin Colour

& Temperature

History of

Intermittent

Claudication

Faint or

Absent Pulses

Reduced or

Absent Hair

Anhydrosis

& Fissures

Changes in

Nail & Rate

of Growth

Loss of Wrinkling of

Skin Around Joints


Peripheral neuropathy

Peripheral Neuropathy

  • Dysfunction of sensory, motor and autonomic nerves:

  • Loss of protectivepain sensation – increased susceptibility to foot ulceration

  • Motor – high medial longitudinal arch, clawed toes, prominent metatarsals

  • Autonomic – dry, fissured skin, sweat loss, distended dorsal veins


The diabetic foot

Well nourished tissue

“Cramping, Tingling, Aching, Burning, Numbness”

Diminished / absent sensation


The diabetic foot

Good DP and PT pulses

Charcot Deformities

Callus at pressure points

Painless ulcerations


Bilateral charcot

Bilateral Charcot


Differential diagnosis

Neuropathic

Warm

Normal colour

Palpable pulses

Skin well nourished

Callus at pressure points

Ulceration plantar

Neuroischaemic

Cool

Pale

Pulses diminished/ absent

Skin thin shiny no hair

No callus fissuring at bony

prominences

Ulcers peripheral

Differential Diagnosis


Pressure ulceration

1. Callus formation

2. Subcutaneous

haemorrhage

3. Breakdown of skin

4. Deep foot infection with osteomyelitis

Pressure Ulceration


Osteomyelitis

Osteomyelitis

  • Approximately 25% of foot ulcers will be affected by osteomyelitis (Young, Diabetic Foot Journal, 2008);

  • Surgery is not always necessary especially in patients without life or limb-threatening infections;

  • 82% of patients studied by Game and Jeffcoate (Diabetologia, 2008) were able to avoid surgery with one or more courses of antibiotics.


Foot problems can be deceptive

Foot problems can be Deceptive

  • Is the diabetic ulcer infected?

  • Compare the temperature of both legs

  • Check blood glucose levels

  • Pain is serious in the neuropathic foot

  • Localised superficial infection is probably the tip of the iceberg

  • Healed wounds need appropriate protection

    to prevent recurrence


Debridement

Debridement

  • Neuropathic ulcers – need to be debrided as soon as possible to determine the depth of the ulcer and removal of necrotic tissue

  • Ischaemic ulcers – should not be debrided unless signs of infection present.


Before sharp debridement

Before Sharp Debridement


After sharp debridement

After Sharp Debridement


Wound dressing

Wound Dressing

  • Aseptic technique;

  • Change dressings daily, more regularly when strike through noted on dressing;

  • Diabetic Foot wounds should be kept dry and clean at all times;

  • Do NOT soak the foot or bath/shower the patient;

  • Apply saline with gauze to clean wound surface.


Wound dressings cont d

Wound Dressings cont’d

  • Do NOT use hydrocolloid dressing as occlude and macerate the wound;

  • Simple wound dressing over ulcer site and secured;

  • Offload with appropriate foot wear/bed rest/turn patient regularly;

  • Review wound regularly and refer early if wound deteriorates;

  • Antibiotics?


The diabetic foot

High blood sugar inhibits body fighting infection

Infection raises blood sugar

The Cycle of Diabetic Infections

Infection gets worse


Criteria for wound dressing selection

Does the dressing:

Stay intact & in-situ?

Prevent leakage?

Cause maceration/allergy

or sensitivity?

Reduce pain?

Reduce odour?

Is the dressing:

Comfortable, conformable,

flexible?

Suitable for leaving in

place for the duration?

Easy to remove?

Easy to use?

Cost effective?

Criteria for Wound Dressing Selection


Who to refer to the diabetes specialists in wph

Who to refer to the Diabetes Specialists in WPH

  • New Ulceration;

  • New Swelling;

  • New Discoloration over all or part of the foot;

  • People with painful leg and foot symptoms whose diabetic control is poor;

  • Deterioration of a presenting wound:

  • ↑Odour ↑Discharge ↑Redness ↑Pain ↑Swelling ↑Feeling unwell

  • Suspected Charcot – Plaster Nurse.


Where to refer

Where to Refer

  • Diabetes Specialist Team:

  • Dr Dove/Dr Akinsola

  • Ward 5Ext ???

  • Tissue Viability Nursing TeamExt ???

  • Vascular TeamExt ???

  • Plaster RoomExt ???

  • Podiatry DepartmentExt 4221

  • (Fax referral: stating Patient Diabetic with active ulcer)


On discharge

On Discharge…..

  • Acute problem contact Diabetes Centre Podiatry, King Edward VII Hospital by:

    Fax on ext 6624.

  • Patient with diabetic complications. Referral to Community Podiatry Clinics based in Slough, Windsor, Ascot, Bracknell, Langley.

  • For type 1 or type 2 patient education or advice send for group education via the Diabetes Centre these Education Sessions are held in Community locations.


Summary of care planning

Summary of Care Planning

  • Good glycaemic control

  • Offloading pressure

  • Safe removal of callus

  • Safe removal of slough, necrotic tissue

  • Treat infection

  • Allow drainage of exudate

  • Encourage patient compliance/patient education

  • Best form of treatment is prevention


The diabetic foot

Any Questions?


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