WellOne Primary Medical Care Program for Medical Clinical Staff

1. DIABETIC FOOT SCREENING WellOne Primary Medical CareProgram for Medical Clinical Staff Click here to move on

2. Diabetes and Amputation • Diabetes is the cause of over 50% of all the non-traumatic amputations in the United States. • The risk of ulcers or amputations is increased in people who have had diabetes >10 years, are male, have poor glucose control, or have cardiovascular, retinal, or renal complications. • The loss of a lower extremity, or even part of a lower extremity, significantly impacts quality of life Click here to view previous screen Click here to move on

3. True of False: Diabetes is the cause of over 50% of all the non-traumatic amputations in the United States. True False Click here to select this answer Click here to select this answer Click here to view previous screen

4. The correct answer is TRUE 5-15% with diabetes will undergo amputation in lifetime That’s up to 30 amputations in 200 patients About 84,000 people with diabetes have lower extremity amputations each year (Centers for Disease Control and Prevention. Diabetes: disabling, deadly and on the rise, 2004..) Click here to view previous screen Click here to move on

5. Diabetes and Amputation • Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday..."- Lancet. 2005;366:1674 Click here to view previous screen Click here to move on

6. Risk Factors: Peripheral Neuropathy (PN) • High levels of glucose are toxic to the nerves • Peripheral neuropathy (PN) is damage to the nerves that connect the spinal cord to the arms and legs (the peripheral nerves) • PN is the # 1 risk factor for diabetic foot ulcer and amputation Click here to view previous screen Click here to move on

7. True of False: Peripheral Neuropathy is the #1 risk factor for foot ulcer and amputation. True False Click here to select this answer Click here to select this answer Click here to view previous screen

8. The correct answer is TRUE • About 60% to 70% of all people with diabetes will eventually develop peripheral neuropathy, although not all suffer pain. This leads to painless trauma, ulceration, infection, and finally amputation. • Because of the lack of pain, the diabetic with neuropathy is prone to foot trauma/injury unawareness. A lack of pain when an ulcer is noted may lull the patient into a false sense of security, perceiving the ulcer to be of little or no significance. Thus, the patient may neglect and/or delay appropriate treatment for their problem. Click here to view previous screen Click here to move on

9. PN: Symptoms • Symptoms can range from mild to severe and perhaps disabling. • Sometimes PN is present even without symptoms. • When people first get PN, they normally feel sensations like tingling, weakness, numbness, pinching, buzzing or stiffness in their toes and feet or fingers and hands. • As it gets worse, people report having a cramping, burning, throbbing or shooting pain. • Some refer to the pain as "frostbite", "pins and needles sticking in", "a lit match held to my foot" or "walking on broken glass". This could be so severe that wearing clothes or sleeping under blankets is painful. • Symptoms of PN vary from person to person. They can appear suddenly, come and go, or persist over time. They usually affect both sides of the body at the same time, and they may get worse at night. • When the nerves going into the feet are damaged, sensation is impaired • Normally pain is protective, letting us know there is a problem. • With PN there may be little to no pain when an injury has occurred Click here to view previous screen Click here to move on

10. Peripheral Neuropathy Click here to view previous screen Click here to move on

11. PN: Physical Exam Findings • Decreased ability to feel pressure with monofilament testing • This is termed an “insensate foot” Click here to view previous screen Click here to move on

12. Risk Factors: Peripheral Arterial Disease • Arterial insufficiency refers to sluggish blood flow through the arteries. • In diabetes, this is usually due to atherosclerosis (plaques that line the blood vessels) • This results in reduced blood flow to the feet and extremities Click here to view previous screen Click here to move on

13. Peripheral arterial disease is usually due to: Peripheral neuropathy Nerve damage Atherosclerosis Click here to select this answer Click here to select this answer Click here to select this answer Click here to view previous screen

14. The correct answer is: Peripheral neuropathy Nerve damage Atherosclerosis Click here to select this answer Click here to learn more; select atherosclerosis from the drop down menu Click here to select this answer Click here to select this answer Click here to view previous screen Click here to move on

15. PAD: Symptoms • The reduced blood flow (and lack of oxygen to the tissues) leads to unhealthy tissues and poor wound healing Many people with diabetes and PAD do not have any symptoms. Some people may experience mild leg pain or trouble walking and believe that it’s just a sign of getting older.  Others may have the following symptoms: • leg pain, particularly when walking or exercising, which disappears after a few minutes of rest (clinical term is intermittent claudication) • numbness, tingling, or coldness in the lower legs or feet • sores or infections on the feet or legs that heal slowly Click here to view previous screen Click here to move on

16. The clinical term for leg/calf pain that occurs with activity and disappears with rest is: Peripheral arterial disease Intermittent claudication Peripheral Neuropathy Click here to select this answer Click here to select this answer Click here to select this answer Click here to view previous screen

17. The correct answer is: • Intermittent claudication Click here to view previous screen Click here to move on

18. PAD: Physical exam findings On physical exam, persons with peripheral arterial disease may have: •  Weak or absent pulses in lower extremities (pedal pulse) • Coolness of the foot or leg • Shiny skin with or without stasis dermatitis • Hair loss (on the legs and toes) • Toe nail changes (brittle, thickened) Red to brownish discoloration, known as stasis dermatitis. Click here to view previous screen Click here to move on

19. A red/brown discoloration of the lower extremities that is seen with arterial disease is termed: Stasis Dermatitis Intermittent claudication Peripheral Neuropathy Click here to select this answer Click here to select this answer Click here to select this answer Click here to view previous screen

20. The correct answer is……. Stasis dermatitis Click here to view previous screen Click here to move on

21. PAD: Risk Factors or developing All of these increase the risk of PAD • Smoking • High blood pressure • High cholesterol Overweight/Obesity • Physical inactivity • Poor control of blood glucose Click here to view previous screen Click here to move on

22. All of the following are signs of arterial disease except: Cool extremities Diminished pedal pulses Loss of sensation Decreased hair growth Click here to select this answer Click here to select this answer Click here to select this answer Click here to select this answer Click here to view previous screen

23. All of the following are signs of arterial disease except: Cool extremitites Diminished pedal pulses Loss of sensation Decreased hair growth Cool extremities, decreased hair growth and diminished pedal pulses are seen with PAD, whereas loss of sensation occurs with peripheral neuropathy Click here to view previous screen Click here to move on

24. Risk Factor: Obesity Obesity is a risk factor for diabetic foot disease because: • There is more weight and shear stress on the feet • Obese persons may have a difficult time inspecting and caring for their feet Click here to view previous screen Click here to move on

25. Risk Factor: Foot Deformity Foot deformities, such as bunions, hammer toes, claw toes, etc. lead to areas of increased friction and pressure Bunion ULCERATION Click here to view previous screen Click here to move on

26. Additional Risk Factors • Impaired vision • Poor glucose control • Poor footwear • Decreased mobility • Severe nail pathology • History of foot ulcers or amputation Click here to view previous screen Click here to move on

27. These nails are hypertrophied (thickened) from fungal infection in this patient with no prior access to podiatric care. Due to the increased pressure transmitted to underlying tissues, these nails can damage the nail bed which may then become secondarily infected and ulcerate. Click here to view previous screen Click here to move on

28. The Diabetic Foot Exam • Also known as the LEAP Exam • LEAP is an acronym for: Lower Extremity Amputation Prevention Click here to view previous screen Click here to move on

29. LEAP PROGRAM The LEAP Program consists of five relatively simple activities: • Foot screening • Patient education • Daily self inspection of the foot • Appropriate footwear selection • Management of simple foot problems Click here to view previous screen Click here to move on

30. Who should have a diabetic foot screening? • The Bureau of Primary Health Care’s (BPHC) Lower Extremities Amputation Program (LEAP) recommend visual foot exams / inspections at each visit. • All patients with diabetes should have a monofilament test done at least annually. Click here to visit the BPHC/HRSA website Click here to view previous screen Click here to move on

31. True of False: A visual foot exam should be performed at every visit with a diabetic patient True False Click here to select this answer Click here to select this answer Click here to view previous screen

32. The correct answer is…… • True Click here to view previous screen Click here to move on

33. Have there been any changes in your feet? How often do you examine your feet for changes? Any burning, numbness, tingling, or pain in your feet or calves? Is there pain in the calf muscles when walking? Do you smoke? Level I Diabetic Foot Screening: Step I:Talk with the patient and document responses Click here to view previous screen Click here to move on

34. Burning, numbness and/or tingling in the feet may indicate: Peripheral Neuropathy Arterial Insufficiency Diabetic nephropathy Stasis Dermatitis Click here to select this answer Click here to select this answer Click here to select this answer Click here to select this answer Click here to view previous screen

35. The correct answer is: Peripheral Neuropathy Arterial Insufficiency Diabetic nephropathy Stasis Dermatitis Click here to view previous screen Click here to move on

36. Explain to the patient that you will be performing a foot screening Ask the patient to remove both the shoes and socks Inspect the shoes for signs of excess wear and the presence of objects such as pebbles, sharp areas, etc Visually inspect the lower extremities- paying particular attention to look between the toes and the back of the heal. Feel for the temperature and condition of the skin. Note any deformities and skin problems Calloused areas Redness and pressure areas Deformity Edema Dry, cracked skin Tight & Shiny Skin Level I Diabetic Foot Screening: Step II: Perform a visual screening of footwear and lower extremities Click here to view previous screen Click here to move on

37. The visual portion of the diabetic foot screening includes inspection of: Footwear and socks Areas between the toes The heels of the feet All of the above Click here to select this answer Click here to select this answer Click here to select this answer Click here to select this answer Click here to view previous screen

38. The correct answer is……. All of the above Click here to view previous screen Click here to move on

39. Explain exam and demonstrate on hand Position for comfort Have patient close their eyes. Ask patient to say “yes” when they feel filament Touch monofilament to testing area, creating a C shaped bend and remove; avoid dragging; avoid calloused areas Level I Diabetic Foot Screening: Step III: Perform the monofilament screening Click here to view previous screen Click here to move on

40. The Monofilament Screening • Is used to determine if there is loss of protective sensation (LOPS) • A lack of sensation in any area with monofilament screening means the patient is at increased risk of foot ulceration and this usually prompts the health care practitioner to refer the patient to a podiatrist Click here to view previous screen Click here to move on

41. What is the preferred way to establish if the patient feels the monofilament? Tell the patient to let you know when he/she feels the sensation Ask the patient to blink 3 times when he/she feels the sensation Ask the patient: “Do you feel this?” Click here to select this answer Click here to select this answer Click here to select this answer Click here to view previous screen

42. The correct answer is……. • Tell the patient to let you know when he/she feels the sensation. This avoids the examiner “prodding” the patient to report the sensation. If the patient does not respond to the monofilament, the examiner should note negative sensation in the area and move on with the screening. Click here to view previous screen Click here to move on

43. True of False: The proper amount of pressure for monofilament testing is that which causes an indentation to be left in the skin. True False Click here to select this answer Click here to select this answer Click here to view previous screen

44. The correct answer is….. • False……the correct pressure is applied by touching the monofilament to the testing area and creating a C shaped bend. Click here to view previous screen Click here to move on

45. MONOFILAMENT SCREENING • A simplified monofilament examination using only 4 sites per foot (total 8 sites) detected 90% of patients with an abnormal 16-site monofilament evaluation. J Gen Intern Med. 1999 July; 14(7): 418–424. doi: 10.1046/j.1525-1497.1999.05208.x. Click here to view previous screen Click here to move on

46. The 4 test sites Click here to move on

47. Prior to performing the monofilament screening, it is important that the examiner: Demonstrate the monofilament on the Patient’s hand or arm Lubricate the monofilament Click here to select this answer Click here to select this answer Click here to view previous screen

48. The correct answer is…… ………..Demonstrate the monofilament on the patient’s arm or hand • This lets the patient know that the monofilament does not hurt and what the monofilament is “suppose to” feel like. Click here to view previous screen Click here to move on

49. Throughout the screening and following the screening….Provide patient education • Awareness of personal risk factors • Daily self inspection of feet • Proper nail and skin care • Injury prevention • When to seek help or specialized referral; For a foot finding call immediately; do not delay • Never walk barefoot • For a foot finding call immediately; do not delay • Smoking cessation • Check water temperature for bathing • Moisturize but not between toes • Proper foot wear selection Click here to view previous screen Click here to move on

50. Education and Goal Setting Is Important • It is estimated that the risk of diabetes-related foot complications can be reduced by 49% to 85% by proper preventive measures, patient education, and foot self-care. (Apelqvist J, Bakker K, van Houtum WH, Nabuurs-Franssen MH, Schaper NC. International consensus and practical guidelines on the management and the prevention of the diabetic foot. International Working Group on the Diabetic Foot. Diabetes Metab Res Rev. 2000;16:S84–S92.) Click here to view previous screen Click here to move on