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Flashcards in Diabetic foot care Deck (30):

Why is foot care so impt in diabetic pts?

- 15-25% of people with type 1 and type 11 diabetes will develop one or more foot ulcers in their lifetime
- 18% of these will go on to have major lower limb amputation
- of all non traumatic lower limb amputations 85% are due to diabetic foot ulcerations


Most common cause for hospitilizations for diabetics?

- problems with diabetic foot
- annual health care cost over $148 billion


What are the principal pathogenic mechanisms of diabetic foot problems?

- neuropathy, PVD, and infection


How does diabetes affect the feet?

- nerve damage (neuropathy)
- musculoskeletal deformities
- infections


pathophysiology of neuropathy?

- accumulation of advanced glycosylation end products
- accumulation of sorbitol
- disruption of hexosamine pathway
- disruption of protein kinase C pathway
- activation of poly (ADP-ribose) polymerase pathway
- increased oxidative stress
- nerve ischemia


Pathophys of neuropathy?

- hyperglycemia!!!
- 80% of pts with foot ulcers have neuropathy
- prevention: tight glycemic control


Different types of peripheral neuropathy?

- sensory neuropathy: nerve damage with sxs of numbness, burning, tingling, pins and needles
- motor neuropathy: nerve damage leading to musculoskeletal deformities
- autonomic neuropathy: nerve damage to autonomic nervous system (absence of pressures, impaired blood flow regulation: lead to dry skin fissures and dilated foot veins - dry foot - lead to foot ulcers)



- decreases body's ability to fight infection and to heal wounds in the footm not getting enough blood flow to foot.
- Smoking would compound this


How do you approach the diabetic foot?

- annual foot exam (always look at the feet)
- ask them about their feet
- visual and hands on inspection
- tx: education and recommendations


Pt history and subjective eval?

- previous diabetic education
- diabetic peripheral neuropathy
- skin condition
- musculoskeletal deformities
- footwear


Visual inspection: objective exam?

- color of skin
- type of skin: dry, thin, hair present?
- callus
- trauma, ulceration
- swelling
- nail deformities
- signs of pressure
- musculoskeletal deformities
- general hygiene/self care


Nail deformities?

- onychomycosis: most common deformity of nail (fungal infection)
- onychocryptosis: ingrown toenails
- subungual ulceration
- may refer to a foot specialist if severe problems


How do you perform sensory testing on a diabetic pt?

- use 10 g semmes weinstein monofilament: effective for 10 pts
- perpendicular to foot
- not over areas of callus or broken skin
- 2-3 seconds after monofilament buckles
- sig. for neuropathy if unable to feel 6 or more sites out of the 10 spots


Vibratory exam - tuning fork?

- let pt know how it feels by placing on wrist or elbow
- have pt close their eyes
- aply fork to bony part of distal hallux
- repeat testing 2x
- test is positive for feeling if pt correctly answered at least 2 out of 3 applications (work from distal to proximal)


Vascular testing -objective testing?

- palpation of foot pulses
- dorsalis pedis and posterior tibialis arteries
- capillary refill testing in digits
- doppler testing if you can't palpate pulses (can't get on doppler: worried about PAD)
- edematous changes


What are signs of arterial disease?

- intermittent claudication (may have lack of pain due to neuropathy)
- thin, shiny skin with lack of hair
- lack of subq padding
- dusky red/cyanotic/grey color


What kind of venous stasis changes might you see?

- decreased venous return will lead to bronzing pigmentation on outside of leg
- get the pt ambulating if able


What kind of musculoskeletal deformities may a diabetic pt have?

- high arch feet (Pes Cavus)
- bunions
- claw and hammer toes
- deformities due to past trauma/surgery
- past ulceration sites
- charcot foot
*** all of these can result in pressure ulcers


Diabetic foot infections?

- most common problem in people with diabetes
- range from superficial cellulitis infections, to deep soft tissue infections to chronic bone infections
- difficult to tx because most are staph infections and
often multi-bacterial infections present


Cellulitis pathogens and tx?

- superficial skin infection
- usually caused by Group A and B strep and S. Aureus
- tx: antibiotics: cephalosporins, clindamycin


What should you suspect and consider when you see a full thickness ulceration?

- that multi-organisms: may include both gram + and - and anaerobes
- consider: a deep wound culture, a CBC, ESR, systemic signs of infection, blood cultures, blood sugars


Tx guidelines of deep skin and soft tissue infection?

- abx: start broad, specify with culture results
- multi organisms may be present
- debridement and flushing
- offloading
- dressing changes


What is acute osteomyelitis? usual cause?

- osteomyelitis: infection down to the bone
- S. Aureus is usual cause
- watch for MRSA
- consider: systemic sxs, blood sugars, CBC, dx studies


What is the tx for acute osteomyelitis?

- abx therapy, start borad then get specific with culture results
- debridement and wash out
- infectious disease consult
- ortho consult if needed


What is charcot foot?

- destructive arthropathy resulting from impaired pain perception and increased bone blood flow
- bone becomes washed out and weak resulting in small periarticular fractures until joints become destroyed
- most commonly involves midfoot joints


Signs and tx of charcot foot?

- signs: painless swelling is hallmark sign
painful foot when normally neuropathic, and bounding pulses
- usually the result of trauma and impaired sensation caused by neuropathy
- neuropathy can cause foot ulcerations
- diabetes is most common cause, but can be seen in other conditions causing neuropathy
- tx: immobilization


footwear for diabetics?

- sufficient room: depth, length, and width to accomodate toes
- fastening: lace or velcro
- hell height: under 5 cm
- smooth seamless lining
- wear socks or stockings
- medicare will pay for 1 pair of diabetic extra depth shoes per year, 3 pairs of diabetic inserts/arch supports
- This is preventative medicine


Pt education?

- check your feet daily for changes in color, swelling, discharge, hot spots and report any changes immediately
- remember to run your hands inside any footwear before putting them on
- pay close attention to fit and style of shoes
- don't remove hard skin or loose skin yourself
- have your feet checked by health care professional as often as advised
- don't smoke - vasoconstriction
- don't go barefoot even at home
- check temp of bathwater with elbow
- avoid use of heating pads and hot water bottles on feet
- wear socks and change daily
- trim toenails in shape of nail, don't trim cuticles, if you are unable to trim nails easily have it done at diabetic clinic or podiatrist


Diabetic foot risk classification?

- low current risk: normal sensation, pulses are palpable
- increased risk: neuropathy or absent pulses
- high risk: neuropathy or absent pulses plus other risk factors
- ulcerated foot/foot care emergency: ulcer present or sign of infection/charcot foot development


When should you refer?

- low risk category: annual review by trained practice staff
- increased risk: refer to orthopedist or podiatrist
- high risk: refer to podiatrist and if ischemia found consider vascular referral, infectious disease
- ulcerated/foot care emergency: immediate referral ot ED/hospital *ulcers, charcot)