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REDUCING FOOT COMPLICATION FOR PEOPLE WITH DIABETES

Learning Package for Champions

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Table of contentsCompetency…………………………………………………………………………………………………………3Initial competency………………………………………………………………………………………………..3Champions Roles………………………………………………………………………………………………….3Diabetes Mellitus Overview………………………………………………………………………………….4RNAO-Clinical Best Practice Guidelines…………………………………………………………………5BPG Recommendations………………………………………………………………………………….…5-6Trillium Health Partners-SCM……………………………………………………………….………………7Foot Risk Assessment Algorithm…………………………………………….…………………………….8How Can Diabetes affect my feet………………………………………….……………………………10Diabetic Neuropathy/ Diabetic Nerve Damage…………………………………………………..10Peripheral Sensory Neuropathy………………………………………………………………………….10Peripheral Motor Neuropathy………………………………………………………………………….…10Types and images of foot………………………………………………………………………..…….11-12Peripheral Autonomic Neuropathy…………………………………………………………….......…12Peripheral Assessment Neuropathy…………………………………………………………...………12Peripheral Vascular Disease………………………………………………………………………………..13 Diabetic Foot Symptoms (Image) …………………………………………………………………...…13Skin Assessment ……………………………………….……………………………………………………….14Acute/ Chronic Trauma………………………………………………...……………………………………14Circulation/Vascular Assessment………………………………………………………………………..15Sensation Assessment………………………………………………………….…………………………….16Steps for Monofilament Test for Neuropathy…………………………………………………….17Self-Care Knowledge & Behaviours…………………………………………………………………….18Check/ Do’s/ don’t…………………………………………………………………………………………….19Education Resources………………………………………………………………………………………….20

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Competency:

The purpose of this learning package is

Educate nurses on how to conduct a foot risk assessment for clients with known

diabetes,

Provide basic education for the prevention of foot ulcers and

Refer clients who are at higher risk for foot ulcers or amputation to specialist resources.

Preventing foot complications in people with diabetes is one of the 6 Best Practice Guidelines

that Trillium Health Partners is implementing along with the RNAO.

Initial Competency

The Champions will:

Review this learning package and identify personal learning needs.

Discuss assessment process and demonstrate assessment technique on the phantom

foot.

Demonstrate properly conducted foot assessment and document on SCM.

Champions Roles

To facilitate and implement guidelines of the THP policies and systems.

To increase awareness of nurses and other health care professionals on significance of

foot care assessment on diabetic patients.

To encourage participation of other colleagues in completing foot assessment and

accurate documentation.

To review and audit data result and outcomes of this initiative.

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Diabetes Mellitus is a metabolic disorder characterized by chronic hyperglycemic condition

resulting from insufficient action of insulin. Type 2 diabetes is caused by combination genetic

and environmental factors.

Genetic factors:

impaired insulin secretion

insulin resistance

Environmental factors:

Obesity,

overeating

lack of exercises

stress aging

One of the most serious complications of diabetes is diabetic foot ulcer. The protective

layer of the skin is broken, deep tissue are exposed to bacterial infection that progress rapidly.

Patients often require amputation minor or major amputation of the lower limb. Foot

complications account for 20% of diabetes related hospital admission. 15% of people with

diabetics will develop foot ulcers. 85% of lower extremity amputations are preceded by non-

healing ulcers which can progress to amputation. The risk of lower extremity amputation is 15

to 46 times higher in diabetics than in persons who do not have diabetes mellitus. Careful

inspection of the diabetic foot on a regular basis is one of the easiest, least expensive and most

effective measures for preventing foot complications. Appropriate care of the diabetic foot

requires recognition of the most common risk factors for limb loss. Many of these risk factors

can be identified based on specific aspects of the history and a brief but systematic examination

of the foot.

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RNAO- Clinical Best Practice Guideline - Assessment and Management of Foot Ulcers for

People with Diabetes

Best practice guidelines is a comprehensive document that provides resources needed

for the support of evidence based practice and Trillium Health Partners is implementing this

best practice guideline.

Reducing Foot Complications for People with Diabetes

BPG Recommendation:

1. Physical examination of the feet to assess risk factors for foot ulceration/ amputation

should be performed by a health care professional.

This examination should be performed at least annually in all people with diabetes over

the age of 15 and at more frequent intervals for those at higher risk.

2. Nurses should conduct a foot risk assessment for clients with known diabetes. This risk

assessment includes the following:

History of previous foot ulcers

Sensation

Structural and biomechanical abnormalities

Circulation

Self-care behaviour and knowledge.

3. Based on assessment of risk factors, clients should be classified as “lower “or “higher”

risk for foot ulceration/amputation.

4. All people with diabetes should receive basic foot care education.

Foot care education should be provided to all clients with diabetes and reinforced at

least annually.

5. Nurses in all practice settings should provide or reinforce basic foot care education, as

appropriate.

The basic foot care education for people with diabetes should include the following six

elements:

Awareness of personal risk factors;

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Importance of at least annual inspection of feet by a health care professional;

Daily self- inspection of feet

Proper nail and skin care

Injury prevention

When to seek help or specialized referral:

- Education should be tailored to client’s current knowledge, individual needs, and risk

factors. Principles of adult learning must be used.

- Individuals assessed as being at "higher" risk for foot ulcer/amputation should be

advised of their risk status and referred to their primary care provider for additional

assessment or to specialized diabetes or foot care treatment and education teams as

appropriate.

6. Nurses need knowledge and skills in the following areas in order to competently assess

a client’s risk for foot ulcers and provide the required education and referral:

Skills in conducting an assessment of the five risk factors;

Knowledge and skill in educating clients;

Knowledge of sources of local referral.

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Trillium Health Partners- SCM

SCM- 4 Metrics

1. Number of diabetics

2. Number completed assessment

3. Number of completed monofilament assessments

4. Number of clients received educations/teachings

Trillium Health Partners - Practice and data

Daily collection for accuracy on list of clients who have diabetes 15years and older

admitted to 2B-surgery that require assessment to be completed;

Monofilament and education are sent to project advisor every 6 hours.

This data is checked and updated daily, as well as a list of completed and outstanding

patients that need assessment.

Results are tabulated with the goal of 80% completion.

M- SURG2B/1 Diabetic Foot Assessment

November 2013

All Outstanding Issues are highlighted in Red

% Assesments Complete

% Monofilaments Complete For Completed Assessments

% Education Complete

100% 100% 100%

Unit Name Account Number Room Bed

#Admit Date

Assessment Filled

MonoFilled

Education Filled

M-SURG2B/1

Mrs. A AT017269/13 M202 1 10/22/2013 Y Y Y

Mr. W. AT018107/13 M226 2 11/1/2013 Y Y Y

Miss H. AT018195/13 M201 2 11/2/2013 Y Y Y

Mr. R. AT018277/13 M207 2 11/3/2013 Y Y Y

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Foot Risk Assessment Algorithm and Risk Reduction Guideline

Step 1Assessment

Complete the Diabetic-Foot Risk Assessment Form in SCM on all persons with diabetes over 15 years of age (excluding women with Gestational Diabetes, psychiatric, Emergency and Pediatric populations) within 24-48 hours of admission to the hospital. The Diabetic-Foot Risk Assessment Form has 5 factors to be assessed; skin; circulation/vascular; sensation (monofilament); structural abnormalities and self-care.

Step #2: Identify Level of Risk

High Risk: If any one of the following is assessed Low Risk: If no potential factors are 1. Current/previous ulcer; identified, the level of risk is 2. Signs of infection- elevated temperature, swelling, considered “lower”. Reinforce theinflammation, discharge and pain; benefits of yearly foot exam and3. Pedal pulses absent preventive self- care actions4. Claudication- leg muscle pain or fatigue with Walking that is relieved with rest5. Dependent rubour or delayed capillary refill.This increases potential for the development of infectious disease (e.g. cellulitis, gangrene) and/orneed for surgical intervention (e.g. amputation, femoral bypass)”.

Step #3: Education Intervention

(For both low and high risk persons with diabetes)

Provide person with the education brochures; “Do’s and Don’ts of Foot Care” and “Diabetes- Healthy Feet and You”

Provide person with foot care products Provide self-care education: level of personal risk, inspection by self or caregiver,

wearing protective footwear, general nail and skin care Provide education regarding when to seek resources; see resource listings Encourage person to watch the “Preventing Diabetic Foot Ulcers” DVD video on the THC

channel Reinforce the importance of notifying their family practitioner regarding their risk

factors.

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Step #4: Follow up

Notify and confirm that MRP is aware of HIGH Risk factors. Notify and confirm that Wound Care Team is aware of current/new ulcer and care plan

is in effect

Step #5: Potential Resources Available in the community and or Hospital

Wound Care Team OT/PT Chiropodist Orthotist CCAC/Wound Clinic Diabetes Centre (for uncontrolled and unmanaged blood sugars) Vascular Surgeon (referral by MRP) Dermatology and Plastics (referral by MRP)

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How can Diabetes affect my feet?

For people with diabetes, having too much glucose (sugar) in their blood for a long time can

cause some serious complications, including foot problems .Diabetes can cause two problems

that can affect your feet:

diabetic neuropathy

peripheral vascular disease

Diabetic neuropathy or diabetic nerve damage

Uncontrolled diabetes can damage nerves. If damaged nerves in legs and feet, one

might not feel heat, cold, or pain. This lack of feeling is called "sensory diabetic neuropathy." If

the individual do not feel a cut or sore on his/her foot because of neuropathy, the cut could get

worse and become infected. The muscles of the foot may not function properly, because the

nerves that make the muscles work are damaged. This could cause the foot to not align

properly and create too much pressure in one area of the foot. It is estimated that up to 10% of

people with diabetes will develop foot ulcers. Foot ulcers occur because of nerve damage and

peripheral vascular disease. The anatomical and structural alterations that are the result of

diabetic neuropathy are divided into 3 types: sensory, motor and autonomic

Peripheral sensory neuropathy

The most common predictor for a patient developing foot ulcer is 78% of cases. The loss

of sensation exacerbates the development of ulcerations. As trauma occurs at the affected site,

patients are often unable to detect the wound to their lower extremities. As a result, many

wounds go unnoticed and progressively worse as the affected area is continuously subjected to

repetitive pressure and shear forces from ambulation and weight bearing.

Peripheral motor neuropathy

It is manifested by damage to the innervations of the fundamental foot muscles leads to

an imbalance between flexion and extension of the affected foot. This produces anatomic foot

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deformities that create abnormal bony prominences and pressure points, which gradually cause

skin breakdown and ulceration.

Clawing toe- with the claw toe, the joint at the base is bent. The middle joint is bent down

Cavus foot- a high arched foot can present a range of problems from retraction of toes to

prominent metatarsal heads which are painful to walk on. In severe cases the patients’

concerns are more fundamental with ankle instability and difficulty in walking. The underlying

cause for the majority of patients is a neurological condition which might be static or

progressive. The other causes include trauma and for others the etiology remains unknown.

Hallus Valgus – bunion or a small bump that forms when the big toe turns in toward the second

toe. The joint at the base of the big toe is pushed to the sides.

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Charcot Foot- in acute stage, there is an inflammation and bone re- absorption which weakens

the bone. In later stages, the arc falls and the foot may develop a “rocker bottom” appearance.

Hammer Toe- the middle joint is bent.

Peripheral autonomic neuropathy leads to a reduction in sweat and oil gland functionality. As a

result, the foot loses its natural ability to moisturize the overlying skin and becomes dry and

increasingly susceptible to tears and the subsequent development of infection.

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Peripheral vascular disease

Diabetes also affects the flow of blood. High blood sugar accelerates atherosclerosis

giving peripheral vascular disease (reduction of blood supply to the foot). The delivery of

essential nutrients and oxygen to the foot is compromised leading to anaerobic infections and

tissue necrosis.Without good blood flow; it takes longer for a sore or cut to heal. Poor blood

flow in the arms and legs is called "peripheral vascular disease." Peripheral vascular disease is a

circulation disorder that affects blood vessels away from the heart. If you have an infection that

will not heal because of poor blood flow, you are at risk for developing ulcers or gangrene (the

death of tissue due to a lack of blood)

Diabetic Foot Symptoms

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Assessment

Five key risk factors for developing foot ulcers and amputation

1. Ulcers / Skin Assessment

2. Circulation

3. Sensation

4. Structural abnormalities

5. Self-care knowledge and behaviour

Skin assessment

• Visually inspect the top & bottom of both feet

• Assess for signs of dry or sweaty feet

• Look for any corns, calluses, fissures or cracks, maceration and other skin abnormalities

• Check between the toes for soft corns or any sign if skin breakdown

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• Be alert for signs of infection such as elevated skin temperature, swelling, inflammation,

discharge, and pain

• Check skin temperature by running the back of your hand down the leg from the below

the knee to the dorsum of the digits

• Ask about previous ulcers

• Be alert to any signs of foot trauma

• Inspect the toenails to see if thickened, discolored, deformed or ingrown – may indicate

vascular or fungal disease

• People with Diabetes may not feel trauma:

Acute Trauma – abrasions and burns occur often due to the absence of nociception. Poor

wound healing makes ulcerations more likely to occur.

Chronic trauma– reduced motor function results in a high arch. Together with decreased pro-

prioception, this creates classical deformed foot shapes. These result in bony prominence

which, in turn, when coupled with high mechanical pressure on the overlying skin, results in

ulceration.

Circulation / Vascular Assessment

• Peripheral Arterial Disease is 4-7 times more prevalent in diabetics than non-diabetics

• Atherosclerosis causes a progressive blocking of the arteries as a result of a buildup of

fatty plaque

• The delivery of essential nutrients and oxygen to the foot is compromised leading to

anaerobic infections and tissue necrosis.

Peripheral Arterial Disease

• Thin, fragile, shiny skin

• Absence of hair growth

• Cool/cold skin

• Pallor on elevation of foot

• Dependent rubor (dusky / bluish / cyanotic

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• Delayed capillary refill (> 3-4 sec)

• Check for edema (evidence of poor venous return)

• Intermittent claudicating: Leg muscle pain or fatigue on walking that is relieved by rest

Dorsalis Pedis

Place fingers just lateral to the extensor tendon of the great toe. (If pulse is not palpable, move

fingers more laterally.)

Posterior Tibial

Place fingers behind and slightly below the medial malleolus of the ankle. (In an obese or

edematous ankle, the pulse may be more difficult to feel.

Sensation

Peripheral neuropathy (nerve damage) occurs because of duration and severity of

hyperglycemia to the distal part of the axons of the nerve. This causes dying back and

dysfunction of the nerves.

Three types of neuropathy

1. Autonomic

2. Motor

3. Sensory

Autonomic Neuropathy

• Reduced sweating results in dry cracked skin, dry toenails predisposing skin to damage

& infection

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• Increases blood flow leading to a warm foot

• Bounding pulse and dilated dorsal veins

Motor Neuropathy

• Limited joint mobility

• Foot deformities develop such as Charcot foot / Hammer toes / Clawed toes

• Pressure points over the plantar forefoot

• Altered gait/tripping

Sensory neuropathy

• Loss of protective sensation is associated with an increased risk of amputation.

• Symptoms are:

Burning

Numbness and Tingling

Pain

Lack of feeling

Steps for Monofilament Test for Neuropathy:

1. Show the monofilament to the patient. Place the end of the monofilament on his/her hand

or arm to show that the testing procedure will not hurt.

2. Ask the patient to turn his/her head and close his/her eyes or look at the ceiling.

3. Hold the monofilament perpendicular to the skin.

4. Place the tip of the monofilament on the sole of the foot. Ask the patient to say ‘yes’ when

He/she feels you touching his/her foot with the monofilament.

DO NOT ASK THE PATIENT ‘did you feel that’?

If the patient does not say ‘yes’ when you touch a given testing site, continue on to another

site. When you have completed the sequence, RETEST the area(s) where the patient did not

feel the monofilament.

5. Push the monofilament until it bends, then hold for 1-3 seconds.

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6. Lift the monofilament from the skin (Do not brush or slide along the skin).

7. Repeat the sequence randomly at each of the testing sites on each foot.

8. Clean the monofilament according to agency control protocols and store according to the

manufacturer’s instructions.

9. Lack of feeling (4 or more out of 10) - indicates a negative reaction = Neuropathy = “YES” on

screening tool.

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Self-Care Knowledge &Behaviours

• Poor foot hygiene, inability to perform self-care and routine inspection of the feet and

inappropriate footwear are common contributors to diabetic foot problems.

• Inspect the feet for signs of poor foot hygiene – dirty, long or poorly shaped nails

• Can the patient see the bottom of feet and/or are they able to reach the bottom of feet?

Ask if foot care assistance is required for hygiene and for performing daily foot

inspections

• If assistance required find out why (poor vision decreased mobility etc.)

Check

• Does the Patient report foot problems to health care provider, e.g. ask,

“What would you do if you found a blister on your foot?”

• Check your feet every day for cuts, cracks, bruises, sores, infections or unusual markings

• Use a mirror to see the bottom of your feet if you can’t lift them up

• Does the Patient take steps to reduce risk of injury, e.g. ask if patient walks bare foot

in/outdoors, checks for foreign objects in shoes before wearing them, checks water

temperature before entering a bath, etc.

Do...

• Change your socks every day

• Always wear a good supportive shoe

• Always wear professional fitted shoes from a reputable store. Professionally fitted

orthotics may help

• Exercise

Don’t...

• Wear tight socks, garters or elastics or knee highs

• Wear over the counter insoles – they can cause blisters if they are not right for your feet

• Sit for long periods of time

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• Never try to treat your own feet if there are sores. Always seek professional help.

• Going barefoot outside or indoors.

If you have diabetes, contact your doctor if you experience any of the following problems:

• Changes in skin color

• Changes in skin temperature

• Swelling in the foot or ankle

• Pain in the legs

• Open sores on the feet that are slow to heal or are draining

• Ingrown toenails or toenails infected with fungus

• Corns or calluses

• Dry cracks in the skin, especially around the heel

• Unusual and/or persistent foot odour

Education Resources

1. Have patient watch DVD on hospital TV’s “Preventing Diabetic Foot Ulcers: The 3 Step

Program”

2. Provide each patient a resource package containing:

• Brochure “Diabetes Foot Care Do’s and Don’ts”

• Coloplast Diabetic Foot Care Brochure

• Brochure “Diabetes, Healthy Feet and You” (CAWC)

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• Resource list of foot clinics

• Products: Sample of foot cream (Atrac-tain cream- Coloplast) and Mirror to check the

bottom of their feet.

3. Reinforce need to notify family physician about risk factor(s).