Regional Skin & Wound Education Facilitator Guide

Regional Skin & Wound Education Facilitator Guide: Diabetic Foot Ulcers (Module 3)

June 2012 1

How to use this guide Learning Objectives:

Each section outlines specific learning objectives that will guide the discussion & activities of this part of the workshop.

Participants know what they will achieve by completing the section.

TO PRINT THIS GUIDE: Use printer DOUBLE-SIDED function & CHOOSE FLIP PAGES UP (this option allows user to staple document from above & flip through pages as one would a book).

Time Topic Facilitator Activities / Questions Media

An estimate of the time each section will take.

Varies by number of participants

General topic being covered.

Describes what facilitator does for each section.

ACTIVITIES: appear in BLUE & include purpose statement, instructions for conducting activity & points for summary

EMPHASIZE: Points for emphasis appear here in RED

Activities undertaken by the group.

QUESTION TO GROUP: questions put to group appear here in GREEN

ANSWERS to questions appear immediately below, also in GREEN

What AV or other material accompanies each section

HO = Handout

FC = Flip chart


June 2012 2


Introduction: the Hook, Learning Outcomes, Objectives, and Icebreaker

0830 – 0900 Connect laptop to Fraser Health Intranet

Open the following link: http://www.cawc.net/

Minimize as this link will be used later in the presentation

There are 2 documents on this link that can be printed off under the diabetes self management plan:

• Healthy feet checklist and

• Personal foot care plan

Pre reading Best Practice recommendations for DFU 2010 & Provincial CDST

Handouts:

• Provincial CDST

• monofilament procedure

• Pixalere foot /sensation

• Guideline summary

Greet learners, acknowledge differing levels of experience and education in the room, discuss format of session

Allow learners to introduce self and area of work to other participants.

Orientate to bathrooms

Encourage interactivity and group discussion and questions through the session

Slide 1

Slide 2


June 2012 3


Vision & Mission Client – All through the education module, the term client is used interchangeably as patients, clients, and residents as appropriate in different health care settings

The vision and mission statements are to reflect on the ultimate learning outcomes (level 4 to 6) that, due to constraint in resources allocation, that the Regional SW CWT/SW Steering Committee are not able to evaluate.

Slide 3

This module will evaluate the following level 1-3 learning outcomes:

1. Level 1: Participation – The number of learners participated in the learning events, e.g. attendance sign-in sheet

2. Level 2: Satisfaction – The degree to which expectations of the learners about the setting and delivery the educational events were met, e.g. Learning Session Evaluation form

3. Level 3: Learning – Changes in the knowledge, skills and/or attitudes of the learner, and the development of competence, e.g. pre- and post-test

Slide 3


June 2012 4


This module will NOT evaluate the following level 4-6 learning outcomes due to constraint in resources allocation. Instead, they are stated as the Vision and Mission of the module:

1. Level 4: Performance – Changes of practice performance as a result of the application of what was learned, e.g. paper or on-line 3-month follow up survey, etc.

2. Level 5: Patient outcomes – Change s in the health status of patients due to changes in practice behaviours, e.g. prevalence and incidence rates, costs incurred in treating peri-stomal skin complications, etc.

3. Level 6: Population outcomes – Changes in the health status of a population of patients due to changes in practice behaviours, e.g. acute care admissions for peri-stomal skin complications, etc.

(Sibbald et al, 2007. Effective Adult Education Principles to Improve Outcomes in Patients with Chronic Wounds)

Slide 3


June 2012 5


0840 – 0850 Ice Breaker / Pre-Test

Introduce yourself and the co-instructors – roles, work areas/program, and credentials

Discuss housekeeping items i.e. (bathroom, pagers/phones on vibrate, no texting during class)

Identify learners’ existing knowledge by:

1. “Ice Breaker” – Learners to introduce themselves to the group: name, area of work, if they have cared for clients with pressure ulcers, why they attend the education, and what they want to gain from attending the education

2. Then ask the learner to complete the Pre-test on the 1st page of the evaluation form

Slide 4


June 2012 6


Objectives Review objectives and briefly outline plan for time frames.

Objectives:

• Describe the etiology & predisposing risk factors of Diabetes

• Describe the strategies in the prevention and management of DFU with an interprofessional team approach

• Describe the components of a vascular and neurological assessment of the foot

• Perform foot inspection, foot wear assessment & identify interventions used to reduce pressure

• Select local wound care interventions

Advise participants of the guest speakers who will be co-presenting

Slide 5


June 2012 7


0850 – 0900 Diabetes Pandemic

The Hook – some facts on DM and DFU (this slide and next slide)

Source:

1. Stats Canada 2010

2. An economic tsunami: the cost of diabetes in Canada, Canadian Diabetes Association (Dec 2009)

More than 20 people are diagnosed every hour of every day.

In 2010, 1,841,527 (6.4%) Canadians have diabetes with 202,442 (5.2%) living in BC

In 2008, DM is the 6th leading cause of death, accountable for the death of 7,521 Canadians (3.2%)

The number of people diagnosed with diabetes in Canada is expected to double between 2000 and 2010, from 1.3 million to about 2.5 million

First Nations population have a prevalence of type 2 DM thrice the national average

Expected economic burden approx. $12.2 billion in 2010 (increase of $5.9 billion, doubled from 2000)

Slide 6


June 2012 8


An Economic Tsunami: The Cost of Diabetes in Canada

The economic burden of diabetes in Canada projected to be about $12.2 billion in 2010, an increase of $5.9 billion; nearly double its level in 2000

The cost of diabetes is expected to rise by another $4.7 billion by 2020

The direct cost of diabetes accounts for 3.5% of public healthcare spending and is likely to continue rising given the expected increasing number of Canadians living with diabetes

Slide 7

Persons with Diabetes Mellitus

Although often overlooked at the onset of DM, one of the common and devastating complications of DM is DFU.

Put diabetic foot ulcers into the context of Canadian health care statistics and help to under score the magnitude of the problem as a way of introducing the topic.

Slide 8

0900 – 0915 Client education on DM Control/Foot Care

Loss of protective sensation is the most significant predictor of diabetic foot ulceration.

Use Animation to introduce Sam, our client all through this presentation.

Sam is an instruction site worker, whose wife Susan is a 40-year old secretary.

They have 2 children: a boy age 12 and a girl age 10.

Slide 9


June 2012 9


This slide is when Sam when he was first diagnosed with Diabetes at age of 45

The outer oval shapes are the anticipated clinical/personal issues related to DM/DM related complications.

SAM and LOPS are the key clinical issues that will be discussed in details later.

The inner circles are the lists of interprofessional team members to support Sam to maintain optimal DM control

Please note that Specialists include: Foot Surgeon, Podiatrist, Endocrinologist, vascular surgeon, etc.

Slide 9

Introduce:

Role of Wound Care Clinician

• Member of the interdisciplinary team

• Provides specialized holistic assessment and management of patients/families with ostomies, acute and chronic wounds, and urinary and fecal continence problems

• Coordinates specialty care requirements with hospitals, community and follow-up services

• Educates and consults about advance nursing skills within areas of expertise in wound and skin care practice.

Slide 9


June 2012 10


Risk Factors For Ulcerations

Review of those at greater risk for development of diabetic foot ulcerations.

• Age

• Obesity

• Duration and control of diabetes

• Nephropathy

• Retinopathy

• Prior foot ulcers or amputations

• Peripheral Neuropathy

• Peripheral Vascular Disease

Retinal changes are common complications of Diabetes and will also increase someone's risk for a DFU due to an inability to visualize the foot.

Slide 10


June 2012 11


ABCs of Optimizing Diabetes

Define A1C:

The A1C test (also known as HbA1C, glycated hemoglobin or glycosylated hemoglobin) is a blood test done in the lab to provide a good general measure of diabetes care.

While conventional home glucose monitoring measures a person’s blood sugar at a given moment, the A1C test indicates a person’s average blood glucose level over the past few months.

AIC should be checked every 3 months

According to Dr Sibbald, a Canadian and International renowned Dermatologist specialized in wound care, A1C greater than 9% will affect wound healing & 7% will impair wound healing. Therefore, recommended A1C is less than 7%

Slide 11

Feet for L.I.F.E. Client Education crucial to promote adherence treatment plan and rapport with healthcare providers:

Lifestyle Choices

• Eat a healthy diet and maintain blood sugars within normal range

• Exercise daily

• If you have foot problems try a stationary bike or swimming

• Don’t smoke – IMPORTANT FOR ALL! – each cigarette decreases leg circulation for 30% for an hour or increase sympathetic tone for 8 hours

Slide 12


June 2012 12


Inspect your feet and footwear

• Look at your feet daily to check for cuts, scratches or blisters

• If you cannot see your feet clearly, have a friend or family member check them or use a mirror

• Check your shoes and socks on a regular basis

• Always wear good fitting shoes and socks

• Check for foreign objects in shoes before putting them on

• Check for rough areas inside shoes

• Wear well fitting socks with no seams or darning

Slide 12

Find Professional Assistance

Your feet deserve the best professional care you can find

• Foot care professionals include MD, podiatrist or RN

• Orthotist

• Shoe fitter (pedorthotist)

Slide 12


June 2012 13


Expect your feet to last a lifetime

• Wash and dry feet daily

o Dry gently between each toe

• Avoid extreme temperature changes

o Test water with a thermometer

• Do not use heating pads on your feet

• Do not soak feet

• Use unscented moisturizer for dry skin

• Do not use adhesive tape, wart treatments, corn plasters or strong antiseptics on your feet

• If you have an open area/crack on your feet, see your health care professional

Slide 12


June 2012 14


Diabetic Educators can help

Therefore, need to emphasize to Sam that Foot Care is important

FH Diabetic Education Center

• If you have trouble seeing or reaching your feet - see a foot doctor or nurse to assist you. These may be covered by your private plan but are not covered under Fair Pharmacare

• Wash feet daily - in warm water with a mild soap.

• Pat dry with a soft towel and dry carefully between toes

• Always check the water temperature with your elbow or wrist. Hot water, hot pavement or heating pads can all cause severe burns.

• If skin is dry, apply a urea-based moisturizer. If you have very dry skin-use a product with urea 10-25%, which will pull moisture to the skin surface. Remember no lotion between toes and this makes the toe webs too wet and may encourage a fungus infection.

• Soak nails for 10 min to soften before cutting and use a nail clipper (not scissors). Cut straight across and file rough edges with an emery board ( not steel)

• Do not self treat corns and warts with chemicals, or sharp instruments- these can damage your feet or cause infection.

• Always protect your feet by wearing hard-soled slippers and shoes avoid flip-flops.

Slide 13


June 2012 15

Time Topic Facilitator Activities / Questions Media • Wear seamless socks that don’t constrict. If

you have swelling ask your doctor about compression stockings available at pharmacies or from a foot care specialist.

• Wear foot shaped shoes with low heels and good support –

o go to specialty shoe store, that knows how to fit shoes for diabetic feet. Always get your feet measured or draw a tracing of your foot standing up. Cut it out and take it with you to insert into the shoe.

o Remember a numb foot cannot feel a tight shoe!

o Shop for shoes in the late afternoon when feet tend to swell and take the socks and orthotics you usually wear with you for fitting.

Be smoke-free

Client Education: Early Detection

Early detection is the second step in caring for your feet.

Look for signs of:

• corns, calluses, blisters, scrapes.

• of infection such as redness, swelling , heat, or discharge.

Wear white socks so you will see if there is blood or drainage from an injury, such as a torn nail or stubbed toe.

Slide 14


June 2012 16


Client Education: Prompt Treatment

Could be an infected cut, sore, blister, callus or bruise

Do not try to treat your feet yourself.

Pain of an injury may not be felt due to loss of sensory related to DM changes

Remember most severe infections and amputations are a result of a minor injury or problem that was left unattended!

Don’t let this happen to you.

Always follow the treatment plan your doctor gives you and finish all the medication as prescribed.

• Antifungal creams must be used twice/day for 6-12 weeks even after the itch and burning has gone.

Slide 15


June 2012 17


Diabetes & Healthy Feet

A CAWC expert advisory group, in collaboration with a patient focus group, has developed a self-assessment brochure and an interactive website in many languages to help patients in recognizing risk factors and identifying foot issues that they may have been previously unaware of.

The brochure and interactive website are available at www.cawc.net/diabetesandhealthyfeet (Botros et al 2010)

Review CAWC page by opening up hyperlink & review the information below

• Select personal self management questionnaire

• Select personal foot care plan.

• Handout Healthy feet checklist and personal plan.

• Select “ Your foot a closer look”

Slide 16

The brochure and interactive website at www.cawc.net/diabetesandhealthyfeet (Botros et al 2010)

Slide 17


June 2012 18


0915 – 0945 SAM, LOPS, Monofilament, Self Management, Nutrition

Review the key points for Prevention and Treatment of DFU

Disclaimer: the term “Client” is used interchangeably with patient in acute care and residents in residential care, or any other settings

(Botros et al 2010)

Diabetic sensory neuropathy is the leading cause of foot ulcers.

It generally presents as a distal symmetric sensori-motor neuropathy and is believed to contribute to ulcers because the patient cannot feel harmful stimuli.

Peripheral neuropathy affects sensory, motor and autonomic nerves.

Emphasize Loss of protective sensation is the most significant predictor of diabetic foot ulceration.

People with diabetes are prone to serious injury from minor trauma because they cannot feel the injury to the foot as it occurs.

In addition to single injurious incidents, such as stepping on a needle, repetitive stress simply from walking can lead to tissue breakdown in the absence of protective sensation.

Slide 18


June 2012 19


Components of Foot Assessment

What would you include under history?

• Reason for referral, general health, co morbidities, history of foot problems/ traumatic surgeries, characteristics of pain, work and leisure activities.

• Glycemic control

Foot appearance and structure:

• Assessing for bunions, callous, corns missing digits, Charcot( discuss later), hallgus limitus ( inflexible great toe)

• Alignment of foot when wt bearing, do the arches drop i.e. flat foot.

Gait:

• Look for lack of range of motion e.g. Shuffling gait indicating inability to dorsiflex.

• Muscle weakness, poor balance, uncoordination

Neuralgic: monofilament testing

Infection: bacterial, viral fungal

Footwear:

• Are they wearing protection in and out doors. What is the fit?

• Are they wearing socks?

Slide 19

Sixty Second Foot Exam

In summary here are guidelines for foot examinations of intact diabetic feet.

Slide 20


June 2012 20


Risk Classification The IWGDF developed this straight forward risk classification system which it modified recently.

It quickly and accurately classifies patients and guides the clinician in predicating foot complications & guides in choosing the most appropriate therapeutic interventions.

Inform the learners that Neuropathy and LOPS will be further discussed later

Refer to handouts provided

Slide 21

Handouts

Peripheral Neuropathy

The presence of vascular disease and neuropathy, or a combination of both, are the most important risk factors in the development of diabetic neuropathy. (Salzeda et al. OWM 2003.)

While neuropathy is the most common reason for diabetic foot ulceration, peripheral vascular disease and infection can also be factors in skin breakdown.

Vascular disease also plays a role in diabetic foot ulcer development and is responsible for 15 to 20% of diabetic foot ulcers.

Diabetes is a risk factor in the development of arteriosclerosis.

Smoking, hypertension and hyperlipidemia are also risk factors in the development of peripheral vascular disease and these factors will add additional risks for the diabetic patient.

Slide 22


June 2012 21


Diabetic neuropathy is thought to be metabolic in origin and related to an over stimulation of the polyol pathway in neural tissue.

Hyperglycemia is associated with uncontrolled diabetes.

Elevated blood glucose is metabolized by the enzyme aldose reductase which then produces sorbitol and polyol.

Sorbitol accumulates in the tissues and causes damage in many ways.

In the nerves, sorbitol is toxic and causes segmental demyelination which leads to lower conduction of speed in the peripheral nerves.

A demyelinating disease is any disease of the nervous system in which the myelin sheath of neurons is damaged.

This impairs the conduction of signals in the affected nerves, causing impairment in sensation, movement, cognition, or other functions depending on which nerves are involved.

Slide 22

Neuropathy Review the three different types of neuropathy and the major outcome of each type of neuropathy which is causative of problems with diabetic foot.

Sensory

Autonomic

Motor

Slide 23


June 2012 22


Sensory Neuropathy (S.A.M.)

Hyperesthesia can lead to poor skin care practices (walking bare foot because they can not stand the feel of socks on the feet, or can not stand to have their feet touched or washed due to the increased sensitivity to touch).

Loss of protective sensation leads to diminished or absent pain sensation.

Chemical trauma from over the counter “wart” or callous remedies such as acids or other inventive chemical applications.

Mechanical trauma can be from improper foot wear, nail care practices or callous “care”

Thermal damage from heat or cold causing tissue damage.

Slide 24

Sensory Neuropathy & LOPS

Sensory Neuropathy results in Loss Of Protective Sensation (LOPS):

Photo shows a client who has no pain even with the toe caught on a piece of furniture.

Slide 25

Why Loss Of Protective Sensation causes ulceration

With no feeling, client cannot protect self from injury from chemical, mechanical and thermal damage.

“Bath room surgery”

Slide 26


June 2012 23


Un-trimmed Nail Causing Pressure (S.A.M.)

Another example of poor nail hygiene due to lack of sensation (client does not sense that the nail is digging into the toe beside it), or that the toe nail is thickened and may be exerting pressure into the nail bed.

Ask participants questions as indicated

QUESTION: What do you assess in terms of infection and vascular supply here (V.I.P.)?

ANSWER: Toe is reddened Hair on knuckles of the toe indicate reason able blood flow

QUESTION: How else would you assess for vascular supply and infection?

ANSWER: Pedal pulses Colour of limb Temp of limb Palour or rubour

QUESTION: Who would you recommend referral of this client to ?

ANSWER: Podiatrist or nail care service

Slide 27


June 2012 24


Monofilament Testing

Assessment for LOPS ins easily accomplished by the clinician, client or caregiver using a Semmes Weinstein monofilament.

The inability to perceive the forces applied by the monofilament is associated with clinically significant large fiber neuropathy.

Monofilaments are available in each office.

Client should have a monofilament test performed.

Refer to handout on Pixalere foot/Sensation assessment

Slide 28

Handout: Pixalere Foot / Sensation Assessment


June 2012 25


5 Minutes Monofilament Testing Activity

Ask learner to take out the Monofilament testing & Pixalere foot/sensation assessment sheet from the handout (Reference: CDST procedure on Monofilament testing).

Before beginning, review the use of the monofilament and read through procedure together.

Ask participants to record findings on Pixalere foot assessment sheet, sites where the participant can feel are checked.

Avoid leading questions and cues when assessing with monofilaments

Interpretation:

If all sites are felt with the monofilament the score is 10/10

If the monofilament is not felt in an area on the foot, this indicates LOPS in that area and requires a referral to the wound clinician

Instruct participants to partner with buddy in groups of 2.

One person will perform a monofilament assessment; the other will be the receiver.

Slide 29

Autonomic Neuropathy (S.A.M.)

Dry skin is 2-3 times more likely to break down

Infection/cellulitis can be initiated with any loss of skin integrity no matter how small and seemingly insignificant esp. in a diabetic client who may not be responding with a full immune system compliment and less than robust inflammatory responses.

Example in this photo is of fungal infection from too much moisture

Slide 30


June 2012 26


Autonomic Neuropathy (S.A.M.)

Examples of the severity of the dry skin related to autonomic neuropathy:

• Xerosis/Anhydrosis and

• Fissures

To correct the dryness of this skin suggest use of pumice stone and moisturizer, off loading and good local wound care.

Slide 31

Moisturizers to Protect Skin (S.A.M.)

Use animation, after discussing bullet 1, 2, 3, pause, and ask what a good moisturizer should be.

Click and review the answer

Water accounts for 60-80% of most commercial moisturizers, but externally applied moisture does not re-moisturize the skin.

The thin consistency of most commercial lotions provide some replacement of natural oils in the stratum corneum, but the effect is short lived due to the continued transepidural moisture loss.

Slide 32


June 2012 27


Lotions have the most water, followed by cremes and then ointments.

Cremes have a higher oil content than lotions but do not provide total occlusion of the skin.

Ointments are near to 100% oil and are occlusive of the skin and generally not well tolerated for cosmetic reasons anyways.

Therefore choices for diabetic foot should be a creme (higher occlusive properties to it than a lotion), containing humectants. (Atractain)

Problem with total occlusion of the skin is that once the occlusive agent is removed water loss resumes to it’s pre-application level

Vaseline (petrolatum) is not totally occlusive and may be a reasonable alternative if costs for other cremes are prohibitive.

Occlusion – physical covering of the skin preventing water loss (total occlusion is not desirable)

Slide 32

Motor Neuropathy (S.A.M.)

Neuropathy of the innervating motor neurons of the lower extremities

Distal to proximal cell death pattern

Intrinsic muscles of the foot are primarily involved

Slide 33

Specifically an imbalance between flexors and extensors muscles of the toes

Intrinsic muscles are the muscles with in the foot. There main function is assisting the extrinsic (i.e. in the calf and shin) to flex and extend the toes.

Slide 34


June 2012 28


Hammer toe is a permanently flexed digit usually the 2nd toe.

Claw toe is a hyperextension of the toes at the metatarsal head, may be claw foot as well, which is an excessively flexed arch of the foot.

Ask participants question indicated.

QUESTION: Where would ulcers occur in the toes seen here?

ANSWER: Tops of the toes from shoes rubbing or bottom of the toes from pressure

Slide 35

Claw Toe & Hammer Toe pictured. Slide 36

Fat Pad Migration (S.A.M.)

Animation : Click to animate the fat pad to move forward, then to move up the pressure

Slide 37

Reduces area to distribute pressure

Increases pressure on the front of the foot

If the client has reduced range of motion in their big toe (i.e. hallicus rigidus) the extra pressure moved to the forefoot frequently causes big toe and 1st metatarsal wounds

Slide 38


June 2012 29


The transverse arch runs across the front of the foot, just before the toes. It’s much less pronounced then the long arch, but integrates to normal distribution of pressure in the fore foot.

As the arch collapses, the metatarsal head drops, creating new / unnatural pressure area.

1. Middle of the foot

2. Sides of the foot (i.e. big / little toes)

This new pressure area is not normal and the tissue in this area is not able to manage the increased load.

Slide 39

How Motor Deformity Contributed To Ulcer?

Use animation, after showing 1, 2, 3, pause and ask question.

Click to review the answer

Example of callous formation that may have gotten so thick that it impeded the blood flow to the underlying tissues and/or there may be loss of fat pads in this foot and the metatarsal heads may be very close to the surface of the skin, leading to ulcerations.

Hammer toe formations may cause this foot to ulcerate in this manner.

QUESTION: What would happen?

ANSWER: All adds up to pressure

Slide 40


June 2012 30


Deformities in the foot

Bunion type deformity which may be related to diabetes or other reasons

Ask participants question indicated.

Click to reveal the 11 spots

QUESTION: Where is the ulcer most likely to occur in this foot?

ANSWER: There are at least 11 spots - boney prominences and at calloused area of foot - toe box of shoe - under great toe and second toe

Slide 41

Address Client Concerns Related to SAM

Treat the patient!

DM control

Diet, exercise, footwear, foot inspection, etc.

Consider pain (nociceptive neuropathic), activities of daily living, financial, social, emotional issues.

Slide 42


June 2012 31


Self Management Remember Effective foot care can reduce amputations by 2/3 (Foster 2002 from Nursing Standard Vol 19, no 45 2005).

Review Diabetic Screening tool handout with participants

Awareness of personal risk factors

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

Daily self inspection of feet

Proper nail and skin care

Proper foot wear selection

Injury prevention and management of problems

When to seek help or specialized referral

Slide 43

Nutrition Optimal glycemic control

Adequate calories

Protein requirements 2-3 times normal

Supplement with multi-vitamins and minerals

Adequate hydration

Referral to dietitian

Slide 44


June 2012 32


Role of Dietitian Macronutrients

There are three primary macronutrients defined as being the classes of chemical compounds humans consume in the largest quantities and which provide bulk energy.

These are protein, fat, and carbohydrate. This list shows the categorization of the most common food components by these macronutrients.

Macronutrients can also refer to the chemical elements humans consume in the largest quantities, see Nutrient.

Micronutrients:

Nutrients that are required by humans and other living things throughout life in small quantities to orchestrate a whole range of physiological functions, but which the organism itself cannot produce.

For people, they include dietary trace minerals in amounts generally less than 100 milligrams/day - as opposed to macrominerals which are required in larger quantities.

The microminerals or trace elements include at least iron, cobalt, chromium, copper, iodine, manganese, selenium, zinc and molybdenum.

Micronutrients also include vitamins, which are organic compounds required as nutrients in tiny amounts by an organism.

Slide 45


June 2012 33


Dietitian Referral For ambulatory client’s in the community a referral can be made to a diabetes services “link on slide” takes to the referral form.

For acute and residential clients there are dietitians in each facility.

Other resources through healthlink BC

Slide 46


June 2012 34


0945 – 1000 Charcot Foot Transition slide to Charcot Foot

Charcot foot is a particularly acute and devastating occurrence which can occur in a person with neuropathy, but is far more common in diabetics with neuropathy.

It is characterized by bony re-absorption and multiple spontaneous fractures which result from autonomic-neuropathy induced bone blood flow hyperemia.

Hypervascularity of the mid foot osseous structures results in decreased structural integrity of the bone significantly increasing risk of fracture.

These fractures may result from ADLs and not obvious trauma.

Clinical presentation includes dermal flush, redness, increased skin temperature, +/- deep bony pain, +/- local edema and bounding pulses.

The condition may mimic cellulitis or deep vein thrombosis.

X-ray and bone scan are used to assess and reconfirm re-ossification

Clients frequently do not experience pain due to their neuropathy

Charcot fracture results in catastrophic deformity often ignored by Clients.

Slide 47

Use Animation to add WCC/ET/WOCN to the team

Specialists include Foot Surgeon, Podiatrist, Endocrinologist

Slide 48


June 2012 35


Risk Factors for Charcot Foot

• Peripheral sensory neuropathy

• Normal circulation

• Preceding trauma, often minor, e.g. sprains or contusions

• Foot deformities, prior amputations, joint infections or surgical trauma disease

Slide 49

This table is an overview of the Stages of Charcot foot compiled by CAWC in the 2010 BPR review

Question: Why is it important to recognize acute Charcot?

Answer: So you can prevent foot deformities ensuring that client is completely offloaded. Stage 1 is the is the most important stage for clinicians to recognized and where they can make the greatest difference in prevention. (Frykberg et al., 2006)

Slide 50


June 2012 36


1000 – 1030 Transition to DFU Sam’s diabetes continues to be poorly managed.

Unfortunately, he developed foot ulcers on his soles

Approx. 9% of clients with diabetic neuropathy develop Charcot foot.

Early recognition & diagnosis of the acute Charcot is essential to prevent increased damage & prevent disastrous consequences including amputation.

Acute Charcot is a medical emergency.

The client must not bear weight and may benefit from medications which prevent bone re-absorption po or IV.

Temperature increases and decreases in the outside temp of the foot signal the amount of activity of bone absorption and is a key indicator of the internal processes of the foot.

2 degree C or 4 degrees F difference in skin temperature from contra lateral foot.

Dermal thermometers are being utilized in some centers and clients are being taught to self monitor for this condition as well as infective processes.

Diagnostics:

• Systemic symptoms, abnormal lab values are usually absent.

• Radiographic changes take time to develop and the initial finding can be normal but repeated xrays on patients who are not immobilized show abnormal findings.

• C reactive protein level is normal in Charcot.

Slide 51


June 2012 37


Reference: American Family Physician June 1998. The Charcot foot in Diabetes: Six Key Points. Caputo, Cavanagh, Ulbrecht & Juliano

According to Caputo, Cavanagh et al 1998 approximately 9% of diabetics with neuropathy develop Charcot.

Slide 51

Diabetic Foot Ulcers (DFUs)

Unfortunately, Sam developed DFUs

Use Animation to Add Prosthetics to the team when amputation is needed for life threatening DFU

Specialists: include Foot Surgeon, Podiatrist, Endocrinologist

Prosthetics – if Amputation is needed

Slide 52

Pathway to Assessment & Treatment of Person with DFU

Draw attention to the best practice recommendations of CAWC 2006.

This algorithm is on pg 59 and highlight the importance of identification of cause, local wound care and client centered concerns being addressed.

Slide 53

Risk Factors Affecting DFU Healing

Don’t smoke – IMPORTANT FOR ALL! – each cigarette decreases leg circulation by 30% for an hour or increase sympathetic tone for 8 hours

Slide 54

DFU Assessment Important ‘take home” acronym when beginning to look at diabetic foot ulcers is Vascular, Infection, Pressure - VIP.

Each of these will be looked at in greater detail within the content of the presentation.

Slide 55


June 2012 38


Vascular Supply

Infection

Pressure

Review with participants what features of the wound shown are indicative of vascular insufficiency (review of content from module #2)

• punched out

• over a boney prominence

• distal portion of foot/toes

• quality of granulation tissue

• hairless toes

• palour with elevation

• dependent rubour

• cool to touch

• capillary refill of greater than 4 secs.

• condition of nails and skin of limb

• often minimal exudate and edema

Slide 56

Vascular Supply Ask participants what features of vascular insufficiency they are seeing here?

• location of wounds

• punched out border

• quality of granulation, slough in wound

• previous toe amp?

• drainage

• edema present?

• condition of nails

Slide 57


June 2012 39


Vascular Assessment

• Thin atrophied skin

• Loss of hair on the foot and ankle

• Temperature of skin, feet

• Thickened nails

• Decreased or absent DP and PT pulses

• Claudication

• Pallor with elevation

• Intolerance of elevation

• Dependent rubour

• Slow capillary re-fill (greater than 4 seconds)

Slide 58

A palpable dorsalis pedis or posterior tibial pulse may indicate a systolic pressure of greater than or equal to 80 mm/Hg with the potential to heal.

Intermittent claudication and rest pain normally associated with vascular disease may be absent in the person with diabetes with peripheral neuropathy

Slide 59

Vascular Supply Occlusion of blood vessels can progress rapidly due to:

• hyperlipidemia

• hypertension

• insulin resistance

• hyperglycemia

• increases in plaque formation and coagulation

Slide 60


June 2012 40


Review Vascular Disease (VIP)

Use animation

Ask question

QUESTION: Ask learners for ideas to assess the foot and the limb

ANSWER: Thin atrophied skin

Loss of hair on the foot and ankle

Temperature of skin, feet

Thickened nails

Decreased or absent DP and PT pulses

Claudication

Pallor with elevation

Intolerance of elevation

Dependent rubour

Slow capillary re-fill (greater than 5 seconds)

Slide 61

Vascular Supply Infection Pressure

Review signs and symptoms of infection (content from module #1)

In persons with diabetes some or all of the symptoms of infection both acute and chronic may not be present or may be difficult to assess.

Slide 62


June 2012 41


Clinical Signs & Symptoms of Wound Infection

Assess the wound for:

• Superficial critical colonization/Deep infection/Abnormal Persistent Inflammation (mnemonic NERDS)

• Deep infection (mnemonic STONEES)

• Persistent inflammation

Treat the wound for:

• Any 3 NERDS – treat topically: Non-healing, ↑Exudate, Red-friable tissue, Debris, Smell

• Any 3 STONEES – treat systemically: ↑Size, ↑Temperature, Os (bone exposure), New breakdown, ↑Exudate, ↑Erythema/Edema (cellulitis), Smell;

• Persistent inflammation (non-infectious) – Topical &/or systemic anti-inflammatories

Slide 63

Increased Bacterial Burden:

• Non healing

• Non-granulation

• Friable or hypergranulation

• Slough

• ↑Exudate

• Serous to purulent

• Odour after cleansing

Slide 64

Localized Infection

Wound deterioration: increased wound dimensions, development of sinus tracts, or satellite wounds

SCI – abbreviation for Spinal Cord Injury

Slide 65


June 2012 42


Systemic Infection

Malaise, predominately in clients who are elderly, immuno-compromised and in children

Fever: may be muted in clients who are elderly or immuno-compromised

Cognition: especially in elderly clients

Slide 66


In persons with diabetes some or all of the symptoms of infection both acute and chronic may not be present or may be difficult to assess.

Skin temperature devices may be used by persons with diabetes at home but this is not widespread practice as of yet.

Swabbing of the wound may not reliably predict presence or causative organism.

Infection involving deep tissue compartment will often cause erythematic that extends 2 cm beyond the wound margin.

Any wound that show sinus tracking formation or undermining must be probed.

Any contact with bone or ligament structure indicates osteomyelitis.

Signs of deep wound and systemic infection are potentially life and limb threatening and require immediate attention.

Slide 67

Blood sugar trends may reflect presence of infection

Pain in the insensate foot may likely indicate deep tissue infection or possible osteomyelitis

Slide 68


June 2012 43



Diabetic neuropathy is the primary cause of structural changes in the foot, leading to pressure.

Pressure is the primary cause of 85% of diabetic foot ulcers and pressures must be offloaded in order for healing to occur.

One step on an improperly offloaded foot, can delay healing by up to 3 days”

Ask question

QUESTION: What structural changes have contributed to these ulcers?

ANSWER: Pressure, then ultimately ulceration

Slide 69

Pressure Related Forces

Each cause cell wall rupture and cell death

Capillary closing pressure ~ 32mmHg (in healthy tissue)

Inverse relationship between time and pressure

High Pressure/Short Duration = tissue death

Lower Pressure/Long Duration = tissue death

ACTIVITY:

Compression: Poke their hand with finger to demonstrate perpendicular force

Friction: Rub palms together

Shear: Place hands under buttocks and feel for ITs while shifting weight front to back.

Slide 70

Braden Scale Assessment

Brief recap that the learners have already learned in Level One Education and, we hope, have been conducting in daily practice

Slide 71

Pressure Slide 72


June 2012 44


Image A: Highlight the higher pressure (red / pink) under the 1st metatarsal, 2-3rd metatarsal, and the 5th metatarsal in image A.

Image B: The insole has reduced the pressure to only the heel and the 1-2nd metatarsals.

Image C: The pressure has been further reduced because the custom insole redistributed pressure over a larger area of the foot.

Note the new pressure (low) in the arch and mid foot.

Slide 73

Pressure and Callous

Slide 74

Footwear, Pressure

Slide 75

Key Criteria for Appropriate Footwear

For people with peripheral neuropathy, it is common for them to chose footwear that is too narrow or too small.

This is because deep pressure sensation can be the last sensation remaining and they can feel tight shoes.

This leads to…..

Pressure, then ultimately ulceration

Slide 76


June 2012 45


Shoe Components

Heel counter

Toe box depth

Ask participants to identify the components of a shoe:

(Click mouse to show components)

1. Toe Box

2. Heel Counter

3. Laces

4. Arch Support

5. Seams / ridges

6. Insole / orthotic / foot bed

7. Grip / Sole

If you have diabetes, you cannot break in your shoes; your shoes will break down your feet

Slide 77


June 2012 46


Foot Tracing

Examine clients footwear.

Check for wear and tear.

“Motor neuropathy produces common abnormal gait characteristics. JPO 2005 page 8. RNAO Criteria for appropriate footwear.

Demonstrate how to check for correct size of shoes being worn.

Ask client to step on a piece of paper in stocking feet (must be weight bearing through the foot).

Trace the client’s foot with a pen onto the paper.

Hold the paper up to the shoe.

Often if the shoe is too small or much to large (potential for causing shearing and friction in the foot) this will be obvious in the diagram created.

ACTIVITY: Foot Tracing

Slide 78

Recommendations for appropriate footwear

So you find a potential problem with the footwear….

Educate the client on who, where, and when to get appropriate footwear.

But, what is appropriate footwear?

Slide 79

Appropriate Footwear

Remember that a person with diabetes and S.A.M (Sensory, Autonomic, and Motor Dysfunction) are at the least at risk for pressure and skin break down

“Pressure downloading is the most effective and least expensive method of addressing the treatable risk factors and reducing the patient’s risk of ulceration and ultimately amputation” (Inlow, et al 1998)”

Slide 80


June 2012 47


1030 – 1045 BREAK Let’s take a 15-min.

After our break, more on Pressure

When we come back, we will discuss the approaches to Local Wound Management

Slide 81

1045 – 1115 Footwear More on Footwear to Manage V.I.Pressure

See hand out given out with this slide.

Cross reference this slide with slide 21 (International Working Group on Diabetic Foot Modified Tool Risk Classification), which will be a handout

Slide 82

Handout

Managing Pressure

1. Or call downloading

2. Or call relief

Slide 83

OT Assistance Slide 84

Footwear / Offloading options

Slide 85

Total Contact Cast Total contact casting requires a trained professional to apply a full plaster cast to the client’s leg and foot.

The cast offloads or redistributes the pressure from the plantar surface of the foot up and over the cone shape of the calf and shin.

The casts can be worn for a few days or weeks, depending on how often the wound requires assessment and dressing changes.

Slide 86


June 2012 48


Not used or provided currently within Fraser Health.

Becoming more and more rare in Canada.

Slide 87

Removable Cast Walkers

The names and designs vary depending on the manufacturer.

The offloading concept is the same as a total contact cast.

The pressure is redistributing from the foot to the calf / shin and extra padding is provided for the foot.

Depending on the model, typically an air bladder is inflated to “suspend” the foot.

Slide 88

Removable Air Cast / Cast Walkers

Shows decreased pressure to the plantar forefoot by using the Cast Walker.

Notice the increased pressure on the heel.

This would not be an good choice with a heal ulcer.

Slide 89

Removable Cast Walkers

Advantages & Disadvantages Slide 90

Half Shoes Forefoot – Darco Ortho-wedge

Rear Foot – Darco Heel wedge

Slide 91

Advantages & Disadvantages

Minimal therapeutic benefits

Slide 92


June 2012 49


Surgical Shoes Often confused with healing sandals, but not the same function or amount of padding

Don’t get focused on the name brands, but more their benefits and drawbacks.

Slide 93


Healing Sandals Technically an open toe sandal that includes a rocker bottom shoe, limited seams / ridges, and a custom or very thick padded insole / foot bed.

Typically available only from pedorthotist, orthotist, or specialized diabetic foot clinics.

Slide 95


OTC Diabetic Orthopaedic Shoes

Variety of types, manufacturers, and features.

Typically over sized with large toe boxes, velcro or limited laces, soft felt like material, and limited seams and ridges.

Can include a basic foam foot bed

Much more common option client’s choose because of cost and appearance

Slide 97

Advantages & Disadvantages

Much more common option client’s choose because of cost and appearance.

Slide 98


June 2012 50


Custom Made Shoes

Only made by pedorthotists or orthotists Slide 99


Customizable Foot Beds

Slide 101


Custom Made Orthotic Foot Beds / Orthotics

Typically made of a foam material called plastazote by pedorthotists and orthotists.

Can be fabricated in specialized diabetic foot clinics.

Vary from ¼ inch thickness up to multi layer and multi-density foams 1 inch thick.

They have two main functions or types, depending on what stage the wound / ulcer or risk of ulcer is at:

1. Healing – very soft and pressure reducing / offloading

2. Preventative – slightly firmer and typically includes custom fitted arch support and accommodation for any deformity

Slide 103


Peak Pressure Reduction Graph Slide 105

Healed Ulcers & Healing # Days Graph

Slide 106


June 2012 51


Wound Healing Effectiveness

Best results at the top, but must have high patient compliance, fit by a professional, and mobility concerns are addressed for all options.

7/8. Orthotics / foot beds and over the counter orthopedic shoes are more effective when combined together.

Slide 107

Other Pressure Related Concerns

Brief reference to Braden Scale Slide 108

Mobility Aides Standard walker, two wheeled walkers, 4 wheeled walkers, canes, quad canes, crutches, forearm crutches, wheelchairs, etc

All can help the client reduce or completely off load the affected leg / foot.

Only the two wheeled walker, wheel less walker, crutches, and wheelchair can full offload

Slide 109


1115 - 1130 PT Assistance (Transition to PT on mobility and exercise)

While the areas that PT’s can help with prevention and treatments of wounds will vary depending on each INDIVIDUAL client/patient/resident, these are some of the possible tools PT’s can bring to the table to help the client/patient/resident and the team.

Therapeutic exercise

To improve foot strength & range of motion to reduce effects of MOTOR changes (SAM)

Slide 111


June 2012 52

Time Topic Facilitator Activities / Questions Media Gait training

To improve gait stability and pattern

Focus on decreasing single stance time, reducing rear foot & forefoot pressures that have been found in client’s with diabetic neuropathy

Modalities (if indicated)

Evidence for use of E-stim (High-voltage pulsed current=HVPC) and Ultrasound on diabetic foot ulcers

Manual therapy (if indicated)

To improve mobility of small joints in the foot

Protective footwear

Work with interdisciplinary team to assess and recommend appropriate footwear for clients/patients/residents

Patient education

In topics such as activity/exercise, mobility aids, pain relief, sensation checks, prevention, self management tips etc.

Adapted from Reference: Dressendorfer, 2009

NOTE: Electrophysical modalities such as Electrical Stimulation should ONLY be applied by those who have received proper training and whose professional scope of practice allows (e.g./ PT’s or wound care nurses with special training)


June 2012 53


When to Refer to PT

As per Diabetic and Neuropathic Ulcer Guideline

Slide 112

Client Centered Concerns

Educational intervention for improvements in foot-care knowledge and behaviour in the short-term for people with diabetes.

People with diabetes who are at higher risk for foot ulceration benefit from both diabetes and foot care education and regular reinforcement of that education.

People who receive formal diabetes education regarding treatment and prevention strategies have a lower risk of amputation than those who receive no formal education.

The clinician needs to develop a plan of care that takes into account the patient’s socioeconomic, cultural and psychosocial and other needs and beliefs.

A self-assessment tool is available to assist in patient education.

Assessment and treatment of pain is essential in wound management.

Persons with DFU often experience moderate to severe neuropathic pain characterized as sharp and burning pain that is often difficult to manage

Slide 113


June 2012 54


Neuropathic Pain Pain – mainly neuropathic

• Nociceptive: Sharp, constant, throbbing, gnawing, aching (e.g. surgical, #bone, burns, metastasis )

• Neuropathic: Burning, shooting, tingling, electric, pins & needles, itchy, numb (e.g. herpes zoster, diabetic neuropathy, phantom limb pain)

Non-cyclic – acute wound pain i.e. debridement

Cyclic - i.e.: daily dressing changes, turning, position, mobilization, night-time vs. daytime

Chronic - i.e.: persistent – no apparent mediating factors

Slide 114

Pain Assessment

• Onset: gradual/sudden?

• Region or radiation – where is pain?

• Severity (use pain scale – numeric, visual)

• Quality: Nociceptive/Neuropathic

• Effect on ADL’s & Quality of life?

• Timing: periodic, intermittent, or persistent?

• Other symptoms: e.g. fever, weakness, parasthesia


June 2012 55


Pain Management

a. Teach client that new onset or worsening pain is a sign of infection and requires immediate medical attention.

b. If client has wound pain or treatment-related pain, organize care to coordinate with analgesic administration allowing sufficient time for the analgesic to take effect.

c. Administer analgesic medication regularly and in the appropriate dose to control pain; refer the client to a physician /NP if pain is not well controlled.

d. Use appropriate medications to control neuropathic pain, if present.

e. Refer to wound care clinician or physician / NP to determine the need for topical analgesic (e.g. morphine) or anaesthetic (e.g. EMLA) if wound pain is not well controlled.

f. Encourage clients to request a “time-out” during painful procedures.

g. Use dressings that require less frequent changes and are less likely to cause pain and trauma on removal, e.g. non adherent dressings.

h. Encourage repositioning as a means to reduce pain; use pressure redistribution devices or surfaces to reduce pressure.

i. When appropriate, use reassurance, music, distraction, conversation, or guided imagery to reduce pain during dressing changes.


June 2012 56

Time Topic Facilitator Activities / Questions Media j. Reassess pain at regular intervals and note any

increase in severity.

Sensory / Pain Characteristics

Slide 115

1120 – 1155 Management of Diabetic Foot Ulcer

Transition to Local Wound Bed Preparation DIM E

Use animation to Transition to DIM E: DFU Local Wound Bed Preparation

Reminder to look at all opportunities to heal the wound and look at the whole patient.

Slide 116

Local Wound Care DIM before DIME Slide 117

Pressure & Ulceration

Unresolved Pressure Leads to Ulcerations

Pressure between the spaces of the toes with exposed bone present

Sensory neuropathy over metatarsal head

Slide 118


June 2012 57



Ask participants how they would describe this wound and what the likely underlying cause may be.

Area at metatarsal head should be assessed for presence of exposed bone.

Percentage of Red versus yellow ~30% red and 70% yellow

Assess area between 6 o'clock and 9 o'clock for undermining

Is this person off loaded?

Calloused edges of wound suggest longer standing pressure issues.

This person may have decreased mobility of the great toe leading to increased friction and shear and pressure with walking

Slide 119

Examples of the severity of conditions that can result from dry skin related to autonomic neuropathy

Potential this client also has some vascular supply problems.

Presence of infection under skin or related to poor toe nail hygiene can precipitate loss of toes/limbs.

Slide 120

Limb Assessment & Ulcer Characteristics

Ask participants to identify the features of the limb and the ulcer they may expect to see and assess for.

Slide 121


June 2012 58


M.E.A.S.U.R.E. Parameter / Clinical Indicator

Measure

Exudate

Appearance Document percentages of granulation tissue, slough, eschar and/or underlying structures.

Suffering

Undermining

Re-Evaluate Remember photos and measurements.

Edge

Slide 122

Assessment Definitions:

Maintenance wounds are divided into 2 categories, those that can be healed; however underlying factors such as offloading or patient adherence are still issues preventing the wound from moving forward

Non healable maintenance wounds are those that do not have sufficient arterial flow for healing, or client is at “end of life care”

For more information go to the palliative wound workshop

Slide 123


June 2012 59


Debridement Refer to CDST.

It depends on if the wound is dry or wet whether or not debriding is commenced.

If wound is wet, it depends on if there is sufficient vascular flow for healing how much debridement should be done.

Slide 124

Dry Stable Eschar Teach client/family to paint daily or every other day to ensure wound remains dry.

Protective dry dressing not required if not draining. Source Provincial CDST on neuropathic ulcers

Povidone Iodine 10%

• If allergic to iodine, use Baxidine solution (Catherine will add details)

Ideally done daily – minimally twice a week

Slide 125

Moist Healable Ulcer

Delay debridement until there are activity modifications/offloading/ appropriate footware.

Quick debridement in diabetes is often preferable due to the risk of infection with necrotic tissue; ONLY IF YOU KNOW THAT WOUND IS HEALABLE.

Slide 126


June 2012 60


Non-Healable Wet Ulcer

Source Provincial CDST on neuropathic ulcers.

Non healable ulcers are those that do not have sufficient vascular flow for healing OR the client is non adherent to treatment recommendations.

ABI of 0.4 indicates critical ischemia with a very low probability for healing.

Requires immediate Referral to WCC/physician or NP

WCC needs to assess and decide on conservative debridement such as iodosorb to reduce bioburden but not completely remove slough, Inadine, which is a povidone impregnated non-adherent gauze.

Keep the wound dry and antiseptic.

Recommended Cleansing Solutions: Iodine 10% and Baxedin 0.05% with no alcohol.

Possible Topical Antiseptics: AMD, Bactigras,

Possible Topical Antimicrobials: Inadine (Low to Moderate Exudate), Iodosorb (Moderate to Large Exudate)

Slide 127


June 2012 61


Choices for Debridement

Surgical debridement is not within the scope of nursing practice

Conservative Sharps wound debridement: CRNBC has placed limits and conditions on Registered Nurses that only those nurses who have advanced education such as CAET, IIWCC, WOCN with mentorship and competency assessment can perform this skill

Autolytic: In the presence of moisture the body’s own mechanism breaks down and liquefies devitalized tissue.

Enzymatic: Santyl Collagenase is available by prescription & covered by fair pharmacare for HH and residential care client’s

Mechanical: Safe mechanical debridement using a 30 cc syringe & wound irrigation tip with at least 100cc of saline used. Wiping slough with dry gauze

Biological: Medical Maggots, sterile, grown in a laboratory setting under strict conditions

Slide 128


June 2012 62


Animation

Determine the type of debridement is within the nurse’s scope of practice in the process the role of home care nurses.

Autolytic Debridement - Utilizes the body’s enzymes to soften and break down devitalized tissue.

• To support autolytic debridement, keep the wound moist with occlusive or semi-occlusive moisture retentive dressings. (such as?)

• Debridement may be speeded up by scoring eschar, however you must receive special training to perform this skill. [1]

• Autolytic debridement with occlusive dressings is contraindicated for infected wounds.

• All wounds undergoing autolytic debridement must be monitored closely for the onset of infection.

• Dressings that support autolytic debridement should not be left in place for longer than 3 days.

Slide 129


June 2012 63


Mechanical Debridement - Physically removes debris from the wound.

• Irrigation is considered mechanical debridement when it is done with a 30 – 35 mL syringe and an irrigation tip catheter or an 18 - 19 gauge device.

• Whirlpool therapy provides mechanical debridement but is contraindicated in clients with diabetic ulcers. ?? infection control concerns

• Using gauze or a Q-tip to create friction over the wound surface to remove biofilm (an accumulation of micro-organisms on a surface).

• Wet to dry dressings must not be used on wounds as they are painful and non selective when removed.

Enzymatic Debridement - Utilizes a naturally occurring enzyme, collagenase [2], which is applied to the wound surface to degrade necrotic tissue in the wound. A physician / NP or wound care clinician order may be required for collagenase.

• Debridement may be accelerated up by scoring eschar. [3]

• Enzyme use can cause excessive exudate, irritation to peri-wound skin and possible infection.

• A moist wound environment must be maintained when using collagenase.


June 2012 64


Biodebridement (Link to Maggot Debridement Therapy DST)

• Is very selective; removes only dead tissue.

• Can be used with infected wounds.

Conservative Sharp Wound Debridement (Link to CSWD DST) - Removes devitalized tissue down to the level of viable tissue using a sterile scalpel, scissors or curette.

• Less invasive than surgical debridement as it does not cause pain or bleeding.

• Must be done by a physician / NP

• Registered nurses must follow established decision support tools and must successfully complete additional education before carrying out CSWD.

• Today, FH does not have a CSWD CDST/Policy to support practice and FH does not have a education module to support the nurses to acquire the required competency to perform CSWD

Surgical Debridement

• Must be done by a physician.

• Out of nurse’s scope of practice


June 2012 65


Healed Hole Beware of ulcers that “heal” over with calloused material.

Beware of new calluses that may be covering up for ulcers underlying especially “blood blisters or blood that forms under calluses”

Slide 130

Non-viable Debridement of Peri-wound Callous

This is in the skillset of an RN, but none in FH have been trained how to do this yet.

Type of debridement is in the process the role of home care nurses. MARINE Please clarify

Slide 131

Maggot Therapy There is a video on CL’ck

Review of medical maggots from module #1

Slide 132

Infection In persons with diabetes some or all of the symptoms of infection both acute and chronic may not be present or may be difficult to assess.

Skin temperature devises may be used by person with diabetes at home but his is not wide spread practice as of yet.

Swabbing of the wound may not reliably predict presence or causative organism.

(85% positive rates for osteo)

Slide 133


June 2012 66


Animation

CAWC best practice guidelines advocate for probing wounds.

Make sure that if there are two wounds in close proximity that they are not in fact one wound with deeper tissue involvements than may be seen from the surface of the skin.

Slide 134

Eliminate Infection

Animation

Baxedin 0.05% is a chlorhexidine solution – For use on non-healable maintenance wounds to decrease bacterial burden and prevent infection (will this sting?).

Povidone 7-10% solution – not the 2% solutions over the counter- ask Pharmacists

Indications

An antiseptic solution used on dry eschar to maintain an intact covering of a wound where to goal of healing has been determined by the Wound Care Clinician as maintenance.

Precautions

1. Use with caution in patients with known sensitivity to iodine

2. Do not use on irritated or broken skin

Slide 135


June 2012 67


If wound is still open and draining – options to dry out:

1. INADINE - Antimicrobial: Povidone Iodine Impregnated Gauze

Key Points

• Broad spectrum topical antimicrobial dressing

• A non-adherent viscose sheet impregnated with a polyethylene glycol base containing 10% povidone-iodine; equivalent to 1% available iodine

Indications

• For shallow wounds which show signs and symptoms (S&S) of local wound infection

• For maintenance/nonhealing shallow wounds

Contraindications

• Do not use with clients with known iodine sensitivity or allergy

• Do not use before and after the use of radio-iodine therapy (until permanent healing)

• Do not use for new-born babies and infants less than 6 months old

• Do not use for pregnant or breast feeding women


June 2012 68

Time Topic Facilitator Activities / Questions Media • Do not use for clients with any type of

thyroid disease/history of thyroid disease or for clients with renal insufficiency as these clients are more susceptible to alternation in thyroid function

• Do not use in cases of Duhring’s herpetiform dermatitis (a rare skin disease)

2. IODOSORB - Antimicrobial: Cadexomer Iodine

Key Points

• Broad spectrum topical antimicrobial; dark brown ointment/paste consisting of cadexomer, polyethylene glycol and iodine

Indications

• For ‘sloughy’ moist wounds which show signs and symptoms of local wound infection

Precautions

• If used for client who is on Lithium, monitor Lithium blood work on a regular basis

• Should be used with caution in clients with severely impaired renal function or a past history of any thyroid disorder as they are more susceptible to alterations in thyroid metabolism

• Use no more than 50gm of Iodosorb per dressing and no more than 150gm per week


June 2012 69

Time Topic Facilitator Activities / Questions Media Contraindications

• Do not use for client with known sensitivity or allergy to iodine

• Do not use on client who are breast feeding or pregnant

• Do not use on children between 0-18 years old

Antimicrobials Animation

There are now at least 5 classes of antimicrobial dressings and some miscellaneous products for use in chronic wounds with critical colonization as defined by any 3 of the NERDS criteria.

Hand out product info sheets re products and the clwk.ca

Discuss options with WCC WOCN ET

Select a dressing to match the appropriate wound and individual person characteristics:

Healable wounds: Autolytic debridement: alginates, hydrogels, hydrocolloids, acrylics

Critical colonization: silver, iodides, PHMB, honey

Persistent inflammation: anti-inflammatory dressings

Moisture balance: foams, hydrofibers, alginates, hydrocolloids, films, acrylics

Non-healable, Maintenance Wounds: chlorhexidine, Povidone-iodine

Slide 136

Handouts: Product Information Sheets


June 2012 70


Discuss broad categories:

A. Silver products

Acticoat: silver in a flexible mesh sheet format which has anti-inflammatory properties

Indications:

For wounds and donor/graft sites which show signs & symptoms (S&S) of local wound infection at risk for developing a local wound infection

Can be used with Negative Pressure Wound Therapy (NPWT) as the small “mesh” allows exudate to move through the dressing

Can be used when client is undergoing Hyperbaric Oxygen therapy or CT Scan

Can be used on pregnant or nursing women

Precautions

Should only be used on premature infants (less than 37 weeks gestation) when clinical benefits outweigh potential risks.

Transient pain may be experienced on application; this can be minimized by carefully following application procedure. Should continuous pain be experienced after application, remove the dressing and discontinue use (inform Wound Clinician, NP or Physician)

Avoid putting electrodes or conductive gels in contact with silver products.

Upon removal for its package, the dressing must be uniform in colour on both sides (no discolouration)


June 2012 71


Contraindications

Do no use for clients with a known sensitivity or allergy to silver or polyester

Do not apply dressing to exposed internal organs

Do not use saline or saline based gels to moisten or cover product

Do not use silver products in combination with oil-based products such as petrolatum or paraffin

Do not use silver products when client is undergoing MRI examination or during radiation therapy (dressing can be replaced after MRI or radiation treatment is completed)


June 2012 72


Silvercel: This product is a combination of silver, alginate and carboxymethyl cellulose sandwiched between non-adherent film layers to help prevent sticking to wounds or shedding fibres

Indications:

Wounds with moderate to large amounts of exudate which show signs and symptoms (S&S) of local wound infection

Contraindications

Do not use for clients with known sensitivity or allergy to silver, alginates or ethylene methylacrylate (EMA)

Do not use for pregnant or lactating women due to absence of specific information


Do not put electrodes or conductive gels in contact with silver products



June 2012 73


Aquacel Ag - Ionic silver in a hydrofiber format. Ribbon is stitched with strengthening fibre for extra strength when saturated.

Indications

Wounds with moderate to heavy drainage which show signs and symptoms (S&S) of local wound infection or that are at increased risk for infection

Contraindications:

Do not use for client with known sensitivity to silver & sodium carboxymethlycellulose


Do not put electrodes or conductive gels in contact with silver products

Do not use silver products when client is undergoing MRI examination or during radiation therapy (dressing can be replaced after MRI or radiation treatment is completed


June 2012 74


Silvasorb - Ionic silver suspended in a hydrogel base. Allows for slow release of silver over 3 days

Indications:

For wounds with small amount of exudate which show signs and symptoms (S&S) of local wound infection

Precautions:

Avoid putting electrodes or conductive gels in contact with silver products

Contraindications:

Do not use for clients with a known sensitivity or allergy to silver

Do not use for wounds with moderate to large amounts of exudate




June 2012 75


B. Honey products:

Product has an antimicrobial effect due to low pH (3.2-4.5) and high osmolarity.

Medihoney Calcium Alginate - Calcium alginate with medical grade Manuka honey (leptospermum). For wounds with moderate to large amounts of exudate

Medihoney Gel - Medical grade Manuka honey (leptospermum). For wounds with a small amount of exudate or ‘sloughy’ wounds needing autolytic debridement.

For both Gel and Alginate:

Indications:

For wounds which show signs and symptoms(S&S) of local wound infection

Precautions:

Low pH may cause transient stinging; discontinue if stinging persists

Contraindications:

Known sensitivity or allergy to honey

C. Iodides

Cadexamer iodine – iodosorb (already discussed in earlier slide)

Inadine – Povidone impregnated gauze (already discussed in earlier slide)


June 2012 76


D. AMD gauze

Broad spectrum topical antiseptic dressing effective against gram negative; gram positive bacteria, (MRSA,VRE, Pseudomonas) fungi, yeast. High tensile strength woven cotton packing strips impregnated with 0.2% PHMB (Polyhexamethylene Biquanide) which remains effective in the presence of blood and/or proteins.

Indications:

For wounds which show signs and symptoms (S•&S) of local wound infection

Contraindications:

Do not use for clients with known sensitivity or allergy to PHMB

Do not use with Dakin’s Solution or bleach solutions as these solutions will deactivate PHMB

The treatment of critical colonization often takes 2 to 4 weeks in a healable wound where the cause has been corrected and patient-centered concerns have been addressed.

If the wound is in bacterial balance, antibacterial dressings are not needed for the re-epitheliazation stage of wound healing, unless they also provide anti-inflammatory activity.

They also are not efficacious in the treatment of deep and surrounding tissue infection that requires the use of systemic agents.


June 2012 77

Time Topic Facilitator Activities / Questions Media The use of antimicrobial dressings should be reviewed at frequent and regular intervals every 1 to 2 weeks and discontinued if critical colonization has been corrected or if they do not demonstrate a beneficial effect after 2 to 4 weeks.

There is currently a great tendency to overuse antimicrobial dressings, creating a cost-inefficient use of these useful devices.

References:

WBP, 2011

Moist Wound Healing

Reminder to learners not to use occlusive dressings (i.e. hydrocolloid) if the wound is infected or if you suspect the wound to be infected.

Consider:

• Foams for absorbency

• Calcium Alginates for absorbency & hemostasis

• Hydrogels for added moisture

• Hydrofibers for absorbency & control of maceration

• Iodosorb for signs of heavy colonization/infection

• Silvers for signs of heavy colonization/infection

Add picture of the category of the wound care product

Slide 137


June 2012 78


Moderate High Absorbency Dressings

Allevyn Gentle – Foam with silicone for moderate to large amounts of exudate

All Dress - A multilayer, absorbent, vapour-permeable dressing with border; border is coated with a water-based solvent-free polyacrylate adhesive. For small to moderate amounts of exudate

ABD Pad

Mesorb – highly absorbant composite dressing for wounds exuding moderate to large amounts and require daily dressing changes

Versiva XC – hydrofibre dressing which turns to gel on contact with exudate. For use with small amounts of exudate. In combination with other wound care products it can be used for wounds with moderate to large amounts of exudate

Combiderm ACD – Absorbant pad with hydrocolloid adhesive border. Can be used on wounds with moderate to large amounts of exudate.

Eclypse – Composite, high capacity wound exudate management dressing. Works by combining rapid wicking action with moisture locking system. For use on wounds with large amounts of exudate

Non-sterile absorbant pad ‘supersoaker’ - For chronic non-healable wounds with copious drainage where a sterile product is not required. Can be used in combination with other wound care products.

Slide 138


June 2012 79


Non-Adherence Dressings

Indications:

1. To prevent skin strip during dressing removal especially when wounds have small exudates

2. To reduce pain during dressing removal, especially for clients experiencing moderate to severe wound pain

These dressings are also the Recommended Dressing Selection Specific to Skin Tears (LeBlanc et al 2008)

Adaptic - Petrolatum impregnated cellulose acetate dressing.

For prevention of wound bed trauma by decreasing adherence of the secondary dressing.

Avoid using this product with silicone-type products as they have the same functionality.

Slide 139

Allevyn Gentle/Allevyn Gentle Lite - Cover Dressing: Foam with Silicone. Combines an absorbent hydrocellular pad sandwiched between a soft gel layer

Coated with silicone adhesive layer for atraumatic dressing removal

Outer pink side is shower-proof, bacteria proof and prevents strike-through of exudate

Coated with silicone adhesive layer for atraumatic dressing removal.


June 2012 80


Allevyn Gentle: For wounds with moderate to large amount of exudate.

Allevyn Lite: For wounds with small exudate.

Contraindication:

Do not use with oxidizing agents such as hypochlorite solutions (Eusol) or hydrogen peroxide.

Do not use if redness or sensitivity occur.

Mepitel/Mepitel One - Silicone contact layer applied directly on the wound bed underneath secondary dressing for preventing wound bed trauma by decreasing adherence of the secondary dressing.

Precaution:

Do not use with skin barrier or sealant

When used on burns treated with meshed grafts or after facial resurfacing, imprints can occur if too much pressure is applied

Mepilex/Mepilex Lite/ Mepilex Transfer – Foam (adhesive border or no border).

Indications:

To be used as a cover dressing

May be used in combination with other wound care products

May be used for shallow and cavity wounds with moderate to heavy drainage

May be used on friable wounds or fragile skin


June 2012 81

Time Topic Facilitator Activities / Questions Media Precautions:

Do not use with skin sealants

Do not use for dry wounds

Does not provide pressure reduction or relief

Do not use during Hyperbaric Oxygen therapy procedure

Tegaderm Acrylic - A semi-occlusive, transparent, moisture retentive primary dressing.

Wear time up to 21 days.

One of the recommended dressing for skin tears, especially for older adults.

For wounds with small to moderate amount of exudate.

Do not use on untreated clinically-infected wounds.

Do not use under compression as compression wrap will not allow for exudate to evaporate

Inadine

Thermal Insulation

Research has shown that wounds which are kept at ideal body temp heal faster than wounds that are cooled and left to warm up to body temp.

Studies using “wound warmers” have demonstrated the importance of thermal insulation to the processes of wound healing.

Slide 140


June 2012 82


Protect Healing Wound & Surrounding Skin

Off loading is critical issue to protect the healing wound. Clients must not take one step on the wound with our being off loaded. Compliance and client understanding of this concept is critical.

Reasons not to soak feet

• adds to the drying effect as it removes the natural skin oils

• may increase risk of infection if basin or vessel that the soaking is being done in

• may macerate the skin

Slide 141

Protect Per-Wound Skin

Protect wound with the cover dressing

No sting

Triad

Dimethicone

EPC

Slide 142

Edge of the Wound

Matrix: Oasis

MMP: Promogram, Prisma

Negative Pressure Wound Therapy:

1. Smith and Nephew: RENASYS◊ GO and EZ

2. KCI – VAC

Slide 143


June 2012 83


1155 – 1200 Summary Refer participates to CDST guideline and review content.

This tool is to assist the HCP to review and ensure that all aspects have been covered in DFU management.

Slide 144

CDST

Interprofessional Team

Transition to address patient concern – brief discussion on common issues that the clients will be experience, particularly those affecting the adherence to the treatment plan

• Consider pain (nociceptive neuropathic)

• Treatment plan determined by healability, cost-effectiveness / burden of treatment

• Educational and addressing person-centered concerns increase adherence to treatment plan, which in turns affects healability

• Adherence to compression for life – comfort, ability to put on/remove daily, daily wash, new pairs every 6 months if wearing I pairs or every 12 if wearing 2 pairs simultaneously

• Affordability of compression stockings

Slide 145


June 2012 84


1200 – 1220 Case Studies

Case Study 1

Home Health

Divide the learners into groups of 6-8: each group will work on the same client, Vic, in home health and acute care settings to address his different health care as stated in the case study scenarios

Give the 3 groups 10 minutes to finalize their care plan mutually agreed with your clients

CASE STUDY 1 QUESTIONS:

1. What assessment the HCN will do?

2. What is his treatment goal and plan?

3. What disciplines need to be included in his care?

4. What education/resources the client needed?

Slide 146

Case Study 2

Acute Care


1. How should the RN approach Victor?

2. What information the RN can give to Victor?

3. What is his treatment goal and care plan?


5. What education/resources Victor and his family will need for discharge planning?

Slide 147


June 2012 85


Case Study 3

Residential Care


1. How should the nurse approach Vic?

2. What information the nurse can give to Vic?

3. What is his treatment goal and care plan?


5. What education/resources Victor and his family will need to support him settling in residential care living?

Slide 148

SWT DFU Education Module SWT Members

Slide 149


June 2012 86


QUESTIONS Slide 150

1220 – 1225 Post Test Post-Assessment

Ask the learners to take out the Evaluation form they partially completed at the beginning of the session and give them 5 minutes to:

• Review the 5 pre-test questions and complete the post-test columns if they have different answers after attending the workshop

• Complete the “Session Evaluation”

• The learners will receive their certificate of attendance when they submit the completed evaluation form to the presenter at the end of the session

Slide 151

Web Resources Slide 152

References Slide 153

Acknowledgment Slide 154

Documents

Regional Skin & Wound Education Facilitator Guide