Slides current until 2008 Diabetic neuropathy Wound healing

Slides current until 2008

Diabetic neuropathyWound healing


Curriculum Module III-7CSlide 2 of 31


The diabetic foot

• Neuropathy – principal problem

• Vascular disease – secondary




Four types of ulcers

• Neuropathic ulcers

• Ischaemic ulcers

• Neuroischaemic ulcers

• Venous ulcers




Determine aetiology

• Neuropathic?

• Vascular?

• Mixed? predominant pathology?

• Determine wound management

• Act quickly




Neuropathic ulcers

• Area of pressure

• Callus

• Red granulating base

• Low-to-moderately exudative

• Bounding pulses

• Painless




Intrinsic – biomechanical




Extrinsic – thermal




Extrinsic – footwear




Extrinsic – chemical




Management of neuropathic ulcers

• Treat infection

• Debridement of callus

• Reduce pressure

• Restrict walking

• Dressings




Pre- and post-debridement




Felt deflection

• Reduces pressure by 61%

• Simple and cheap

• Replace weekly

• Impractical for exudating ulcers

• Risk of tinea/skin tears




Ulcer healing with felt deflective padding

Week 1: pre-debridement Week 1: post-debridement

Week 3 Week 6: healed




Pre-fabricated casts

• Simple to use

• Will not fit all feet

• Removable

• Less effective in maintaining foot shape




Ischaemic ulcer

• On toes and foot margins

• Pale granulation, sloughy tissue or eschar

• Dry with irregular borders

• Painful

• Pulses weak or impalpable




Management of ischaemic ulcers

• Vascular assessment and treatment

• Treat infection

• Pain management

• Dressings

• Avoid compression/bandaging




Treatment goals

• Control infection

• Improve blood supply

• Optimize wound healing environment

• Protect wound from trauma




Neuro-ischaemic ulcer

• Mixed neuropathic and vascular processes

• One process more dominant

• Need to assess




Practice tips: neuropathic ulcers

• Foams 2 cm larger than the wound

• Use gels sparingly

• Keep foot dry – wash separately

• Do not use occlusive dressings

• Extra pads increase pressure and occlude the wound




Practice tips: ischaemic ulcers

• Gels contraindicated in the presence of ischaemia

• Do not debride

• Do not use compression

• Keep foot dry in shower and wash separately

• Be very careful with tapes to prevent skin tears




Foot infection

• Swelling, redness, heat

• Odour from ulcer

• Increase in exudate

• Failure to heal

• Elevated blood glucose levels

Pain may not be present if the person has loss of sensation. Signs of inflammation may be absent in people with severe ischaemia.




In diabetes, clinical signs may

be masked leading to delayed

diagnosis of infection.




Do not withhold antibiotics until results

of culture available

Rely on clinical judgement




Antibiotic treatment is an essential aspect of treating diabetic foot ulcers – maintain until ulcer has healed.

Depending on clinical response, frequent changes and long-term antibiotics may be required.




Foot infection

• Ulcer = risk of infection

• Osteomyelitis (sausage toe)

• Amputation




Treatment of osteomyelitis

• Antibiotics

– minimum of 3 months until

there is evidence of healing on

x-ray or scan

• Infected bones may need to be

removed surgically




Prevention of the diabetic foot disease

Primary prevention

• No successful clinical trials

• Metabolic control

• Smoking cessation

Secondary prevention

• Identify high risk feet

• Foot education

• Foot care

• Management of active foot problems (ulceration)




Key points

• Assess

• Determine aetiology

• Arrange appropriate wound management


Curriculum Module III-7cSlide 29 of 31

ACTIVITY


Case study

• 70-year old man

• Type 2 diabetes

• Diabetes for 35 years

• Smoker for 35 years



ACTIVITY


Case study

• Pulses absent

• ABI’s

Left - 0.69

Right - 0.71

• Left 1st MPJ ulcer

• Right hallux (great toe) ulcer – had bypass now ABI improved to 1.00



ACTIVITY


Case study

Biothesiometer– >50 volts

Monofilament– cannot feel

Reflexes– absent

Documents

Slides current until 2008 Diabetic neuropathy Wound healing