The Diabetic Foot Screen and Management

Foundation Series of Modules for Primary Care

Anita Murray - Senior Podiatrist Diabetes, SCH

Learning Outcomes

Knowledge of the Model of Care For The Diabetic Foot

Understand how to do the Diabetic Foot Screen

How to look out for Common Nail and Foot conditions that increase amputation risk

How to access the Foot

Protection Team

How Diabetes affects the feet

The Stairway to Amputation, 2010

Model of Care For The Diabetic Foot (National Diabetes Programme 2011)

Aims at highlighting foot complications associated with Diabetes with the aim of preventing ulceration and Limb Loss

All people living with diabetes should have their feet assessed at least annually and their feet will be given a risk classification Low Risk

Moderate Risk

High Risk

Active foot disease

Diabetic Foot Screen

Assessment of the diabetic foot should include inspection, palpation & sensory testing.

Record signs of neuropathy, ischemia, deformity, callus, swelling, ulceration, infection or necrosis should be recorded

Each patient should be given a RISK STATUS and referred on if necessary

SCH Records Audit : April 2016 72%

August 2016: 88%

Tests – Vascular exam

Dorsalis Pedis Test

Tests – Vascular exam

Posterior tibial artery Palpate

Tests – Vascular exam

If pulses not palpable use doppler

Monophasic

Biphasic

Triphasic

Signs and Symptoms of Vascular compromised foot

Pain – Claudication, night cramps, rest pain

Pallor - white

Pulselessness

Parathesia

Paralysis

Pershing cold

Tests – Neurological exam

Tuning Fork To be tested initially on wrist to

demonstrate sensation

Should be used on a prominence i.e. 1st Metatarsal head

First stages on neuropathy

Tests – Neurological exam

10g monofilament Sites

Observations of a neuropathic foot

Dysfunction of motor, sensory and autonomic nerves

Foot is warm, well perfused with bounding pulses

What could it look like?

Clawing of the toes

Prominent metatarsal heads

Possible rocker bottom deformity (charcot)

High arch

Callus formation

Foot Deformities

• Bunion joints

• Hammer toes

• Prominent Metatarsal Heads

Uncovering ulcers

• Ulcer underlying callus

Ulcer post debridement

Looks can be deceiving...

Status

Pulses Vibration Sensation History of ulceration

Foot Deformity

Visual Impairment

Low Risk All normal None

Moderate Risk

One of above abnormal None maybe

High Risk All compromised Always maybe maybe

Review process

Initial Diabetic Foot Ulcer Management

Begins with a comprehensive history and physical

Thorough wound assessment, treatment and referral including:

•Management of peripheral arterial disease (PAD) – referral to Vascular team?

•Infection control and management - eg. Culture and sensitivity, Antibiotic cover?

•Debridement and Off-loading necessary * referral to Podiatry*

•Maintaining a moist wound environment – eg. sterile dry dressing and refer to Podiatry

***Timely wound healing is less likely without comprehensive management, including off-loading, Vascular input and monitoring for infection***

Referral to Local Podiatry Services

All referrals will be triaged by the Podiatrist or a member of the foot protection team. They will be prioritised as the following: Active diabetic foot ulcer (non infected): 1 day or next working day in SCH Infected diabetic foot ulcer with spreading cellulitis, Suspected Osteomyelitis: Attend ED at SVUH for admission on the Diabetic Foot Care Pathway At Risk Diabetic Foot Classification: Telephone review within 2 weeks, appointment date to be agreed for SCH or Primary Care Centre Request for Clarification of Risk Status/: Telephone review within 2 weeks, appointment to be made if required at SCH or Primary Care Centre

Podiatry Service Development Update

Diabetic Foot Care pathway, SVUH Integrated pathway championed by Edel Kellegher, Clinical Specialist Podiatrist in conjunction with

Vascular, Endocrinology, Opate team, In patient unit and Microbiology. Reduced hospital diabetes related amputation rates and cost to patients quality of life and to hospital

bed stays Nominated for National Award for clinical excellence

At Risk Foot Offloading and Orthoses Clinic

Neuropathic Ulcer Prevention Care pathway, SCH and Primary Care Patient centred service across primary and secondary care setting. Podiatry lead Orthoses and footwear Service (including integrated clinic with Orthotist) so far reducing cost of orthoses by 63% and waiting times for orthoses from 9 months to six weeks.

DEMONSTRATION

Group Work

Case Based learning and group feedback

How would you describe the wound presentation?

How would you assess this? (Observations, history tests)

What about management? (Immediate Actions and referrals)