working with you for better health the diabetic foot angela walker diabetes specialist podiatrist

Working with you for Better Health

Berkshire East

Community Health Services


Berkshire East


The Diabetic Foot

Angela WalkerDiabetes Specialist Podiatrist


Berkshire East



Berkshire East


“Why Worry …?” Approximately 15% of all people with diabetes will be

affected by foot ulcer during their lifetime;

85% of diabetes-related amputations are preceded by foot ulcers (International Diabetes Federation) ;

Up to 70% of amputations are performed on people with Diabetes;

“Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday…”

Lancet. 2005;366:1674


Berkshire East



Berkshire East


Multifactorial Aetiology

Vascular: macro and microangiopathy results in poor skin quality, poor healing and potential for ulceration and amputation.

Neuropathy causes loss of sensation, potential for injury, infection, leading to ulceration and possible amputation.

Delayed immune response: any injury to the foot is a potential cause for concern.


Berkshire East



Berkshire East


Diabetic Ischaemia

Micro-vascular and Macro-vascular

Pathology identical to non-diabetics

Earlier onset

Complications of high blood pressure, high cholesterol and smoking are all amplified by diabetes

1 Cigarette reduces peripheral blood flow by 30% for 1 hour.


Berkshire East



Berkshire East


Reduced or Absent Hair

Changes in Nail & Rate

of Growth

History ofIntermittent Claudication

Faint or Absent Pulses

Anhydrosis& Fissures

Loss of Wrinkling ofSkin Around Joints

Skin Colour & Temperature


Berkshire East



Berkshire East



Berkshire East



Berkshire East


Peripheral Neuropathy

Dysfunction of sensory, motor and autonomic nerves:

Loss of protective pain sensation – increased susceptibility to foot ulceration

Motor – high medial longitudinal arch, clawed toes, prominent metatarsals

Autonomic – dry, fissured skin, sweat loss, distended dorsal veins


Berkshire East



Berkshire East


Well nourished tissue

Diminished / absent sensation

“Cramping, Tingling, Aching, Burning,

Numbness”


Berkshire East



Berkshire East


Callus at pressure points

Good DP and PT pulses

Painless ulcerations

Charcot Deformities


Berkshire East



Berkshire East


Bilateral Charcot


Berkshire East



Berkshire East


Differential Diagnosis

Neuropathic

Warm Normal colourPalpable pulsesSkin well nourished Callus at pressure pointsUlceration plantar

Neuroischaemic

CoolPalePulses diminished/ absentSkin thin shiny no hairNo callus fissuring at bony prominencesUlcers peripheral


Berkshire East



Berkshire East


Pressure Ulceration

1. Callus formation

2. Subcutaneous haemorrhage

3. Breakdown of skin

4. Deep foot infection with osteomyelitis


Berkshire East



Berkshire East


Osteomyelitis

Approximately 25% of foot ulcers will be affected by osteomyelitis (Young, Diabetic Foot Journal, 2008);

Surgery is not always necessary especially in patients without life or limb-threatening infections;

82% of patients studied by Game and Jeffcoate (Diabetologia, 2008) were able to avoid surgery with one or more courses of antibiotics.


Berkshire East



Berkshire East



Berkshire East



Berkshire East


Foot problems can be Deceptive

Is the diabetic ulcer infected?

Compare the temperature of both legs Check blood glucose levels Pain is serious in the neuropathic foot Localised superficial infection is probably the

tip of the iceberg Healed wounds need appropriate protection

to prevent recurrence


Berkshire East



Berkshire East


Debridement

Neuropathic ulcers – need to be debrided as soon as possible to determine the depth of the ulcer and removal of necrotic tissue

Ischaemic ulcers – should not be debrided unless signs of infection present.


Berkshire East



Berkshire East


Before Sharp Debridement


Berkshire East



Berkshire East


After Sharp Debridement


Berkshire East



Berkshire East



Berkshire East



Berkshire East


Wound Dressing

Aseptic technique;

Change dressings daily, more regularly when strike through noted on dressing;

Diabetic Foot wounds should be kept dry and clean at all times;

Do NOT soak the foot or bath/shower the patient;

Apply saline with gauze to clean wound surface.


Berkshire East



Berkshire East


Wound Dressings cont’d

Do NOT use hydrocolloid dressing as occlude and macerate the wound;

Simple wound dressing over ulcer site and secured;

Offload with appropriate foot wear/bed rest/turn patient regularly;

Review wound regularly and refer early if wound deteriorates;

Antibiotics?


Berkshire East



Berkshire East


Infection raises blood sugar

High blood sugar inhibits body fighting infection

Infection gets worse

The Cycle of Diabetic Infections


Berkshire East



Berkshire East


Criteria for Wound Dressing Selection

Does the dressing:

Stay intact & in-situ?Prevent leakage?Cause maceration/allergy or sensitivity?Reduce pain?Reduce odour?

Is the dressing:

Comfortable, conformable, flexible?Suitable for leaving in place for the duration?Easy to remove?Easy to use?Cost effective?


Berkshire East



Berkshire East


Who to refer to the Diabetes Specialists in WPH

New Ulceration;

New Swelling;

New Discoloration over all or part of the foot;

People with painful leg and foot symptoms whose diabetic control is poor;

Deterioration of a presenting wound: ↑Odour ↑Discharge ↑Redness ↑Pain ↑Swelling ↑Feeling unwell

Suspected Charcot – Plaster Nurse.


Berkshire East



Berkshire East



Berkshire East



Berkshire East


Where to Refer

Diabetes Specialist Team: Dr Dove/Dr Akinsola Ward 5 Ext ???

Tissue Viability Nursing Team Ext ???

Vascular Team Ext ???

Plaster Room Ext ???

Podiatry Department Ext 4221 (Fax referral: stating Patient Diabetic with active ulcer)


Berkshire East



Berkshire East


On Discharge….. Acute problem contact Diabetes Centre Podiatry, King

Edward VII Hospital by:Fax on ext 6624.

Patient with diabetic complications. Referral to Community Podiatry Clinics based in Slough, Windsor, Ascot, Bracknell, Langley.

For type 1 or type 2 patient education or advice send for group education via the Diabetes Centre these Education Sessions are held in Community locations.


Berkshire East



Berkshire East


Summary of Care Planning

Good glycaemic control Offloading pressure Safe removal of callus Safe removal of slough, necrotic tissue Treat infection Allow drainage of exudate Encourage patient compliance/patient education

Best form of treatment is prevention


Berkshire East



Berkshire East


Any Questions?

working with you for better health the diabetic foot angela walker diabetes specialist podiatrist

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