'Best Feet Forward'

1. Module 4.1.1 'Best Feet Forward' Workshop material developed by the The Alfred DPMI Workforce Development Team for the Central West Gippsland PCP Diabetes Prevention & Management Initiative Produced by The Alfred Workforce Development Team on behalf of DHS Public Health - Diabetes Prevention and Management Initiative June 2005

2. Acknowledgements • This resource was developed in consultation with the Central West Gippsland PCP: DPMI Technical Working Group. • The presentation has been adapted from the: • Footcare in Diabetes Workbook for Health Professionals. Australian Diabetes Educators Association DPMI Workforce Development – The Alfred Workforce Development Team June 2005

3. Workshop purpose – Level 2 Target • Registered nurses involved in caring for people with diabetes i.e. those involved in community, home or acute nursing, general practitioner practice nurses. Objective • To provide training to increase skills in: • Appropriate foot assessment and documentation of assessment • Identification of foot at high risk of ulceration or amputation • Identification of active foot problems that require further assessment and/or treatment • Development of foot care action/care plans consistent with assessment findings. DPMI Workforce Development – The Alfred Workforce Development Team June 2005

4. “Best Feet Forward” Project • Aim • To decrease foot problems in people with diabetes • Objectives • Train health care providers in the assessment, classification and care of the diabetic foot • To support appropriate action planning and multidisciplinary care of diabetic foot problems DPMI Workforce Development – The Alfred Workforce Development Team June 2005

5. Diabetes complications • Admission rates in the Central West Gippsland catchment are 2.5 times higher than the state • A large percentage of those admitted with complications occur below the knee Reference: Public Health Division, Department of Human Services, The Victorian Ambulatory Care Sensitive Conditions Study: Opportunities for Targeted Interventions, June 2002 DPMI Workforce Development – The Alfred Workforce Development Team June 2005

6. Why perform a foot assessment? • Prevention of: • foot ulceration gangrene amputation • Assist in the maintenance of: • Mobility • Independence • Healthy active lifestyle DPMI Workforce Development – The Alfred Workforce Development Team June 2005

7. Function of the feet • To act as a stable base of support • To provide shock absorption with each step • To adapt to surface irregularities • To provide sensory feedback DPMI Workforce Development – The Alfred Workforce Development Team June 2005

8. Peripheral vascular disease • Degenerative vascular disease • Most commonly it is seen as multiple occlusions of the popliteal artery and its branches • Risk factors • Hyperglycemia • Smoking • Hypertension • Hyperlipidemia Normal Artery Stenosed Artery Fibrous and/or fatty plaques DPMI Workforce Development – The Alfred Workforce Development Team June 2005

9. Peripheral neuropathy • Impairment of nerve function segmental demyelination • All nerve fibres can be affected • Sensory • Autonomic • Motor Ne r V e Axon Ne r V e Axon Myelin Sheath necessary for normal impulse conduction Demyelination of axon i.e. no impulse conduction DPMI Workforce Development – The Alfred Workforce Development Team June 2005

10. Foot ulceration • Predisposing factors • Vascular Disease • Peripheral Neuropathy • Infection • Physical injury • Precipitating factors • Physical injury • Mechanical (pressure) DPMI Workforce Development – The Alfred Workforce Development Team June 2005

11. Foot ulceration Extrinsic Pressure Tissue Hypoxia Repetitive rubbing Footwear Intrinsic Pressure Limited joint mobility Callus Formation Altered tissue strength Foot deformity Irregular foot structure DPMI Workforce Development – The Alfred Workforce Development Team June 2005

12. Foot ulceration-mechanism DPMI Workforce Development – The Alfred Workforce Development Team June 2005

13. Diabetic Osteopathy (Charcot’s disease) • Presents as a warm swollen foot or ankle • Often misdiagnosed as cellulites • Affects ankle, subtalar and mid-tarsal joints • Severe peripheral neuropathy is nearly always present • Urgent orthopedic referral is required • Foot must be immobilised while inflammation present DPMI Workforce Development – The Alfred Workforce Development Team June 2005

14. Diabetic Osteopathy (Charcot’s disease) DPMI Workforce Development – The Alfred Workforce Development Team June 2005

15. Foot assessment • WHY? • Most foot problems are preventable when identified early, treated appropriately and when people are educated to avoid problems • GOAL • Prevent amputations DPMI Workforce Development – The Alfred Workforce Development Team June 2005

16. Foot assessment • Aim to identify the high risk foot using as indicators • History of previous ulcer • Peripheral neuropathy • Peripheral vascular disease • Foot deformity DPMI Workforce Development – The Alfred Workforce Development Team June 2005

17. Foot assessment • Aim to identify active foot problems check for: • Infection • Ulceration • Calluses or corns • Any skin breaks • Nail disorders DPMI Workforce Development – The Alfred Workforce Development Team June 2005

18. Assessment tool

19. Assessment tool - back page

20. General footcare • Feet clean • State of Skin – moist/ dry/shiny/hairless/thin • Interdigitial areas – macerated/ dry • Callus • Must be regarded as pre- ulcerative, esp in neuropathic foot. • Appears as yellow thickened skin • Occurs at pressure points • Early treatment and pressure relief prevents ulceration • Socks, pantyhose, shoes – appropriate, well fitting, provide adequate support • Orthotics/prosthesis DPMI Workforce Development – The Alfred Workforce Development Team June 2005

21. General footcare • Shoes • Appropriate, provide adequate support- general rule leather and lace are best • Good condition • Well fitting – shoes should fit three ways length/width/depth • Poorly fitting shoes can cause blisters and corns that may ulcerate DPMI Workforce Development – The Alfred Workforce Development Team June 2005

22. General footcare • Nails • Thickened • Fungal infection • Ingrown DPMI Workforce Development – The Alfred Workforce Development Team June 2005

23. General footcare • Note and draw on feet on assessment form • Ulceration- Non-healing wounds may occur anywhere on the feet, look particularly at pressure areas e.g. tops/tips of toes, ball of foot,heel, under callus. • May be painless • Infection- look forredness, warmth, discharge, swelling • Signs and symptoms may be masked byischemia or neuropathy • Deformities- such ascorns, callus, bunions, claw/hammer toes, heel cracks • These areas are more susceptible to pressure and require special attention to shoe fit DPMI Workforce Development – The Alfred Workforce Development Team June 2005

24. Neurological status • Symptoms of neuropathy • Pain • Burning, numbness, pins & needles • Symptoms usually bilateral • Often worse at night • May be hypersensitive to touch • May be present when first diagnosed with diabetes • May worsen with unstable blood glucose levels DPMI Workforce Development – The Alfred Workforce Development Team June 2005

25. Vascular assessment • Symptoms of intermittent claudication • Pain in calf muscle when walking, leg cramps • Pulses • Dorsalis Pedis • Posterior tibial • Ulcer • Gangrene • Amputation DPMI Workforce Development – The Alfred Workforce Development Team June 2005

26. Assess self care capability • Does/can the client: • Understand effects of diabetes on the feet • Identify appropriate foot care practices • Smoke • Able to adequately care for their feet • Have impaired vision/mobility DPMI Workforce Development – The Alfred Workforce Development Team June 2005

27. Flow chart for diabetes foot exams Start Type 1 and Type 2 Diabetes: when diagnosed Annual Comprehensive Foot Exam and Risk Categorization By diabetes educator/podiatrist /general practitioner Include education for self care of the feet and reassess metabolic control Visually inspect feet 6 monthly Visually inspect feet at every visit Low Risk Feet High Risk Feet Action plan to support self care and identification of foot problems Action plan to restore and/or maintain integrity of the feet DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program http://www.ndep.nih.gov/resources/health.htm

28. Risk categories DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program http://www.ndep.nih.gov/resources/health.htm

29. Action Plan DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program http://www.ndep.nih.gov/resources/health.htm

30. Case study one DPMI Workforce Development – The Alfred Workforce Development Team June 2005

31. Case study two DPMI Workforce Development – The Alfred Workforce Development Team June 2005

32. Case study three DPMI Workforce Development – The Alfred Workforce Development Team June 2005

33. Case study four DPMI Workforce Development – The Alfred Workforce Development Team June 2005

34. Case study five DPMI Workforce Development – The Alfred Workforce Development Team June 2005

35. Diabetic Osteopathy (Charcot’s disease) DPMI Workforce Development – The Alfred Workforce Development Team June 2005