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Canadian Diabetes Association Clinical Practice Guidelines Foot Care

Canadian Diabetes Association Clinical Practice Guidelines Foot Care. Chapter 32 Keith Bowering, John Embil. Foot Care Checklist. 2013. EDUCATE about proper foot care EXAMINE for structural, vascular, neuropathy problems DO a 10 gram monofilament assessment

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Canadian Diabetes Association Clinical Practice Guidelines Foot Care

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  1. Canadian Diabetes Association Clinical Practice GuidelinesFoot Care Chapter 32 Keith Bowering, John Embil

  2. Foot Care Checklist 2013 • EDUCATE about proper foot care • EXAMINE for structural, vascular, neuropathy problems • DO a 10 gram monofilament assessment • IDENTIFY those at high risk of foot ulcers and educate, assess more frequently, consider footwear • REFER ulcers to multidisciplinary team specialized in foot care

  3. Patients with DM are 20X More Likely to be Hospitalized for Non-traumatic Limb Amputation Public Health Agency of Canada (August 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).

  4. Prevention through educationProper risk assessmentEarly and aggressive treatment

  5. Educate Patients on Proper Foot Care – The “DO’s”

  6. Educate Patients on Proper Foot Care – The “DON’Ts”

  7. How to Perform Proper Foot Examination Skin changes Evidence of infection Callous or ulcer Range of motion Charcot foot Structural Abnormalities Temperature Skin changes Ankle Brachial Index Peripheral Arterial Assessment Neuropathy Assessment 10 gram monofilament

  8. Rapid Screening for Diabetic Neuropathy Using 10 gram Semmes-Weinstein Monofilament Loss of sensation over the distal plantar surface to the 10g monofilament is a significant and independent predictor of foot ulceration and lower-extremity amputation.

  9. Who is at High Risk of Developing a Foot Ulcer? • Peripheral neuropathy • Monofilament sensation loss • Previous ulceration or amputation • Structural deformity or limited joint mobility • Peripheral arterial disease • Microvascular complications • Elevated A1C • Onychomycosis

  10. When Should a Foot Exam be Performed? Low Risk Annually More frequent E.g. Every 3-6 months High risk for ulcer Refer to multidisciplinary team with expertise in foot ulcers Foot ulcer present

  11. High Risk for Ulcer: Prevention and Early Treatment Foot care education Professionally-fitted footwear High risk for ulcer Prompt referral to multidisciplinary team with expertise in foot ulcers If ulcer develops

  12. Foot Ulcer: Multidisciplinary Team Approach Wound care Pressure offloading Debridement (nonischemic wounds) Local factors Glycemic control Treat infection Address lower-extremity vascular status Systemic factors

  13. Recommendation 1 • In people with diabetes, foot examinations by healthcare providers should be an integral component of diabetes management to identify persons at risk for ulceration and lower-extremity amputation [Grade C, Level 3]and should be performed at least annually and at more frequent intervals in those at high risk [Grade D, Level 4]

  14. Recommendation 1 (continued) • Assessment by healthcare providers should include the assessment of skin changes, structural abnormalities (e.g., range of motion of ankles and toe joints, callus pattern, bony deformities), skin temperature, evaluation for neuropathy and peripheral arterial disease, ulcerations and evidence of infection[Grade D, Level 4]

  15. Recommendation 2 • People at high risk of foot ulceration and amputation should receive foot care education (including counseling to avoid foot trauma), professionally-fitted footwear, and early referrals to a healthcare professional trained in foot care management if foot complications occur [Grade B, Level 2]

  16. Recommendation 3 • Individuals who develop a foot ulcer should be managed by a multidisciplinary healthcare team with expertise in the management of foot ulcers to prevent recurrent foot ulcers and amputation [Grade C, Level 3]

  17. Recommendation 4 2013 • There is currently insufficient evidence to recommend any specific dressing type for diabetic foot ulcers [Grade C, Level 3]. General principles of wound management involve the provision of a moist wound environment, debridement of nonviable tissue (nonischemic wounds) and offloading of pressure areas [Grade B, Level 3]

  18. Recommendation 5 2013 • Evidence is currently lacking to support the routine use of adjunctive wound- healing therapies such as topical growth factors, granulocyte-colony stimulating factors, dermal substitutes, or HBOT in diabetic foot ulcers but they may be considered in nonhealing, nonischemic wounds when all other options have been exhausted [Grade D, Level 4]

  19. CDA Clinical Practice Guidelines www.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca – for patients

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