The Diabetic Foot Stratification, Assessment & Referral

1. The Diabetic FootStratification, Assessment & Referral

2. Introduction • Scope of Podiatry and its role in prevention of lower limb ulceration and amputation. • Nursing - diabetic foot risk assessment • Risk stratification & referral to podiatry services. • Vasc & neuroAssessment – practical • What clinicalfeatures = high risk diabetic foot • Case study • Funding • Discussion & foot related questions

3. Podiatry – Scope of Practice • Diagnostic Profession concerned with all aspects of foot health • Pharmacology • Medicine • Biomechanics • Radiology • Neurological, Vascular & Dermatological Assessment & Treatment • Orthotics Prescription and Fabrication • Surgery

4. Podiatry & DiabetesOur Role in Prevention • Vascular and Neurological Assessment • Biomechanical & Dermatological Assessment • Off-loading Plantar Pressures • Mechanical and Orthotic Therapies • Specialized Skin & Nail Care • Prophylactic Surgery • Education

5. Nursing Diabetes Stratification & Risk Assessment • Do they have an active ulceration, severe infection or unexplained swelling, heat and redness? • Do they have Peripheral Arterial Disease and/or Peripheral Neuropathy with any of the following: • Foot deformity • Thick nails or corns/callus? • Are they ESRF? • Are the Maori? • Do they have a history of foot ulceration or amputation? • Do they have Peripheral Arterial Disease and/or Peripheral Neuropathy?

6. Diabetes Stratification • Active Foot Disease - Hospital Pod • Current Ulceration/ Hot,red, swollen foot / severe infection-cellulitus • High Risk - Community Pod • PAD or Peripheral Neuropathy with High Risk Features - Two funded consults with Community Pod • Moderate Risk - Community Pod • PAD and/or Peripheral Neuropathy -One Funded Consults and treatment plan with Pod • Low Risk - GP, Nurse, • WINZ funding available for all Diabetes Beneficiaries or Pensioners

7. Diabetes Stratification • Low Risk Foot (no referral needed) • Good blood flow and protective sensation is intact • Moderate Risk Foot (referral to Primary/ Private Podiatry) • Peripheral Vascular Disease (PVD) and/or Peripheral Neuropathy with no other pathology • High Risk Foot • with ‘high risk’ pathology • Active Foot Disease • Current ulceration or charcotneuro-athropathy

8. Vascular Assessment • Signs • Pulses not palpable • Doppler – pulses not detected or very low pitched sound • CRT more than 5 seconds (micro-angiopathy?) • Poor Colour & cool temp gradient • Diminished pedal hair • Symptoms • Intermittent Claudication (pain on walking, every time they walk at the same distance, have to rest for pain to ease) • Rest Cramps (cramps in bed each night or at rest)

9. Macro-vascular Assessment - Pulses • Vascular Anatomy DorsalisPedis

10. Macro-vasc Assessment • Posterior Tibial Pulse

11. Macro-vascularDoppler Assessment • Doppler is an excellent tool to have, as often even good pedal pulses are hard to palpate, especially if there is oedema present • Use ultrasonic gel, and move the ultrasound head until you get the loudest reading on that pulse. A good pulse is very loud with 3 phases of sound, a poor pulse is very low pitched with only one phase.

12. Micro-Vascular Assessment • CRT – normal is less than 5 seconds • Absence of pedal hair indicates poor micro-vascular status • Thick atrophied nails can indicate poor circulation to the skin also • Temperature – cold feet • Poor Colour

13. How to do the Monofilament Test • Show the patient that the monofilament test is not painful by touching your own hand with the monofilament. • Let them feel it on their hand – so they know what to expect • Patient closes their eyes and says ‘yes’ every time they feel it. • Avoid askingthe patient “Can you feel that?” • Press the monofilament perpendicular to the skin and let it buckle and hold for 1-2 seconds before releasing it. • Re-test each site that the patient could not feel to be sure we have an accurate test. • Be aware that callused areas will have less sensation. • Twoor more sites gone undetected by patient is considered Moderate Risk

14. Dermatological & Biomechanical features of the High Risk Foot If your patient has PAD or Peripheral Neuropathy with: • Thick nails • Corns or Callus • Foot Deformity • End Stage Renal Failure • History of lower limb ulceration or amputation • Maori ethnicity This is considered a High Risk Foot

15. HighRisk Pathologies – Callus & CornsPre- ulcer lesions

16. High Risk Pathologies Pre-ulcer Lesions • Corns and Callus are known in Podiatry as pre-ulcer lesions. • Peripheral Neuropathy with Corns and Callus are the common causal pathway to ulceration. • This is why patients with PAD and/or Peripheral Neuropathy are considered High Risk.

17. HighRisk Pathologies – Deformityleads to pre-ulcer lesions

18. Highrisk Pathologies - Nails

19. Case Study Case Study - Ruth 88 year old female Diabetes with impaired nerve function and blood flow Visual impairment Unable to care for feet at home Good Health otherwise Presents with thick crumbly nails due to peripheral vascular disease Requires regular nail treatment to prevent ulceration of nail bed

20. Case Study • No pain in feet • During treatment (grinding thick nails) infected wound discovered under the nail plate

21. Case Study • Early detection through routine nail care by a Podiatrist prevented ulceration and amputation

22. Available Funding • PHO Packages of Care • High Risk Feet – Two Consultations Private Podiatry • Moderate Risk Feet – One ConsultationPrivate Podiatry WINZ – Disability Allowance – all diabetes patients Parkinson’s Society

23. PHO Packages of Care • The packages of care are designed to provide full assessment, including ABI where indicated. • Also the Podiatrist, puts a treatment plan in place with the Primary Health Providers, GPs & Practice Nurses. • Work with WINZ for regular care

24. Foot Questions

25. Located within the new Whareora o Tikipunga Clinic, 157 Kiripaka Road, Tikipunga. Phone: 09 437 0015 Fax: 09 437 0016

26. Mid North Clinic: • Paihia Medical Services, 22 Selwyn Ave, phone: 402 8407 Far North Clinics: • Mamaru Clinic, Coopers Beach Shopping Mall, phone: 406 0074 • Kaitaia Clinic, TeWhareHauora, Redan Road, phone: 408 0049