'Best Feet Forward' Module 4.1.1 Workshop material developed by the The Alfred DPMI Workforce Development Team for the Central West Gippsland PCP Diabetes Prevention & Management Initiative Module One for Diabetes Educators reviews content of module two pre reading utilising level two PowerPoint presentation. Pre reading module follows module two PowerPoint presentation in this section of the folder. Participants work through the level two footcare PowerPoint presentation and in the process they have the opportunity to: Practice teaching footcare assessment Discuss local footcare assessment tool and clinical pathways including variations in Diabetes Educator Assessment tool ( follows PowerPoint in this section) and Registered Nurse Assessment tool,(copies in prof both can be found in section three. Discuss documentation of foot assessment and practical implications Review care planning and clinical pathways, discuss local situations that may promote or impede implementation. Produced by The Alfred Workforce Development Team on behalf of DHS Public Health - Diabetes Prevention and Management Initiative June 2005

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

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

“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

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 Note local admission rates for the Central West Gippsland project were used to highlight the relevance of the issue locally If local figures are not available prevalence and incidence rates outlined in the pre workshop workbook could be used DPMI Workforce Development – The Alfred Workforce Development Team June 2005

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

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

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

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

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

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

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

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 Will try to get a photo to include DPMI Workforce Development – The Alfred Workforce Development Team June 2005

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

Foot assessment WHY? GOAL 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

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

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

Assessment tool Note factors to consider when working towards a common foot assessment form include: Inclusive collaborative approach of all key players in developing assessment form Meeting medical record requirements of local organisations Branding that is recognisable to all organisations involved Local resources and referral patterns Copies of the assessment form can be found following the presentations in this section

Assessment tool - back page

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

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

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

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 for redness, warmth, discharge, swelling Signs and symptoms may be masked by ischemia or neuropathy Deformities- such as corns, 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

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

Vascular assessment Symptoms of intermittent claudication Pulses Ulcer Pain in calf muscle when walking, leg cramps Pulses Dorsalis Pedis Posterior tibial Ulcer Gangrene Amputation Allow participants to break into pairs and perform a foot assessment on each other working through the foot assessment form DPMI Workforce Development – The Alfred Workforce Development Team June 2005

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

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

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

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

Case study one Mrs H is 45 years of age and has been newly diagnosed with diabetes. Little foot pathology is evident, apart from a small fissure on the right foot between the third and fourth toes.   From the information provided, what would be your assessment of this lady? Minor foot problem Need to check if seen educator What immediate advice would you give?  Keep clean and dry. Take particular care after shower to dry well Wear cotton/wollen socks and leather shoes to decrease moisture Complete a care plan (overleaf) for this lady Low Risk Foot Active foot problem; Refer to podiatrist and/or general practitioner DPMI Workforce Development – The Alfred Workforce Development Team June 2005

Case study two Mrs W. is 43 years of age she had type 2 diabetes for 2 years. Seven days ago she dropped a can on her toe, since then she has had a very painful toe with pus coming from the side of the nail. She has been soaking the foot in water "as hot as I can stand". Today the blood glucose is 17mmol/L.   From the information provided, what would be your assessment of this lady? Infected Raised BGLs Foot self care knowledge poor What immediate advice will you give? Clean and cover Relieve pressure/immoblise Stop Soaking See Gp  Complete a care plan (overleaf) for this lady High Risk Foot: signs of infection Active Foot Problem: Refer to podiatrist and/or general practitioner Inadequate Knowledge of Foot care practices: Refer to diabetes educator/Provide education DPMI Workforce Development – The Alfred Workforce Development Team June 2005

Case study three Mrs A. is 65 years of age and has had Type 2 diabetes for 25 years. She measures her blood glucose levels very infrequently. BGL today is 13 mmol/L. She has had a sore on her foot for 3-4 months which she has treated herself with a razor and an antiseptic. She is unconcerned by this wound and tells you she usually heals well.   From the information provided, what would be your assessment of this lady? Neuropathic ulcer Elevated blood glucose Inappropriate self care practices What immediate advice would you give her? Need to stress needs immediate action: GP and Podiatrist referral Keep clean and dry and relieve pressure Stop using razor Complete a care plan (overleaf) for this lady High Risk Foot Ulceration /signs of infection: Immediate referral to general practitioner High Risk Foot: Referred to podiatrist/diabetes educator Refer for medical assessment at least every six months Visual inspection at every visit Inadequate Inadequate Knowledge of Foot care practices: Refer to diabetes educator/Provide education DPMI Workforce Development – The Alfred Workforce Development Team June 2005

Case study four Mr S is 75 years old and has had Type 2 diabetes for 10 years. BGLs are usually below 9mmol/L. He reports having calf pain when walking 50 metres or more. You are unable to palpate pulses on either foot. He complains of no foot problems. He has reasonable eyesight but has difficulty bending to reach his toes. He lives with his wife.   From the information provided, what would be your assessment of this gentleman?  PVD Nails poorly cared for What immediate advice would you give him? Use moisturiser on feet Suggest podiatrist cut toenails Check if wife able to help with foot care Review footwear  Complete a care plan (overleaf) for this gentleman. High Risk Foot: Referred to podiatrist/diabetes educator Refer for medical assessment at least every six months Visual inspection at every visit Inadequate Symptomatic Peripheral Vascular Disease: Refer to General Practitioner or Physician Inability to perform safe self care practices: Refer to diabetes educator Educate Family member or carer DPMI Workforce Development – The Alfred Workforce Development Team June 2005

Case study five Mr B is 75 years and lives in an elderly persons unit. Recently diagnosed with Type 2 diabetes. He is a non smoker and BGLs have been well controlled. His pulses are palpable and he has no symptoms of neuropathy. He walks only around the block with the aid of a stick. He says his feet hurt but have done so for years. He is frightened of loosing his legs and becoming immobilised and helpless.   From the information provided, what would be your assessment of this gentleman? Severe callus/may have ulcer underneath Cannot exclude PVD/ dry skin thick toenails What immediate advice would you give him? Reassurance podiatrist referral Moisturiser for feet Check shoes Complete a care plan (overleaf) for this gentleman High Risk Foot: Referred to podiatrist/diabetes educator Refer for medical assessment at least every six months Visual inspection at every visit Inadequate Foot Deformity or abnormality; Referred to podiatrist DPMI Workforce Development – The Alfred Workforce Development Team June 2005

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