1. Reducing Foot Complications for People with Diabetes – Champion Training

2. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Agenda Welcome Diabetic Foot assessment programbackground Diabetic neuropathy 101 Diabetic foot assessment and documentation Hands on foot assessment 2

3. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Background Diabetes is a common, serious, lifelongcondition in more than 1 million Canadians Foot complications account for 20% ofdiabetes related hospital admissions. 15% of people with diabetics will develop afoot ulcer. 85% of lower extremity amputations arepreceded by a non-healing ulcer 3

4. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Big Picture We want to decrease the number of diabeticsthat develop foot problems. These problemsare likely to result in ulcers but may takeother forms of problems from poormanagement of diabetes and foot care. RNAO – Best Practice Guideline Assessmentand Management of Foot ulcer for peoplewith diabetes. 4

5. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Health- care professionals evidence basedteam approach to initiative. Participation in continuing education toenhance knowledge and skills to competency. Utilizing Best Practice Guideline as astructured model for implementing practicechange. 5

6. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Nurses role in prevention 1.Conduct and document a foot assessment for patients with known diabetes. 2.Patient education to promote the maintenance of healthy feet. 3.Identify patients at risk for developing foot ulcers and /or amputation. 4.Refer high risk individuals for specialized care. 6

7. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 7 Complete the Diabetic-Foot Risk Assessment Form in SCM on all persons with diabetes over 15 years of age (excluded are women with Gestational Diabetes, Psychiatric, Emergency and Pediatric populations) within 24-48 hours of admission to the hospital. The Diabetic-Foot Risk Assessment Form has 5 factors to be assessed; skin; circulation/vascular; sensation (monofilament); structural abnormalities and self-care knowledge and behaviour. High Risk: If any one of the following is assessed -current ulcer; signs of infection – elevated temperature, swelling, inflammation, discharge, pain; no palpable pedal pulses; presence of leg muscle pain or fatigue on walking that relieved by rest; dependent rubor; delayed capillary refill - then the person is at HIGH Risk. This increases potential for the development of infectious disease (e.g. cellulitis, gangrene) and/or need for surgical intervention (e.g. amputation, femoral bypass). Low Risk: If no potential factors are identified, the level of risk is considered “lower”. Reinforce the benefits of yearly foot exam and preventive self-care actions. Step #3: Education Intervention (For both low and high risk persons with diabetes)  Provide person with the education brochures; “Diabetes and Foot Care – Do’s and Don’ts & Diabetes, Healthy Feet and You.  Provide person with foot care products.  Provide self-care education: level of personal risk, inspection by self or caregiver, wearing protective footwear, general nail and skin care.  Provide education regarding when to seek resources; see resource listings.  Encourage person to watch the “Preventing Diabetic Foot Ulcers” DVD video on the THC channel.  If person requires more detailed education materials, please provide them with the Ministry of Health’s “Diabetes and You” information package.  Reinforce the importance of notifying their family practitioner regarding their risk factors. Step #4: Follow up Notify and confirm that MRP is aware of HIGH Risk factors. Notify and confirm that Wound Care Team is aware of current/new ulcer and care plan is in effect. Step #5: Potential Resources Available in the community and or Hospital Wound Care Team  OT/PT  Chiropodist  Orthotist  CCAC/Wound Clinic  Diabetes Centre (for uncontrolled and unmanaged blood sugars)  Vascular Surgeon (referral by MRP)  Dermatology and Plastics (referral by MRP) Foot Risk Assessment Algorithm and Risk Reduction Guidelines Step #1: Assessment Step #2: Identify Level of Risk

8. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Basic foot education Awareness of personal risk factors Importance of at least annual inspection offeet by health care professional. Daily self inspection of feet Proper nail and skin care Injury prevention Check for the wear and tear of footwear When to seek help or specialized referral 8

9. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Five key risk factors for developing foot ulcers and amputation 1.Ulcers / Skin Assessment 2.Circulation 3.Sensation 4.Structural abnormalities 5.Self-care knowledge and behaviour 9

10. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 1. Skin Assessment Visually inspect the top & bottom of both feet Assess for signs of dry or sweaty feet Look for any corns, calluses, fissures or cracks, maceration and other skin abnormalities Check between the toes for soft corns or any sign if skin breakdown Be alert for signs of infection such as elevated skin temperature, swelling, inflammation, discharge, and pain

11. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 1. Skin Assessment Check skin temperature by running the back of your hand down the leg from the below the knee to the dorsum of the digits Ask about previous ulcers Be alert to any signs of foot trauma Inspect the toenails to see if thickened, discolored, deformed or ingrown – may indicate vascular or fungal disease

12. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Ulcers / Skin Assessment People with Diabetes may not feel trauma 1.Acute Trauma – abrasions and burns occur often due to the absence of nociception. Poor wound healing makes ulcerations more likely to occur 2.Chronic trauma – reduced motor function results in a high arch. Together with decreased proprioception, this creates classical deformed foot shapes. These result in bony prominence which, in turn, when coupled with high mechanical pressure on the overlying skin, results in ulceration. 12

13. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Circulation / Vascular Assessment Peripheral Arterial Disease is 4-7 times more prevalent in diabetics than non-diabetics Atherosclerosis causes a progressive blocking of the arteries as a result of a build up of fatty plaque The delivery of essential nutrients and oxygen to the foot is compromised leading to anaerobic infections and tissue necrosis. 13 Posterior Tibial pulse Dorsalis Pedis pulse

14. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Peripheral Arterial Disease Thin, fragile, shiny skin Absence of hair growth Cool/cold skin Pallor on elevation of foot Dependent rubor (dusky / bluish / cyanotic Delayed capillary refill (> 3-4 sec) Check for edema (evidence of poor venous return Intermittent claudication: Leg muscle pain or fatigue on walking that is relieved by rest

15. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Loss of Sensation Numbness Tingling Pain Lack of feeling Peripheral neuropathy (nerve damage) occurs because of duration and severity of hyperglycemia to the distal part of the axons of the nerve. This causes dying back and dysfunction of the nerves. Three types of neuropathy 1.Autonomic 2.Motor 3.Sensory 15

16. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Autonomic Neuropathy Symptoms are: Reduced sweating results in dry cracked skin, dry toenails predisposing skin to damage & infection Increases blood flow leading to a warm foot Bounding pulse and dilated dorsal veins 16

17. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Sensory neuropathy Symptoms are: Burning Numbness and Tingling Pain Lack of feeling Loss of protective sensation is associated with an increased risk of amputation. 17

18. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Steps for Monofilament Test for Neuropathy : Check for sensory intactness, using a 10 gram monofilament 1.Show and touch monofilament to patient’s arm or upper leg. 2.Ask the patient to close their eyes and say yes when they feel the monofilament. 3.Touch monofilament until filament bends in a letter “c” shape, assessing all 10 areas on diagram (Do not test over calluses, scars or ulcers) 4.Lack of feeling (4 or more out of 10) - indicates a negative reaction = Neuropathy = “YES” on screening tool 18

19. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Motor Neuropathy Includes; Limited joint mobility Foot deformities develop such as Charcot foot / Hammer toes / Clawed toes Pressure points over the plantar forefoot Altered gait/tripping 19

20. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Diabetic foot 20

21. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Pathophysiology of Diabetic Foot Ulcer 2 Major components1. Peripheral neuropathy- 2/3 of patients with ulcers occurs due to prolonged glucoseelevation. 2. Peripheral vascular disease- 1/3 of patients will also have atherosclerosis of the large limbvessels and not from micro vascular disease. Itis usually symmetrical in both limbs, longsegments below the knees. 21

22. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Self Care Knowledge & Behaviors Poor foot hygiene, inability to perform self-care and routineinspection of the feet and inappropriate footwear arecommon contributors to diabetic foot problems. Inspect the feet for signs of poor foot hygiene – dirty, long orpoorly shaped nails Can the patient see the bottom of feet and/or are they able toreach the bottom of feet? Ask if foot care assistance isrequired for hygiene and for performing daily foot inspections If assistance required find out why – poor vision decreased mobility etc. 22

23. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 5. Self Care Knowledge & Behaviors Check Does the Patient report foot problems to health care provider, e.g. ask, “What would you do if you found a blister on your foot?” Check your feet every day for cuts, cracks, bruises, sores, infections or unusual markings Use a mirror to see the bottom of your feet if you can’t lift them up Check Does the Patient take steps to reduce risk of injury, e.g. ask if patient walks bare foot in/outdoors, checks for foreign objects in shoes before wearing them, checks water temperature before entering a bath, etc.

24. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 5. Self Care Knowledge & Behaviors- the Do’s & Don’ts Do… Check the color of your legs and feet. Is there is swelling, warmth or redness or if you have pain, see your doctor or foot specialist right away Clean a cut or scratch with a mild soap and water and cover with a dry dressing for sensitive skin Don’t… Use over- the -counter medications to treat corns and warts. They are dangerous for people with diabetes Apply heat to your feet with a hot water bottle or electric blanket. You could burn your feet without realizing it

25. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 5. Self Care Knowledge & Behaviors- the Do’s & Don’ts Do… Trim your nails straight across. Get help to cut your nails if needed Wash and dry your feet every day, especially between the toes Apply a good skin lotion every day on your heels and soles. Wipe off any excess lotion Don’t… Soak your feet Take very hot baths Use lotion between your toes Walk barefoot inside or outside

26. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 5. Self Care Knowledge & Behaviors- the Do’s & Don’ts Do… Change your socks every day Always wear a good supportive shoe Always wear professional fitted shoes from a reputable store. Professionally fitted orthotics may help Exercise Don’t… Wear tight socks, garters or elastics or knee highs Wear over the counter insoles – they can cause blisters if they are not right for your feet Sit for long periods of time Never try to treat your own feet if there are sores. Always seek professional help

27. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Education Resources 1. Have patient watch DVD on hospital TV’s “Preventing DiabeticFoot Ulcers: The 3 Step Program” 2. Provide each patient a resource package containing: Brochure “Diabetes Foot Care Do’s and Don’ts” Coloplast Diabetic Foot Care Brochure Brochure “Diabetes, Healthy Feet and You” (CAWC) Resource list of foot clinics Products: Sample of foot cream (Atrac-tain cream- Coloplast)and Mirror to check the bottom of their feet. 3. Reinforce need to notify family physician about risk factor(s) 27

28. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 28

29. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 29

30. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 30

31. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 31

32. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 32

33. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 33

34. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto Mentors role To facilitate and implement guidelines of theTHP policies and systems. To increase awareness of nurses and otherhealth care professionals on significance offoot care assessment on diabetic patients. To encourage participation of othercolleagues in completing foot assessment andaccurate documentation. To review and audit data result and outcomesof this initiative. 34