National Health Care for the Homeless Conference

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National Health Care for the Homeless Conference
Update on Wound Care for Homeless Providers The
Neuropathic Patient June 14, 2008 CDR Alicia S.
Hoard U.S. Department of Health and Human
Services (HHS) Health Resources and Services
Administration (HRSA) Bureau of Primary Health
Care (BPHC) National Hansens Disease Programs
(NHDP)
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CARVILLE HISTORY Indian Camp Plantation 1890s
First seven patients arrive at Louisiana Leper
Home 1894
Daughters of Charity 1896
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U.S. Public Health Service 1921

• U.S. Public Health Hospital No. 66

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The Neuropathic Wound Why it is different than
other wounds
Understanding the Insensitive Patient
Loss of Protective Sensation Pressure
Neuropathic Ulceration
Dr. Paul Brand
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Facts About Diabetes and Neuropathy

• 16 Million Cases in United States
• 90 Eventually Lose Protective Sensation
• 15 Develop Foot Ulcerations Lifetime
• Within 3 Years 60 of Ulcers Recur and 10
  require Amputation
• Amputation Rate 1 per Year
• 60,000 Amputations a Year in USA
• Cost of Lower Extremity Complications
• 6 Billion / Year
• 2/3 of all amputations are linked to diabetes
• 5 years after the initial amputation, 28-51
• undergo a second amputation
• 5 year mortality following amputation is
• between 39-68
• Prevention Programs could reduce this by gt 50

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LEAP Program
Lower Extremity Amputation Prevention
Gillis W. Long Hansens Disease
Program Carville, Louisiana
National Hansens Disease Programs Baton
Rouge, Louisiana
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LEAP

• I. Annual Foot Screen
• Ongoing Patient Education
• Daily Self Inspection
• Footwear Selection
• V. Management of Simple Problems and Scheduled
  Follow-up
• a Skin
• b. Nails
• c. Callous
• d. Pre-Ulcer

LOWER EXTREMITY AMPUTATION PREVENTION
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The Neuropathic Foot

• Motor Neuropathy
• loss of intrinsic muscularity and control
• Autonomic Neuropathy
• loss of sweat and oil glands and hair follicles
• Sensory Neuropathy
• Loss of protective sensation

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I. Foot Evaluation
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I. Foot Screen

• Self exam

• Professional exam

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Sensory Neuropathy

• Loss of protective sensation
• Repeated stress
• Unrecognized trauma
• Non-painful Ulceration

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10 gm Filament Application
10 gram filament only (document using or -)
Filament provider video 1-888-275-4772
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Risk Categories
A risk category is a summary of the foot screen
components sensation, deformity, and skin
integrity. The high risk patient should be
educated about avoidance of injury, use of
therapeutic footwear and preventative self care.

• 0 Normal plantar sensation
• (low risk)
• 1 Loss of Protective Sensation (LOPS)
• (HIGH RISK)
• 2 LOPS with either high pressure or poor
  circulation.
• (HIGH RISK)
• 3 History of ulceration, amputation or
  neuropathic fracture.
• (HIGH RISK)

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Guidelines for Routine Management
Those with high risk feet should see their foot
care specialist on a routine basis as directed by
the risk category.
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II. Ongoing Patient Education
Of all the approaches to saving the Diabetic
(Neuropathic) Foot, the most important is Patient
Education. Levin
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A Multidiciplinary Team
All disciplines communicate and reinforce the
same message!
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III. Daily Self Inspection
Self inspection is the most effective method to
protect the feet and avoid foot problems.
Diabetes Care 18 943-949 1995
Inspect both feet Use a mirror if unable to
see bottom of foot Have another person inspect
feet if vision is poor.
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Self Inspection
Early detection of foot injuries is necessary to
prevent more serious problems. Identification
of minor issues may be managed by the patient who
has been taught simple, basic self-management
techniques. If quick resolution of a minor
problem is not met, immediate contact should be
made with the physician or foot care specialist.
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Self Inspection

• The person with insensitive feet should inspect
  for
• Redness Blister Callus
• Open sore (ulcer) Swelling
• Dryness Nail thickness,
• length or tenderness

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Early detection and treatment of problems . . .
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Will PREVENT ulceration and ultimately AMPUTATION
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In addition to the Feet, inspect Shoes, Socks
and Insoles
Inspect in the morning, evening, and everytime
shoes are changed!
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IV. FOOTWEAR SELECTION
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A Simple Sobering Equation

AND

Insensitivity
Ulceration
Improper footwear
LEADS TO
Ulceration
Amputation
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Footwear Recommendations

• Shoe Sizing
• ½ inch space beyond longest toe
• Snug fit of the heel
• Adequate ball width
• Adequate toe spread and clearance
• Correct heel to ball fit

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• Proper Shoe Design
• Shape of shoe matches
• shape of foot
• Accommodates an orthotic
• Leather or other
• accommodative uppers
• Low heels
• Adjustable closure

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Pressure Relief with Insoles
Simple Non-molded Insert
Barefoot
Bony Contact Area
Soft and Molded Insert
Complete Plantar Contact
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F- Scan Case Study
Darco Shoe with no Insert
Molded Sandal
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Patients with Loss of Protective Sensation MUST
wear shoes. . .at all times that provide an
appropriate fit!
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Shoe Modifications for Minor Deformity
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Custom Footwear for Major Deformity
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Risk CategoriesandGeneral Footwear
Recommendations
Rigid rocker shoe
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V. Management of Simple Foot Problems

• Simple foot problems involve
• Skin
• Nails
• Callus
• Pre-ulcer

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Skin Care
Wash feet everyday in warm, not hot, water. Dry
feet well especially between toes. Rub lotion,
cream or petroleum jelly over the tops and
bottoms of your feet, but do not put lotion
between toes because this may cause an infection.
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Skin Care
Skin hydration can be provided by
over-the-counter lotions and other products. In
the case of severe dryness, prescription topicals
are available.
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Temperature

• Check bath water temperature with elbow or
  thermometer. Dont test bath water with your
  feet.
• No heating pad, hot water bottle, or soaking
• Check your feet often in cold weather to avoid
  frostbite.
• Keep your feet away from radiators and open
  fires.
• Wear socks at night if your feet get cold.

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Shower Shoes
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Nail Care
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Nail Care
Thickened nails can cause pressure to the
underlying tissue
Unkempt nails may snag and avulse from socks,
clothes, or bedding
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Nail Trimming

• Protect eyes from flying nail particles
• Trim hypertrophic nails in small pieces/bites.
• Do not angle clippers into nail bed this will
  prevent injury to nail pulp
• Cut nails straight across
• Dont dig at the corners of the nail
• Dont trim too closely (err on the side of
  caution)

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Callous Care
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3-Wea (Phenyl Mercuric Nitrate) can be used to
soften hard callous for easier removal.
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Trimming callous with a scalpel
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A Dremmel Tool adapted with a sanding disk
(garnet course 7/8 ) can be used to remove the
remainder of the callous and smooth rough skin
and nails.
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Before and After
Callous
Callous Trimmed (Note pre-ulcerative sites from
callous pressure)
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Callus Trimming/Scalpel
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DREMMEL TOOL - CALLOUS REMOVAL DEMONSTRATION
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Pre-Ulcerative Condition
A closed lesion such as a blister, hematoma or
callus on the verge of becoming an open wound.
Treatment includes routine callus trimming,
possible footwear or orthotic modification,
inspection of shoe and insoles for wear and a
review of self management protocol with patient.
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Off-Loading Techniques to heal simple foot
problems
Ideally, off-loading techniques to heal a plantar
ulcer include the Total Contact Cast and
Posterior Walking Splint. These techniques are
unrealistic in some settings where expertise and
resources are not available. In this case, it
is possible to incorporate the principles of
off-loading with alternative techniques to reduce
pressures on the foot to heal simple ulcers.

• Alternative Off-loading Options
• Accommodative Dressings
• Healing Footwear
• Removable Walking Boots
• Ambulation assist devices
• Gait Strategies

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Alternative Offloading Techniques

• Accommodative Dressings

• Healing Footwear

• Removable Walking Boots

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Toe Pillow Used for relief of pressure on
the distal toe.




Materials 6-7 piece of moleskin and 2x2
gauze pad. Other material can be substituted for
the gauze
Roll the gauze into an appropriate size depending
on the size of the relief you need. Remove the
adhesive cover off the back of the moleskin and
place the rolled material near the center
Fold the moleskin snuggly over the folded gauze,
being careful to avoid wrinkles.

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Toe Pillow (continued)
Trim the excess material and cut a small hole
just above the rolled gauze pad
Toe pillow should fit snuggly under the involved
toe and provide pressure relief to the wound
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Adhesive backed felt used on the plantar aspect
of the
foot to relieve pressure on
a specific area
Use ¼ inch or ½ inch Adhesive backed felt
Apply clear covering So the wound remains visible
Original ulcer
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Adhesive backed felt (continued)
Trace the outline of the foot from the
metatarsal heads to the base of the heal
A mark should remain Indicating the location of
the wound
Mark the wound area with lipstick
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Adhesive backed felt (continued)
Cut out the tracing and bevel the edges to
minimize edge pressure
Compare tracing to foot to ensure accuracy of
relief placement
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Adhesive backed felt (continued)
Once the felt pad is complete, a dressing can be
applied to the affected area if needed. Use of
the adhesive backed felt is most effective when
used in combination with other forms of pressure
relief such as a sandal or Darco shoe. The felt
can be replaced as needed depending on the
amount of soiling.
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Alternative Offloading Techniques used in
combination


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Prevention and Healing through Pressure Reduction

• Pressure Force
• Area
• Pressure by Force or Pressure by Force
• Area
  Area
• Pressure can be reduced by decreasing the
  force or by increasing the area.

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• Summary
• Lower Extremity Amputation Prevention
• 1. Annual Foot Screen
• 2. Ongoing patient education
• Daily self inspection
• Footwear selection
• 5. Management of simple problems and scheduled
  follow-up
• a Skin
• b. Nails
• c. Callous
• d. Pre-Ulcer

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Contact Information

• National Hansens Disease Programs
• 1770 Physicians Park Dr.
• Baton Rouge, LA 70808
• 1-800-642-2477
• www.bphc.hrsa.gov/nhdp
• www.bphc.hrsa.dhhs.gov/leap
• jmajor_at_hrsa.gov
• (Blackboard online courses)