WellOne Primary Medical Care Program for Medical Clinical Staff

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WellOne Primary Medical CareProgram for Medical
Clinical Staff

• DIABETIC FOOT SCREENING

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Diabetes and Amputation

• Diabetes is the cause of over 50 of all the
  non-traumatic amputations in the United States.
• The risk of ulcers or amputations is increased in
  people who have had diabetes gt10 years, are male,
  have poor glucose control, or have
  cardiovascular, retinal, or renal complications.
• The loss of a lower extremity, or even part of a
  lower extremity, significantly impacts quality of
  life

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True of False Diabetes is the cause of over
50 of all the non-traumatic amputations in the
United States.

• True
• False

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The correct answer is

• TRUE
• 5-15 with diabetes will undergo amputation in
  lifetime
• Thats up to 30 amputations in 200 patients
• About 84,000 people with diabetes have lower
  extremity amputations each year (Centers for
  Disease Control and Prevention. Diabetes
  disabling, deadly and on the rise, 2004..)

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Diabetes and Amputation

• Someone, somewhere, loses a leg because of
  diabetes every 30 seconds of everyday..."-
  Lancet. 20053661674

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Risk Factors Peripheral Neuropathy (PN)

• High levels of glucose are toxic to the nerves
• Peripheral neuropathy (PN) is damage to the
  nerves that connect the spinal cord to the arms
  and legs (the peripheral nerves)
• PN is the 1 risk factor for diabetic foot ulcer
  and amputation

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True of False Peripheral Neuropathy is the 1
risk factor for foot ulcer and amputation.

• True
• False

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The correct answer is

• TRUE
• About 60 to 70 of all people with diabetes will
  eventually develop peripheral neuropathy,
  although not all suffer pain. This leads to
  painless trauma, ulceration, infection, and
  finally amputation.
• Because of the lack of pain, the diabetic with
  neuropathy is prone to foot trauma/injury
  unawareness. A lack of pain when an ulcer is
  noted may lull the patient into a false sense of
  security, perceiving the ulcer to be of little or
  no significance. Thus, the patient may neglect
  and/or delay appropriate treatment for their
  problem.

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PN Symptoms

• Symptoms can range from mild to severe and
  perhaps disabling.
• Sometimes PN is present even without symptoms.
• When people first get PN, they normally feel
  sensations like tingling, weakness, numbness,
  pinching, buzzing or stiffness in their toes and
  feet or fingers and hands.
• As it gets worse, people report having a
  cramping, burning, throbbing or shooting pain.
• Some refer to the pain as "frostbite", "pins and
  needles sticking in", "a lit match held to my
  foot" or "walking on broken glass". This could be
  so severe that wearing clothes or sleeping under
  blankets is painful.
• Symptoms of PN vary from person to person. They
  can appear suddenly, come and go, or persist over
  time. They usually affect both sides of the body
  at the same time, and they may get worse at
  night.

• When the nerves going into the feet are damaged,
  sensation is impaired
• Normally pain is protective, letting us know
  there is a problem.
• With PN there may be little to no pain when an
  injury has occurred

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Peripheral Neuropathy
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PN Physical Exam Findings

• Decreased ability to feel pressure with
  monofilament testing
• This is termed an insensate foot

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Risk Factors Peripheral Arterial Disease

• Arterial insufficiency refers to sluggish blood
  flow through the arteries.
• In diabetes, this is usually due to
  atherosclerosis (plaques that line the blood
  vessels)
• This results in reduced blood flow to the feet
  and extremities

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Peripheral arterial disease is usually due to

• Peripheral
• neuropathy
• Nerve damage
• Atherosclerosis

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The correct answer is

• Peripheral neuropathy
• Nerve damage
• Atherosclerosis

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Click here to learn more select atherosclerosis
from the drop down menu
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PAD Symptoms

• The reduced blood flow (and lack of oxygen to the
  tissues) leads to unhealthy tissues and poor
  wound healing

• Many people with diabetes and PAD
• do not have any symptoms. Some
• people may experience mild leg pain
• or trouble walking and believe that
• its just a sign of getting older.  Others
• may have the following symptoms
• leg pain, particularly when walking or
  exercising, which disappears after a few minutes
  of rest (clinical term is intermittent
  claudication)
• numbness, tingling, or coldness in the lower legs
  or feet
• sores or infections on the feet or legs that heal
  slowly

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The clinical term for leg/calf pain that occurs
with activity and disappears with rest is

• Peripheral arterial
• disease
• Intermittent
• claudication
• Peripheral
• Neuropathy

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The correct answer is

• Intermittent claudication

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PAD Physical exam findings

• On physical exam, persons with peripheral
  arterial disease may have
•  Weak or absent pulses in lower extremities
  (pedal pulse)
• Coolness of the foot or leg
• Shiny skin with or without stasis dermatitis
• Hair loss (on the legs and toes)
• Toe nail changes (brittle, thickened)

Red to brownish discoloration, known as stasis
dermatitis.
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A red/brown discoloration of the lower
extremities that is seen with arterial disease is
termed

• Stasis Dermatitis
• Intermittent
• claudication
• Peripheral
• Neuropathy

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The correct answer is.

• Stasis dermatitis

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PAD Risk Factors or developing
All of these increase the risk of PAD

• Smoking
• High blood pressure
• High cholesterol Overweight/Obesity
• Physical inactivity
• Poor control of blood glucose

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All of the following are signs of arterial
disease except

• Cool extremities
• Diminished pedal
• pulses
• Loss of sensation
• Decreased hair growth

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All of the following are signs of arterial
disease except

• Cool extremitites
• Diminished pedal pulses
• Loss of sensation
• Decreased hair growth

Cool extremities, decreased hair growth and
diminished pedal pulses are seen with PAD,
whereas loss of sensation occurs with peripheral
neuropathy
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Risk Factor Obesity

• Obesity is a risk factor for diabetic foot
  disease because
• There is more weight and shear stress on the feet
• Obese persons may have a difficult time
  inspecting and caring for their feet

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Risk Factor Foot Deformity

• Foot deformities, such as
• bunions, hammer toes,
• claw toes, etc. lead to areas
• of increased
• friction and
• pressure

Bunion
ULCERATION
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Additional Risk Factors

• Impaired vision
• Poor glucose control
• Poor footwear
• Decreased mobility
• Severe nail pathology
• History of foot ulcers or amputation

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These nails are hypertrophied (thickened) from
fungal infection in this patient with no prior
access to podiatric care. Due to the increased
pressure transmitted to underlying tissues, these
nails can damage the nail bed which may then
become secondarily infected and ulcerate.
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The Diabetic Foot Exam

• Also known as the LEAP Exam
• LEAP is an acronym for

Lower Extremity Amputation Prevention
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LEAP PROGRAM

• The LEAP Program consists of five relatively
  simple activities
• Foot screening
• Patient education
• Daily self inspection of the foot
• Appropriate footwear selection
• Management of simple foot problems

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Who
should have a diabetic foot screening?

• The Bureau of Primary Health Cares (BPHC) Lower
  Extremities Amputation Program (LEAP) recommend
  visual foot exams / inspections at each visit.
• All patients with diabetes should have a
  monofilament test done at least annually.

Click here to visit the BPHC/HRSA website
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True of False A visual foot exam should be
performed at every visit with a diabetic patient

• True
• False

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The correct answer is

• True

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Level I Diabetic Foot Screening Step ITalk with
the patient and document responses

• Have there been any changes in your feet?
• How often do you examine your feet for changes?
• Any burning, numbness, tingling, or pain in your
  feet or calves?
• Is there pain in the calf muscles when walking?
• Do you smoke?

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Burning, numbness and/or tingling in the feet may
indicate

• Peripheral Neuropathy
• Arterial Insufficiency
• Diabetic nephropathy
• Stasis Dermatitis

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The correct answer is

• Peripheral Neuropathy
• Arterial Insufficiency
• Diabetic nephropathy
• Stasis Dermatitis

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Level I Diabetic Foot Screening Step II Perform
a visual screening of footwear and lower
extremities

• Explain to the patient that you will be
  performing a foot screening
• Ask the patient to remove both the shoes and
  socks
• Inspect the shoes for signs of excess wear and
  the presence of objects such as pebbles, sharp
  areas, etc
• Visually inspect the lower extremities- paying
  particular attention to look between the toes and
  the back of the heal. Feel for the temperature
  and condition of the skin.
• Note any deformities and skin problems

Calloused areas
Redness and pressure areas
Deformity
Edema
Dry, cracked skin
Tight Shiny Skin
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The visual portion of the diabetic foot screening
includes inspection of

• Footwear and socks
• Areas between the toes
• The heels of the feet
• All of the above

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The correct answer is.

• All of the above

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Level I Diabetic Foot Screening Step III
Perform the monofilament screening

• Explain exam and demonstrate on hand
• Position for comfort
• Have patient close their eyes. Ask patient to
  say yes when they feel filament
• Touch monofilament to testing area, creating a C
  shaped bend and remove avoid dragging avoid
  calloused areas

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The Monofilament Screening

• Is used to determine if there is loss of
  protective sensation (LOPS)
• A lack of sensation in any area with monofilament
  screening means the patient is at increased risk
  of foot ulceration and this usually prompts the
  health care practitioner to refer the patient to
  a podiatrist

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What is the preferred way to establish if the
patient feels the monofilament?

• Tell the patient to let you know when he/she
  feels the sensation
• Ask the patient to blink 3 times when he/she
  feels the sensation
• Ask the patient Do you feel this?

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The correct answer is.

• Tell the patient to let you know when he/she
  feels the sensation. This avoids the examiner
  prodding the patient to report the sensation.
  If the patient does not respond to the
  monofilament, the examiner should note negative
  sensation in the area and move on with the
  screening.

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True of False The proper amount of pressure
for monofilament testing is that which causes an
indentation to be left in the skin.

• True
• False

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The correct answer is..

• Falsethe correct pressure is applied by
  touching the monofilament to the testing area and
  creating a C shaped bend.

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MONOFILAMENT SCREENING

• A simplified monofilament examination using only
  4 sites per foot (total 8 sites) detected 90 of
  patients with an abnormal 16-site monofilament
  evaluation.
• J Gen Intern Med. 1999 July 14(7) 418424. doi
  10.1046/j.1525-1497.1999.05208.x.

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• The 4 test sites

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Prior to performing the monofilament screening,
it is important that the examiner

• Demonstrate the
• monofilament on the
• Patients hand or arm
• Lubricate the
• monofilament

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The correct answer is

• ..Demonstrate the monofilament on the
  patients arm or hand
• This lets the patient know that the monofilament
  does not hurt and what the monofilament is
  suppose to feel like.

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Throughout the screening and following the
screening.Provide patient education

• Awareness of personal risk factors
• Daily self inspection of feet
• Proper nail and skin care
• Injury prevention
• When to seek help or specialized referral For a
  foot finding call immediately do not delay
• Never walk barefoot
• For a foot finding call immediately do not delay
• Smoking cessation
• Check water temperature for bathing
• Moisturize but not between toes
• Proper foot wear selection

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Education and Goal Setting Is Important

• It is estimated that the risk of diabetes-related
  foot complications can be reduced by 49 to 85
  by proper preventive measures, patient education,
  and foot self-care.
• (Apelqvist J, Bakker K, van Houtum WH,
  Nabuurs-Franssen MH, Schaper NC. International
  consensus and practical guidelines on the
  management and the prevention of the diabetic
  foot. International Working Group on the Diabetic
  Foot. Diabetes Metab Res Rev. 200016S84S92.)

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Lastly, Be sure to..

• Document all findings and education
• Verbally report findings to the PCP

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You have reached the end of this program..

• Once you are confident that you are comfortable
  with all the materials presented, proceed to the
  Diabetic Foot Screening post-test at
  http//www.classmarker.com/professional/
• Your username is the first initial of your first
  name followed by your full last name. Your
  password is nwhealth

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