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1362397244 patient self care program prev.ulcer


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patient self care program prev.ulcer

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1362397244 patient self care program prev.ulcer

  1. 1. Prevention Of Diabetic Foot Ulcer Disease A Patient Self Care Program Dr. Vijay Viswanathan, M.D, Ph.D., Joint Director Diabetes Research Centre Chennai.
  2. 2. The diabetic patient is often divorced from his feet, unable to see them because of poor eyesight and unable to feel them. [Bloom A. Clin. Endocrinal. Metab 1977].
  3. 3. Upto 50% of all non-traumatic lower limb amputations are performed on diabetic patients. Most & Sinnock “Diabetes Care” 1983.
  4. 4. DIABETIC FOOT PROBLEMS ARE A MAJOR CAUSE OF HOSPITALISATION IN INDIA. Sathe S.R. : Int. J. Diab. Dev. Countries 1994 Pendsey S : IDF bulletin 1993 V. Vijay et al IDF bulletin 1997
  5. 5. DIABETES MELLITUS Autonomic neuropathy Somatic neuropathy (sensorimotor) Peripheral vascular disease Neuroischaemic ulcer Neuropathic ulcer Decreased Altered blood sweating flow Limited joint mobility Cigarette smoking dyslipidaemia Small muscle wasting Decreased pain & proprioception Ischaemic ulcer Pathways to foot ulceration in diabetic patients Increased foot pressures Psychological/behavioural problems Trauma At risk neuropathic foot Dry skin Callus Distended foot veins: warm foot At risk neuropathic foot
  6. 6. Neuropathy Deformity Minor trauma Baseline Pathophysiologic Environmental Time Ulceration pathology involvement event Accumulation of component causes to form a sufficient cause Completed causal chain to ulcer The commonest causal pathway to incident diabetic foot ulcers.
  7. 7. Risk factors for development and progression of neuropathy and development of neuropathic foot ulceration. Risk factors for the development Risk factors for the development of and progression of neuropathy of neuropathic foot ulceration * Poor glycaemic control * Loss of pain sensation * Undiscovered Type 2 diabetes * Undiscovered Type 2 diabetes * Smoking * Smoking * High alcohol intake * High alcohol intake * Low socio-economic status * Low socio-economic status * Renal failure. * Patient lives alone * Lack of flexibility / suppleness * Ill-fitting footwear * Poor foot hygiene / footcare * Denial of condition * Lack of diabetes education * History of previous ulceration or amputation * Poor glycaemic control * Peripheral vascular disease * Decreased vibration sensitivity.
  8. 8. Staging of diabetic neuropathy • Stage 0 : No neuropathy (no symptoms and fewer than two abnormalities on formal testing). • Stage 1 : Asymptomatic neuropathy (two or more abnormalities on formal testing with no symptoms) • Stage 2 : Symptomatic neuropathy (two or more abnormalities on formal testing with minor symptoms). • Stage 3 : Disabling neuropathy (two or more abnormalities on formal testing with severe symptoms).
  9. 9. The Risk of Foot Ulceration in Diabetic Patients with High Foot Pressure : A Prospective Study. [A. Veves, H.J.Murray, M.J. Young and A.J.M.Boulton Diabetologia, 1992.] The Association Between Callus Formation, High Pressures and Neuropathy in Diabetic Foot Ulceration. [ H.J.Murray, M.J. Young, S. Hollis, A.J.M.Boulton Diabetic Med. 1996]
  10. 10. Mrs.Banamali Sahu
  11. 11. Peak Plantar Pressure in the study groups Group 1 Group 2 Group 3 Group 4 n=40 n=123 n=118 n=26 Plantar Pressure 207 260* 347* 638* K Pa (median) (100-441) (53-3274) (101-2942) (354-4484) % with values above median of controls - 63.4 79.7** 100 * P<0.02 Vs Group 1 by median test; ** P<0.008 Vs Group 2 by χ2 test.
  12. 12. Predictive factors for Recurrent Diabetic Foot infection in South India. Follow-up study of 374 patients who had undergone surgery for foot infection during January 1994 and December 1997. [M:F 227:147; Mean age 54.9 + 9.4 yrs; Diabetes duration 10.9 + 7.7 yrs]. Vijay Viswanathan, D.V.L Narasimham, R.Seena, C. Snehalatha, A. Ramachandran, Diabetic Medicine [2000]
  13. 13. Comparison of predisposing factors in relapsers and non-relapsers. Relapsers Non relapsers P value n =198 n = 176 Age years 54.5 + 8.9 55.3 + 9.8 Smoking 33 (16.67 %) 31 (17.6 %) Diabetes duration yrs 11.5 + 8.14 10.2 + 7.1 Mean base line HbA1 % 10.3 + 1.1 10.4 + 1.1 Mean follow up HbA1% 9.7 + 0.9 9.6 + 0.9 PVD** 49 (24.7%) 27 (15.3%) χ2=4.53 P<0.03* Neuropathy** 134 (67.7%) 67 (38.0%) χ2=31.7 P<0.001* * Significant ** Chi square test, all others were compared by the 't' test
  14. 14. Diabetic foot infection is a common cause for hospital admission of diabetic patients in India. Probable reasons a. Socio-cultural practices such as bare foot walking. b. Poor knowledge of foot care among diabetic patients. c. Delayed referral of patients with foot infection to specialists. d. Inadequate facilities for diabetes care. e. Poor socio-economic conditions.
  15. 15. Studies in Europe Recurrence rate of 34% during a follow-up of 1 year and 70% over a period of 5 years. Apelquist et al. J. Intern. Med..1993.
  16. 16. Routine foot examination : the first step towards prevention of diabetic foot amputation. Aim of the study To determine the prevalence of common foot problems among apparently healthy diabetic patients. Vijay Viswanathan et al. Practical Diabetes International [2000].
  17. 17. PATIENTS AND METHODS : Every third diabetic patient who came to the foot clinic for routine testing of feet for neuropathy and PVD. 1010 patients (M:F - 706:304) were examined by the foot educator. Patients were examined for (i) Dry skin (ii) Heel fissures (iii) Fungal nail infection (iv) Ingrowing toe nails (v) Intertrigo (vii) Callus. Dr. Vijay Viswanathan / DRC.
  18. 18. SMOKING x2 P Yes No (n = 288) (n = 722) n % n % Dry skin 238 82.6 540 74.8 6.73 0.009* Heel fissures 166 57.6 432 59.8 0.33 0.57 Fungal nail infection 17 5.9 53 7.3 0.455 0.499 Ingrowing toe nail 25 8.7 47 6.5 1.155 0.28 Intertrigo 5 1.7 26 3.6 1.82 0.177 Callus 43 14.9 90 12.5 0.88 0.345 Neuropathy 75 26.0 128 17.7 8.35 0.003* PVD 32 11.1 34 4.7 12.78 0.0003* * Significant
  19. 19. Neuro Normal x2 P (n = 165) (n=779) n % n % Dry skin 134(81.2) 591(75.9) 2.719 0.436 Heel fissures 99(60) 458(58.8) 1.802 0.614 Fungal nail infection 16(9.7) 48(6.2) 3.435 0.329 Ingrowing toe nail 33(20) 35(4.5) 52.27 0.0001* Intertrigo 8(4.9) 19(2.4) 8.32 0.039* Callus 46(27.9) 68(8.7) 67.67 0.0001* COMPARISON OF PATIENTS WITH AND WITHOUT NEUROPATHY
  20. 20. FOOTWEAR χ2 P Always Outside (n=113) (n=891) n % n % Dry skin 62 54.8 711 79.8 33.79 0.0001* Heel fissures 45 39.8 549 61.6 18.82 0.0001* Fungal nail infection 2 1.8 68 7.6 4.44 0.034* Ingrowing toe nail 4 3.5 68 7.6 1.945 0.163 Tinea pedis 2 1.8 28 3.1 0.264 0.607 Callus 5 4.4 128 14.4 7.780 0.005*
  21. 21. Teaching patients how to practise foot care is widely accepted as an important part of diabetes education programs in order to prevent amputations. Barth et al. “Diabetic Medicine” (1991).
  22. 22. Using Mirrors
  23. 23. What needs to be controlled for foot at risk? Metabolic control Hyperglycemia Hypertension Hyperlipidaemia Cessation of smoking
  24. 24. What needs to be controlled for foot at risk? Deformity The importance of Callus removal in Neuropathic Diabetic Foot - decrease plantar pressure Dry skin and fissure management
  25. 25. What needs to be controlled for foot at risk? Debridement and ulcer management Mechanical control Off load, Off load, Off load by rest, crutches, walkers, protective shoes, heel protective pad, decrease plantar pressure by removal callus The importance of callus removal in NFU shows full dimension of the ulcer deep swab possible drainage of exudate, removal of dead tissue Infection control Education
  26. 26. • Learn to take good care of your feet. • Practice what you learn every day. • Foot problems must be detected and treated properly. • Take help of a Foot care specialist or your Diabetes Care Team. Need of the hour –Self care
  27. 27. Diabetes and your Feet Why People with Diabetes require good care of their Feet? There are several reasons • Loss of Sensation . • Poor Circulation ( Slow Healing of wounds) • Higher likelihood of developing foot infections that heal slowly or improperly.
  28. 28. Self Foot Care Recognize the Symptoms of Foot Problems • Pay attention to peculiar sensations such as the feeling of walking on Cotton or or on nuts. • Beware of feeling of wearing tight socks even when the feet are bare. • Stabbing pain or burning sensations. These all are major risk factors for the development of serious foot problems.
  29. 29. Daily Foot Care You can prevent major foot problems, if you can • Inspect your feet daily • Keep your feet clean and dry • Trim your toenails carefully • Protect you feet with appropriate footwear • Have your doctor or nurse examine your feet regularly (especially if you have any loss of sensation in your feet or toes)
  30. 30. Daily Foot Care Inspect your feet daily • Examine your feet in good light after bath. • Check for calluses, dry skin or areas that are reddened • Check to see that the nails are well trimmed. • Use a mirror to see the bottom of and between the feet. • Look and feel carefully for possible injuries, for breaks in the skin, cuts, scratches, bruises, blisters, sores, and discolouration.
  31. 31. Inspect your feet daily Learn to recognize the early signs of Infection • Unusual warmth over the injured area • Redness • Swelling • Pain ( if you still have good Sensation) • Drainage of pus from an opening in the skin. If you find any of these immediately take Doctor’s advice or ask your Diabetes Care team.
  32. 32. Keep your feet clean and dry • Wash your feet everyday.Wash them as you wash your hands, using soap and lukewarm water. • Use a moisturising cream to add oil to your skin and keep it smooth and soft. • Dry your feet carefully after bathing, especially between the toes where moisture can lead to a fungal infection. • Use mirror, if required.
  33. 33. Trim your Toenails carefully • It helps to avoid ingrown toenails, which can lead to infection. • Cut toenails after a bath, when soft and pliable. • Cut your toenails straight across the top and not too far back on the sides. • Do not use a sharp instrument to clean under the nail, or in the grooves. • If your toe nails are too thick to cut, you can have them cut by your Diabetes Care team.
  34. 34. Protect your feet with appropriate footwear Many foot problems can be avoided if you are careful to protect your feet at all times • Don’t walk barefoot. • Choose Proper footwear of the correct shape and size. • Always shop for shoes in the evening when the feet are the largest. • Check the size of the shoes wearing the thickest socks. • Choose cotton or wool Socks. • Socks should be free of wrinkles and holes.
  35. 35. Proper Footwear • Shoe should be comfortable and fit well. • Never wear Shoes which are too short or too narrow. • Rounded toes give more space to the feet. • Always choose flat shoes with thick, sturdy soles to protect the feet from sharp objects. • Leather shoes let the foot breathe freely. • When buying a pair of Shoe, take in to account any bunions or other irregularities. These will require wider and deeper shoe to avoid pressure points.
  36. 36. Pressure Sores or Ulcers • It starts with a callus, which is a sign of continuous pressure or friction on a particular part of feet • It is always advisable to treat the callus before an ulcer occurs. See your Doctor or Diabetes Care Team immediately. • If not treated properly , such ulcers can lead to serious foot problems like Gangrene. • The presence of Gangrene can sometimes lead to the removal of a toe or foot (Amputation).
  37. 37. Red marks on the foot
  38. 38. Cuts, and Injuries • Keep the affected area or Injury clean and apply a sterile bandage. • If you have decreased sensation in your feet , you have to be more careful to avoid Injuries such as minor accidents, Burns etc. • In absence of pain (alarm system), these minor injuries may become serious and can lead to amputation or removal of that part of the foot.
  39. 39. Fungal infection between the toes
  40. 40. Blisters and Cracks • Never squeeze or puncture a blister. • Proper bandage and Careful inspection is most important. • If the blisters appears to contain blood or becomes inflated see your doctor or Diabetes care team. • Cracks are difficult to heal and Infections occur easily. Daily use of foot cream to soften the skin as well as a shock absorbing insole is recommended.
  41. 41. Blister on the foot
  42. 42. • It often caused by Improper nail trimming or poorly fitted shoe. • The problem can be solved by correcting the footwear. You can ask you Diabetes Care Team for assistance. • As with all foot problems , prevention is the best cure for ingrown nails. Ingrown Nails
  43. 43. Inflamed toe
  44. 44. Corns and Calluses • Usually Corns and calluses result from poorly fitted footwear that puts pressure on certain area of the Foot. • A deep ulcer or crack can result if the callus is left untreated. • Consult your Doctor or Diabetes Care Team for further treatment of Corns and calluses.
  45. 45. Callused skin
  46. 46. Nerve problems and Foot Care • Nerve fibers carry messages between the brain and all parts of the body. • Nerve damage in your feet may lead to loss of sensations and muscle weakness. • It decreases your ability to sweat or impair blood flow to your feet. • It can affect the way you walk, leading to joint fractures that occur without any apparent accident or other cause.
  47. 47. Symptoms of nerve problems in your feet • Tingling, or a feeling of “PINS and NEEDLES”. • Numbness • A peculiar feeling of walking on cotton or nuts. • Stabbing or burning Pain. • Pain with light touch of a bed sheet. • A feeling like wearing tight stockings. • Keeping your blood sugar as close as normal ( 90- 110 mg/dl) can slow the development of Nerve problems.
  48. 48. Who is at a risk of Foot Ulcers ? Some People with Diabetes have a greater risk of developing foot ulcers than others. The factors which may play a role are: • Those with more than 15 years of poorly controlled diabetes • Impaired Vision • Smoking
  49. 49. You should take more care of your feet if you have any of the following • Loss of sensation in your feet • Poor Blood circulation as in pain at rest. • Bunions or other foot deformities • Previous foot ulcers Who is at a risk of Foot Ulcers ?
  50. 50. Blood Sugar Control • Poor blood sugar control is a risk factor for the development of foot ulcers. • Good control can prevent the development and progression of nerve problems ( Loss of Sensations). • The better you blood control , the better your body can take care for itself.
  51. 51. Poor Vision • Poor vision puts your feet at risk, because you may not be able to see the minor sores and other foot problems at the bottom of the feet. • Ask your diabetes care team for complete inspection of the feet.
  52. 52. Smoking • Do not smoke as nicotine causes blood vessels to shrinks and slows down the blood flow to the foot. • Impaired blood circulation can increase the foot Problems.
  53. 53. Examination of your feet • Assess the general condition of your skin and nails • Check for signs of poor circulation. – Cold extremities, absent or weak pulsations • Check if you can feel normal sensations. • Look for the deformities such as bunions. • Note any calluses. • Check for signs of infection, injury and ulcers. • Watch the way you walk and note any changes.
  54. 54. Tests Done On Feet • For the loss of protective sensation like pain. • Your ability to feel vibration. • Light touch with a monofilament. • For impaired blood circulation, or foot pulses. • Toe blood pressure. • An angiogram of arteries if required.
  55. 55. Foot at risk - 1 • Our job – look after “NDF at risk” • A: Preventive measures • Treatment - rapid and intensive • Rest • Off load • Antibiotics • Foot wear • Patient education