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Screening and
Treatment of the
diabetic foot in
The Netherlands Bela Pagrach
Diabetic Nurse
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Hospital Amstelland
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Diabetic Foot team
Vascular Surgeon
Rehabilitation Specialist
Plaster Master
Wound Care Nurse
Orthopedic Shoemaker
Diabetic Nurse
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Guidelines Diabetic Foot 2017
The old guidlines where from 2006
What has changed in 11 years?
There is a difference between primary care and hospital
care
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Changes in Diabetic Foot care 2017
Primary care: examination of the foot ones a year
When there is a wound in primary care and there is no wound healing
within 3 days, than reference to a Hospital.
There has to be a diabetic foot team in the Hospital care.
Casemanager
Additional chapter about the Charcot foot
Choice for Wound care products
Control after Wound healing
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How to perform a risk qualification
You have to have:
1. Knowledge of the Diabetic Foot and its risk factors
2. Skills to perform a screening
3. Know how to make a right interpretation of the screening results and make up the risk classificationof the foot
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The screening of the Diabetic Foot
1. Take the history
2. Inspection and test:
- for signs of mechanical stress and/or
foot deformities
- wounds
- shoes
3. Test protective sensibility
4. Test for signs of peripheral arterial disease
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Important abbreviations
PAD = Peripheral Arterial Disease
PS = Protective Sensibility
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Risk Qualification
In Dutch: Simms QualificationNo. Risk Examination Control
1 No No signs of PS of PAD 1 x per year
2 Mild Signs of PS or PAD 2x per year
3 High Signs of PS and/or PAD
and/or footdeformities
and/or callus
4x per year
4 Very
high
Healed ulcer or healed after
amputation
Every month
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Risk classification 1-4
Risk Category 1 = NO risk for ulceration
Your patients risk is as big as yours for
developing an ulcer…..practically zero
NO loss of protective sensibility (PS)
NO PAD
Review of risk classification: Once per year
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Risk classification 1-4
Risk Category 2 = MILD risk for ulceration
OR Loss of protective sensibility (PS)
OR Signs of PAD
NO signs of mechanical stress (too much callus or
impaired foot deformation)
Review the status of the foot: 2x per year
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Risk classification 1-4Risk Category 3 = HIGH risk for ulceration:
Loss of PS in combination with PAD
Loss of PS in combination with mechanical stress and/or foot deformation
Signs of PAD in combination with mechanicalstress and/or foot deformation
Both loss of PS, signs of PAD and mechanicalstress and/or foot deformation
Review: 4 x per year12
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Risk classification 1-4
Risk Category 4 = VERY HIGH risk forulceration:
Every diabetic foot after healing of an ulcer OR after (healed) amputation
These patients have a risk for re-ulceration: 50-70%
Review: every 1-3 months
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Skin temperature measurement
Palpation from proximal (just below the knee) to distal
(toes):
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Infra red skin temperature
measurement device
More accurate than
just palpation
Evidence based:
More than 2° Celsius
difference between
both feet = alarm!
Possible problems:
- ‘warm’ foot = infection – acute Charcot?
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Skintemperature
Depends always from the temperature of the
surrounding
You have to look
for a temperature
difference more
than 2° Celsius!
If so send your
patient to the doctor
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Test for (loss of) Protective Sensibility (PS)
This is your most important instrument!!
10 gram Semmes Weinstein Monofilament
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NOT a test for a risk of an ulcer
Vibration Perception Test = test the risk of losing
balance risk of falling
loss of perception or ‘deep’ sensibility
use a Tuning Fork 128 Hz
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Test for LJM
Prayer’s sign
..but also: look for the place of callus formation!
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Shoe inspection
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Care Profile
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Reimbursement Foot Care
Risk 1 /care profile 1 = No reimbursement
Risk 1 /care profile 2 = reinbursement
Risk 2,3 and 4/ care profole 2 till 4 = reimbursement
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Reimbursement foot care by Podiatrist
and Pedicure
With an high risk care profile the patient have to visit the podiatrist.
The podiatrist is doing the foot test again and make profile for foot
care executed by the pedicure.
The pedicure care will be reimbursed between the 6 and 12 times a
year, depending on risk profile and foot care profile.
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Inspection
Why do you see callus on this
spot of the foot?
Look and look good: also between the toes!
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Inspection of the color of the
foot Pink = normal
White = cold, lack of circulation
Red = Inflammation?
Early stage Charcotfoot?
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Shoes should fit…..
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Very important
This test does NOT tell us about the risk of foot
ulceration
Important to discover lack of propriocepsis
imbalance, increased risk for falling
Therapy: Education!!
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Interpretation of the examination
1. Which Risk Classification?
2. What Treatmentplan?
3. Always: Education of the patient!
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Extra vision test
Visual-check card
Telescope mirror
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Daily inspection
If the patient can read 4-5 lines: OK
If not hetero-inspection of the foot by??
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Interpretation
Your patient can read:
All 5 lines no loss of vision
self inspection is OK
2-4 lines deminished vision
no self-inspection
1 of no lines very bad vision
no self-inspection
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Test for signs of PAD
Protocol International Consensus (May 2011):
1. Palpate pulsations:- a. dorsalis pedis- a. tibialis posterior
2. Listen to the vascular tones (pulsations) with a hand Doppler
3. Measure the Ankle-Arm-Index
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Interpretation
According the Int. Consensus 2011:
On each foot 1 of the 2 arteries
pulsations have to be present
If no pulsations can be detected listen to the
vascular tones:
Tri- or Bifasic = normal
Monofasic = not normal
No sounds at all = acute alarm!
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ALL (!) callus has to be removed
Treatment
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Off-loading
Off-loading:
Felt padding in case of superficial
ulcers
BUT:
Total Contact Cast (TCC)
is the ‘Golden Standard’
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Patient education!!!!
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Content of education Daily inspection
Good foot care
NEVER walk on bare feet
NO footbath (no soaking)
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More issues to discuss
Good shoe advice ( Width,right shoe size, heel hight))
Ware of seamless socks.
How and where to gaininformation: internet??
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Important: Can your patient
inspect his/her own feet? We advise every patiënt to look good ad
his/her feet twice a day
But…how do we know that this patient has a
good enough vision?
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