The Diabetic FootStratification, Assessment & Referral

Introduction

• Scope of Podiatry and its role in prevention of lower limb ulceration and amputation.

• Nursing - diabetic foot risk assessment• Risk stratification & referral to podiatry services.• Vasc & neuro Assessment – practical• What clinical features = high risk diabetic foot• Case study• Funding• Discussion & foot related questions

Podiatry – Scope of Practice

• Diagnostic Profession concerned with all aspects of foot health– Pharmacology– Medicine– Biomechanics– Radiology– Neurological, Vascular & Dermatological Assessment

& Treatment– Orthotics Prescription and Fabrication– Surgery

Podiatry & DiabetesOur Role in Prevention

• Vascular and Neurological Assessment• Biomechanical & Dermatological Assessment• Off-loading Plantar Pressures• Mechanical and Orthotic Therapies• Specialized Skin & Nail Care• Prophylactic Surgery• Education

Nursing Diabetes Stratification & Risk Assessment

• Do they have an active ulceration, severe infection or unexplained swelling, heat and redness?

• Do they have Peripheral Arterial Disease and/or Peripheral Neuropathy with any of the following:

• Foot deformity • Thick nails or corns/callus?• Are they ESRF?• Are the Maori?• Do they have a history of foot ulceration or amputation?

• Do they have Peripheral Arterial Disease and/or Peripheral Neuropathy?

Diabetes Stratification

• Active Foot Disease - Hospital Pod• Current Ulceration/ Hot,red, swollen foot / severe infection-cellulitus

• High Risk - Community Pod• PAD or Peripheral Neuropathy with High Risk Features - Two funded consults with Community Pod

• Moderate Risk - Community Pod• PAD and/or Peripheral Neuropathy -One Funded Consults and treatment plan with Pod

• Low Risk - GP, Nurse, • WINZ funding available for all Diabetes Beneficiaries or Pensioners

Diabetes Stratification

• Low Risk Foot (no referral needed)– Good blood flow and protective sensation is intact

• Moderate Risk Foot (referral to Primary/ Private Podiatry)– Peripheral Vascular Disease (PVD) and/or Peripheral

Neuropathy with no other pathology• High Risk Foot – with ‘high risk’ pathology

• Active Foot Disease– Current ulceration or charcot neuro-athropathy

Vascular Assessment

• Signs– Pulses not palpable – Doppler – pulses not detected or very low pitched sound– CRT more than 5 seconds (micro-angiopathy?)– Poor Colour & cool temp gradient – Diminished pedal hair

• Symptoms– Intermittent Claudication (pain on walking, every time they

walk at the same distance, have to rest for pain to ease)– Rest Cramps (cramps in bed each night or at rest)

Macro-vascular Assessment - Pulses

• Vascular AnatomyDorsalis Pedis

Macro-vasc Assessment• Posterior Tibial Pulse

Macro-vascularDoppler Assessment

• Doppler is an excellent tool to have, as often even good pedal pulses are hard to palpate, especially if there is oedema present

• Use ultrasonic gel, and move the ultrasound head until you get the loudest reading on that pulse. A good pulse is very loud with 3 phases of sound, a poor pulse is very low pitched with only one phase.

Micro-Vascular Assessment

• CRT – normal is less than 5 seconds• Absence of pedal hair indicates poor micro-

vascular status• Thick atrophied nails can indicate poor

circulation to the skin also• Temperature – cold feet• Poor Colour

How to do the Monofilament Test• Show the patient that the monofilament test is not painful by touching

your own hand with the monofilament.• Let them feel it on their hand – so they know what to expect• Patient closes their eyes and says ‘yes’ every time they feel it.• Avoid asking the patient “Can you feel that?”• Press the monofilament perpendicular to the skin and let it buckle and

hold for 1-2 seconds before releasing it.• Re-test each site that the patient could not feel to be sure we have an

accurate test.• Be aware that callused areas will have less sensation.

• Two or more sites gone undetected by patient is considered Moderate Risk

Dermatological & Biomechanical features of the High Risk Foot

If your patient has PAD or Peripheral Neuropathy with:• Thick nails• Corns or Callus• Foot Deformity • End Stage Renal Failure• History of lower limb ulceration or amputation• Maori ethnicity

This is considered a High Risk Foot

High Risk Pathologies – Callus & CornsPre- ulcer lesions

High Risk Pathologies Pre-ulcer Lesions

• Corns and Callus are known in Podiatry as pre-ulcer lesions.

• Peripheral Neuropathy with Corns and Callus are the common causal pathway to ulceration.

• This is why patients with PAD and/or Peripheral Neuropathy are considered High Risk.

High Risk Pathologies – Deformityleads to pre-ulcer lesions

High risk Pathologies - Nails

Case Study

Case Study - Ruth88 year old femaleDiabetes with impaired nerve function and blood flowVisual impairmentUnable to care for feet at homeGood Health otherwisePresents with thick crumbly nails due to peripheral vascular diseaseRequires regular nail treatment to prevent ulceration of nail bed

Case Study

• No pain in feet• During treatment (grinding thick nails) infected

wound discovered under the nail plate

Case Study

• Early detection through routine nail care by a Podiatrist prevented ulceration and amputation

Available Funding

• PHO Packages of Care– High Risk Feet – Two Consultations Private Podiatry

– Moderate Risk Feet – One Consultation Private Podiatry

WINZ – Disability Allowance – all diabetes patients

Parkinson’s Society

PHO Packages of Care

• The packages of care are designed to provide full assessment, including ABI where indicated.

• Also the Podiatrist, puts a treatment plan in place with the Primary Health Providers, GPs & Practice Nurses.

• Work with WINZ for regular care

Foot Questions

Located within the new Whareora o Tikipunga Clinic, 157 Kiripaka Road, Tikipunga.Phone: 09 437 0015Fax: 09 437 0016

Mid North Clinic: – Paihia Medical Services, 22 Selwyn Ave, phone:

402 8407

Far North Clinics:– Mamaru Clinic, Coopers Beach Shopping Mall, phone:

406 0074

– Kaitaia Clinic, Te Whare Hauora, Redan Road, phone: 408 0049