Dr Sue Benbow Diabetes is one of the biggest health challenges facing the UK today. Merseyside is no exception, with over 70,000 people already diagnosed with the condition and the numbers are increasing year on year. Disease of the foot is a complication of diabetes caused by either damage to the nerves or the blood vessels that service the limbs. But, worryingly, one in three people with diabetes don’t realise that having the condition puts them at increased risk of having an amputation. The literature suggests that 15 per cent of the population.
With diabetes will experience an ulcer during their lifetime, with 6 per cent having an amputation a complication that is both costly to the individual and to the NHS. But if the incidence of ulcers and amputations could be reduced by intensive preventative measures, there could be a significant saving to both the NHS and to the individual. Diabetes is the commonest cause of nontraumatic amputation in the UK, with up to 80 per cent of amputations being preceded by a foot ulcer. However, ulceration and amputation should not be seen as an inevitable.
Consequence of diabetes. Many foot ulcers and amputations could be prevented. The early identification of the atrisk foot, combined with patient education and the application of other preventative measures, as well as the rapid treatment of complications by the multidisciplinary footcare team, should help avoid this scenario. So what are the principles of good foot care These should be simple, visual examination of both feet at least once every year as an essential management of the person with diabetes, no matter where they’re seen. All clinical staff seeing people with diabetes should be trained and competent in.
Diabetes Foot Screening
Undertaking a basic foot check. The potential threat of active foot disease should also be recognised by nonspecialist healthcare professionals. Screening the foot is vital, but once assessed, the person should have the risk level classified as low, increased or high current risk and, where necessary, action must be taken to reduce future problems. Where active foot disease is found, it requires a relevant history to be taken, a thorough examination and immediate referral onwards to a multidisciplinary footcare team with the necessary skills in the management of the diabetic foot.
Helen Pendlebury There are two main conditions that affect the foot due to diabetes. These are peripheral neuropathy, which affects feeling and peripheral arterial disease, which results in reduced circulation. Diabetic peripheral neuropathy is defined as the presence of symptoms andor signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes. One of the symptoms of neuropathy can be the loss of protective sensation in the feet. A person with loss of protective sensation could injure their foot and be completely unaware of any resulting problems. Peripheral arterial disease causes calcification, arterial.
Narrowing and blockage of blood vessels, which can result in reduced blood flow to the feet. This can manifest itself in many ways and, in particular, it may cause pain when walking or at rest and result in a reduced ability to heal. To start a diabetic foot screening, sit the patient on the examination couch with their shoes or socks or stockings removed. Inform them that you are going to examine their feet and carry out a diabetic foot screening to check their risk of developing any diabetic foot complications. All the results of the.
Baseline foot examination should be recorded on the baseline footscreening form or on the GP template. Firstly, check if the patient has suffered any previous amputation. The next stage of the screening process is to check the general shape of the feet for any nail or foot deformities such as pes cavus, claw toes or hallux valgus, all of which could increase the patient’s risk of developing foot complications. Check both feet for any areas of significant callus or dry skin, paying particular attention to the heel area. Check between the toes for problems such as athlete’s foot, soft corns or fissures. Check both feet.
For areas of ulceration and ask the patient if they have suffered any previous ulceration. Check if the patient is able to selfcare. This can be done by checking if the patient can reach their feet with ease and if they are able to see their feet clearly. Check if there are any other risk factors present, such as nail pathologies or inappropriate footwear. The next stage of the screening process is to check the patient’s circulation to their feet. There are two pulses we look for in each foot the dorsalis pedis and.
The posterior tibial. To find the dorsalis pedis pulse, palpate the foot between the first and second metatarsals. Note that the dorsalis pedis pulse is absent in about ten per cent of the population. To find the posterior tibial, palpate the area behind the medial malleolus. Record whether each pulse is present or absent. Ask the patient if they are experiencing intermittent claudication which is pain or tightness in the calves on walking, relieved by stopping or if they have had any previous vascular intervention. The next test we carry.
Out is for diabetic neuropathy. This is to easily enable us to check if the patient’s protective sensation is intact. For this test, we use a 10gram monofilament. It is important that you only use reputable makes of monofilament, such as manufactured by Bailey Instruments and Owen Mumford. This will ensure the information you are collecting is accurate. The monofilament must be rested for 24 hours after ten patients and replaced after 100 uses. The advantages of this test are its simplicity, accuracy and low cost. Studies have shown that inability.
To feel a 10gram monofilament is a useful test as a predictor of future occurrence of diabetic foot ulcers. Inform the patient you are going to test the sensation in their feet with the monofilament. Show the patient that it is not sharp by first testing it on their hand. You may need to test it on the patient’s elbow or forehead if the patient has neuropathy affecting their hands. Patients must have their eyes closed so they cannot see where the filament is being applied. The monofilament should be applied perpendicular to the surface.
Of the skin and with sufficient pressure to cause a slight bend in the filament. If it is kinked, it will need to be replaced. Test on the plantar aspect of the first toes and the first and fifth metatarsal heads, as demonstrated. Avoid testing areas on the foot where there is callus present, areas of ulceration or scar tissue. You may have to test proximally or distally when any of these are present. Do not make any repetitive contact or allow the monofilament to slide across the skin. Press the filament to the skin and ask the.
Patient if their feel pressure and next where they feel the pressure being applied. Clinician Can you feel that Patient Yep, like, underneath me big toe. Clinician Can you feel that Patient Yep. Underneath me little toe. Clinician Thank you. Can you feel that Patient Yep. Underneath me other big toe. Helen Pendlebury Repeat this application twice at the same site, but alternate this with at least one mock application in which no filament is applied. Clinician Can you feel that Patient No. Clinician Can you feel that Patient No. Helen Pendlebury This gives a total of three questions per site. The total time from contact.
To removal of the monofilament should be approximately two seconds in duration. Protective sensation is present at each site if the patient correctly answers two out of three applications. Protective sensation is absent with two out of three incorrect answers and the patient is considered to be at risk of ulceration. Ask the patient if they are experiencing any pain or paresthesia, often described as tingling or burning in their feet and record as appropriate. The findings from these tests will enable the patient’s risk category to be recorded on the form. Following the pathway with then determine if the patient needs to be referred.
To another healthcare professional, such as a podiatrist, or whether they can receive the appropriate foothealth education and continue to be screened annually at the practice. We are now going to carry out a simple diabetic foot screening on our patient in a clinical situation. Firstly we check that there have been no previous amputations. We then check the general shape of the foot for any structural abnormalities. Check for any callus, paying particular attention around the heel areas. Check between the toes for any problems such as athlete’s foot or fissuring. Ask the patient if there has been any previous ulceration.
Check if the patient is able to selfcare by being able to reach and see their feet easily. We then check the two pulses on either foot. Firstly the dorsalis pedis and then the posterior tibial. We are now ready to carry out the neurological test, using the monofilament. We test the plantar aspect of the first toes and the first and fifth metatarsal heads, recording as appropriate. Clinician Just going to check the sensation in your feet. If I just show you this it’s a very light touch. I’ll just show you on the underside of your arm. Smashing. I’m going.
To touch different parts of your foot. If you can just say yes when you feel it touching, just describe where you think it’s touched, OK Close your eyes for me as we do the test. Can you feel that Patient Yep, on my big toe. Clinician Can you feel that Patient Yep, like, underneath me big toe. Clinician Can you feel that Patient Yep. Underneath me little toe. Clinician Thank you. Can you feel that Patient Yep. Underneath me other big toe. Clinician Can you feel that Patient Yep, underneath me big toe.
Clinician Can you feel that Patient No. Clinician Can you feel that Patient Yep, underneath me little toe. Clinician Can you feel that Patient Yep, like, underneath me big toe. Clinician Can you feel that Patient No. Clinician Can you feel that Patient Yep. Clinician Whereabouts did that last one feel like Patient Erm, underneath my little toe. Clinician That’s great. OK, you can open your eyes now. Patient Thanks. Helen Pendlebury Once you have completed the patient screening, you will enter all the relevant findings on the baseline footscreening form. Following a diabetes foot screening,.
Patients should be categorised into low risk, increased risk, high risk or foot ulcer. If a patient has palpable pulses and normal sensation, the lefthand side of the pathway will be followed and the patient classified as low risk. The patient should be encouraged to continue with their own foot care. Lowrisk verbal advice should be given and supported by a lowrisk advice leaflet. A diabetes foot screening should be completed annually. Where a patient has neuropathy or absent foot pulses or has a risk factor which impacts on foot health, such as inability to selfcare, foot or nail deformity and pathological callus,.
The patient should be categorised as increased risk. This is the blue section on the footscreening pathway. All these factors require podiatry management. The patient should be referred directly to the local podiatry department. Following podiatry assessment and management plan, any advice will be supported with an increasedrisk advice leaflet. Ideally, the management plans should be reviewed every three to six months and annual diabetes foot screening will follow within the podiatry service. Where a patient has neuropathy or absent foot pulses and foot deformity or pathological callus, the patient should be categorised.
As high risk. This is the yellow section of the pathway. A highrisk advice leaflet for neuropathy or poor circulation or deformity is supplied by a podiatrist in support of any verbal advice given following a podiatry appointment. Ideally, the patient should be reviewed by a podiatrist every one to three months and annual foot screening will ensue. If a patient presents at a footscreening consultation with a chronic or stable diabetes foot ulceration, this represent the foot ulcer or red section of the pathway. A footulcer leaflet will be given followed by referral to the diabetes multidisciplinary footcare.
Team and to the podiatry service. Where a patient may present with critical ischaemia, spreading cellulitis, severe infection or acute charcot osteoarthropathy, this is classed as a foot emergency. Immediate referral should be made to AE or admission arranged via the patient’s GP. The next available appointment should also be made at the multidisciplinary footcare team for further investigations and assessment. This is as directed in red at the bottom of the pathway. Fred In my opinion, it’s important for me to get my feet checked on a regular basis because of the nerve damage that diabetes induces on your feet and it’s important that,.
On a daytoday basis, I get a check done, but I also get a check done by a professional. They can tell if there’s anything that’s actually going wrong with it that I can’t detect. Joan I see annual foot screening as an essential in my diabetes care. It means a lot to me and I do go regularly to get it done because, long term, as I say, it can cause problems and, after this length of time, I prefer to keep problems away rather than encourage them. When I go for my footscreening appointment, the podiatrist normally checks the nerve sensation,.
Checks the circulation and it’s not painful, it’s no problem and the maximum, I would say, about ten minutes. Fred My immediate results with my foot screening are there and then and the other information I need about that is given to me in that I might have to go and see somebody else for further screening. Joan When the foot screening has been done, they normally give you the results at the end of it, they usually say what risk you are, whether it’s low, moderate or high risk. And then you’re given information on. you’re given a leaflet about the risk factor involved.
And you’re also given advice on who to contact should there be a problem before your next footscreening appointment. Fred If you are a bit nervous about getting your feet screened, you actually don’t need to be nervous about it because it’s quite a quick and easy process and it’s important, if you have got diabetes, that you’re able to get it checked and your doctor will either check it himself or herself or will pass you on to somebody, a podiatrist, who has a better understanding of how the feet are and should work.
Joan It’s something that you really need to do because, long term, diabetes can have horrendous complications and the sooner you do something, the better. You know, it is very important, certainly from my viewpoint, and with doing what I’ve been doing, I’ve now gone 50 years without. with very few complications and I think that’s been as a result of making sure that I get screening for feet and any other areas that need checking. Dr Sue Benbow We hope that the production of this DVD will help both healthcare professionals.