Posts Tagged ‘Diabetic Foot’

Diabetic Toenails: Watch for Change

Thursday, February 23rd, 2017

Changes in the diabetic foot can happen fast: here are the signs and types clinicians in wound care need to look for.

Diabetic Toenails: Watch for Change

 

As a wound care professional, chances are you’ve treated a number of nail conditions and abnormalities that occur among the general population. But when you’re working with diabetic patients, noticing and identifying variations is even more crucial. This is because change can happen more rapidly in the diabetic foot, and pathologies can ultimately lead to skin breakdown, foot ulcerations and infection. So, what causes the nails to change, and what exactly should you look for? We’ve got you covered.

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Diabetic Toenails: Top Tips for Proper Trimming

Friday, November 11th, 2016

Check out these best practices for trimming your diabetic patient’s toenails, which can help in preventing foot ulceration.

Diabetic Toenails: Top Tips for Proper Trimming

 

Did you know that a whopping 10-25% percent of all patients with diabetes ultimately develop a foot ulcer – a diagnosis that brings a five-year mortality rate of nearly 50%? Consistent foot care, such as regular screenings, footwear assessment and nail maintenance can help prevent ulceration.

You can help diabetic patients with nail maintenance by taking extra care to preserve the integrity of the toenails. This includes keeping the cuticles and surrounding skin intact, and following best practices when trimming the nails. That’s why we’ve put together our top tips for proper trimming.

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Diabetic Foot Screening Guide

Friday, July 29th, 2016

Five clinical tests for diagnosing loss of protective sensation in the diabetic foot, plus tips on inflammation assessment.

 

Diabetic Foot Screening Guide

 

How serious are diabetic foot ulcers? The statistics are sobering:

  • It is estimated that between 10 and 25% of patients with diabetes will develop a foot ulcer in their lifetime.
  • Diabetic foot ulcers precede 84% of all lower leg amputations.
  • The five-year mortality of patients with newly diagnosed diabetic foot ulcers (DFUs) is nearly 50%, and carries a worse prognosis than breast cancer, prostate cancer, or Hodgkin’s lymphoma.

In addition, DFUs are at increased risk for infections and other complications, and continue to be a major cause of hospitalizations and additional healthcare expenditures.  So while patients suffer greatly from DFUs, these chronic wounds are also a huge financial burden on healthcare systems. This is because these same patients spend more days in the hospital, and experience more visits to the emergency room and outpatient physician offices than other patients with diabetes.

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Diabetic Footwear: If The Shoe Fits, Wear It

Friday, April 29th, 2016

When it comes to diabetic wound care, footwear matters – and proper diabetic patient shoe assessment is key.

Diabetic Footwear

 

Wound clinicians know how devastating foot amputations are for diabetic patients. But what you might not know is that a whopping 50% of diabetic foot amputations are a direct result of patients wearing improper footwear. Surprised? Unfortunately, this staggering statistic is accurate. But the good news is that there’s something we can do about it. If we get diabetic patients to wear the proper shoes, we can cut diabetic foot amputations in half.

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Diabetic Wound Care: Monofilament Testing

Friday, March 11th, 2016

Detecting neuropathy in the diabetic foot is crucial for patient care, which is why this 10-step test is a must when it comes to injury and ulceration prevention.

Monofilament Testing

 

Healing patients and helping them get on the road to recovery are always at the top of any wound clinician’s list. We are always on alert and in constant assessment mode, looking for ways to prevent further complications or possible injury. So when a patient also happens to be diabetic, our assessment mode goes into overdrive.

One of the most common complications of diabetes is neuropathy, or nerve damage of the extremities. With sensory neuropathy, the patient loses protective sensation and the ability to feel pain and temperature changes. Without protective sensation, the diabetic patient is at an increased risk for foot injury or ulceration, and may not realize anything is amiss until there are serious complications.

Semmes Weinstein 10g Monofilament Test

This is why testing your diabetic patients for neuropathy is so important. In fact, the American Diabetes Association recommends that we screen diabetic patients for neuropathy annually, at minimum. Once we note any diminished sensation, we should check quarterly.

One way to assess protective sensation in the diabetic foot is to perform a Semmes Weinstein 10g Monofilament Test across designated sites on the foot.  The test uses a 5.07 monofilament that exerts 10 grams of force when bowed into a C-shape against the skin for one second.

 

Monofilament Diagrams

 

The test procedure is as follows:

  1. Use the 10gm monofilament to test sensation.
  2. Have patient close his or her eyes.
  3. Apply the filament perpendicular to the skin’s surface.
  4. Be aware that the approach, skin contact and departure of the monofilament should be approximately 1.5 seconds in duration.
  5. Apply sufficient force to allow the filament to bend. (Figure 1).
  6. Do not apply to an ulcer site or on a callous, scar, or necrotic tissue.
  7. Do not allow the filament to slide across the skin or make repetitive contact at the test site. Randomly change the order and timing of successive tests.
  8. Ask the patient to respond, “Yes,” when the filament is felt.
  9. Document response when felt, and test for sensation (Figure 2).
  10. Be aware that neuropathy usually starts in the first and third toes, and progresses to the first and third metatarsal heads. It is likely that these areas will be the first to have negative results with the 10gm monofilament. Repeated testing can demonstrate vividly to the patient the progression of the disease.

Record the results on the screening form, noting a “+” for sensation felt, and a “-” for no sensation felt. The patient is said to have an insensate foot if they fail on retesting at just one or more sites on either foot. Injury is much more likely to occur in these insensate areas and we must take protective measures. Provide patient education verbally and in writing, such as these materials from the American Diabetes Association, and be sure to do a good shoe fit assessment as part of your care plan.

Do you administer this test?

Are you familiar with the Semmes Weinstein 10g Monofilament Test, and do you administer it on a regular basis to your diabetic patients? Have you noticed significant results in terms of prevention and assessment? We are interested to know about your experiences in diabetic foot testing, so please leave your comments below.

 

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Click to download this easy-to-use resource for performing foot examinations.

Dry Skin Alert: Foot Xerosis in Diabetic Patients

Thursday, January 14th, 2016

Diabetic wound management requires awareness, including knowing the signs and progression of xerosis – an abnormal dryness of skin.

Xerosis in Diabetic Patients

Patients with diabetes are prone to dry skin, particularly when blood glucose levels are running high. And as a clinician, one of the most common types of skin conditions you will see in your diabetic patients is xerosis, which is an abnormal dryness of the skin. This is just one reason why clinicians should routinely inspect the feet of diabetic patients.

According to research, 82.1% of patients with diabetes had skin with dryness, cracks or fissures, which serves as a predictor of foot lesions. In addition, an unpublished survey of 105 consecutive patients with diabetes revealed that 75% had clinical manifestations of dry skin. This serves as further evidence that xerosis in diabetic patients is a threat to foot ulcers, and the more we know about the condition, the better we can treat and heal our patients.

The Signs

The most common characteristics of xerosis include excessively dry, rough, uneven and cracked skin. Other signs include:

  • Possible raised or uplifted skin edges (scaling), desquamation (flaking), chapping, and pruritus.
  • Excessive dryness and scaling on the heels and feet.
  • Possible fissures (linear cracks in the skin) with hyperkeratotic tissue.

Progression and Patterns

The progression of xerosis follows a defined pattern that begins when the skin becomes dry and rough, with pronounced skin lines. As the condition progresses, you’ll see the development of superficial scaling, with fissuring and erythema. In severe cases, a crisscrossing pattern with superficial scaling is present. The skin becomes less elastic and loses both its flexibility and its ability to withstand trauma, which may result in skin breakdown and subsequent infection.

Causes

A number of conditions contribute to the onset of xerosis in diabetic patients, including the loss of natural moisturizing factors and moisture from the stratum cor­neum and intercellular matrix of the skin. Additionally:

  • Sebaceous and sweat glands normally maintain skin lubrication and control the oil and moisture in the foot, but they become atrophied when autonomic neuropathy occurs.
  • Corneocytes (cells that make up the top layer of epidermis) are aligned parallel to each other in normal skin; xerosis causes structural changes to these cells and disrupts the surface, resulting in a rough epidermal surface.
  • The dryness is due to the redistribution of blood flow in the soles of the feet by persistent and inappropriate dilatation of arteriovenous shunts. This activity diverts blood away from the skin surface. When this occurs in combination with alterations in the elasticity of the skin (due to nonenzymatic glycosylation of structural proteins and glycoproteins), the skin splits, creating portals for bacteria to enter.

Treatment

Once you see initial signs of xerosis in your patients, what should you do? Start by applying an agent to the feet every day in order to maintain skin moisture, such as an emollient lotion or cream. Use moisturizers that contain urea or lactic acid.

  1. Urea works by enhancing the water-binding capacity of the stratum corneum. Long-term treatment with urea has been demonstrated to decrease transepidermal water loss. Urea also is a potent skin humidifier and descaling agent, particularly in 10% concentration.
  2. Lactic acid (in the form of an alpha hydroxy acid) can accelerate softening of the skin, dissolving or peeling the outer layer of the skin to help maintain its capability to hold moisture. Lactic acid in concentrations of 2.5% to 12% is the most common alpha hydroxy acid used for moderate to severe xerosis.
  3. Examples of products with urea or lactic acid include Atrac-Tain Cream, Eucerin 10% Urea Lotion, Lac-Hydrin 12%, and AmLactin Foot Cream Therapy.

Additionally, it’s important to avoid:

  • Products that contain alcohol – because they evaporate, and their drying action compounds the original problem.
  • Petroleum-based products, because they seal the skin surface and prevent what little lubrication is made from evaporating. These products don’t penetrate the surface of the skin and don’t replace skin moisture.

Patient education

As always, part of our job is to continuously educate patients and their family members or caretakers. When it comes to your patients suffering from xerosis, make sure they know to:

  • minimize bathing to no more than once a day (or even every other day)
  • use cool or lukewarm water
  • pat – don’t rub – to dry the skin
  • avoid harsh soaps
  • avoid lotions with dyes or perfumes
  • ensure skin moisturizers are applied appropriately and at the right frequency

What do you think?

Knowing the signs of xerosis and how to treat it is crucial for diabetic patients. Have you had experience with this condition, and are there any specific techniques, treatments or products you find most effective? And what are the biggest challenges you face when it comes to this particular type of wound management? We would love to hear about and learn from your experiences! Please share your stories below.

 

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

Urgent! Risks and Diagnosis of Diabetic Foot Infections

Friday, January 8th, 2016

For effective diabetic wound management, clinicians must know the risk factors for foot infections, and be able to diagnose them properly – and as soon as possible.

Diabetic Foot Infections

Wound care clinicians deal with foot infections all the time, but when the patient is also diabetic, an infection can progress rapidly to a critical state. In fact, it is estimated that around 56% of diabetic foot ulcers become infected, and an infected foot wound precedes about two-thirds of amputations.  Being able to treat diabetic foot infections promptly – before they progress too far – helps prevent amputations, which is why your role is so crucial to a patient’s well-being.

What are the risk factors?

If you are treating a diabetic patient with a foot infection, there are a number of risk factors to consider. These include:

  • 30-day-old wounds
  • Wounds that go down to the bone
  • Recurrent foot infections
  • Peripheral vascular disease
  • An etiology from trauma

In particular, be on high alert with your diabetic patients for what they call an occult (hidden) infection. A diabetic foot ulcer could clearly have an infection, but fail to show any of the classic signs and symptoms that you traditionally look for, like erythema, heat, pain and purulence.

Because a diabetic patient’s immune system is compromised, you might be on the lookout for typical signs but not see any of them at all. This does not mean that an infection isn’t there; only half of diabetic foot ulcer patients will show classic signs, which means we also need to work our patients up for infection.

The best approach? Be persistent and keep looking for more signs, like:

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  • Serous exudate (thin, clear, watery)
  • Delay in healing
  • Friable (fragile) granulation tissue
  • Discolored granulation
  • Odor
  • Pocketing in the wound bed

How do we diagnose infection?

Diagnosing infection in any wound, particularly with diabetic patients, is a clinical one (versus a lab diagnosis). So if you ever hear a colleague say, “We’re going to wait for the lab results to see if our patient has a wound infection,” it’s time to stand up and emphatically say, “No!” Why? Because lab results, specifically the swab cultures that are most commonly used, are often inconclusive in the presence of biofilm. Instead of waiting for the results, you need to act immediately.

That’s not to say that lab results aren’t useful. They can sometimes help us confirm infections and target which antibiotic we want to use. But again, most infections are polymicrobial (containing more than one kind of bacteria), and swab cultures don’t pick up everything. We need to use our clinical judgment and supplement with lab and cultures.

The Final Word

As wound care professionals, prevention is obviously our first line of defense against any wound complications from infections. But when caring for diabetic patients, clearly understanding the risk factors for foot infections, and then being able to diagnose conditions as soon as possible, are crucial for effective treatment.

What do you think?

Have you had experience in treating diabetic patients with foot infections? Have you been able to identify the infection in a timely manner? Is there a particular case that was exceptionally challenging or difficult? Please tell us about it, and leave your comments below.

Really, How Important is that Monofilament Test?

Monday, January 26th, 2015

Neuropathy is one of the most common risk factors for lower extremity complications in our diabetic patients. With sensory neuropathy the patient has a loss of protective sensation that leads to a decrease in the ability for our diabetic patient to sense pain and temperature changes. This loss of protective sensation puts the patient at an increased risk for plantar foot injury. Unfortunately the patient may not feel the injury until significant complications have occurred.

The American Diabetes Association set up guidelines for us as healthcare professionals, these guidelines recommend screening in diabetic patients for neuropathy to check for loss of protective sensation on an annual basis, one way this can be done by doing the Semmes Weinstein Monofilament test. If the patient is found to have decreased sensation and is found to be at high risk the monofilament test should then be done quarterly.

The Semmes Weinstein 10g Monofilament is a test that checks for protective sensation in the diabetic foot.  It uses a 5.07 monofilament that exerts 10 grams of force when bowed into a C-shape against the skin for one second.  We don’t apply the filament directly to the ulcer site, callous, scar or necrotic tissue. Ask the patient to close their eyes during the exam and tell them to reply “yes” when the monofilament is felt, repeat without touching skin occasionally to be sure of patients response. Be sure to use random order on successive tests.

Areas to be tested include the dorsal midfoot, plantar aspect of the foot including pulp (fleshy mass on the distal plantar aspect) of the first, third, and fifth digits, the first, third and fifth metatarsal heads, the medial and lateral midfoot and at the calcaneus.  Record the results on the screening form, noting a “+” for sensation felt and a “-” for no sensation felt. The patient is said to have an “insensate foot” if they fail on retesting at just one or more sites on either foot.

Those patients who cannot feel the application of the monofilament to designated sites on the plantar surface of their feet have lost their “protective sensation”. Without this protective sensation the diabetic is now at increased for injury or ulceration. Neuropathy is usually noted in the first and third toes and then progresses to the first and third metatarsal heads.

Injury is much more likely to occur in the diabetic insensate foot at these areas and interventions must be implemented to protect the diabetic foot that is at risk for ulceration. Patient education and good “shoe fit assessment” will be part of our plan of care to protect the diabetic neuropathic patients foot.

 

The Diabetic Foot A house of Cards

Thursday, August 12th, 2010

The Wild on Wounds National Convention is coming up  September 23-25, 2010 in Las Vegas. Continuing in our session highlights, The Diabetic Foot: A House of Cards? will be presented by Jeffrey Jensen DPM FACFAS, Diabetic Foot and Wound Center, Denver CO

In this two part session, attendees will receive an overview of diabetic foot ulcer care-highlighted priorities and multiple needs of this difficult patient. We’ll discuss neuropathy, and understanding its role in diabetes. Our top-line priorities will include infection and perfusion. We’ll also look at outpatient challenges including debridement, off loading, wound dressings and compliance. Emphasis will be placed on clinical ramification if the needs aren’t met

There will be Two Parts to this offered session ( the first being a pre-requisite for Part 2)

For more information about the Wild on Wound National Conference or to register, please check out http://www.wcei.net/wow-conference

For more information about the Wound Care Education Institute and their Skin and Wound Management Course, please visit http://www.wcei.net/course_info