Regional Skin & Wound Education Facilitator Guide: Diabetic Foot Ulcers (Module 3) June 2012 1 How to use this guide Learning Objectives: Each section outlines specific learning objectives that will guide the discussion & activities of this part of the workshop. Participants know what they will achieve by completing the section. TO PRINT THIS GUIDE: Use printer DOUBLE-SIDED function & CHOOSE FLIP PAGES UP (this option allows user to staple document from above & flip through pages as one would a book). Time Topic Facilitator Activities / Questions Media An estimate of the time each section will take. Varies by number of participants General topic being covered. Describes what facilitator does for each section. ACTIVITIES: appear in BLUE & include purpose statement, instructions for conducting activity & points for summary EMPHASIZE: Points for emphasis appear here in RED Activities undertaken by the group. QUESTION TO GROUP: questions put to group appear here in GREEN ANSWERS to questions appear immediately below, also in GREEN What AV or other material accompanies each section HO = Handout FC = Flip chart
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Each section outlines specific learning objectives that will guide the discussion & activities of this part of the workshop.
Participants know what they will achieve by completing the section.
TO PRINT THIS GUIDE: Use printer DOUBLE-SIDED function & CHOOSE FLIP PAGES UP (this option allows user to staple document from above & flip through pages as one would a book).
Time Topic Facilitator Activities / Questions Media
An estimate of the time each section will take.
Varies by number of participants
General topic being covered.
Describes what facilitator does for each section.
ACTIVITIES: appear in BLUE & include purpose statement, instructions for conducting activity & points for summary
EMPHASIZE: Points for emphasis appear here in RED
Activities undertaken by the group.
QUESTION TO GROUP: questions put to group appear here in GREEN
ANSWERS to questions appear immediately below, also in GREEN
What AV or other material accompanies each section
Time Topic Facilitator Activities / Questions Media
Vision & Mission Client – All through the education module, the term client is used interchangeably as patients, clients, and residents as appropriate in different health care settings
The vision and mission statements are to reflect on the ultimate learning outcomes (level 4 to 6) that, due to constraint in resources allocation, that the Regional SW CWT/SW Steering Committee are not able to evaluate.
Slide 3
This module will evaluate the following level 1-3 learning outcomes:
1. Level 1: Participation – The number of learners participated in the learning events, e.g. attendance sign-in sheet
2. Level 2: Satisfaction – The degree to which expectations of the learners about the setting and delivery the educational events were met, e.g. Learning Session Evaluation form
3. Level 3: Learning – Changes in the knowledge, skills and/or attitudes of the learner, and the development of competence, e.g. pre- and post-test
Time Topic Facilitator Activities / Questions Media
This module will NOT evaluate the following level 4-6 learning outcomes due to constraint in resources allocation. Instead, they are stated as the Vision and Mission of the module:
1. Level 4: Performance – Changes of practice performance as a result of the application of what was learned, e.g. paper or on-line 3-month follow up survey, etc.
2. Level 5: Patient outcomes – Change s in the health status of patients due to changes in practice behaviours, e.g. prevalence and incidence rates, costs incurred in treating peri-stomal skin complications, etc.
3. Level 6: Population outcomes – Changes in the health status of a population of patients due to changes in practice behaviours, e.g. acute care admissions for peri-stomal skin complications, etc.
(Sibbald et al, 2007. Effective Adult Education Principles to Improve Outcomes in Patients with Chronic Wounds)
Time Topic Facilitator Activities / Questions Media
0840 – 0850 Ice Breaker / Pre-Test
Introduce yourself and the co-instructors – roles, work areas/program, and credentials
Discuss housekeeping items i.e. (bathroom, pagers/phones on vibrate, no texting during class)
Identify learners’ existing knowledge by:
1. “Ice Breaker” – Learners to introduce themselves to the group: name, area of work, if they have cared for clients with pressure ulcers, why they attend the education, and what they want to gain from attending the education
2. Then ask the learner to complete the Pre-test on the 1st page of the evaluation form
Time Topic Facilitator Activities / Questions Media
An Economic Tsunami: The Cost of Diabetes in Canada
The economic burden of diabetes in Canada projected to be about $12.2 billion in 2010, an increase of $5.9 billion; nearly double its level in 2000
The cost of diabetes is expected to rise by another $4.7 billion by 2020
The direct cost of diabetes accounts for 3.5% of public healthcare spending and is likely to continue rising given the expected increasing number of Canadians living with diabetes
Slide 7
Persons with Diabetes Mellitus
Although often overlooked at the onset of DM, one of the common and devastating complications of DM is DFU.
Put diabetic foot ulcers into the context of Canadian health care statistics and help to under score the magnitude of the problem as a way of introducing the topic.
Slide 8
0900 – 0915 Client education on DM Control/Foot Care
Loss of protective sensation is the most significant predictor of diabetic foot ulceration.
Use Animation to introduce Sam, our client all through this presentation.
Sam is an instruction site worker, whose wife Susan is a 40-year old secretary.
They have 2 children: a boy age 12 and a girl age 10.
Time Topic Facilitator Activities / Questions Media
This slide is when Sam when he was first diagnosed with Diabetes at age of 45
The outer oval shapes are the anticipated clinical/personal issues related to DM/DM related complications.
SAM and LOPS are the key clinical issues that will be discussed in details later.
The inner circles are the lists of interprofessional team members to support Sam to maintain optimal DM control
Please note that Specialists include: Foot Surgeon, Podiatrist, Endocrinologist, vascular surgeon, etc.
Slide 9
Introduce:
Role of Wound Care Clinician
• Member of the interdisciplinary team
• Provides specialized holistic assessment and management of patients/families with ostomies, acute and chronic wounds, and urinary and fecal continence problems
• Coordinates specialty care requirements with hospitals, community and follow-up services
• Educates and consults about advance nursing skills within areas of expertise in wound and skin care practice.
Time Topic Facilitator Activities / Questions Media
ABCs of Optimizing Diabetes
Define A1C:
The A1C test (also known as HbA1C, glycated hemoglobin or glycosylated hemoglobin) is a blood test done in the lab to provide a good general measure of diabetes care.
While conventional home glucose monitoring measures a person’s blood sugar at a given moment, the A1C test indicates a person’s average blood glucose level over the past few months.
AIC should be checked every 3 months
According to Dr Sibbald, a Canadian and International renowned Dermatologist specialized in wound care, A1C greater than 9% will affect wound healing & 7% will impair wound healing. Therefore, recommended A1C is less than 7%
Slide 11
Feet for L.I.F.E. Client Education crucial to promote adherence treatment plan and rapport with healthcare providers:
Lifestyle Choices
• Eat a healthy diet and maintain blood sugars within normal range
• Exercise daily
• If you have foot problems try a stationary bike or swimming
• Don’t smoke – IMPORTANT FOR ALL! – each cigarette decreases leg circulation for 30% for an hour or increase sympathetic tone for 8 hours
Time Topic Facilitator Activities / Questions Media
Diabetic Educators can help
Therefore, need to emphasize to Sam that Foot Care is important
FH Diabetic Education Center
• If you have trouble seeing or reaching your feet - see a foot doctor or nurse to assist you. These may be covered by your private plan but are not covered under Fair Pharmacare
• Wash feet daily - in warm water with a mild soap.
• Pat dry with a soft towel and dry carefully between toes
• Always check the water temperature with your elbow or wrist. Hot water, hot pavement or heating pads can all cause severe burns.
• If skin is dry, apply a urea-based moisturizer. If you have very dry skin-use a product with urea 10-25%, which will pull moisture to the skin surface. Remember no lotion between toes and this makes the toe webs too wet and may encourage a fungus infection.
• Soak nails for 10 min to soften before cutting and use a nail clipper (not scissors). Cut straight across and file rough edges with an emery board ( not steel)
• Do not self treat corns and warts with chemicals, or sharp instruments- these can damage your feet or cause infection.
• Always protect your feet by wearing hard-soled slippers and shoes avoid flip-flops.
Time Topic Facilitator Activities / Questions Media • Wear seamless socks that don’t constrict. If
you have swelling ask your doctor about compression stockings available at pharmacies or from a foot care specialist.
• Wear foot shaped shoes with low heels and good support –
o go to specialty shoe store, that knows how to fit shoes for diabetic feet. Always get your feet measured or draw a tracing of your foot standing up. Cut it out and take it with you to insert into the shoe.
o Remember a numb foot cannot feel a tight shoe!
o Shop for shoes in the late afternoon when feet tend to swell and take the socks and orthotics you usually wear with you for fitting.
Be smoke-free
Client Education: Early Detection
Early detection is the second step in caring for your feet.
Look for signs of:
• corns, calluses, blisters, scrapes.
• of infection such as redness, swelling , heat, or discharge.
Wear white socks so you will see if there is blood or drainage from an injury, such as a torn nail or stubbed toe.
Time Topic Facilitator Activities / Questions Media
Diabetes & Healthy Feet
A CAWC expert advisory group, in collaboration with a patient focus group, has developed a self-assessment brochure and an interactive website in many languages to help patients in recognizing risk factors and identifying foot issues that they may have been previously unaware of.
The brochure and interactive website are available at www.cawc.net/diabetesandhealthyfeet (Botros et al 2010)
Review CAWC page by opening up hyperlink & review the information below
• Select personal self management questionnaire
• Select personal foot care plan.
• Handout Healthy feet checklist and personal plan.
• Select “ Your foot a closer look”
Slide 16
The brochure and interactive website at www.cawc.net/diabetesandhealthyfeet (Botros et al 2010)
Review the key points for Prevention and Treatment of DFU
Disclaimer: the term “Client” is used interchangeably with patient in acute care and residents in residential care, or any other settings
(Botros et al 2010)
Diabetic sensory neuropathy is the leading cause of foot ulcers.
It generally presents as a distal symmetric sensori-motor neuropathy and is believed to contribute to ulcers because the patient cannot feel harmful stimuli.
Peripheral neuropathy affects sensory, motor and autonomic nerves.
Emphasize Loss of protective sensation is the most significant predictor of diabetic foot ulceration.
People with diabetes are prone to serious injury from minor trauma because they cannot feel the injury to the foot as it occurs.
In addition to single injurious incidents, such as stepping on a needle, repetitive stress simply from walking can lead to tissue breakdown in the absence of protective sensation.
Time Topic Facilitator Activities / Questions Media
Components of Foot Assessment
What would you include under history?
• Reason for referral, general health, co morbidities, history of foot problems/ traumatic surgeries, characteristics of pain, work and leisure activities.
• Glycemic control
Foot appearance and structure:
• Assessing for bunions, callous, corns missing digits, Charcot( discuss later), hallgus limitus ( inflexible great toe)
• Alignment of foot when wt bearing, do the arches drop i.e. flat foot.
Gait:
• Look for lack of range of motion e.g. Shuffling gait indicating inability to dorsiflex.
• Muscle weakness, poor balance, uncoordination
Neuralgic: monofilament testing
Infection: bacterial, viral fungal
Footwear:
• Are they wearing protection in and out doors. What is the fit?
• Are they wearing socks?
Slide 19
Sixty Second Foot Exam
In summary here are guidelines for foot examinations of intact diabetic feet.
Time Topic Facilitator Activities / Questions Media
Risk Classification The IWGDF developed this straight forward risk classification system which it modified recently.
It quickly and accurately classifies patients and guides the clinician in predicating foot complications & guides in choosing the most appropriate therapeutic interventions.
Inform the learners that Neuropathy and LOPS will be further discussed later
Refer to handouts provided
Slide 21
Handouts
Peripheral Neuropathy
The presence of vascular disease and neuropathy, or a combination of both, are the most important risk factors in the development of diabetic neuropathy. (Salzeda et al. OWM 2003.)
While neuropathy is the most common reason for diabetic foot ulceration, peripheral vascular disease and infection can also be factors in skin breakdown.
Vascular disease also plays a role in diabetic foot ulcer development and is responsible for 15 to 20% of diabetic foot ulcers.
Diabetes is a risk factor in the development of arteriosclerosis.
Smoking, hypertension and hyperlipidemia are also risk factors in the development of peripheral vascular disease and these factors will add additional risks for the diabetic patient.
Time Topic Facilitator Activities / Questions Media
Diabetic neuropathy is thought to be metabolic in origin and related to an over stimulation of the polyol pathway in neural tissue.
Hyperglycemia is associated with uncontrolled diabetes.
Elevated blood glucose is metabolized by the enzyme aldose reductase which then produces sorbitol and polyol.
Sorbitol accumulates in the tissues and causes damage in many ways.
In the nerves, sorbitol is toxic and causes segmental demyelination which leads to lower conduction of speed in the peripheral nerves.
A demyelinating disease is any disease of the nervous system in which the myelin sheath of neurons is damaged.
This impairs the conduction of signals in the affected nerves, causing impairment in sensation, movement, cognition, or other functions depending on which nerves are involved.
Slide 22
Neuropathy Review the three different types of neuropathy and the major outcome of each type of neuropathy which is causative of problems with diabetic foot.
Time Topic Facilitator Activities / Questions Media
Sensory Neuropathy (S.A.M.)
Hyperesthesia can lead to poor skin care practices (walking bare foot because they can not stand the feel of socks on the feet, or can not stand to have their feet touched or washed due to the increased sensitivity to touch).
Loss of protective sensation leads to diminished or absent pain sensation.
Chemical trauma from over the counter “wart” or callous remedies such as acids or other inventive chemical applications.
Mechanical trauma can be from improper foot wear, nail care practices or callous “care”
Thermal damage from heat or cold causing tissue damage.
Slide 24
Sensory Neuropathy & LOPS
Sensory Neuropathy results in Loss Of Protective Sensation (LOPS):
Photo shows a client who has no pain even with the toe caught on a piece of furniture.
Slide 25
Why Loss Of Protective Sensation causes ulceration
With no feeling, client cannot protect self from injury from chemical, mechanical and thermal damage.
Time Topic Facilitator Activities / Questions Media
Un-trimmed Nail Causing Pressure (S.A.M.)
Another example of poor nail hygiene due to lack of sensation (client does not sense that the nail is digging into the toe beside it), or that the toe nail is thickened and may be exerting pressure into the nail bed.
Ask participants questions as indicated
QUESTION: What do you assess in terms of infection and vascular supply here (V.I.P.)?
ANSWER: Toe is reddened Hair on knuckles of the toe indicate reason able blood flow
QUESTION: How else would you assess for vascular supply and infection?
ANSWER: Pedal pulses Colour of limb Temp of limb Palour or rubour
QUESTION: Who would you recommend referral of this client to ?
Time Topic Facilitator Activities / Questions Media
5 Minutes Monofilament Testing Activity
Ask learner to take out the Monofilament testing & Pixalere foot/sensation assessment sheet from the handout (Reference: CDST procedure on Monofilament testing).
Before beginning, review the use of the monofilament and read through procedure together.
Ask participants to record findings on Pixalere foot assessment sheet, sites where the participant can feel are checked.
Avoid leading questions and cues when assessing with monofilaments
Interpretation:
If all sites are felt with the monofilament the score is 10/10
If the monofilament is not felt in an area on the foot, this indicates LOPS in that area and requires a referral to the wound clinician
Instruct participants to partner with buddy in groups of 2.
One person will perform a monofilament assessment; the other will be the receiver.
Slide 29
Autonomic Neuropathy (S.A.M.)
Dry skin is 2-3 times more likely to break down
Infection/cellulitis can be initiated with any loss of skin integrity no matter how small and seemingly insignificant esp. in a diabetic client who may not be responding with a full immune system compliment and less than robust inflammatory responses.
Example in this photo is of fungal infection from too much moisture
Time Topic Facilitator Activities / Questions Media
Autonomic Neuropathy (S.A.M.)
Examples of the severity of the dry skin related to autonomic neuropathy:
• Xerosis/Anhydrosis and
• Fissures
To correct the dryness of this skin suggest use of pumice stone and moisturizer, off loading and good local wound care.
Slide 31
Moisturizers to Protect Skin (S.A.M.)
Use animation, after discussing bullet 1, 2, 3, pause, and ask what a good moisturizer should be.
Click and review the answer
Water accounts for 60-80% of most commercial moisturizers, but externally applied moisture does not re-moisturize the skin.
The thin consistency of most commercial lotions provide some replacement of natural oils in the stratum corneum, but the effect is short lived due to the continued transepidural moisture loss.
Time Topic Facilitator Activities / Questions Media
Lotions have the most water, followed by cremes and then ointments.
Cremes have a higher oil content than lotions but do not provide total occlusion of the skin.
Ointments are near to 100% oil and are occlusive of the skin and generally not well tolerated for cosmetic reasons anyways.
Therefore choices for diabetic foot should be a creme (higher occlusive properties to it than a lotion), containing humectants. (Atractain)
Problem with total occlusion of the skin is that once the occlusive agent is removed water loss resumes to it’s pre-application level
Vaseline (petrolatum) is not totally occlusive and may be a reasonable alternative if costs for other cremes are prohibitive.
Occlusion – physical covering of the skin preventing water loss (total occlusion is not desirable)
Slide 32
Motor Neuropathy (S.A.M.)
Neuropathy of the innervating motor neurons of the lower extremities
Distal to proximal cell death pattern
Intrinsic muscles of the foot are primarily involved
Slide 33
Specifically an imbalance between flexors and extensors muscles of the toes
Intrinsic muscles are the muscles with in the foot. There main function is assisting the extrinsic (i.e. in the calf and shin) to flex and extend the toes.
Time Topic Facilitator Activities / Questions Media
Hammer toe is a permanently flexed digit usually the 2nd toe.
Claw toe is a hyperextension of the toes at the metatarsal head, may be claw foot as well, which is an excessively flexed arch of the foot.
Ask participants question indicated.
QUESTION: Where would ulcers occur in the toes seen here?
ANSWER: Tops of the toes from shoes rubbing or bottom of the toes from pressure
Slide 35
Claw Toe & Hammer Toe pictured. Slide 36
Fat Pad Migration (S.A.M.)
Animation : Click to animate the fat pad to move forward, then to move up the pressure
Slide 37
Reduces area to distribute pressure
Increases pressure on the front of the foot
If the client has reduced range of motion in their big toe (i.e. hallicus rigidus) the extra pressure moved to the forefoot frequently causes big toe and 1st metatarsal wounds
Time Topic Facilitator Activities / Questions Media
The transverse arch runs across the front of the foot, just before the toes. It’s much less pronounced then the long arch, but integrates to normal distribution of pressure in the fore foot.
As the arch collapses, the metatarsal head drops, creating new / unnatural pressure area.
1. Middle of the foot
2. Sides of the foot (i.e. big / little toes)
This new pressure area is not normal and the tissue in this area is not able to manage the increased load.
Slide 39
How Motor Deformity Contributed To Ulcer?
Use animation, after showing 1, 2, 3, pause and ask question.
Click to review the answer
Example of callous formation that may have gotten so thick that it impeded the blood flow to the underlying tissues and/or there may be loss of fat pads in this foot and the metatarsal heads may be very close to the surface of the skin, leading to ulcerations.
Hammer toe formations may cause this foot to ulcerate in this manner.
Time Topic Facilitator Activities / Questions Media
Role of Dietitian Macronutrients
There are three primary macronutrients defined as being the classes of chemical compounds humans consume in the largest quantities and which provide bulk energy.
These are protein, fat, and carbohydrate. This list shows the categorization of the most common food components by these macronutrients.
Macronutrients can also refer to the chemical elements humans consume in the largest quantities, see Nutrient.
Micronutrients:
Nutrients that are required by humans and other living things throughout life in small quantities to orchestrate a whole range of physiological functions, but which the organism itself cannot produce.
For people, they include dietary trace minerals in amounts generally less than 100 milligrams/day - as opposed to macrominerals which are required in larger quantities.
The microminerals or trace elements include at least iron, cobalt, chromium, copper, iodine, manganese, selenium, zinc and molybdenum.
Micronutrients also include vitamins, which are organic compounds required as nutrients in tiny amounts by an organism.
Time Topic Facilitator Activities / Questions Media
0945 – 1000 Charcot Foot Transition slide to Charcot Foot
Charcot foot is a particularly acute and devastating occurrence which can occur in a person with neuropathy, but is far more common in diabetics with neuropathy.
It is characterized by bony re-absorption and multiple spontaneous fractures which result from autonomic-neuropathy induced bone blood flow hyperemia.
Hypervascularity of the mid foot osseous structures results in decreased structural integrity of the bone significantly increasing risk of fracture.
These fractures may result from ADLs and not obvious trauma.
Clinical presentation includes dermal flush, redness, increased skin temperature, +/- deep bony pain, +/- local edema and bounding pulses.
The condition may mimic cellulitis or deep vein thrombosis.
X-ray and bone scan are used to assess and reconfirm re-ossification
Clients frequently do not experience pain due to their neuropathy
Charcot fracture results in catastrophic deformity often ignored by Clients.
Slide 47
Use Animation to add WCC/ET/WOCN to the team
Specialists include Foot Surgeon, Podiatrist, Endocrinologist
This table is an overview of the Stages of Charcot foot compiled by CAWC in the 2010 BPR review
Question: Why is it important to recognize acute Charcot?
Answer: So you can prevent foot deformities ensuring that client is completely offloaded. Stage 1 is the is the most important stage for clinicians to recognized and where they can make the greatest difference in prevention. (Frykberg et al., 2006)
Time Topic Facilitator Activities / Questions Media
1000 – 1030 Transition to DFU Sam’s diabetes continues to be poorly managed.
Unfortunately, he developed foot ulcers on his soles
Approx. 9% of clients with diabetic neuropathy develop Charcot foot.
Early recognition & diagnosis of the acute Charcot is essential to prevent increased damage & prevent disastrous consequences including amputation.
Acute Charcot is a medical emergency.
The client must not bear weight and may benefit from medications which prevent bone re-absorption po or IV.
Temperature increases and decreases in the outside temp of the foot signal the amount of activity of bone absorption and is a key indicator of the internal processes of the foot.
2 degree C or 4 degrees F difference in skin temperature from contra lateral foot.
Dermal thermometers are being utilized in some centers and clients are being taught to self monitor for this condition as well as infective processes.
Diagnostics:
• Systemic symptoms, abnormal lab values are usually absent.
• Radiographic changes take time to develop and the initial finding can be normal but repeated xrays on patients who are not immobilized show abnormal findings.
Time Topic Facilitator Activities / Questions Media
Foot Tracing
Examine clients footwear.
Check for wear and tear.
“Motor neuropathy produces common abnormal gait characteristics. JPO 2005 page 8. RNAO Criteria for appropriate footwear.
Demonstrate how to check for correct size of shoes being worn.
Ask client to step on a piece of paper in stocking feet (must be weight bearing through the foot).
Trace the client’s foot with a pen onto the paper.
Hold the paper up to the shoe.
Often if the shoe is too small or much to large (potential for causing shearing and friction in the foot) this will be obvious in the diagram created.
ACTIVITY: Foot Tracing
Slide 78
Recommendations for appropriate footwear
So you find a potential problem with the footwear….
Educate the client on who, where, and when to get appropriate footwear.
But, what is appropriate footwear?
Slide 79
Appropriate Footwear
Remember that a person with diabetes and S.A.M (Sensory, Autonomic, and Motor Dysfunction) are at the least at risk for pressure and skin break down
“Pressure downloading is the most effective and least expensive method of addressing the treatable risk factors and reducing the patient’s risk of ulceration and ultimately amputation” (Inlow, et al 1998)”
Time Topic Facilitator Activities / Questions Media
Surgical Shoes Often confused with healing sandals, but not the same function or amount of padding
Don’t get focused on the name brands, but more their benefits and drawbacks.
Slide 93
Advantages & Disadvantages Slide 94
Healing Sandals Technically an open toe sandal that includes a rocker bottom shoe, limited seams / ridges, and a custom or very thick padded insole / foot bed.
Typically available only from pedorthotist, orthotist, or specialized diabetic foot clinics.
Slide 95
Advantages & Disadvantages Slide 96
OTC Diabetic Orthopaedic Shoes
Variety of types, manufacturers, and features.
Typically over sized with large toe boxes, velcro or limited laces, soft felt like material, and limited seams and ridges.
Can include a basic foam foot bed
Much more common option client’s choose because of cost and appearance
Slide 97
Advantages & Disadvantages
Much more common option client’s choose because of cost and appearance.
Time Topic Facilitator Activities / Questions Media
Wound Healing Effectiveness
Best results at the top, but must have high patient compliance, fit by a professional, and mobility concerns are addressed for all options.
7/8. Orthotics / foot beds and over the counter orthopedic shoes are more effective when combined together.
Slide 107
Other Pressure Related Concerns
Brief reference to Braden Scale Slide 108
Mobility Aides Standard walker, two wheeled walkers, 4 wheeled walkers, canes, quad canes, crutches, forearm crutches, wheelchairs, etc
All can help the client reduce or completely off load the affected leg / foot.
Only the two wheeled walker, wheel less walker, crutches, and wheelchair can full offload
Slide 109
Advantages & Disadvantages Slide 110
1115 - 1130 PT Assistance (Transition to PT on mobility and exercise)
While the areas that PT’s can help with prevention and treatments of wounds will vary depending on each INDIVIDUAL client/patient/resident, these are some of the possible tools PT’s can bring to the table to help the client/patient/resident and the team.
Therapeutic exercise
To improve foot strength & range of motion to reduce effects of MOTOR changes (SAM)
Time Topic Facilitator Activities / Questions Media Gait training
To improve gait stability and pattern
Focus on decreasing single stance time, reducing rear foot & forefoot pressures that have been found in client’s with diabetic neuropathy
Modalities (if indicated)
Evidence for use of E-stim (High-voltage pulsed current=HVPC) and Ultrasound on diabetic foot ulcers
Manual therapy (if indicated)
To improve mobility of small joints in the foot
Protective footwear
Work with interdisciplinary team to assess and recommend appropriate footwear for clients/patients/residents
Patient education
In topics such as activity/exercise, mobility aids, pain relief, sensation checks, prevention, self management tips etc.
Adapted from Reference: Dressendorfer, 2009
NOTE: Electrophysical modalities such as Electrical Stimulation should ONLY be applied by those who have received proper training and whose professional scope of practice allows (e.g./ PT’s or wound care nurses with special training)
Time Topic Facilitator Activities / Questions Media
When to Refer to PT
As per Diabetic and Neuropathic Ulcer Guideline
Slide 112
Client Centered Concerns
Educational intervention for improvements in foot-care knowledge and behaviour in the short-term for people with diabetes.
People with diabetes who are at higher risk for foot ulceration benefit from both diabetes and foot care education and regular reinforcement of that education.
People who receive formal diabetes education regarding treatment and prevention strategies have a lower risk of amputation than those who receive no formal education.
The clinician needs to develop a plan of care that takes into account the patient’s socioeconomic, cultural and psychosocial and other needs and beliefs.
A self-assessment tool is available to assist in patient education.
Assessment and treatment of pain is essential in wound management.
Persons with DFU often experience moderate to severe neuropathic pain characterized as sharp and burning pain that is often difficult to manage
Time Topic Facilitator Activities / Questions Media
Pain Management
a. Teach client that new onset or worsening pain is a sign of infection and requires immediate medical attention.
b. If client has wound pain or treatment-related pain, organize care to coordinate with analgesic administration allowing sufficient time for the analgesic to take effect.
c. Administer analgesic medication regularly and in the appropriate dose to control pain; refer the client to a physician /NP if pain is not well controlled.
d. Use appropriate medications to control neuropathic pain, if present.
e. Refer to wound care clinician or physician / NP to determine the need for topical analgesic (e.g. morphine) or anaesthetic (e.g. EMLA) if wound pain is not well controlled.
f. Encourage clients to request a “time-out” during painful procedures.
g. Use dressings that require less frequent changes and are less likely to cause pain and trauma on removal, e.g. non adherent dressings.
h. Encourage repositioning as a means to reduce pain; use pressure redistribution devices or surfaces to reduce pressure.
i. When appropriate, use reassurance, music, distraction, conversation, or guided imagery to reduce pain during dressing changes.
Maintenance wounds are divided into 2 categories, those that can be healed; however underlying factors such as offloading or patient adherence are still issues preventing the wound from moving forward
Non healable maintenance wounds are those that do not have sufficient arterial flow for healing, or client is at “end of life care”
For more information go to the palliative wound workshop
Time Topic Facilitator Activities / Questions Media
Non-Healable Wet Ulcer
Source Provincial CDST on neuropathic ulcers.
Non healable ulcers are those that do not have sufficient vascular flow for healing OR the client is non adherent to treatment recommendations.
ABI of 0.4 indicates critical ischemia with a very low probability for healing.
Requires immediate Referral to WCC/physician or NP
WCC needs to assess and decide on conservative debridement such as iodosorb to reduce bioburden but not completely remove slough, Inadine, which is a povidone impregnated non-adherent gauze.
Keep the wound dry and antiseptic.
Recommended Cleansing Solutions: Iodine 10% and Baxedin 0.05% with no alcohol.
Possible Topical Antiseptics: AMD, Bactigras,
Possible Topical Antimicrobials: Inadine (Low to Moderate Exudate), Iodosorb (Moderate to Large Exudate)
Time Topic Facilitator Activities / Questions Media
Choices for Debridement
Surgical debridement is not within the scope of nursing practice
Conservative Sharps wound debridement: CRNBC has placed limits and conditions on Registered Nurses that only those nurses who have advanced education such as CAET, IIWCC, WOCN with mentorship and competency assessment can perform this skill
Autolytic: In the presence of moisture the body’s own mechanism breaks down and liquefies devitalized tissue.
Enzymatic: Santyl Collagenase is available by prescription & covered by fair pharmacare for HH and residential care client’s
Mechanical: Safe mechanical debridement using a 30 cc syringe & wound irrigation tip with at least 100cc of saline used. Wiping slough with dry gauze
Biological: Medical Maggots, sterile, grown in a laboratory setting under strict conditions
Time Topic Facilitator Activities / Questions Media
Mechanical Debridement - Physically removes debris from the wound.
• Irrigation is considered mechanical debridement when it is done with a 30 – 35 mL syringe and an irrigation tip catheter or an 18 - 19 gauge device.
• Whirlpool therapy provides mechanical debridement but is contraindicated in clients with diabetic ulcers. ?? infection control concerns
• Using gauze or a Q-tip to create friction over the wound surface to remove biofilm (an accumulation of micro-organisms on a surface).
• Wet to dry dressings must not be used on wounds as they are painful and non selective when removed.
Enzymatic Debridement - Utilizes a naturally occurring enzyme, collagenase [2], which is applied to the wound surface to degrade necrotic tissue in the wound. A physician / NP or wound care clinician order may be required for collagenase.
• Debridement may be accelerated up by scoring eschar. [3]
• Enzyme use can cause excessive exudate, irritation to peri-wound skin and possible infection.
• A moist wound environment must be maintained when using collagenase.
Time Topic Facilitator Activities / Questions Media
Biodebridement (Link to Maggot Debridement Therapy DST)
• Is very selective; removes only dead tissue.
• Can be used with infected wounds.
Conservative Sharp Wound Debridement (Link to CSWD DST) - Removes devitalized tissue down to the level of viable tissue using a sterile scalpel, scissors or curette.
• Less invasive than surgical debridement as it does not cause pain or bleeding.
• Must be done by a physician / NP
• Registered nurses must follow established decision support tools and must successfully complete additional education before carrying out CSWD.
• Today, FH does not have a CSWD CDST/Policy to support practice and FH does not have a education module to support the nurses to acquire the required competency to perform CSWD
Time Topic Facilitator Activities / Questions Media
Animation
CAWC best practice guidelines advocate for probing wounds.
Make sure that if there are two wounds in close proximity that they are not in fact one wound with deeper tissue involvements than may be seen from the surface of the skin.
Slide 134
Eliminate Infection
Animation
Baxedin 0.05% is a chlorhexidine solution – For use on non-healable maintenance wounds to decrease bacterial burden and prevent infection (will this sting?).
Povidone 7-10% solution – not the 2% solutions over the counter- ask Pharmacists
Indications
An antiseptic solution used on dry eschar to maintain an intact covering of a wound where to goal of healing has been determined by the Wound Care Clinician as maintenance.
Precautions
1. Use with caution in patients with known sensitivity to iodine
Time Topic Facilitator Activities / Questions Media • Do not use for clients with any type of
thyroid disease/history of thyroid disease or for clients with renal insufficiency as these clients are more susceptible to alternation in thyroid function
• Do not use in cases of Duhring’s herpetiform dermatitis (a rare skin disease)
2. IODOSORB - Antimicrobial: Cadexomer Iodine
Key Points
• Broad spectrum topical antimicrobial; dark brown ointment/paste consisting of cadexomer, polyethylene glycol and iodine
Indications
• For ‘sloughy’ moist wounds which show signs and symptoms of local wound infection
Precautions
• If used for client who is on Lithium, monitor Lithium blood work on a regular basis
• Should be used with caution in clients with severely impaired renal function or a past history of any thyroid disorder as they are more susceptible to alterations in thyroid metabolism
• Use no more than 50gm of Iodosorb per dressing and no more than 150gm per week
Time Topic Facilitator Activities / Questions Media Contraindications
• Do not use for client with known sensitivity or allergy to iodine
• Do not use on client who are breast feeding or pregnant
• Do not use on children between 0-18 years old
Antimicrobials Animation
There are now at least 5 classes of antimicrobial dressings and some miscellaneous products for use in chronic wounds with critical colonization as defined by any 3 of the NERDS criteria.
Hand out product info sheets re products and the clwk.ca
Discuss options with WCC WOCN ET
Select a dressing to match the appropriate wound and individual person characteristics:
Time Topic Facilitator Activities / Questions Media
Discuss broad categories:
A. Silver products
Acticoat: silver in a flexible mesh sheet format which has anti-inflammatory properties
Indications:
For wounds and donor/graft sites which show signs & symptoms (S&S) of local wound infection at risk for developing a local wound infection
Can be used with Negative Pressure Wound Therapy (NPWT) as the small “mesh” allows exudate to move through the dressing
Can be used when client is undergoing Hyperbaric Oxygen therapy or CT Scan
Can be used on pregnant or nursing women
Precautions
Should only be used on premature infants (less than 37 weeks gestation) when clinical benefits outweigh potential risks.
Transient pain may be experienced on application; this can be minimized by carefully following application procedure. Should continuous pain be experienced after application, remove the dressing and discontinue use (inform Wound Clinician, NP or Physician)
Avoid putting electrodes or conductive gels in contact with silver products.
Upon removal for its package, the dressing must be uniform in colour on both sides (no discolouration)
Time Topic Facilitator Activities / Questions Media
Contraindications
Do no use for clients with a known sensitivity or allergy to silver or polyester
Do not apply dressing to exposed internal organs
Do not use saline or saline based gels to moisten or cover product
Do not use silver products in combination with oil-based products such as petrolatum or paraffin
Do not use silver products when client is undergoing MRI examination or during radiation therapy (dressing can be replaced after MRI or radiation treatment is completed)
Time Topic Facilitator Activities / Questions Media
Silvercel: This product is a combination of silver, alginate and carboxymethyl cellulose sandwiched between non-adherent film layers to help prevent sticking to wounds or shedding fibres
Indications:
Wounds with moderate to large amounts of exudate which show signs and symptoms (S&S) of local wound infection
Contraindications
Do not use for clients with known sensitivity or allergy to silver, alginates or ethylene methylacrylate (EMA)
Do not use for pregnant or lactating women due to absence of specific information
Do not use silver products in combination with oil-based products such as petrolatum or paraffin
Do not put electrodes or conductive gels in contact with silver products
Do not use silver products when client is undergoing MRI examination or during radiation therapy (dressing can be replaced after MRI or radiation treatment is completed)
Time Topic Facilitator Activities / Questions Media
Aquacel Ag - Ionic silver in a hydrofiber format. Ribbon is stitched with strengthening fibre for extra strength when saturated.
Indications
Wounds with moderate to heavy drainage which show signs and symptoms (S&S) of local wound infection or that are at increased risk for infection
Contraindications:
Do not use for client with known sensitivity to silver & sodium carboxymethlycellulose
Do not use silver products in combination with oil-based products such as petrolatum or paraffin
Do not put electrodes or conductive gels in contact with silver products
Do not use silver products when client is undergoing MRI examination or during radiation therapy (dressing can be replaced after MRI or radiation treatment is completed
Time Topic Facilitator Activities / Questions Media
Silvasorb - Ionic silver suspended in a hydrogel base. Allows for slow release of silver over 3 days
Indications:
For wounds with small amount of exudate which show signs and symptoms (S&S) of local wound infection
Precautions:
Avoid putting electrodes or conductive gels in contact with silver products
Contraindications:
Do not use for clients with a known sensitivity or allergy to silver
Do not use for wounds with moderate to large amounts of exudate
Do not use silver products in combination with oil-based products such as petrolatum or paraffin
Do not use silver products when client is undergoing MRI examination or during radiation therapy (dressing can be replaced after MRI or radiation treatment is completed)
Time Topic Facilitator Activities / Questions Media
B. Honey products:
Product has an antimicrobial effect due to low pH (3.2-4.5) and high osmolarity.
Medihoney Calcium Alginate - Calcium alginate with medical grade Manuka honey (leptospermum). For wounds with moderate to large amounts of exudate
Medihoney Gel - Medical grade Manuka honey (leptospermum). For wounds with a small amount of exudate or ‘sloughy’ wounds needing autolytic debridement.
For both Gel and Alginate:
Indications:
For wounds which show signs and symptoms(S&S) of local wound infection
Precautions:
Low pH may cause transient stinging; discontinue if stinging persists
Contraindications:
Known sensitivity or allergy to honey
C. Iodides
Cadexamer iodine – iodosorb (already discussed in earlier slide)
Inadine – Povidone impregnated gauze (already discussed in earlier slide)
Time Topic Facilitator Activities / Questions Media
D. AMD gauze
Broad spectrum topical antiseptic dressing effective against gram negative; gram positive bacteria, (MRSA,VRE, Pseudomonas) fungi, yeast. High tensile strength woven cotton packing strips impregnated with 0.2% PHMB (Polyhexamethylene Biquanide) which remains effective in the presence of blood and/or proteins.
Indications:
For wounds which show signs and symptoms (S•&S) of local wound infection
Contraindications:
Do not use for clients with known sensitivity or allergy to PHMB
Do not use with Dakin’s Solution or bleach solutions as these solutions will deactivate PHMB
The treatment of critical colonization often takes 2 to 4 weeks in a healable wound where the cause has been corrected and patient-centered concerns have been addressed.
If the wound is in bacterial balance, antibacterial dressings are not needed for the re-epitheliazation stage of wound healing, unless they also provide anti-inflammatory activity.
They also are not efficacious in the treatment of deep and surrounding tissue infection that requires the use of systemic agents.
Time Topic Facilitator Activities / Questions Media The use of antimicrobial dressings should be reviewed at frequent and regular intervals every 1 to 2 weeks and discontinued if critical colonization has been corrected or if they do not demonstrate a beneficial effect after 2 to 4 weeks.
There is currently a great tendency to overuse antimicrobial dressings, creating a cost-inefficient use of these useful devices.
References:
WBP, 2011
Moist Wound Healing
Reminder to learners not to use occlusive dressings (i.e. hydrocolloid) if the wound is infected or if you suspect the wound to be infected.
Consider:
• Foams for absorbency
• Calcium Alginates for absorbency & hemostasis
• Hydrogels for added moisture
• Hydrofibers for absorbency & control of maceration
• Iodosorb for signs of heavy colonization/infection
• Silvers for signs of heavy colonization/infection
Add picture of the category of the wound care product
Time Topic Facilitator Activities / Questions Media
Moderate High Absorbency Dressings
Allevyn Gentle – Foam with silicone for moderate to large amounts of exudate
All Dress - A multilayer, absorbent, vapour-permeable dressing with border; border is coated with a water-based solvent-free polyacrylate adhesive. For small to moderate amounts of exudate
ABD Pad
Mesorb – highly absorbant composite dressing for wounds exuding moderate to large amounts and require daily dressing changes
Versiva XC – hydrofibre dressing which turns to gel on contact with exudate. For use with small amounts of exudate. In combination with other wound care products it can be used for wounds with moderate to large amounts of exudate
Combiderm ACD – Absorbant pad with hydrocolloid adhesive border. Can be used on wounds with moderate to large amounts of exudate.
Eclypse – Composite, high capacity wound exudate management dressing. Works by combining rapid wicking action with moisture locking system. For use on wounds with large amounts of exudate
Non-sterile absorbant pad ‘supersoaker’ - For chronic non-healable wounds with copious drainage where a sterile product is not required. Can be used in combination with other wound care products.
Time Topic Facilitator Activities / Questions Media
Allevyn Gentle: For wounds with moderate to large amount of exudate.
Allevyn Lite: For wounds with small exudate.
Contraindication:
Do not use with oxidizing agents such as hypochlorite solutions (Eusol) or hydrogen peroxide.
Do not use if redness or sensitivity occur.
Mepitel/Mepitel One - Silicone contact layer applied directly on the wound bed underneath secondary dressing for preventing wound bed trauma by decreasing adherence of the secondary dressing.
Precaution:
Do not use with skin barrier or sealant
When used on burns treated with meshed grafts or after facial resurfacing, imprints can occur if too much pressure is applied
Mepilex/Mepilex Lite/ Mepilex Transfer – Foam (adhesive border or no border).
Indications:
To be used as a cover dressing
May be used in combination with other wound care products
May be used for shallow and cavity wounds with moderate to heavy drainage
Time Topic Facilitator Activities / Questions Media
Protect Healing Wound & Surrounding Skin
Off loading is critical issue to protect the healing wound. Clients must not take one step on the wound with our being off loaded. Compliance and client understanding of this concept is critical.
Reasons not to soak feet
• adds to the drying effect as it removes the natural skin oils
• may increase risk of infection if basin or vessel that the soaking is being done in
Time Topic Facilitator Activities / Questions Media
1155 – 1200 Summary Refer participates to CDST guideline and review content.
This tool is to assist the HCP to review and ensure that all aspects have been covered in DFU management.
Slide 144
CDST
Interprofessional Team
Transition to address patient concern – brief discussion on common issues that the clients will be experience, particularly those affecting the adherence to the treatment plan
• Consider pain (nociceptive neuropathic)
• Treatment plan determined by healability, cost-effectiveness / burden of treatment
• Educational and addressing person-centered concerns increase adherence to treatment plan, which in turns affects healability
• Adherence to compression for life – comfort, ability to put on/remove daily, daily wash, new pairs every 6 months if wearing I pairs or every 12 if wearing 2 pairs simultaneously
Time Topic Facilitator Activities / Questions Media
1200 – 1220 Case Studies
Case Study 1
Home Health
Divide the learners into groups of 6-8: each group will work on the same client, Vic, in home health and acute care settings to address his different health care as stated in the case study scenarios
Give the 3 groups 10 minutes to finalize their care plan mutually agreed with your clients
CASE STUDY 1 QUESTIONS:
1. What assessment the HCN will do?
2. What is his treatment goal and plan?
3. What disciplines need to be included in his care?
4. What education/resources the client needed?
Slide 146
Case Study 2
Acute Care
CASE STUDY 2 QUESTIONS:
1. How should the RN approach Victor?
2. What information the RN can give to Victor?
3. What is his treatment goal and care plan?
4. What disciplines need to be included in his care?
5. What education/resources Victor and his family will need for discharge planning?