Risk Factors for Developing Diabetic Foot Problems

Most diabetic foot complications that result in amputation start with a skin ulcer.  Several factors contribute to diabetic lower-limb skin ulcers, including: ^3,4

• Decreased sensation
• Injury
• Foot deformity such as hammer toes, bunions, corns, calluses
• Poor circulation
• Edema
• Decreased sweating and dry skin (autonomic neuropathy)
• Limited joint mobility (making it difficult to keep feet clean)
• Obesity
• Impaired vision (may prevent adequate cleansing and inspection. Patients may not know they have a bump or a sore on their lower extremities)
• Poor glucose control (may promote delayed wound healing)
• Inadequate or ill fitting footwear (may contribute to skin breakdown)
• Prior history of foot ulcer or lower extremity amputation
• Smoking

Preventing diabetic foot ulcers and recognizing them early is critical.

Patient Education: Tools and Information from the American Diabetes Association (ADA)

The first line of defense in preventing foot ulcers is patient education about good self-care and hygiene of the feet.  The ADA has a patient education instruction sheet, at: http://www.diabetes.org/type-2-diabetes/foot-care.jsp .  The website contains a wealth of information for both patients and professionals.

For Nurses: Comprehensive Foot Assessment

Assess the feet of all CKD patients with diabetes on initial visit and monthly.  Look for structural abnormalities, pedal pulses, color, ulcerations, and signs of infection.  The following components should be included in the assessment:

• Ask the patient about any complaints related to their feet such as pain, coldness, tingling, and/or numbness. Find out if they are limber enough and see well enough to inspect and wash their feet themselves, or if they need (and have) assistance. Ask about any remedies they may use to care for their feet.

• Ask them if they are able to walk regularly for exercise. Ask about foot pain or difficulty while walking, including how long they have had pain. Assess for musculoskeletal deformities such as hammer toes, claw toes, corns, calluses, bunions and Charcot foot.
  • Charcot foot is a sudden softening of the bones in the foot that can occur in people who have significant neuropathy. http://www.diabetes.niddk.nih.gov/dm/pubs/neuropathies/ See also: http://www.footphysicians.com/footankleinfo/charcot-foot.htm

• Assess for decreased sensation. Use a Semmes-Weintein monofilament if available. For more information: http://diabetes.acponline.org/custom_resources/tools/using_10g_monofilament.pdf?dbp

• Examine the skin and hair growth. Patients with poor blood circulation to the lower extremities may have skin that is fragile, shiny and hairless

• Assess feet for dryness. Autonomic neuropathy may cause drying and cracking of the skin. Recommend a bland lotion, applied on top or bottom of the feet, but not between toes.

• Inspect toenails for excessive thickness, deformity, fungal growth, or in-growth. Examine skin between the toes for cleanliness, cracks, and sores. If present, refer to a Podiatrist.

• Palpate pedal, dorsalis pedis, and posterior tibial pulses. Absence of these pulses should be reported to the physician or NP. Select the following links for hints on location: http://www.netterimages.com/image/2632.htm , http://www.la.ac.uk/ibls/US/fab/tutorial/generic/sapulse.htm .

• Examine socks and shoes for presence of blood or drainage, abnormal wear patterns, fit, and appropriate foot protection.² Report the presence of blood or drainage for appropriate culturing and antibiotic therapy.

• Ulcers usually develop over areas of bony prominence and the pad and heels of the foot. Bunions, calluses and hammer-toes may be prone to irritation and ulceration. If pressure points are noted, suggest that the patient see a Podiatrist. Caution against use of commercial nail salons for foot care.

• Ask the patient if they feel burning, tingling, or numbness in their feet. They could easily be unaware of an infection or ulcer. 82 % of patients with foot wounds have symmetric polyneuropathy, or loss of sensation . This may contribute to diabetic foot problems. Patients with neuropathy may be unable to feel an injury, and are especially prone to burns from hot water or heating pads.

• Ask the patient if their feet feel cold most of the time. Assess feet for color, temperature, and vascular refilling. Note if the feet appear bluish, reddish, or pale. Feel the feet. Cold feet may be a symptom of poor circulation. Gently press the skin just enough to make the skin blanch. If it does not immediately "pink-up" when you release pressure, it may be a symptom of vascular problems.

If you have access to a Doppler blood pressure instrument, you can perform an assessment of the lower vascular system called the Ankle-Brachial Index (ABI). The ABI is the ratio of systolic blood pressure in the ankle compared to an arm measurement with a handheld Doppler instrument. An ABI of less than 0.9 indicates peripheral vascular disease. Complete directions for calculating the ankle-brachial index and test result interpretation can be found at http://www.webmd.com/heart-disease/ankle-brachial-index-test . Refer suspected vascular problems to the nephrologist and vascular surgeon.

Prevention of Ulcers and Amputations

One of the most important ways to prevent foot complications in CKD patients with diabetes is regular screening and early referral for identified problems.

Locking-Cusolito, et al ⁵ conducted a onetime assessment of risk in 230 subjects in a hemodialysis unit in Canada. They found that dry skin, cracked/fissured skin, claw toes, calluses and ingrown toe nail, all of which increase the risk for ulcers, were common and are very responsive to simple interventions such as moisturizing, therapeutic footwear and basic podiatry care. Although 75% of the subjects had adequate vision and 60% had adequate dexterity and 55% had adequate flexibility for self care, only 2.6% of the subjects were performing adequate foot self-care. See tips about adequate self-care, above under Patient Education.

A multidisciplinary foot-screening program is an excellent way to identify potential problems before they become complications. An example is a foot screening program developed by the Louisiana State School of Medicine called Lower Extremity Amputation Prevention Program (LEAP). To find ideas you can use, follow the link. http://www.medschool.lsuhsc.edu/dfp/download.html . The website contains examples and instructions for foot screening, illustrations, and a simple, one-page evaluation form.

Management of Foot Infections Related to Diabetes

If ulceration or infection is present, obtain a vascular surgical consultation and orders for cultures and appropriate antibiotic therapy. Assessment for underlying osteomyelitis is very important and requires four to six weeks of culture-directed antibiotic therapy.³ Treatment may include rest and elevation of the affected foot, debridement of necrotic and fibrotic tissue, application of topical medications and dressings. Treatment of underlying vascular ischemia may be necessary. Read an excellent review of the nurse’s role in managing diabetic foot ulcers  at http://www.nursingcenter.com/pdf.asp?AID=604643

Conclusion

• Patients with diabetes and CKD are at high risk for lower limb amputation.
• The first line of defense in preventing foot ulcers is patient education.
• Forming a designated team to screen patient’s feet regularly is a good way to start.
• Assessment for potential problems will assure timely interventions and referrals to prevent amputations.

Create a "Foot Day" in Your Practice

All CKD patients should have foot assessment on admission and regularly thereafter. The frequency should be established by care-givers at a manageable but regular interval.  For example, in a dialysis unit, "foot day" could be held once per month, perhaps in conjunction with medication reviews. Use the table below to get started.  Be sure to tailor to your practice and patient needs.

Other Helpful Resources

National Diabetes Education Program http://ndep.nih.gov/resources/feet/prevention-early-intervention.htm

Resources for professionals including a monograph titled "Feet can last a lifetime" , includes reference and resource materials, illustrations, foot exam format and checklist, sources for monofilaments, diagram for testing with monofilament and patient education materials.

National Diabetes Information Clearinghouse http://www.diabetes.niddk.nih.gov

Resources for lay people and professionals caring for individuals with diabetes containing an A-Z list of diabetes topics including a nine page patient education handout, Prevent diabetes problems: Keep your feet and skin healthy.

American Diabetes Association http://www.diabetes.org

This useful site contains general information for patients and professionals, including a helpful tool kit on diabetes and cardiovascular disease, weight loss, and recipes.

References

1. United States Renal Data System, 2007 Annual Data Report. http://www.usrds.org
2. National Diabetes Education Program, 2008, http://ndep.nih.gov
3. Frykberg, R. (2002). Diabetic foot ulcers: Pathogenesis and management. American Family Physician, 66 (9), 1655-1662.
4. Armstrong, D. & Lavery, L. (1998). "Diabetic foot ulcers: Prevention, diagnosis and classification." American Family Physician, 57 (6), 1325-1337.
5. Locking-Cusolito, H., Harwood, L., Wilson, B., Burgess, K., Elliot, M., Gatto, K. et al (2005). "Prevalence of risk factors predisposing to foot problems in patients on hemodialysis." Nephrology Nursing Journal, 31 (1) 53-61.

Individuals with CKD suffer with pain in many different ways whether from vascular access, bone disease and muscle aches, dialysis related complications, or some form of neuralgia, among other causes.

Second in our series of Clinical Solutions is an approach to Pain in CKD.

1. Recognize that pain is real and requires intervention.
2. Include pain as a vital sign.
3. Implement pain management strategies.

Recognition of Pain

Pain is a significant issue for people with CKD and impacts quality of life. The Dialysis Outcomes and Practice Patterns Study (DOPPS) compared analgesic use from 1997 to 2000 for 3,749 patients in 142 U.S. facilities. They report a decrease in use of all types of analgesics and an increase in the number of patients receiving no analgesics at all. Seventy-four percent of patients with pain interfering with work had no analgesic prescribed¹ . Hurdles we must overcome:

Patients may:

• Fail to seek treatment until pain is severe
• Refuse to use medication unless when absolutely necessary
• Fear addiction
• Avoid additional medications

Healthcare professionals may:

• Desire evidence based practice guidelines for pain management
• Require additional education specific to assessment and management of pain in CKD

Assessing Pain

The first principle of assessment is to believe the patient’s complaint of pain and initiate discussions: location; when and frequency; severity; and relief tactics used, if any. In addition, patients may have more than one type pain. Educating the patient about pain terms, definitions and descriptors will help as we rely on the patient’s subjective information.

Pain Scales will help diagnose and measure the intensity of a patient’s pain. Most scales used are visual, verbal or neumerical or some combination of all three forms. Commonly used pain scales are listed below. A combination of two or more may illicit a more thorough evaluation.

1. Visual Analog Scale:www.ndhcri.org/pain/Tools/Visual_Analog_Pain_Scale.pdf
2. Wong-Baker Scale: www.mdanderson.org/pdf/pted_painscale_faces.pdf
3. Comfort Scale:http://painconsortium.nih.gov/pain_scales/COMFORT_Scale.pdf
4. Checklist for Non-verbal:http://painconsortium.nih.gov/pain_scales/ChecklistofNonverbal.pdf

Pain Management

The goal is to help the patient return to the highest level of function and independence possible, while improving overall quality of life – physically, emotionally and socially. Pain management techniques assist in reducing the suffering experienced by a person with chronic pain.

Principles of a Pain Management Program:

• May not be able to achieve “pain free”. Work to an acceptable level defined by patient.
• Pain may be affected by other factors including psychological.
• Manage through a “team” approach. May include an outside referral and subsequent addition to the team.
• Education on the use of opiods and adjuvants to opiods.
• Identify any misconceptions to pain management and opoid use.
• Educate patient and family on the goals of therapy, management and complications² .

Potential interventions include³ :

• Medications, including:
  • Over-the-counter (OTC) medications: aspirin and/or acetaminophen.
  • Prescription pain medications
  • Prescription antidepressants
• Heat and cold treatments
• Physical and occupational therapy
• Exercise
• Local electrical stimulation
• Nerve blocks and regional anesthesia
• Surgery
• Acupuncture
• Alternative medicine and therapy treatments, as appropriate
• Emotional and psychological support may include the following:
  • Stress management
  • Relaxation training
  • Meditation
  • Hypnosis
  • Biofeedback
  • Behavior modification
  • Assertiveness training
  • Psychotherapy and group therapy
  • Patient and family education and counseling

Start Now!

1. Ensure that the multidisciplinary team recognizes and supports the program. Find out which pain medications and treatments physicians prefer to use.
2. Identify program director – coordinates staff education, identifies pain assessment instrument, describes documentation and treatment plan, oversees patient education plan and materials, and assures outcomes monitoring and reporting.
3. Educate staff on pain assessment and management. Identify any staff concerns regarding pain management.
4. Choose pain scale and incorporate into monthly patient assessment.
5. Assess all patients for pain – Document all aspects of pain in a clear and consistent manner
6. Educate patients and caregivers: purpose of assessment questions as well as pain terms, definitions and descriptors they can use.
7. Treatment plans should be individualized to the patient’s needs and include both pharmacologic and non-pharmacologic options. Anticipate and effectively manage side effects of pain medications
8. Identify community resources for referral
   • Physical therapy
   • Psychotherapy or counseling
   • Exercise programs
   • Pain specialists and clinics
9. Implement advocacy program for patients, if needed
10. Outcome monitoring
    • Routinely evaluate effectiveness of treatment plans and adjust as needed
    • Incorporate outcome results into existing quality monitoring program

* Comply with all state and federal laws and regulations regarding prescribing, dispensing, and administering controlled substances

* Stay up to date on pain management practices via continuing educational programs

Let us know how you have approached pain management in your practice. Contact us at vavrinchik@nephrologyclinicalsolutions.com

References

1. Williams A, Manias E. (2007). A structured literature review of pain assessment and management of patients with chronic kidney disease. J. of Clinical Nursing 69-81
2. Davison, S. (2005). Chronic Pain in End-Stage Renal Disease. Advances in Chronic Kidney Disease , 12(3), 326-334.
3. University of Utah University Health Care Web Site. Physical Medicine and Rehabilitation: Chronic Pain. http://healthcare.utah.edu/healthinfo/adult/Rehab/chronic.htm

• 46% had total cholesterol levels well over 160 mg/dL and
• 40% exceed the desired threshold for triglycerides (150 mg/dL) (1).

While complex to manage, there are several resources available. In 2003, KDOQI released its Clinical Practice Guidelines for Managing Dyslipidemias in CKD (2). To summarize, the guidelines state for all adults and adolescents with CKD:

• Assessment should include a complete fasting lipid profile with total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), and triglycerides.
• Dyslipidemias should be evaluated upon presentation (when the patient is stable), at 2–3 months after a change in treatment or other conditions known to cause dyslipidemias; and at least annually thereafter.

Nephrology Nursing Standards of Practice and Guidelines for Care offers guidelines for assessment, intervention, and patient education to achieve these outcomes (3). In part, the stated desired patient outcomes in the management of dyslipidemia are, the patient will:

• Achieve lipoprotein levels within targeted ranges
• Demonstrate a reduction in modifiable risk factors that contribute to the development of CVD.

All of this is informative, but how can we implement this in a simple and sustainable manner? How do we create an action plan that will achieve the desired patient outcomes?

Clinical Solutions offers a three-pronged approach to Triglycerides (TG) and HDL management.
“Assessment, Treatment, and Evaluation of the Patient with Elevated Triglycerides and Low HDL” from the Preventive Cardiovascular Nurses Association (PCNA), includes:

1. A professional course, “Assessment, Treatment, and Evaluation of the Patient with Elevated Triglycerides and Low HDL”, provides an overview of triglycerides and HDL. Invited speaker, Carol M. Mason, ARNP, FAHA (USF Heart Health, University of South Florida) reviews current clinical practice guidelines, assessment of risk including clinical assessment and laboratory testing, treatment options, and patient education including nutrition, exercise, weight loss, lifestyle changes, and medications. This program is offered free of charge and offers one hour of continuing education for registered nurses.
2. Clinical reference tool, “Elevated TG and Low HDL: A Quick Look at Patient Evaluation”, free to download, is a unique pocket guide providing for clinicians:
• ATP III Guidelines
• Risk Factors and Common Causes
• Clinical Assessment Guide
• Supporting Lifestyle Changes
• Pharmacologic Therapy
3. “What you need to know: Triglycerides and HDL” – a patient focused information handout that is applicable to patients with CKD, may be download at no cost. It describes TG and HDL, laboratory values, and risk factors, as well as advice on how to lower TG with an emphasis on nutrition, activity, weight and lifestyle changes. Over-the-counter and prescribed medications are discussed, and is followed by an action plan to be customized for each patient.

Start Now! Use the checklist. Let us know how you have reduced lipid levels in your practice. Contact us at Sallybh@nephrologyclinicalsolutions.com

TRIGLYCERIDES AND HDL PROGRAM CHECK LIST
OBJECTIVE: Achieve lipoprotein levels within targeted ranges

Steps	Start Date	Target Completion	Progress Date	Progress/Comments
1. Log into www.pcna.net/members/exams/Triglycerides/
2. Attend professional educational program (online or download). Complete the evaluation and print your CE certificate
3. Download and print Clinical Reference Tool Distribute copies to colleagues with direct clinical responsibilities. As a group, review the pocket guide asking and seeking answers to questions. Use laboratory-reporting system to identify patients who exceed the TG target range and those who have low HDL. Assign specific staff members to these patients. e. Include dietitian, social worker, physician, and others.
4. Download and print patient handout Photocopy for patients with high levels of TG and/or low levels of HDL. Review the content with the patient. Include interactive education; encourage questions, comments, and discussion about current and potential changes in self-management activities. Complete the action plan section. Tailor interventions to patient need. Assure that goal setting identifies barriers, and provides patient skill building and problem solving. For those patients with normal levels, use the handout as a preventative teaching opportunity.
5. Follow-up activities include reviewing with patient progress toward agreed upon goals. Include discussion of current laboratory results, nutritional intake, lifestyle changes, and medications. Support self-monitoring through dietary and exercise logs and review of laboratory test results.

References:

1. U.S. Renal Data System, USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2007. www.usrds.org
2. National Kidney Foundation. Clinical practice guidelines for managing dyslipidemias in chronic kidney disease. Am J Kidney Dis 2003 Apr;41(4Suppl 3):S1-91. [452 references] www.kidney.org
3. Burrows-Hudson, S. & Prowant, B. [Eds.] Nephrology nursing standards of practice and guidelines for care, 2005. Pitman, NJ:ANNA. www.annanurse.org
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