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www.DiabetesEd.net 1998-2017 Diabetes Education Services© Page 1
Lower Extremity Assessment
Beverly Dyck Thomassian, RN, MPH, BC‐ADM, CDE®President, Diabetes Education Services
2017
Objectives:
1. Describe risk factors for lower extremity complications
2. Discuss prevention strategies.
3. Demonstrate steps involved in lower extremity assessment.
4. State 3 diagnostic tools that help assess sensation and blood flow.
Objectives:
Lets take a look at Lower Extremities
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Comprehensive Foot Exam
Lower Extremity Complications Combination of vascular, neurological, and musculoskeletal dysfunction
After Lower Extremity Amputation (LEA), people have higher mortality rates and subsequent amputation
Poll Question 1 Which of the following is true about diabetes and lower extremities?A. Over 30% of people with diabetes
experience amputation.
B. Over 50% of amputations could have been avoided.
C. Most amputations happen before the age of 70
D. The rate of amputations is increasing.
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Lower Extremity Amputations Dropping over past 10yrs
60% of amputations in 7% of pop
Higher in men, elderly, minorities, Chronic Kidney Disease (CKD)
Lower extremity complications represent 20% of hospitalizations for elderly
Amputations cost $40,000
Amputation associated w/ earlier death compared to revascularization
10 yr survival after LEA
Diabetes and Amputations
Rate declined by 65% from
1996‐2008 From 11.2 per 1000 to 3.9 per 1000
Diabetes = 8 fold risk of amputations
Highest rate in those over 75
50% of amputations can be avoided through self‐care skill education and early intervention
Stats from CDC 2012
Diabetes and Lower Extremity Ulcers
Up to 15% of DM patients have ulcers in their lifetime
Mortality with foot ulcers is twice usual
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Poll Question 2 Which of the following factor(s) increase risk for amputation in diabetes?
A. Frequent hypoglycemia
B. Cigarette smoking
C. Previous amputation
D. Foot deformity
Profile of a High Risk Foot ADA Poor glycemic control Peripheral neuropathy Cigarette smoking Foot deformity Preulcerative callus or corn Peripheral arterial disease Previous foot ulcer history Previous amputation Vision impairment Diabetic nephropathy (esp if on dialysis)
Pathway to Amputation – Pecoraro, Frykberg
Minor Trauma (environmental)
+
Faulty Healing (intercurrentpathophysiology: circulation,
WBC/platelet function)
+
Ulceration
Predicts 72% of amp
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“I didn’t notice” Needle in foot Pebble in shoe Stepped on a nail Cut too deep Shoes were rubbing
Others?
Poll question #3 What is the most common cause of ulcers?
A. Dr. Scholl’s corn pads
B. Too tight of shoes
C. Trimming calluses
D. Burns from hot water
Common Causes of Ulcers
Tight shoe ‐ 86% is single precipitating event leading to ulcer
Neuropathy and peripheral vascular disease Autonomic: blood pooling, swelling Motor: atrophic musculature, deformity, joint stiffness
Resulting increased plantar pressure, trauma
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Pressure Area Breakdown
Neuropathic Diabetes Foot Ulcers
Walking Cast for Neuropathic Ulcers
Emotional aspects
Impact on BG
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Foot Deformities
Circulation Issues lead to Lower Extremity Problems
Peripheral Arterial Disease
Vascular Disease
Smoking
Peripheral Arterial Disease Intermittent Claudication
Physical Exam – Skin Pale or blue, purple
Dependent rubor, blanching when elevated
Cool to touch, loss of hair, nonhealing wounds, gangrenous
Diminished pulses
Treatment = Protect feet
Avoid constriction, increase walking, stop smoking, medications and/or surgery
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Foot Wounds
Blisters Ulcers Bone infection
Calluses
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No Bathroom Surgery
45 years with Type 1 Diabetes
Poll Question 4 Which of the following is a characteristic of peripheral vascular disease?A. Pitting edema
B. Foot blanches on elevation
C. No hair on toes
D. Absent pulses
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Peripheral Vascular Disease – Venous Disease
On exam Skin brownish, reddish, mottled
Skin warm to touch, may be edematous
May have stasis ulcers on lower leg
Pulses difficult to locate due to edema
Treatment Support hose, elevate feet, avoid constriction
Shoes that can accommodate feet
Pitting Edema
Venous Ulceration
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Diabetes and Charcot Foot
Damaged nerves
Blocked blood vessels
Shifting bones
Collapsed arch joints
Charcot’s• Neurotraumatic theory:
bony destruction due to loss of pain sensation and proprioception + repetitive and mechanical trauma to foot.
• Neurovascular theory:
joint destruction secondary to autonomically stimulated hyperemia and periarticular osteopenia associated with trauma.
45 yr old, type 2 on orals, Random BG 201mg/dl
Tx during acute phase = Casting for 3-6 mo’s then custom footwear
1st Step – Watch Pt Walk
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What to Ask in 1 minute Does the patient have a history of: Diabetes – how is control?
Previous leg/foot ulcer or LE amputation
Prior angioplasty, stent or leg bypass surgery
Foot wound that took > 3 wks to heal
Smoking or nicotine use
Does patient have: Burning or tingling in feet
Leg or foot pain with activity or at rest
Changes in skin color or skin lesions
Loss of lower extremity sensation?
Lower Extremities
Lift the Sheets and Look at the Feet
Lower Extremities "Every time you see your doctor, take off your shoes and socks and show your feet!"
For those at high risk for foot complications
All patients with loss of protective sensation, foot deformities, or a history of foot ulcers
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What to look for (1 minute) Skin exam Discolored, ingrown, or elongated nails
Signs of fungal infection
Dry or discolored skin, lesions, calluses or corns
Open wounds or fissure
Cleanliness
Interdigital maceration
Neurological Exam Monofilament or Ipswich Touch Test
Tuning fork
Callus and underneath
What to look for (1 minute) Musculoskeletal exam Full range of joints
Obvious foot deformities? If yes, how long?
Midfoot hot, red or inflamed
Vascular Exam Hair growth normal or decreased
Dorsalis pedis and posterior tibial pulses palpable
Temperature difference between calves and feet? Left and right foot?
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Flexibility Assessment Stiff joint Syndromes
Biomechanical Foot Assessment –
Test
Plantarflexion & Dorsiflexion of ankles, great toes
Watch pt ambulate
Inspect Shoes
Inspect for deformity
Significant Finding
Diminished joint mobility
Decreased vision, gait imbalance, need for assistive devices
Ability to see/ reach feet
Corn, calluses, bunions, prominent metatarsal heads, hammertoes, claw toes
Foot Deformities
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Visual Inspection/Palpation
Breaks in the skin Erythema Trauma Pallor on elevation Dependent rubor Changes in the size or shape of the foot
Nail deformities Extensive callus Tinea pedis Pitting edema
Onychomycosis Chronic Infection 50% of nail problems
We treat on skin but reluctant in nails
Mean duration of > 10 years
Rarely resolves spontaneously
Spreads to other nails, skin, other people
May be source of more serious infections
Affects quality of life
Vicks Vapor Rub?
Foot Exam – Screening for Neuropathy
Test
Semmes‐Weinstein monofilament 10g
Vibration perception threshold testing
Tuning Fork 128 Hz
Significant Finding
Lack of perception at one or > sites
Vibration perception threshold >24 volts
Abnormal vibration perception
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Loss of Protective Sensation
Monofilament Testing 5.07 touched to plantar
surface and top of foot
C shape delivers 10 gmspressure
Test four sites
Plantar surfaces of Each great toe1st, 3rd and 5th metatarsal head
5.07 monofilament delivers 10gms linear pressure
10 Free Monofilamentswww.hrsa.gov/hansensdisease/leap/
Monofilament (MF) Procedure(Int Consensus Grp)
Demonstrate procedure on pts forearm or hand
Have pt close their eyes
Test four sites in random sequence
(if callus or ulcer, test adjacent surface)
Bow the MF and ask, “Do you feel it touch you, yes or no?”
Randomly test at each site 3 times (one of which is a “sham” application – MF not applied)
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If no monofilament
Tuning Fork to Detect Polyneuropathy
128 tuning fork
Plantar halax
Compare sensation to that of examiner
Back to Basics in Diagnosing Diabetic Polyneuropathy with the Tuning Fork! Meijer, et all Diabetes Care, Vol 28, #9 Sept 2005
Tuning Fork Procedure
On each test: Ask pt to ID beginning of vibration
“Is it vibrating”?
Ask pt to ID cessation by dampening TF.
“Tell me when the vibrating stops”
The number of correct responses = 0‐8
At least 5 incorrect responses = peripheral neuropathy
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Foot Exam – Vascular Exam
Test Palpation of pulses dorsalis pedis
tibial
Ankle – Brachial Index (ABI)
Significant Finding Absent pulses
ABI <0.90, consistent w/ peripheral arterial disease
Vascular Status Assessment
Posterior tibial pulse
Dorsalis pedis pulse
Temperature
Appearance
Dorsalis Pedis Pulse
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Taking the DP Pulse
Posterior Tibial Pulse
Taking the Posterior Tibial Pulse
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Lower extremity systolic pressureBrachial artery systolic pressureABI =
The Ankle‐Brachial Index
Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34;
Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14
• The ankle‐brachial index is 95% sensitive and 99% specific for PAD
• Establishes the PAD diagnosis
• Identifies a population at high risk of CV ischemic events
• The “population at risk” can be clinically and epidemiologically defined:
Ankle Brachial Index Technique Measure highest systolic reading in both arms Record first doppler sound as cuff is deflated Record at the radial pulse Use highest of the two arm pressures
Measure systolic readings in both legs Cuff applied to calf Record first doppler sound as cuff is deflated Use doppler ultrasound device
Record dorsalis pedis pressure Record posterior tibial pressure
Use highest ankle pressure (DP or PT) for each leg
Calculate ratio of each ankle to brachial pressure Divide each ankle by highest brachial pressure
Using the ABI: An Example
ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure.
Right ABI80/160=0.50
Brachial SBP160 mm Hg
PT SBP 120 mm Hg
DP SBP 80 mm Hg
Brachial SBP150 mm Hg
PT SBP 40 mm HgDP SBP 80 mm Hg
Left ABI120/160=0.75
Highest brachial SBP
Highest of PT or DP SBP
ABI(Normal >0.99)
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Interpreting the Ankle‐Brachial Index
Adapted from Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Figure 6.
ABI Interpretation
1.00–1.29 Normal
0.91–0.99 Borderline
0.41–0.90 Mild‐to‐moderate disease
≤0.40 Severe disease
≥1.30 Noncompressible
Poll Question 5A patient has a dry skin crack in the back of their heel. What is the best action?
A. Gently scrape the dead skin with a razor
B. Use a pumice stone on area when skin is damp
C. Walk barefoot to promote healing
D. Wear white cotton socks
Foot Care Standards ADA Provide foot care education to pts w/ diabetes
High risk pts – use multidisciplinary approach Wound specialist, Vascular specialist,
Pedorthist etc.
Refer to foot care specialists for lifelong surveillance if: smoke, loss of protective sensation, structural
abnormalities, hx of lower extremity complications
Initial screen for PAD includes: Assess for intermittent claudication and pedal
pulses. Refer high risk pts for further vascular assess
and consider exercise, meds, surgical options.
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You Can Make A Difference
Assess Nail condition, nail care, in between the toes
Who trims your nails
Have you ever cut your self?
Shoes – type and how often
Socks
Skin/skin care and vascular health
Ability to inspect
Loss of protective sensation
What to Teach Daily foot care Visual inspection of feet, including in between toes. If pt can’t do this, ask family member for help
Keep feet dry by regularly changing shoes and socks
Report any new sores, discolorations or swelling
Shoes Don’t walk barefoot, even when indoors
Use good fitting footwear
Replace shoes yearly
No Bathroom Surgery
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Three Most Important Foot Care Tips
Inspect and apply lotion to your feet every night before you go to bed.
Do NOT go barefoot, even in your house. Always wear shoes!
Every time you see your doctor, take off your shoes and show your feet. Report any foot problems right away!
Thank You
Questions?
Email us at bev@diabetesed.net
Online Website Diabeteseduniversity.net
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