The Diabetic Foot
Stratification, Assessment & Referral
Introduction
• Scope of Podiatry and its role in prevention of lower
limb ulceration and amputation.
• Nursing - diabetic foot risk assessment
• Risk stratification & referral to podiatry services.
• Vasc & neuro Assessment – practical
• What clinical features = high risk diabetic foot
• Case study
• Funding
• Discussion & foot related questions
Podiatry – Scope of Practice
• Diagnostic Profession concerned with all aspects
of foot health
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Pharmacology
Medicine
Biomechanics
Radiology
Neurological, Vascular & Dermatological Assessment
& Treatment
– Orthotics Prescription and Fabrication
– Surgery
Podiatry & Diabetes
Our Role in Prevention
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Vascular and Neurological Assessment
Biomechanical & Dermatological Assessment
Off-loading Plantar Pressures
Mechanical and Orthotic Therapies
Specialized Skin & Nail Care
Prophylactic Surgery
Education
Nursing
Diabetes Stratification & Risk Assessment
• Do they have an active ulceration, severe infection or unexplained
swelling, heat and redness?
• Do they have Peripheral Arterial Disease and/or Peripheral Neuropathy
with any of the following:
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Foot deformity
Thick nails or corns/callus?
Are they ESRF?
Are the Maori?
Do they have a history of foot ulceration or amputation?
• Do they have Peripheral Arterial Disease and/or Peripheral Neuropathy?
Diabetes Stratification
• Active Foot Disease •
Hospital Pod
Current Ulceration/ Hot,red, swollen foot / severe infection-cellulitus
• High Risk -
Community Pod
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- Two funded consults with Community Pod
PAD or Peripheral Neuropathy with High Risk Features
• Moderate Risk -
Community Pod
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-One Funded Consults and treatment plan with Pod
PAD and/or Peripheral Neuropathy
• Low Risk •
WINZ funding available for all Diabetes Beneficiaries or Pensioners
GP, Nurse,
Diabetes Stratification
• Low Risk Foot (no referral needed)
– Good blood flow and protective sensation is intact
• Moderate Risk Foot
(referral to Primary/ Private
Podiatry)
– Peripheral Vascular Disease (PVD) and/or Peripheral
Neuropathy with no other pathology
• High Risk Foot
– with ‘high risk’ pathology
• Active Foot Disease
– Current ulceration or charcot neuro-athropathy
Vascular Assessment
• Signs
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Pulses not palpable
Doppler – pulses not detected or very low pitched sound
CRT more than 5 seconds (micro-angiopathy?)
Poor Colour & cool temp gradient
Diminished pedal hair
• Symptoms
– Intermittent Claudication (pain on walking, every time they
walk at the same distance, have to rest for pain to ease)
– Rest Cramps (cramps in bed each night or at rest)
Macro-vascular Assessment - Pulses
• Vascular Anatomy
Dorsalis Pedis
Macro-vasc Assessment
• Posterior Tibial Pulse
Macro-vascular
Doppler Assessment
• Doppler is an excellent tool to have, as often
even good pedal pulses are hard to palpate,
especially if there is oedema present
• Use ultrasonic gel, and move the ultrasound
head until you get the loudest reading on that
pulse. A good pulse is very loud with 3 phases
of sound, a poor pulse is very low pitched with
only one phase.
Micro-Vascular Assessment
• CRT – normal is less than 5 seconds
• Absence of pedal hair indicates poor microvascular status
• Thick atrophied nails can indicate poor
circulation to the skin also
• Temperature – cold feet
• Poor Colour
How to do the Monofilament Test
• Show the patient that the monofilament test is not painful by
touching your own hand with the monofilament.
• Let them feel it on their hand – so they know what to expect
• Patient closes their eyes and says ‘yes’ every time they feel it.
• Avoid asking the patient “Can you feel that?”
• Press the monofilament perpendicular to the skin and let it buckle
and hold for 1-2 seconds before releasing it.
• Re-test each site that the patient could not feel to be sure we have
an accurate test.
• Be aware that callused areas will have less sensation.
• Two or more sites gone undetected by patient is considered
Moderate Risk
Dermatological & Biomechanical
features of the High Risk Foot
If your patient has PAD or Peripheral
Neuropathy with:
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Thick nails
Corns or Callus
Foot Deformity
End Stage Renal Failure
History of lower limb ulceration or amputation
Maori ethnicity
This is considered a High Risk Foot
High Risk Pathologies – Callus & Corns
Pre- ulcer lesions
High Risk Pathologies
Pre-ulcer Lesions
• Corns and Callus are known in Podiatry as preulcer lesions.
• Peripheral Neuropathy with Corns and Callus
are the common causal pathway to ulceration.
• This is why patients with PAD and/or
Peripheral Neuropathy are considered High
Risk.
High Risk Pathologies – Deformity
leads to pre-ulcer lesions
High risk Pathologies - Nails
Case Study
Case Study - Ruth
88 year old female
Diabetes with impaired nerve function and blood flow
Visual impairment
Unable to care for feet at home
Good Health otherwise
Presents with thick crumbly nails due to peripheral
vascular disease
Requires regular nail treatment to prevent ulceration of
nail bed
Case Study
• No pain in feet
• During treatment (grinding thick nails) infected
wound discovered under the nail plate
Case Study
• Early detection through routine nail care by a
Podiatrist prevented ulceration and
amputation
Available Funding
• PHO Packages of Care
– High Risk Feet – Two Consultations Private Podiatry
– Moderate Risk Feet – One Consultation Private Podiatry
WINZ – Disability Allowance – all diabetes patients
Parkinson’s Society
PHO Packages of Care
• The packages of care are designed to provide
full assessment, including ABI where
indicated.
• Also the Podiatrist, puts a treatment plan in
place with the Primary Health Providers, GPs
& Practice Nurses.
• Work with WINZ for regular care
Foot Questions
Located within the new Whareora o Tikipunga
Clinic, 157 Kiripaka Road, Tikipunga.
Phone:
09 437 0015
Fax:
09 437 0016
Mid North Clinic:
– Paihia Medical Services, 22 Selwyn Ave, phone:
402 8407
Far North Clinics:
– Mamaru Clinic, Coopers Beach Shopping Mall, phone:
406 0074
– Kaitaia Clinic, Te Whare Hauora, Redan Road, phone:
408 0049