1. 'Best Feet Forward' Module 4.1.1 Workshop material developed by the
The Alfred DPMI Workforce Development Team
for the Central West Gippsland PCP
Diabetes Prevention & Management Initiative
Module One for Diabetes Educators reviews content of module two pre reading utilising level two PowerPoint presentation.
Pre reading module follows module two PowerPoint presentation in this section of the folder.
Participants work through the level two footcare PowerPoint presentation and in the process they have the opportunity to:
Practice teaching footcare assessment
Discuss local footcare assessment tool and clinical pathways including variations in Diabetes Educator Assessment tool ( follows PowerPoint in this section) and Registered Nurse Assessment tool,(copies in prof both can be found in section three.
Discuss documentation of foot assessment and practical implications
Review care planning and clinical pathways, discuss local situations that may promote or impede implementation.
Produced by The Alfred Workforce Development Team
on behalf of DHS Public Health -
Diabetes Prevention and Management Initiative
June 2005

2. Acknowledgements
This resource was developed in consultation with the Central West Gippsland PCP: DPMI Technical Working Group.
The presentation has been adapted from the:
Footcare in Diabetes Workbook for Health Professionals. Australian Diabetes Educators Association
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

3. Workshop purpose – Level 2
Target
Registered nurses involved in caring for people with diabetes i.e. those involved in community, home or acute nursing, general practitioner practice nurses.
Objective
To provide training to increase skills in:
Appropriate foot assessment and documentation of assessment
Identification of foot at high risk of ulceration or amputation
Identification of active foot problems that require further assessment and/or treatment
Development of foot care action/care plans consistent with assessment findings.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

4. “Best Feet Forward” Project
Aim
To decrease foot problems in people with diabetes
Objectives
Train health care providers in the assessment, classification and care of the diabetic foot
To support appropriate action planning and multidisciplinary care of diabetic foot problems
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

5. Diabetes complications
Admission rates in the Central West Gippsland catchment are 2.5 times higher than the state
A large percentage of those admitted with complications occur below the knee
Reference:
Public Health Division, Department of Human Services, The Victorian Ambulatory Care Sensitive Conditions Study: Opportunities for Targeted Interventions, June 2002
Note local admission rates for the Central West Gippsland project were used to highlight the relevance of the issue locally
If local figures are not available prevalence and incidence rates outlined in the pre workshop workbook could be used
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

6. Why perform a foot assessment?
Prevention of:
foot ulceration gangrene
amputation
Assist in the maintenance of:
Mobility
Independence
Healthy active lifestyle
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

7. Function of the feet To act as a stable base of support
To provide shock absorption with each step
To adapt to surface irregularities
To provide sensory feedback
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

8. Peripheral vascular disease
Degenerative vascular disease
Most commonly it is seen as multiple occlusions of the popliteal artery and its branches
Risk factors
Hyperglycemia
Smoking
Hypertension
Hyperlipidemia
Normal Artery
Stenosed Artery
Fibrous and/or fatty plaques
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

9. Peripheral neuropathy
Impairment of nerve function segmental demyelination
All nerve fibres can be affected
Sensory
Autonomic
Motor Ne r V e
Axon Ne r V e
Axon
Myelin Sheath necessary for normal impulse conduction
Demyelination of axon i.e. no impulse conduction
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

10. Foot ulceration Predisposing factors Precipitating factors
Vascular Disease
Peripheral Neuropathy
Infection
Physical injury
Precipitating factors
Mechanical (pressure)
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

11. Foot ulceration Extrinsic Pressure Intrinsic Pressure Tissue Hypoxia
Repetitive rubbing
Footwear
Intrinsic Pressure
Limited joint mobility
Callus Formation
Altered tissue strength
Foot deformity
Irregular foot structure
Waiting for graphics to arrive
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

12. Foot ulceration-mechanism
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

13. Diabetic Osteopathy (Charcot’s disease)
Presents as a warm swollen foot or ankle
Often misdiagnosed as cellulites
Affects ankle, subtalar and mid-tarsal joints
Severe peripheral neuropathy is nearly always present
Urgent orthopedic referral is required
Foot must be immobilised while inflammation present
Will try to get a photo to include
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

14. Diabetic Osteopathy (Charcot’s disease)
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

15. Foot assessment WHY? GOAL
Most foot problems are preventable when identified early, treated appropriately and when people are educated to avoid problems
GOAL
Prevent amputations
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

16. Foot assessment Aim to identify the high risk foot using as indicators
History of previous ulcer
Peripheral neuropathy
Peripheral vascular disease
Foot deformity
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

17. Foot assessment Aim to identify active foot problems check for:
Infection
Ulceration
Calluses or corns
Any skin breaks
Nail disorders
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

18. Assessment tool
Note factors to consider when working towards a common foot assessment form include:
Inclusive collaborative approach of all key players in developing assessment form
Meeting medical record requirements of local organisations
Branding that is recognisable to all organisations involved
Local resources and referral patterns
Copies of the assessment form can be found following the presentations in this section

19. Assessment tool - back page

20. General footcare Feet clean
State of Skin – moist/ dry/shiny/hairless/thin
Interdigitial areas – macerated/ dry
Callus
Must be regarded as pre- ulcerative, esp in neuropathic foot.
Appears as yellow thickened skin
Occurs at pressure points
Early treatment and pressure relief prevents ulceration
Socks, pantyhose, shoes – appropriate, well fitting, provide adequate support
Orthotics/prosthesis
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

21. General footcare Shoes
Appropriate, provide adequate support- general rule leather and lace are best
Good condition
Well fitting – shoes should fit three ways length/width/depth
Poorly fitting shoes can cause blisters and corns that may ulcerate
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

22. General footcare Nails Thickened Fungal infection Ingrown
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

23. General footcare Note and draw on feet on assessment form
Ulceration- Non-healing wounds may occur anywhere on the feet, look particularly at pressure areas e.g. tops/tips of toes, ball of foot,heel, under callus.
May be painless
Infection- look for redness, warmth, discharge, swelling
Signs and symptoms may be masked by ischemia or neuropathy
Deformities- such as corns, callus, bunions, claw/hammer toes, heel cracks
These areas are more susceptible to pressure and require special attention to shoe fit
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

24. Neurological status Symptoms of neuropathy Pain
Burning, numbness, pins & needles
Symptoms usually bilateral
Often worse at night
May be hypersensitive to touch
May be present when first diagnosed with diabetes
May worsen with unstable blood glucose levels
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

25. Vascular assessment Symptoms of intermittent claudication Pulses Ulcer
Pain in calf muscle when walking, leg cramps
Pulses
Dorsalis Pedis
Posterior tibial
Ulcer
Gangrene
Amputation
Allow participants to break into pairs and perform a foot assessment on each other working through the foot assessment form
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

26. Assess self care capability
Does/can the client:
Understand effects of diabetes on the feet
Identify appropriate foot care practices
Smoke
Able to adequately care for their feet
Have impaired vision/mobility
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

27. Flow chart for diabetes foot exams
Start
Type 1 and Type 2 Diabetes: when diagnosed
Annual Comprehensive Foot Exam and Risk Categorization
By diabetes educator/podiatrist /general practitioner
Include education for self care of the feet and reassess metabolic control
Visually inspect feet 6 monthly
Visually inspect feet at every visit
Low
Risk
Feet
High
Risk
Feet
Action plan to support self care and identification of foot problems
Action plan to restore and/or maintain integrity of the feet
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program

28. Risk categories
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program

29. Action Plan
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Adapted from Feet can last a life time. A health professionals guide to preventing diabetes foot problems. National Diabetes Education Program

30. Case study one
Mrs H is 45 years of age and has been newly diagnosed with diabetes.
Little foot pathology is evident, apart from a small fissure on the right foot between the
third and fourth toes.
From the information provided, what would be your assessment of this lady?
Minor foot problem
Need to check if seen educator
What immediate advice would you give?
 Keep clean and dry.
Take particular care after shower to dry well
Wear cotton/wollen socks and leather shoes to decrease moisture
Complete a care plan (overleaf) for this lady
Low Risk Foot
Active foot problem; Refer to podiatrist and/or general practitioner
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

31. Case study two
Mrs W. is 43 years of age she had type 2 diabetes for 2 years. Seven days ago she dropped a can on her toe, since then she has had a very painful toe with pus coming from the side of the nail.
She has been soaking the foot in water "as hot as I can stand". Today the blood glucose is 17mmol/L.
From the information provided, what would be your assessment of this lady?
Infected
Raised BGLs
Foot self care knowledge poor
What immediate advice will you give?
Clean and cover
Relieve pressure/immoblise
Stop Soaking
See Gp
 Complete a care plan (overleaf) for this lady
High Risk Foot: signs of infection
Active Foot Problem: Refer to podiatrist and/or general practitioner
Inadequate Knowledge of Foot care practices: Refer to diabetes educator/Provide education
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

32. Case study three
Mrs A. is 65 years of age and has had Type 2 diabetes for 25 years. She measures her blood glucose levels very infrequently. BGL today is 13 mmol/L. She has had a sore on her foot for 3-4 months which she has treated herself with a razor and an antiseptic. She is unconcerned by this wound and tells you she usually heals well.
From the information provided, what would be your assessment of this lady?
Neuropathic ulcer
Elevated blood glucose
Inappropriate self care practices
What immediate advice would you give her?
Need to stress needs immediate action: GP and Podiatrist referral
Keep clean and dry and relieve pressure
Stop using razor
Complete a care plan (overleaf) for this lady
High Risk Foot
Ulceration /signs of infection: Immediate referral to general practitioner
High Risk Foot: Referred to podiatrist/diabetes educator
Refer for medical assessment at least every six months
Visual inspection at every visit Inadequate
Inadequate Knowledge of Foot care practices: Refer to diabetes educator/Provide education
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

33. Case study four
Mr S is 75 years old and has had Type 2 diabetes for 10 years. BGLs are usually below 9mmol/L.
He reports having calf pain when walking 50 metres or more. You are unable to palpate pulses on either foot. He complains of no foot problems. He has reasonable eyesight but has difficulty bending to reach his toes. He lives with his wife.
From the information provided, what would be your assessment of this gentleman?
 PVD
Nails poorly cared for
What immediate advice would you give him?
Use moisturiser on feet
Suggest podiatrist cut toenails
Check if wife able to help with foot care
Review footwear 
Complete a care plan (overleaf) for this gentleman.
High Risk Foot: Referred to podiatrist/diabetes educator
Refer for medical assessment at least every six months
Visual inspection at every visit Inadequate
Symptomatic Peripheral Vascular Disease: Refer to General Practitioner or Physician
Inability to perform safe self care practices: Refer to diabetes educator Educate Family member or carer
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

34. Case study five
Mr B is 75 years and lives in an elderly persons unit. Recently diagnosed with Type 2 diabetes.
He is a non smoker and BGLs have been well controlled.
His pulses are palpable and he has no symptoms of neuropathy.
He walks only around the block with the aid of a stick. He says his feet hurt but have done so for years.
He is frightened of loosing his legs and becoming immobilised and helpless.
From the information provided, what would be your assessment of this gentleman?
Severe callus/may have ulcer underneath
Cannot exclude PVD/ dry skin thick toenails
What immediate advice would you give him?
Reassurance
podiatrist referral
Moisturiser for feet
Check shoes
Complete a care plan (overleaf) for this gentleman
High Risk Foot: Referred to podiatrist/diabetes educator
Refer for medical assessment at least every six months
Visual inspection at every visit Inadequate
Foot Deformity or abnormality; Referred to podiatrist
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

35. Diabetic Osteopathy (Charcot’s disease)
DPMI Workforce Development – The Alfred Workforce Development Team June 2005