Diagnosis and treatment of diabetic foot
Diabetic foot disease is an important and common complication of diabetes mellitus, which is very difficult to diagnose and treat, so prevention should be given priority, especially for the physicians and diabetic patients. It is very important to prevent the occurrence of diabetic foot disease.
Screening of risk factors: Screening of risk factors is of utmost importance for effective prevention of diabetic foot disease. Patients with a history of diabetes mellitus for more than 10 years should be closely observed, as the risk of ulceration or amputation is higher in this group, especially in male patients, as their blood sugar control is often poor and cardiovascular and renal complications are more common. The following conditions must be noted as being closely related to podiatry and increasing the risk of amputation.
(1) Peripheral neurogenic lesions that lack self-protective sensation.
(2) Altered biomechanics in the presence of peripheral neuropathy.
(3) Evidence of increased plantar pressure (erythema under the callus, hemorrhage).
(4) Bone deformities of the lower extremities.
(5) Presence of peripheral arterial disease with varying degrees of pressure reduction as measured by Doppler.
(6) History of ulceration or amputation.
(7) severe lesions of the toenails.
1.Examination of the foot
(1) All diabetics should undergo a foot examination at least once a year for timely detection of high-risk conditions leading to morbidity. These examinations should include assessment of foot protection sensation, foot structure, biomechanics, vascular supply status and skin integrity.
(2) The most basic examination of the foot should include palpation and auscultation, a special 10-g nylon wire, and tuning fork examination.
(3) Patients with one or more risk factors should be evaluated more frequently for the development of risk factors.
(4) Diabetic patients with neuropathy should have their feet carefully examined at each visit to a health care facility.
(5) Low-risk feet should also be examined by quantitative somatosensory testing with a specially designed 10-g nylon wire.
(6) The first examination of peripheral artery disease (PAD) should include a history of claudication and pressure measured by Doppler, ankle-brachial index (ABI), as a number of patients with PAD are asymptomatic.
(7) Check the integrity of the skin of the foot, especially between the toes and under the metatarsal heads.
(8) The presence of erythema, elevated local temperature, and callus formation may be an injury to the tissue near the rupture.
(9) Attention must be paid to bone deformities, restricted joint movement, gait and balance problems.
2.Prevention of high-risk foot
(1) Proportional distal polyneuropathy is one of the most important precursors of ulceration and amputation.
(2) Try to maintain the liver anti-insulin substances close to normal levels can effectively slow down the progression of neuropathy.
(3) Stopping smoking can effectively reduce the complications of vascular system disease.
(4) Timely consultation with a podiatrist is essential.
(5) For diabetic patients with a history of smoking or lower extremity complications, continuous preventive foot care and lifelong observation should be carried out.
3, the management of high-risk foot
(1) try to control blood sugar in the normal range, to prevent the occurrence of diabetic foot disease to lay a good foundation.
(2) have neuropathy or evidence of increased plantar pressure of diabetic patients, should be appropriate to wear soft enough shoes or sports shoes in order to redistribute the plantar pressure, and maintain good ventilation.
(3) Patients should be educated about foot sensory loss and learn other alternative examination methods (palpation and visualization) in order to detect early podiatric problems in a timely manner.
(4) Calluses should be cleared with a scalpel by a podiatrist or experienced or specially trained medical personnel.
(5) Patients with bony deformities such as mallet toe, significantly enlarged metatarsal heads and capsulitis (inflammation of the medial aspect of the big toe) may require looser fitting footwear.
(6) Patients with terminal bone deformities who cannot use commercially available therapeutic footwear may only be able to use specially tailored special footwear or preferably a dedicated diabetic foot disease prevention boot.
(7) Patients with significant claudication or significantly decreased ABI values are advised to undergo further vascular evaluation and then consider the use of exercise, medical or surgical interventions.
(8) Diabetic patients with a history of foot ulcers should have an evaluation of the pathologic basis and use this as a basis for managing the diseased foot.
(9) When the skin is thin, for example, skin cracking and ringworm should be treated aggressively to avoid its deterioration.
(10) For existing foot ulcers and high-risk feet, especially those with a history of previous ulcers or amputations, it is recommended to use a multidisciplinary approach to prevention and treatment, and daily self-examination of the foot is required.
4.Patient education
(1) Knowledge should be disseminated according to the risk factors of patients with diabetes and high-risk foot disease and their appropriate management strategies.
(2) Acquire knowledge of assessment of basic conditions and care training.
(3) Patients with risk factors should understand the risk of loss of protective sensation, the importance of daily foot monitoring, and appropriate foot care, including cleaning the feet with warm water on a soft towel and good toenail and skin care and appropriate footwear selection.
(4) Regarding foot washing soak the feet 1-2 times a day with hot water, which can maintain foot hygiene and promote blood circulation, but the water temperature should be <38℃ to avoid scalding, test the water temperature by family members or test the water temperature by hand by myself, do not test the water temperature by feet, because the foot sensory nerves are damaged and have been dulled.
(5) Whether the patient has adequate understanding of the above knowledge and the ability to direct appropriate monitoring and care of the foot should be assessed.
(6) Diabetic patients with neuropathy should be given advice to wear new shoes gradually to minimize blister and ulcer formation.
(7) Avoid foot acupuncture treatment to prevent accidental infection.
(8) Foot massage should be gentle, avoid pushing, rubbing, pinching and other actions that damage the skin.
(9) In the cold winter, pay attention to keep warm.
(10) Try to avoid standing for a long time, because the foot is the end of the lower limb, blood supply and oxygen supply is less than other tissues, especially when the blood sugar is poorly controlled, it will make the microcirculation of the foot impaired, blood supply and oxygen supply is obviously reduced, resulting in the hidden danger of diabetic foot.
(11) Patients with visual impairment, limited mobility or cognitive difficulties need serious and effective assistance from other family members because they lose the ability to assess foot conditions and respond in a timely manner.
(12) For the foreseeable risk of ulceration or amputation of diabetic patients to focus on the foot examination and foot self-protection education courses.
5.Education for medical and nursing staff of diabetic foot disease
(1) All relevant personnel should pass the examination of neurology, angiology and dermatology, musculoskeletal system.
(2) Health care workers who are interested in diabetic foot control should be selected to grant further training in order to provide quality services to high-risk podiatric patients.
(3) For the education of diabetic patients need expert advice and expertise, including correction of footwear, toenail, callus care and surgical treatment of the foot.
6.Foot skin care and maintenance
Foot skin care and maintenance is an important part of the prevention of diabetic foot, on the basis of strict control of blood sugar and correction of poor metabolic status, pay attention to foot hygiene and avoid foot trauma can effectively prevent the occurrence and development of diabetic foot.
(1) Care of the skin.
① Wash your feet every night with warm water (no more than 35℃) and neutral soap, and gently dry them with a soft, absorbent towel, especially between the toe seams to avoid rubbing to prevent minor skin damage.
②After drying, apply lubricant (lubricating milk or nutritional cream) and rub fully to maintain the softness of the skin, remove scales and prevent dryness and cracking, without rubbing between the toes, if the skin has pressure pain, you can rub with 75% alcohol once a week.
③ Massage the foot from the tip of the toe, gradually up, so as to facilitate blood circulation.
④If the toenail is dry and brittle, use the Chinese medicine borax (one tablespoon per liter of water, about 15g) every night, slightly warm water to soak the foot for 30 minutes to soften the toenail, then massage around the toe with a soft cloth to keep the toenail around dry and clean.
⑤ Learn to properly cut the toenail, do not cut the toenail too short, cut the toenail must be cut straight along the horizontal, you can use a small file for filing nails to file the edge of the toenail round and smooth.
6) To keep your feet warm in winter, wear loose and loose cotton socks, never use electric heaters or hot water bags to dry your feet to avoid burning your skin, and avoid wearing unsuitable footwear and walking barefoot.
(7) Some topical medications are too irritating and must be approved by a doctor before being applied to the foot.
(2) Care of skin abrasions.
(1) Timely inspection and early detection of foot blisters, cracks and abrasions, etc., because foot ulcer infection and gangrene are caused by microtrauma, once found, should immediately go to the hospital.
②Keep the skin of the foot intact and clean. When the epidermis on the foot is abraded, do not use your nails to tear it, but immediately disinfect and clean it with soap and alcohol, and then wrap it with a disinfected bandage, without applying ointment.
③Prohibit irritating disinfectant solution such as iodine, etc. If necessary, use gentian violet for external application.
④Prevent foot mold infection by puffing prickly heat powder between the toes after each foot wash or bath to keep the area dry. If you already have tinea pedis, use clotrimazole ointment, and patients with secondary infections of tinea pedis should use 1:8000 potassium permanganate solution to wash their feet 1-2 times/d, wipe dry and wrap with anti-inflammatory ointment and gauze externally, and take oral antibiotics if necessary.
(3) Select a suitable pair of shoes.
①Buy shoes to draw the size on paper first, and cut out the shoe sample to be used as the standard for choosing shoes, because diabetic patients mostly have peripheral neuropathy and dull feeling, can not just choose shoes by feeling.
②Choose cloth shoes is good, because cloth shoes air circulation performance is better, can reduce foot sweating, cause the risk of foot skin allergy or infection also decreased accordingly.
③ avoid wearing high-heeled shoes should wear flat-soled shoes, because high-heeled shoes can put extra pressure on the toes, which can affect blood circulation and even cause extrusion injuries or blisters.
(4) Pay attention to the toe of the shoe: the toe of the shoe should not be too crowded, and a certain width and length should be reserved to avoid pinching and squeezing and affecting the terminal circulation.
(5) New shoes: the purchase of new shoes, the first few days on the easy to rub parts, place a little cotton, etc., the first wear should be tried on for half an hour to see if any part of the skin has been rubbed red and swollen, etc., if no problems occur, can gradually increase the wearing time.
(6) check the shoes: often check the interior of the shoes, pay attention to the presence of rough edges, cracks or stone gravel, should be instantly repaired and removed.