REVOLUSI 4.

0 NURSING

Griya Husada Center

ADVANCED IN DIABETIC FOOT CARE

ASMAT BURHAN
ENTEROSTOMAL THERAPY NURSE
Di Sampaikan Pada Seminar Revolusi Industri 4.0 Nursepreuneur
Clinic Griya Husada Center
FOOT CARE NURSE
Kediri, 29 September 2019 DIABETIC CARE UNIT, CLINIC GRIYA HUSADA CENTER
REVOLUSI 4.0
REVOLUSI 4.0 NURSING
 OUTLINE
1. Introduction
5. Management DIMES
2. Foot screening 6. Conclucion
3. Complication
4. Assessment and diagnosis
1. Diabetes –related history
2. Foot assessment
3. Footwear assessment
4. Education needs
5. Initial ulcer assessment
6. Risk stratification
 FOOT
COMPLICATION
INTRODUCTION
 Diabetic foot can be defined as infection,
ulceration or destruction of tissues of the
foot associated with neuropathy and/or
peripheral arterial disease of people with
diabetes mellitus. IWGDF, 2016

 80% of non-traumatic lower

limb amputations

 50% die within 5 years of foot ulcer

 70% die within 5 years after an amputation.
 2. The Diabetic Foot Complications
Risk
Categories
1 DM Foot • Neuropathy
Mod Syndrome • Vasculopathy

2 • Foot Deformity
High Pre-Ulcer • Skin / Nail
Changes
3
Very DM Foot • Infection
10-30%
High Ulcer • Inflammation

10-20X Amputation
Clinic Griya Husada Center Protocol
 Clinic Griya Husada Center Protocol

2.1 HYPERGLIKEMIA

DPN

Foot
PVD Trauma
Ulcer

Infection DFI DFO

Clinical Case PVD Dokumentasi GHC
Clinical Case DPN

Dokumentasi GHC
Clinical Case DFU

Dokumentasi GHC
Clinical Case DFU Dokumentasi GHC
Clinical Case DFI

Dokumentasi GHC
Clinical Case DFO

Dokumentasi GHC
Dokumentasi GHC
 Dokumentasi GHC Dokumentasi GHC

Dokumentasi GHC Dokumentasi GHC

 3. FOOT SCREENING

 recognized as the modality to identify those at ‘low current risk’ or ‘at risk’of
ulceration.
 Is intended to find patients at risk of comorbidities and offer appropriate advice to
access services in a timely and effective manner .
 at least annually for people with diabetes to assess how the condition has
affected his/her foot health
 Primary care physicians

endocrinologist
Healthcare podiatrists
professional

nurses
3.1 DIABETES –RELATED
HISTORY
1. Type of diabetes 6. Smoking status
2. year of diagnosis and duration 7. Occupation
3. Treatment 8. Previous foot ulcers
4. Hba1c % onset of the foot wound and 9. Previous vascular intervention
date taken 10. Previous amputation
5. Status of retinopathy, nephropathy,
cardiovascular disease
 To address the potential current status
of developing diabetic foot problem .
 3.2 FOOT ASSESSMENT

A. Neurologic examination
B. Vascular examination
C. Dermatological examination
D. Musculoskeletal examination
 A. Neurological examination

• Screening for peripheral neuropathy

Clinical test
1. Light touch
2. Pin prick
3. Monofilament test
4. Vibration-tuning fork
5. Proprioception
1. Light touch 2. Pin prick
3. Monofilament test 4. Tuning fork
6. Proprioception
 A. Neurological examination

• Numbness
• Burning sensation
• Pricking feeling
• Able to sense feet while walking
B. Vascular examination

• Screening for peripheral arterial

disease
Check for :
1. Dorsalis pedis pulse
2. Posterior tibial pulse
3. Popliteal pulse
4. Changes in Skin color
5. Changes of skin temperature gradient
6. Capillary refill
 Ankle Brachial Pressure
Index
 take blood pressure with cuff in both arms and at
around lower leg using a doppler probe
 (highest cuff pressure at which pulse can be heard)
leg blood pressure/ arm blood pressure = ABPI

< 0,5 0,5 – 0,7 0,7 – 0,8 > 0,9 > 1,2
Arterial Mixed Arterial – Venous Venous Possible
Ulcer Ulcer Ulcer Calcified
Vessels
- test that compares the blood pressure in your arms No Three Layer Bandages Four False
Bandage Layer
and legs to determine if you have PAD. Bandages

- evaluate the strength of the pulse in your legs and feet

 B. Vascular examination

Symptom :
1. Claudication -pain when walking,
required stop to relief pain

2. Rest pain - pain in bed at night, ,

dropping the legs over the side of bed
to relieve pain
C. Dermatological examination
Dokumentasi GHC

2. Callous
Skin
3. Corn
– Dry
4. Fissure
– Shiny
5. Fungal infections
– Pigmentation
– Hair loss
 D. Musculoskeletal examination

Screening for Charcot neuropathy

Foot deformity
- ( Claw toes, hammer toe, Bunions, Bony prominences, Pes planus, Pes cavus )
 D. Musculoskeletal examination

• Range of motion

 Muscle strength of
dorsiflexion and plantarflexion
 3.3 FOOTWEAR ASSESSMENT
• Shoe evaluation - assess point of irritation or skin breakdown related to the shoes and
bony prominences.
• The sole of the shoes should be inspected for excessive wear patterns.

1. Style
2. Condition
3. Fit
3.4 EDUCATION NEED
1) Check feet daily- site, spot for foot problem
7) Exercise regular-promot good blood
2) Wash feet daily-mild soap, lukewarm water, no circulation in foot
soaking of foot
3) Apply lotion daily-soft, smooth, not in between 9) When to call for help- corn ,cllous, wound
toes
4) Nail care- cuts carefully, straight across, do
not to short.
5) Socks- not too tight, light color, avoid have
seams
6) Shoes- cannot too tight, buy shoes in the late
afternoon, adjustable strip and wide toe.

This lack of diabetic foot education and risk factor

awareness may be a factor in more than 90% of
recurrent ulcer (Giovinco& miller 2015)
3.5 INITIAL ULCER ASSESSMENT

1. Date of ulcer occurred 5. Cause of diabetic foot ulcer

2. Reason for visit 6. Recurrent?
3. Affected foot 7. Antibiotic?
4. Ulcer site 8. Size of wound
9. Grading/classification
• 2 final points that should conclude the diabetic
foot assessment:
1. Next appointment
2. Any referral needed
 The DIMES Concept © Ayello 2015

D Devitalized tissue
• Fokus : membersihkan jaringan mati dan eksudat Action: Debridement
• Outcome: warna dasar luka merah

I Infection & inflammation control

• Fokus: Pengendalian infeksi, mengurangi inflamasi Action: Antimikrobial

Dokumentasi GHC
• Outcome: infeksi (-), biofilm (-)

M Moisture balance
• Fokus: Menjaga kelembaban luka Action: Kontrol eksudat, dressing
• Outcome: pertumbuhan jaringan baru (++)

E Epithelial advancement + environment

• Fokus: Menumbuhkan kulit baru Action: Proteksi, wound edge, dressing
• Outcome: Terbentuk kulit baru dari tepi luka
S Support
• Fokus: Support sistemik, knowledge Action: Education, nutrition, fixation
• Outcome: support system +
New innovations products Dokumentasi GHC

SILVOSEPT SPRAY CHITOHEAL GEL CHITO POWDER DEBRID GEL

• Antiseptik Nano • Gel pelembab luka • Chitosan konsentrasi • Kelembaban luka

colloidal silver dengan dengan chitosan tinggi optimal
ion Ag+ yang terisolasi • Penguat proliferasi sel • Sangat kuat • Bekerja dengan 2
• Membunuh 99,999% • Membuat lapisan merangsang proliferasi fungsi: autolysis dan
microba dalam 60 protektif pada sel enzymatic
detik permukaan luka • Sangat sesuai untuk debridement. Pertama
• Non toxic • Antimicrobial luka yang dalam dan satu satunya di
• No allergy Indonesia
• Sangat efektif thd
biofilm
 Aplikasi konsep DIMES dengan compression bandage
Dokumentasi GHC
Case: venous ulcer + diabetes ABPI: 0,8

D: Autolysis debridement (Metcovazin D: control biofilm

+ cadexomer) I : PHMB VERY NICE 
I : Metcovazin + cadexomer M: Metcovazin + cutimed gel
M: Metcovazin + cadexomer + siltec E: wound edge
E: wound edge S: Reduce smoking, 3 layer
S: Reduce smoking, 3 layer bandage bandage

Kontrol biofilm

Kontrol hipergranulasi

3 Layer Bandage  100% healing in 6 wks

The DIMES Concept

Dokumentasi GHC 2019

The DIMES Concept

Dokumentasi GHC 2019

The DIMES Concept

Dokumentasi GHC 2019

 The DIMES Concept

Dokumentasi GHC 2019

‘’Clinic Griya Husada Center DF Care Module:
TERTIARY CARE
5
4
SECONDRY CARE
3

Stairway of Amputation
PRIMARY CARE 2
1

Footwear Care

Normal DF Care

PNP/PVD Care
DFU care
DFI Care
Dokumentasi GHC 2019 Rehabilitation care
 5. CONCLUSION

• Diabetic foot complications can be life altering, limb threatening and may be prevented
or slowed down with a complete and thorough diabetic foot assessment.
• All healthcare professionals who may be a point of first contact for the patient, should
conduct a diabetic foot assessment that may lead to a referral for further risk factor
assessment, continued diabetic foot assessment, treatment, and continued foot care
education.
• The diabetic foot assessment should not be an afterthought in diabetic care but a key
component to the whole care of the patient with diabetes and their quality of life