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0 NURSING
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
Dokumentasi GHC
Clinical Case DFU
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Clinical Case DFU Dokumentasi GHC
Clinical Case DFI
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Clinical Case DFO
Dokumentasi GHC
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Dokumentasi GHC Dokumentasi GHC
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
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
< 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
Symptom :
1. Claudication -pain when walking,
required stop to relief pain
2. Callous
Skin
3. Corn
– Dry
4. Fissure
– Shiny
5. Fungal infections
– Pigmentation
– Hair loss
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.
D Devitalized tissue
• Fokus : membersihkan jaringan mati dan eksudat Action: Debridement
• Outcome: warna dasar luka merah
Dokumentasi GHC
• Outcome: infeksi (-), biofilm (-)
M Moisture balance
• Fokus: Menjaga kelembaban luka Action: Kontrol eksudat, dressing
• Outcome: pertumbuhan jaringan baru (++)
Kontrol biofilm
Kontrol hipergranulasi
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