個案討論會糖尿病與足部照護

報告者:黃琬詩醫 師陳雅芳護理師

專家指導: 王朝弘醫 師陳立仁醫 師

趙 強營養師

張美珍護理師

94年07月16日 15:45~16:45 pm.馬偕紀念醫院 糖尿病人教育推廣中心

學習目標

瞭解糖尿病可能引發的周邊血管病變

認識糖尿病周邊血管病變之診斷及治療原則

瞭解糖尿病周邊血管病變引發之足部併發症

認識治療糖尿病患足部病變的策略

1. 瞭解藥物的使用2. 瞭解糖尿病足部照護衛教重點

個案簡介

Age:79y/o,femaleFamily Hx:(-)Personal Hx:

(+)DM18years(+)Hypertension 15years(一)smoking (一)alcohol drinking(+)mild stretch exercise 20 mins. b.i.d.

個案簡介

History:個案因罹患有糖尿病及高血壓 ,規則於門診追蹤治療:

Trandate 200mg 1# bid.Renitec 20mg 1# q.d.

Glucophage 500mg 1# bid.93.04.27 糖尿病照護網收案

糖尿病照護網收案

93.04.27 PPE:BP:152/94mmHg ,PR:72,BH:155cm,

BW:70kg,BMI:29(-)JVE lung:clear (-)heart murmurs (-)abdomen (-)abdominal bruit

Ext:(-)pedal edemanormal temp normal hair distribution

(+) Tinea pedis, mild skin excoriation

檢查報告

93.4.27

AC/PC 161/221mg/dl HbA1C 9.2%

T-CHO 187mg/dl TG 154mg/d

HDL-C 44 mg/dl LDL-C 114mg/d

GPT 27U/L Cr. 0.8mg/dl

UA 5.0mg/dl Urine pro. (-)

用藥調整

Px:Dietary AdvisedTrandate 200mg 1# b.i.d. Renitec 20mg 1# q.d.Glucophage 500mg 1# t.i.d.Behyd 1/4# q.d.

追蹤過程

93.05 AC/PC:152/151,BP:140/80.93.06 AC/PC:152-155/180,BP:140/80.93.07 BP:130/80,AC/PC:118/155, HbA1C:8.0,Noticed ↓↓Dorsalis pedison both lower extremities.Repeat questioning:noticed soreness of both legs during asleep for years . Add aspirin 1# q.d. Refer to CV surgeon.

追蹤過程

93.08 DC aspirin,Duplex scanning of arteries from Mckay Hosp.Suggested Pletaal 1#Bid.for 2wks. Then 2#Bid. Refer to our Diabetic nurse for 勃氏 Exercise and advised walking exercise.93.09 BP:140/86, AC/PC:150/21493.10 BP:130/90, PC:15093.11 BP:132/80, AC:120 HbA1C:7.593.12 BP:140/90, AC/PC:141/14394.01/02 lost follow up.

追蹤過程94.03 BP:140/70,AC/PC:138/376 Complained of SOB after climbing stairs and pedal edema. CV referral :CHF,EKG: non-specific ST-T wave changes.MEDS Prescribed :Renitec 20 mg 1 # q.d.Natrilix 1.5SR 1 # q.d. Norvasc 1/2 # q.d.Lasix 1 # q.d. After 2wks 1/2 # q.d.Glucophage 500mg 1 # t.i.d. Amaryl 2mg 1/2 # q.d.Pletaal 2 # b.i.d.

94.04 BP:140/84,AC :130-161 /PC :175, HbA1C:7.5,T-CHO:169,TG:116,HDL/LDL-C:46/100 ,GPT:17.94.05 BP:120/70,AC/PC:123/201,BW:65kgLatest Meds :Renitec 200mg 1 # q.d.Natrilix 1.5mg 1 # q.d. Norvasc 1/2 # q.d.Lasix 1/2 # q.d. Glucophage 1 # t.i.d. Amaryl 1/2 # q.d.Pletaal 2 # b.i.d.

追蹤過程

Peripheral Vascular Disease Arteriosclerosis Obliterans

Vascular System:Central blood vesselPeripheral blood vessel

Peripheral vascular Disease:refer to damage or dysfunction within peripheral arteries and veins.

2 types of Peripheral Vascular Disease

Peripheral Arterial Diseasetypes:Carotid artery disease ,PAD and lower

extremities,PAD of renal arteries abdominal aorta aneurysm ,Raynaud’s Syndrome ,Buerger’s disease ,Polyarteritis nodosa .

Peripheral Venous Diseasetypes:thrombophlebitis,varicose veins,chronic

venous insufficiency.

Peripheral Vascular Disease

Risk factors of Peripheral Arterial Disease:family history of atherosclerosis,DM,obesity,smoking,H/T,exposure to lead,Cadmium kidney disease.

Risk factors of Peripheral Venous Disease:lack of exercise,smoking,obesity,long period of

immobility.

Pathophysiology

Result of atherosclerosis.Atheroma consists of a core of cholesterol joined to proteins core fibrous intravascular covering.The process is gradually progressive to complete arterial occlusion.It may manifest acutely when thrombi/ emboli/acute trauma compromise perfusion.Lower extremities >upper extremities.

Peripheral Arterial DiseaseOf Lower Extremities

Clinical Manifestation of PAD (Lower Ext )

Intermittent claudicationpain or discomfort of lower extremity brought on by walking,ceases when stopping.Onset is gradual.Physicians may attribute the symptoms to arthritis, muscular pain or simply aging.Claudication may described as aching cramping, tightness, tiredness,or pain occurs when walking.Discomfort often occurs in muscle group immediately distal to the arterial obstruction.Triad classic symptoms of vascular claudication.

Discomfort brought on by exercise.

Relief within 2 to 5 min of stopping.

Ability to walk again the same distance once the discomfort has disappeared.

Progression of limb ischemia is evidenced by onset of ischemic rest pain,or presence of ischemic ulceration or gangrene.

Pain at rest indicates severe arterial disease.It may described as a dull,aching sensation in the toes or forefoot,or as a severe,burningnagging type of pain.Ischemic rest pain often is exacerbated by poor cardiac output .

Trauma to or pressure on one of the

toes or bone prominences in patient

with severe PAD may result in ischemic

ulceration and the onset gangrene.

History of Patient with PAD

Ask for presence of chest discomfort or

angina,smoking,DM,hypertension and

Hyperlipidemia.

Physical Examination Classical “5P’s”

PulselessnessPallorParalysisParesthesia—suggest limb threatening ischemia and mandate prompevaluation and consultation. Pain

Physical Examination

Check for heart murmurs.Palpate all peripheral vessels,includingcarotid,abdominal,femoral,popliteal,posterior tibialis and dorsalis pedis for pulse quality and bruit bilaterally .Check the skin and nails.

Lab. Exam.Lp(a),homocysteine,fibrinogen,plasminogen

activator inhibitor.Non-invasive vascular lab.

Doppler Ankle-Brachial Index Duplex UltrasonographySegmental volume PlethysmographyMRI

Invasive vascular lab.testarteriography .

Differentiating True Claudicationfrom Pseudoclaudication

Character of discomfort

Location of discomfort

Cramping,tightness, Same or tingling,tiredness,aching weakness,clumsiness

Buttock,hip,thigh, Samecalf,foot

Exercise induced

Distance to claudication

Yes Yes or no

Same each time Variable

Occurs with standing Relief

No YesStop walking Often must sit or change

body positions

Claudication Pseudoclaudication

Treatment of Peripheral Arterial Disease

Risk-factor reductionSmoking cessation.Lower LDL-C to

Treatment of Peripheral Arterial Disease

Antiplatelet therapy AspirinPlavixTiclopidine

Exercise rehabilitation

Drug therapyTrental (Pentoxifylline)Pletaal (Cilostazol )

Surgery–• Peripheral bypass surgery

Angioplasty.

Ankle Brachial Index(ABI)Right Arm Systolic Pressure

137 mmHg Used in ABI calculation

Supine Position

Right Ankle Systolic Pressure137 mmHg

(CV)Supine Position

Right ABI

Right Ankle Pressure

Higher Arm Pressure 0.64

Ankle Brachial Index(ABI)left Arm Systolic Pressure

130 mmHg

Supine Position

left Ankle Systolic Pressure95 mmHg

(CV)Supine Position

Left ABILeft Ankle Pressure Higher Arm Pressure 0.69

Ankle Brachial IndexInterpretation

N Engl J Med,Vol.344,No21,Page1608-1621>1.30 Non-compressible

0.91-1.30 Normal

0.41-0.90 Mild to moderate peripheral artery disease

0.00-0.40 Severe peripheral artery disease

衛教糖尿病足部照護

資料評估

訂定計畫

追蹤評值

糖尿病足部照護評估

(主觀資料)1. 主訴晚上睡覺時,雙腳會疼痛已很多年2. 平日偶爾會做體操及甩手運動

(客觀資料)1. 糖尿病18年,高血壓15年2. HbA1c:8-9.5%,BP:135-155/90~mmHg3. BW:70kg(理想體重:47.5-58.1kg)

糖尿病足部照護評估

(客觀資料)足部檢查:

1.外觀評估:皮膚-溫度、濕潤度、皮屑、毛髮分布

腳趾間-龜裂、脫皮、潮濕、水泡

足底-厚皮、潰瘍、雞眼、傷口

潰瘍-腳趾、足底、足背、足邊

=>個案:趾縫脫皮有香港腳

糖尿病足部照護評估2.針刺感:(小神經纖維痛覺測試)

5.07號單股尼龍纖維測試足部11個部位觸壓感覺，若一處感覺異常為不正常。

=>個案: L’t(-) R’t(+)

3.震動感:(大神經纖維測試)128周期音叉測試於大拇趾關節處，感覺震幅5以上為正常。

=>個案: L’t(+) R’t(+)

糖尿病足部照護評估4. 循環評估:食指及中指觸摸評估，足背動脈(第2腳趾至踝關節連線的下1/3處) 及脛後動脈(腳踝內側下方)的脈動及強度。

=>個案: L’t (-) R’t (-)

93/08 心臟外科足動脈超音波檢查:Several left below-knee arterial insufficiency ( due to marked arteriosclerosis )

糖尿病足部照護計畫

理想血糖,血壓,體重控制目標適當運動,改善循環衛教足部自我照護

與個案討論控制目標

飯前血糖目標:140mg/dl以下飯後血糖目標:180mg/dl以下糖化血色素:7.0%以下血壓目標:130/85mmHg以下

糖尿病足部照護衛教勃氏運動

1. 平躺床上、雙腳抬高放在枕頭上約30-45度角

2. 坐在床緣、雙腳懸空不碰到地、擺動3分鐘

3. 平躺床上休息3分鐘

糖尿病足部照護衛教

間斷式運動:避免負重式的運動，可以使足部壓力減低-走路,踩腳踏車,建議30-60分鐘/日(15-30min twice/day),若當中疼痛時則休息,直到改善後再繼續。

改善休息痛:床頭抬高4-6吋,利用地心引力使下肢血管充盈,減輕疼痛

糖尿病足部照護衛教

足部自我照護原則

1.檢查足部　　　　　　　　　　　　　每天自我檢查趾甲、趾頭、腳底、足背及趾縫間等部位有無發紅、腫脹、起水泡、傷口、厚繭、雞眼等情形。　

糖尿病足部照護衛教

2.清潔足部‧每天用溫水洗腳，用中性肥皂清洗。　

‧以棉質毛巾擦乾，注意腳趾間的清潔。

‧塗抹如綿羊油等乳液，防止過度乾裂。

但趾縫間不要擦，以免造成黴菌感染。

糖尿病足部照護衛教

3.趾甲的修剪　　　　　　　　　　　　　‧修剪指甲，雙手為圓弧形，雙腳剪平的為宜。

‧指甲過硬，修剪前可泡水軟化。

‧避免修剪硬繭、雞眼及趾甲邊挖皮肉。若趾甲太厚太硬，有龜裂或嵌入肉內，應請醫師處理

‧要在光線明亮處修剪，視力不佳，應請家屬代勞，以免受傷。

糖尿病足部照護衛教4.鞋子的選擇‧選擇寬頭厚底、鞋墊柔軟、低跟、合腳的鞋。

‧避免赤腳走路，在室內、廚房、浴室都要穿鞋。

‧新鞋較硬，初穿時不可穿太久，應逐漸適應並檢查雙腳是否有水泡或破皮。

‧穿鞋前應檢查鞋子內是否有異物。

‧購買鞋時，選擇下午時段，兩隻腳都得試穿。

‧至少備兩雙鞋子更換，以保持鞋內乾燥。

糖尿病足部照護衛教

5.襪子的選擇‧穿鞋一定要穿襪子，選擇柔軟,吸汗的棉質襪，避免穿尼龍襪。

‧襪子不要太緊，以免影響血液循環。

‧天氣寒冷時，選擇較厚的羊毛襪子。

‧每天換洗襪子，保持清潔。

糖尿病足部照護衛教

6.避免不當行為，以免影響血液循環‧兩腿交叉於膝蓋上。

‧盤腿而坐。

‧穿著緊身衣襪。

‧吸煙。

糖尿病足部照護評值

血糖值及血壓值改善

執行運動

遵守足部自我照護原則

謝謝聆聽

個案討論會糖尿病與足部照護學習目標個案簡介個案簡介糖尿病照護網收案檢查報告用藥調整追蹤過程追蹤過程追蹤過程Peripheral Vascular Disease Arteriosclerosis Obliterans2 types of Peripheral Vascular DiseasePeripheral Vascular DiseasePathophysiologyClinical Manifestation of PAD (Lower Ext )History of Patient with PADPhysical Examination Classical “5P’s”Physical ExaminationLab. Exam.Differentiating True Claudication from PseudoclaudicationTreatment of Peripheral Arterial DiseaseTreatment of Peripheral Arterial DiseaseAnkle Brachial Index(ABI)衛教糖尿病足部照護糖尿病足部照護評估糖尿病足部照護評估糖尿病足部照護評估糖尿病足部照護評估糖尿病足部照護計畫與個案討論控制目標糖尿病足部照護衛教糖尿病足部照護衛教糖尿病足部照護衛教糖尿病足部照護衛教糖尿病足部照護衛教糖尿病足部照護衛教糖尿病足部照護衛教糖尿病足部照護衛教糖尿病足部照護評值謝謝聆聽