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Transcript of Kuliah 17 : Penjagan kaki - jknj.moh.gov.myjknj.moh.gov.my/ncd/latihanpengurusan/kuliah/Kuliah 34...
PENGENDALIAN PERKHIDMATAN PENYAKIT TIDAK BERJANGKIT (NCD) UNTUK PARAMEDIK
KEMENTERIAN KESIHATAN MALAYSIA
KULIAH 34
REHABILITASI : AMPUTASI KAKI
ANJURAN : BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA DAN BAHAGIAN KAWALAN PENYAKIT
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM
KANDUNGAN
o Patofisiologi amputasi kaki
o Pesakit berisiko amputasi kaki
o Klassifikasi dan diagnosa
o Rawatan dan rehabilitasi kes amputasi kaki (prinsip umum)
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM
PATOFISIOLOGI
Neuropati
‘Vasculopathy’ ‘Immunopathy’
DIABETIC TRIAD
3 komponen yang bertindak dalam pelbagai kombinasi
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
Neuropati
Motor Sensori Autonomik
↓ nocicepsi
↓ Proprioception, Tidak mengetahui
posisi kaki A-V Shunt
Meningkatkan pengaliran
darah ke kaki
Vena kaki menimbul, Kaki panas
Kurang peluh
Kulit kering
Fisur dan kulit pecah
Otot dan kaki menjadi lemah
Ketidakseimbangan posisi badan
Kecacatan, tekanan dan koyak
Kecederaan
Tekanan kepada tulang, sendi dan plantar
Pembentukan callus
Jangkitan Luka
PATOFISIOLOGI NEUROPATI
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM
Penyakit Arteri Periferi
Artherosclerosis Penyempitan
dan penutupan lumen arteri
Iskemia kaki
Luka kaki Necrosis/ Gangren
Jangkitan
Plak arteroma
menyebab lumen
arteri menjadi sempit
PATOFISIOLOGI PENYAKIT ARTERI PERIFERI
Jari menjadi
gangren akibat
arterosclerosis
Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
KAKI BERISIKO…. • Ischaemia
• Numbness
• Structural Deformities
• Callus and / or Corn
• Absence of Pedal Pulses
• A capillary refill time in excess of 3 secs
• Limb pain and / or parasthesia
• Intermittent Claudication
• History of Foot Ulcer
• Loss of sensation of light touch,sharp and blunt touch
AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002
Pre-ulcer
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
Diabetic Foot Ulcer
• Diabetic Foot Ulcer menyebabkan ‘Non-Traumatic Lower Extremity Amputation’ (LEA).
• 15% daripada Pesakit diabetes mengalami ulser kaki.
• Risiko LEA adalah 8 kali ganda di kalangan mereka yang pernah mendapat ulser kaki
• 25% daripada semua kemasukan pesakit diabetes ke wad adalah disebabkan ulser kaki diabetes
Modul Latihan Perkhidmatan NCD Untuk
Paramedik KKM
“Tragic “Rule of 50”
• 50% drp amputasi
• 50% drp pesakit
• 50% drp pesakit
Paras Transfemoral/ transtibial
amputasi kedua dlm 5 tahun
Meninggal dunia 5
tahun
Clinical Care of the Diabetic Foot, 2005
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
Tragic “Rule of 15”
• 15% drp pesakit DM > Ulser kaki sepjg hidup
• 15% drp ulser kaki > Osteomyelitis
• 15% drp ulser kaki > Amputasi
Clinical Care of the Diabetic Foot, 2005
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
PENILAIAN
LUKA
Bhg tepi ulser
‘Assess for
undermining &
condition of
margin’
Saiz
Ukur saiz
Kedalaman
ulser
‘Wound bed’
Assess for:
necrotic and
granulation
tissue,
fibrin slough,
epithelium,
exudate,odor
Kulit sekeliling ulser
Penilaian: warna,
kelembapan, kelembutan
KLASSIFIKASI
• King’s College Foot Classification
• Wagner’s Classification
• University of Texas Classification
KING’S COLLEGE FOOT CLASSIFICATION
• Stage 1: The Normal Foot
• Stage 2: The High Risk Foot
• Stage 3: The Ulcerated Foot
• Stage 4: The Cellulitic Foot
• Stage 5: The Necrotic Foot
• Stage 6: Major Amputation
•Simple classification to use
•Specific management recommended for each stage
• No Risk Factor present: – Neuropathy – Ischemia – Deformity – Callus – Swelling
• One or More Risk Factors present:
• Neuropathy • Peripheral Vascular Disease • Deformity • Callus • Swelling
Stage 1: The Normal Foot
Stage 2: The High Risk Foot
• Skin breakdown and ulceration • No classification as each ulcer must be
assessed on its own merits • Differentiate between neuropathic and
neuroischemic • X-ray newly presenting ulcers for:
– Osteomyelitis – Foreign body – Gas – Charcot changes
• Microbiological control is lost and foot has become cellulitic
• Local infection • Spreading sepsis • Sloughing of soft tissue • Vascular compromise • Blue discolouration
Stage 3: The Ulcerated Foot
Stage 4: The Cellulitic Foot
Gangrene (necrosis)
Type: Dry, Wet
Pain is agonizing and cannot be controlled
Overwhelming infection
Extensive necrosis
Rare in neuropathic
Stage 5: The Necrotic Foot
Stage 6: Major Amputation
UJIAN
• Full Blood Count • Renal profile
• HbA1C (Glycosylated Haemoglobin) - indicator of diabetes control over last 3 months • Culture of wound
• X-rays of the foot and leg, ECG, CXR, Urine
Modul Latihan Perkhidmatan NCD Untuk
Paramedik KKM
Ankle Brachial Index (ABI)
Ankle systolic pressure measured using a cuff and a handheld continuous wave Doppler Ultra Sound Probe placed over pedal vessels (DP or TP = whichever is higher)
Ankle Systolic Pressure
Brachial Systolic Pressure
ABI: Normal 1 to 1.2
Ischaemia <0.8
Critical Ischaemia <0.5
Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and
prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181:150-154. Figure 1, p.151
Ankle-Brachial Index
• Screening: 2004 ADA recommendation
– “Consider” at age 50 years and every 5 years
• Diagnosis:
– Claudication, absent DP/PT pulses, foot ulcer
• Limitations:
– Underestimates severity in calcified arteries
Diabetes Care. 2005;28:2206
Diabetes Care. 2004;27(Suppl 1):S15-S35
Interpretation of the ABI
Interpretation ABI
Normal 0.90-1.30
Mild obstruction 0.70-0.89
Moderate obstruction* 0.40-0.69
Severe obstruction* <0.40
Poorly compressible** >1.30
2° to medial calcification
*Poor ulcer healing with ABI < 0.50
**Further vascular evaluation needed
PRINCIPLES OF TREATMENT
• Debridement of necrotic tissue
• Wound care
• Reduction of plantar pressure (off-loading)
• Treatment of infection
• Vascular management of ischaemia
• Medical management of co morbidities
• Surgical management to reduce or remove bony prominences and / or improve soft tissue cover
• Reduce risk of recurrence
Debridement of necrotic tissues
Removal of all non-viable tissues and slough
• Surgical debridement
• Mechanical debridement (surgical debridement, wet-to-
dry dressings and high- pressure irrigation)
• Enzymatic debridement (topical proteolytic enzymes;
controversial)
• Autolytic debridement (naturally in healthy, moist wound
environment with adequate circulation)
Wound Care
• After debridement, the ulcer is covered to protect
it from trauma and contaminants.
• Moist wound environment will facilitate healing
• Wound size, depth, location, surface and
discharge
Reduction of plantar pressure (Off-loading)
Allow healing
The methods of off-loading include:
• Total non-weight bearing
• Total contact cast (gold standard for neuropathic foot)
• Foot cast or boots
• Removable walking braces with rocker bottom soles
• Total contact orthoses – custom walking braces
• Patellar tendon bearing braces
• Half shoe or wedge shoes
• Healing sandal – surgical shoe with molded insole
• Accommodative dressing: felt, foam, felted-foam, etc
• Shoe cutouts (toe box, medial, lateral or dorsal pressure points).
• Assistive devices: crutches, walker, cane, etc.
Charcot restraint orthotic walker (CROW)
Bottine shoe with a full-contact insole and a rocker bar
with an early pivot point
Depth-inlay soft leather
laced shoe with custom
accommodative pressure-
dissipating foot orthosis
Vascular Management of
Ischaemia
• Vascular reconstruction surgery
• Any clinically suspicious lower extremity
ischaemia should be fully investigated and
corrected before any definitive foot surgery
is contemplated
Surgical Management
• Chronic foot ulcers
– best treated surgically
– removal of infected bone or joints
– metatarsal head resections, partial calcanectomy,
exostectomy, sesamoidectomy and digital arthroplasty
• Structurally deformed foot
– correction of hammertoes, excision of exostoses, bunions
and tendo-achilles lengthening
• Gangrene and ulcers with OM
– Amputation
– goal of treatment is preservation of function, not just
preservation of tissue
– first step in rehabilitation
DIABETIC CHARCOT’S FOOT
• impairment of the efferent sensory input from joint receptors
• progressive destruction of foot architecture
– pathological fracture, joint dislocation and fragmentation of articular cartilage
• Assessment
– Clinical examination
• acute Charcot’s foot will have swelling, erythema, raised skin temperature, joint effusion and bone resorption in an insensate foot
• 75% of patient with Charcot’s foot have some degree of pain in an otherwise insensate foot, thus complicating diagnosis
• in the presence of a concomitant ulcer, Dx of OM may be difficult to rule out
AETIOLOGY • classically due to neuroarthropathy
• hypervascular diabetic limb
– ↑blood flow ↑osteoclastic activiti bone and joint destruction
• ischaemic intrinsic muscles alter loading dynamics of the foot joint instability
• Investigations
– plain X-ray : osteoarthropathy
– white cell count (WBC), ESR : rule out OM
– bone biopsy :
• most specific way of distinguishing between
osteomyelitis and osteoarthropathy.
• pathognomonic biopsy showing neuropathic
osteoarthropathy
• consists of multiple shards of bone and soft
tissue embedded in the deep layers of synovium
Neuropathic Charcot's joint
Osteomyelitis
Goals of Treatment
• interrupt destructive process
• maintain adequate alignment of midfoot and ankle
• early diagnosis
• prevent progression
• Treatment
– Acute stage: immobilization and rest
– Post-acute: protected weight bearing
• After 4-6 months, patients may resume using
their usual footwear
– Surgery : create a stable and plantigrade
foot
• commonly, exostectomies for prominent plantar
(rocker bottom) deformities
• Others: ankle fusion, tibiocalcaneal fusion,
isolated or multiple midfoot fusion and triple arthrodesis
WOUND MANAGEMENT
FACTORS AFFECTING WOUND HEALING
• Systemic
– Age
– Nutrition
– Trauma
– Metabolic diseases
– Immunosuppression
– Connective tissue disorders
– Smoking
– Stress
FACTORS AFFECTING WOUND HEALING
• Local
– Mechanical injury
– Infection
– Edema
– Ischemia//necrotic tissue
– Topical agents
– Ionizing radiation
– Low oxygen tension
– Foreign bodies
Factors that delay the wound healing process
Local Factors
• Continued pressure
• Desiccation and dehydration
• Infection or heavy colonization
• Necrosis
• Incontinence leading to maceration
• Lack of oxygen delivery to the tissues
Systemic Factors
• Old age
• Chronic diseases (e.g DM, anaemia)
• Malnutrition
• Vascular insufficiency
• Immunodefiency
• Smoking
• Stress
• Poor health
Topical Therapy: Principles
• Remove necrotic tissue and foreign bodies or particles
• Identify and eliminate infection
• Obliterate dead space
• Absorb excess exudate
• Maintain a moist wound surface
• Provide thermal insulation
• Protect the healing wound from trauma and bacterial invasion
Doughty, Acute and Chronic Wounds, 1992
Wound Care Product Selection: Other Considerations
• Is wound partial or full thickness?
• Is wound dry or draining?
• Is wound superficial or deep?
• Need to develop treatment protocols based on wound characteristics rather than wound type.
Types of Topical Wound Dressings
• Hydrocolloid dressings
• Hydrogel dressings
• Alginate dressings
• Hydrofiber dressings
• Transparent film dressings
• Foam dressings
• Absorption dressings
• Gauze dressings
• Biologic dressings
• Other
Rehabilitasi Kes Amputasi
• Perlu dimulakan secepat mungkin untuk memaksimumkan tahap pemulihan
• Physiotherapy dan Occupational Therapy yang berkaitan keperluan pesakit boleh menyumbang kepada pemulihan
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
Tahap Amputasi dan Rehabilitasi
• Pesakit amputasi ringan boleh dirawat sebagai pesakit luar
• Pesakit tahap sederhana disarankan untuk menerima rawatan rehabilitasi di pusat atau unit rehabilitasi strok
• Pesakit strok tahap teruk disarankan untuk mendapat rawatan jangka panjang di pusat khas rehabilitasi strok.
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
TAKE HOME MESSAGE
• Anggota kesihatan perlu mengetahui pesakit yang berisiko mendapat amputasi
• Anggota kesihatan perlu tahu mengesan komplikasi kaki di peringkat awal dan memberi rawatan ulser dan masalah kaki yang lain
• Pemeriksaan kaki perlu dibuat pada kedua-dua belah kaki, termasuk ‘stump’
Modul Latihan Perkhidmatan NCD Untuk
Paramedik KKM
SELAMATKAN KAKI PESAKIT ANDA DENGAN MEMBERIKAN RAWATAN
MASALAH-MASALAH KAKI DIABETIK YANG BETUL
Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM