Objectives

 State 2 protective mechanisms that are commonly diminished by diabetes.

 Describe how vascular changes can cause neuropathy.
 List 3 conditions that can be lessened by good serum glucose control.
 Describe 4 team actions that can help decrease complications related to diabetes.

There’s an epidemic of amputations, which disproportionately affects people

who have diabetes. Overall, about 200,000 people in the United States have
amputations each year, and about 130,000 of those people have diabetes. 8
Diabetes continues to be the leading cause of lower–limb amputations in the
United States.
This CE studies the connection between diabetes and amputations. More
importantly, it discusses techniques to help decrease the need for
amputations in our dialysis patient population. It begins with a look at some
numbers.
Key data: Consider the following:
Why foot care is so important  In 2018 the Centers for Disease Control and
Prevention (CDC) estimated that 10.5% of the U.S.
population (34.2 million people of all ages) had
diabetes. 7.3 million adults aged 18 years or older who
met laboratory criteria for diabetes were not aware of
or did not report having diabetes.1
 Among individuals with ESKD receiving dialysis,
amputation is about 10X that of the general diabetic
population.2
 More than half of all foot ulcers become infected and
require hospitalization. 5-24% of these patients
require an amputation within 6-18 months of the
initial evaluation of the foot ulcer.3

Authors/Contributors/Reviewers  This free Continuing Education (CE) offering is provided

 Carol Farthing, BSN, RN, CNN by DaVita’s Clinical Education & Training.
 Susan Juarez, MS, ARNP, CNN  To receive a CE certificate for 1.0 contact hours, complete the
 Mona Master, RN online posttest.
 Jacqueline Staudt-Netzel, BSN, RN, CNN, MBA  Thank you for your interest in learning!
 Donna Swartzendruber, MSN, RN, CNN,

©2013-2022 DaVita Inc. Page 1 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
Diabetes, pain, and sight Why are amputations so common in persons with diabetes? Lack
of normal pain sensations (neuropathy) and lack of adequate
vision (retinopathy) are two key reasons.

 Pain is a critical protective mechanism. It lets us know, for

example, when to quickly pull our feet from a tub filled
with dangerously hot water or when it’s time to seek care
if an ulcer is forming. But the nervous system must be
healthy for this protective mechanism to work effectively
– it takes a healthy nervous system for signals to move
from an injury to one’s brain for interpretation.

Neuropathy, a common problem in persons with diabetes,

can hinder this transfer of information. Since their brains
may not receive the “pain” message, our patients may not
know when their feet or legs are in danger.

neuro- (nervous system) + -pathy (disease of) = neuropathy (disease of the nervous system)

 Sight can also be a protective mechanism. Without good

vision and the normal presence of pain, injuries of the foot
go unnoticed. If I were to get a thorn in my foot, I would
quickly remove it, both because I could see it and it would
hurt. But a person with diabetes may not recognize that a
problem exists. Other peoples’ eyes may be needed to
recognize a problem.

retino- (retina ) + -pathy (disease of) = retinopathy (disease of the retina in the eye)

Examples of everyday situations that, when left unseen and unnoticed,

have led to amputations that could have been prevented.

 A blister from an ill-fitting shoe

 Bunions or pressure points
 A small cut
 A cat scratch
 Ingrown nails
 Nail fungus (causes the nail to grow thick and become deformed)
 Hammertoes (a claw-like deformity of usually the second or third toe where
there is a permanent flexion of the second and third joints)
 Burn from hot water or walking on hot sand
 A splinter
 Dry, cracked heels

©2013-2022 DaVita Inc. Page 2 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
Diabetes and Why are retinopathy and neuropathy common in patients with
vascular changes diabetes? Vascular damage related to elevated blood glucose
levels is believed to be a primary cause for both of these
conditions.

 With diabetic retinopathy, the blood vessels within the eye’s

retina slowly become damaged. The injured vessel may allow
blood to leak from it into the vitreous humor (the clear gel
between the lens and the retina). This clouding of the vitreous
humor (from the blood) can lead to reduced and/or blurred
vision.

How common is this issue of poor sight? Even when patients

with diabetes first begin dialysis, retinopathy is present in a
large percentage of patients, and approximately one-third are
considered legally blind.4

While diabetes is the leading cause of blindness in the United

States, good serum glucose (blood sugar) levels and blood
pressure (metabolic) control can help. For those patients who
do not respond to tight control of blood glucose and blood
pressure medications retinal laser therapy (photocoagulation)
may help.5 Studies show that keeping serum glucose levels
close to normal can reduce retinal eye hemorrhages.

 Diabetic neuropathy encompasses a similar storyline. High

serum glucose levels, especially when seen over many years,
are believed to cause microvascular injury to the tiny blood
vessels that feed the nerves of the feet and lower legs.
Vasoconstriction (narrowing) of these blood vessels also
occurs, which decreases the blood and oxygen supply to the
area. The resulting lack of adequate oxygen to these nerves
(neuroischemia) is believed to be a primary reason diabetic
neuropathy develops.

Neuropathy symptoms typically appear 10 to 20 years after

diabetes has been diagnosed. About 60% to 70% of people with
diabetes have mild to severe forms of neuropathy.

Why are a person’s lower limbs more likely to be affected by

neuropathy than, for example, one’s face or upper arms? The
velocity (speed) of nerve conduction slows in proportion to a
nerve's length, causing longer nerve fibers to be affected first.
With diabetic neuropathy, the decrease in feeling typically
begins in the patient’s legs and toes.

Diabetic neuropathy can also be one of the causes of Charcot

foot. Here destruction, dislocation and deformity of bones in
the foot occur. With this condition multiple small fractures
©2013-2022 DaVita Inc. Page 3 of 9 CEC2165
Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
 cause the “arch” of the foot to collapse downward and the
bottom of the foot to develop a “rocker-bottom” shape.

Test your knowledge

Is Charcot foot typically painful?
a. Yes, very painful
b. Yes, somewhat painful
c. No, it is usually not painful

Answer: While the deformity looks like it would be quite

uncomfortable, the patient often has no pain. Yet an
amputation may be needed if ulcerations and infections
occur.
Definition
Atherosclerosis
 A disease of the Peripheral vascular disease (PVD), when seen in persons with
arterial blood diabetes, is a third vascular condition that can lead to lower-
vessels (arteries), extremity amputations. PVD involves atherosclerotic blockages
where the walls of
(see text box) that decrease normal circulation to both the feet
the blood vessels
become thickened and the lower legs. The resulting shortage of oxygen and food to
and hardened by the surrounding tissue leads to (1) poorer wound healing, (2) a
cholesterol and marked decrease in skin temperature compared to the other leg,
other lipids. (3) an increased likelihood of infection, and even (4) the potential
for gangrene.
Injury + poor sensations + poor circulation  wound/ulcer  gangrene

Definitions

Ulcer
o A breakdown in the skin that can reach to the depth
of the muscle or bone.
o Produced by the sloughing of inflamed necrotic
tissue.

Gangrene
o Caused by a lack of blood supply.
o With “dry gangrene” (the type of gangrene seen most in
persons with diabetes), the skin first appears reddened
and then brownish in color – it eventually becomes
blackened and withered. At that stage, debridement or
amputation are typically recommended to help decrease
the risk the gangrenous area starting a systemic blood
infection (septicemia).

©2013-2022 DaVita Inc. Page 4 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
 Test your knowledge
In persons with diabetes, is gangrene typically painful?
a. Yes, very painful
b. Yes, somewhat painful
c. No, it is usually not painful

Answer: The affected necrotic area may be somewhat

painful, but many patients, especially when older, feel
nothing, making our role as care givers even more
important. For our dialysis population, the best answer is c.

Diabetes and In addition to the retinopathy, neuropathy, and peripheral

the immune system vascular disease that is common in persons with diabetes, the
body’s immune system (see text box) can also be affected,
especially when elevated serum glucose levels are common.

Data indicates that persons with diabetes have more infections

than persons without diabetes and that the course of the infection
is often more complicated. The following paragraphs help explain
why.
Definition
Immune system  Part of a healthy immune system’s response to an
 Protects the body infection involves phagocytosis, where the pathogen (i.e.,
from pathogens bacteria) is first surrounded and then digested/killed by a
(i.e., bacteria) and type of white blood cells.
other foreign  This process of phagocytosis can be hindered by elevated
substances serum glucose levels. And, without effective phagocytosis,
 Destroys infected the normal formation of healthy, new granulation tissue is
cells and removes affected and an accumulation of unwanted debris may
cellular debris form within the wound -- without effective phagocytosis,
healing of a wound becomes delayed or simply doesn’t
occur.
 As with diabetic retinopathy and diabetic neuropathy,
maintaining serum glucose levels that are not elevated can
help the patient’s immune system work as designed.

What we can do – how can we stay a StepAhead?

As all who work in dialysis know, diabetes can be a vicious disease. Yet study after study has shown
that continuous monitoring and ongoing patient education can do much to decrease the risk of
amputation -- the American Diabetes Association believes that 85% of amputations are
avoidable.6

The following table first lists the problems just reviewed and then reviews various ways to
decrease a patient’s risks through various actions that the health-care team can consider to help
limit hospitalizations and amputations.

©2013-2022 DaVita Inc. Page 5 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
 Potential problems Team actions that can help decrease risk
 Limited sight  Be their eyes -- examine their feet at least monthly (as ordered)
 Assure patients have had an eye exam in the past year (if you
determine that an exam is needed, refer the patient for a visit to
an eye care specialist based on patient and physician choice)
 Provide patient with the StepAhead basic self- care foot
education available on the VillageWeb after placing ‘StepAhead’
into the search box
 Limited sensation  Be their eyes -- examine their feet at least monthly (as ordered)
of pain  Provide patient with StepAhead basic self- care foot education

 Poor serum  Provide the patient with serum glucose self-monitoring

glucose control education
 Evaluate need for glucometer and supplies
 If determined that no MD is managing the diabetes, refer the
patient for a visit with primary care physician and/or
endocrinologist based on patient and physician choice

Key point: Studies show that for every percentage point increase in
A1C blood test results, for example, from 7.0 to 8.0 percent, the risk
of microvascular complications—eye, kidney, and nerve diseases are
increased by 80 percent.7
 Neuropathy  Again, be their eyes
 Consider a vasodilator (i.e., ACE inhibitors, α1-antagonists) to
diminish the vasoconstriction seen with neuropathy – to increase
the blood flow to the involved nerves and thereby improve nerve
conduction
 Avoid hypertension, obesity and smoking (tend to worsen
neuropathy)
 Peripheral venous  Be their eyes – check patient legs for (1) sores that are not
disease (PVD) healing, (2) changes in color (blueness or paleness), (3) skin that
is shiny, or 4) coolness in temperature when compared to the
other leg
 Manage cholesterol (high levels are linked with PVD)
 Work with patient to maintain a healthy weight and not smoke
 Foot ulcer (a  Be their eyes – look for new difficulties with walking, drainage on
crater, could be stocking, stocking being stuck to foot
shallow or deep)  Debride surgically to remove (1) necrotic tissue, (2) peri-wound
callus, or (3) foreign bodies (remove down to viable tissue)
 Practice offloading (avoidance of weight bearing)
 Address the conditions that led to the ulcer
 Control and treat infections
 Charcot foot  Be their eyes – look for redness, swelling, warmth within the
foot, or inability to fit a foot into its shoe
 Use protective cast and practice non-weight bearing
 Gangrene  Be their eyes (signs of gangrene are listed on the previous page)
 Debride surgically

©2013-2022 DaVita Inc. Page 6 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
  Prevent infection (or if infection is already present, prevent it
spreading)
 Address the conditions that led to gangrene

A patient quote: “My toe was turning black. I thought it was just bruised,
but it was gangrene.”

The patient’s role The StepAhead Initiative has several easy-to-understand

education pieces for our patients. Key content areas of this
information are reviewed below. Test your knowledge! Then use
this knowledge to help inform your patients.

Test your knowledge!

Questions Possible answers

Patients (or a caregiver) are asked to:

1. Check their feet every ___. A. Dryness
2. Use a ___ (as needed) to look at the soles of their B. Tight
feet. C. Barefoot
3. Check for any blood or drainage on their ____. D. Seams
4. Inspect their feet for redness, callous, ___ , blisters or E. Lotion
open wounds. F. Socks
5. Check between their ___ for cracks or open areas G. Vinyl or
6. Avoid putting ___ between the toes as this could plastic
cause the skin to break down. H. Mirror
7. Use a _____ lotion on the top and bottom of their I. Day
feet every day to help avoid cracks in the skin that J. Toes
could lead ulcers and amputations (neuropathy K. Non-
decreases sweating which leads to extremely dry alcohol
skin). based
8. Do not walk ____– not even indoors – since it’s easy L. Shoes
to step on something and not know it.
9. Wear shoes with socks at all times to prevent
unknown injury due to loss of sensation or rubbing
from ____.
10. Choose clean, lightly padded socks that fit well.
Socks that have no ___ are best.
11. Do not wear ___ socks, bands, or garters around
their legs.
12. Never wear ______ shoes since they cannot stretch
or “breathe.”

Answers: 1. I; 2. H; 3. F; 4. A; 5. J; 6. E; 7. K; 8. C; 9. L; 10. D; 11. B; 12. G.

©2013-2022 DaVita Inc. Page 7 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
 Additional information patients are to be taught include to:
o Work with their health care team to control their A1C
(blood glucose), blood pressure and cholesterol.
o Avoid cutting corns and calluses -- not using razorblades,
corn plasters, or liquid corn and callus removers.
o Have a foot-care physician to trim their toenails if:
 They can’t see well or can’t reach their feet
 Their toe nails are thick or yellowed
 Their nails curve and grow into the skin (ingrown
nail).
o Trim toenails straight across and smooth them with an
emery board or nail file.
o Keep their feet away from radiators and open fires.
o Do not put hot water bottles or heating pads on their feet.
o Encourage good blood flow by:
 Putting their feet up when sitting.
 Wiggling their toes for 5 minutes, two or three
times a day.
 Moving ankles up and down and in and out.
 Not crossing their legs for long periods of time.
 Not smoking -- smoking reduces blood flow to the
feet.

To summarize – but does Does intensive diabetes education and monitoring work?
this work? Can A1C levels decrease? Can the number of
hospitalization and amputation continue to lessen? And,
maybe most importantly, can the quality of life for our
patients with diabetes improve? According to various
studies, the answer to these questions is a bold yes!

Thank you for your interest in learning -- thank you for

your interest in continuous improvement.

References

1. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963496/
3. https://www.medicalnewstoday.com/articles/324875.php
4. http://care.diabetesjournals.org/content/27/suppl_1/s84
5. https://www.nfb.org/images/nfb/publications/vod/vod214/vodfall0604.htm
6. https://professional.diabetes.org/abstract/amputation-prevention-diabetic-patients
7. http://care.diabetesjournals.org/content/31/11/2198
8. https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-
practice/reducing-disparities-in-diabetic-
amputations#:~:text=A%3A%20There's%20an%20epidemic%20of,of%20those%20people%
20have%20diabetes.

©2013-2022 DaVita Inc. Page 8 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022
Post Test Questions (to be completed on StarLearning)
Select the best answer.

___ 1. T or F Two protective mechanisms that ___ 6. The American Diabetes Association
are believes that ___ percent of
commonly diminished by diabetes amputations are avoidable.
are pain sensation and good sight. a. 25
b. 40
___ 2. Vascular damage related to elevated c. 55
blood d. 85
glucose levels is thought to be a primary
cause for which of the following ___ 7. Studies show that for every
conditions: percentage point increase in A1C
a. Neuropathy blood test results (for example,
b. Retinopathy from 7.0 to 8.0 percent), the risk of
c. Both of the above microvascular complications—eye,
kidney, and nerve diseases are
___ 3. The condition where multiple small increased by ___ percent.
fractures cause the “arch” of the foot to a. 25
collapse downward and the bottom of the b. 40
foot to develop a “rocker-bottom” shape c. 55
is called: d. 80
a. Hammertoe
b. Gangrene ___ 8. Patients with diabetes are to be
c. Charcot foot instructed to
d. Phagocytosis check their feet ____.
a. Every day
___ 4. Elevated blood glucose levels increase the b. Once a week
risk of which of the following: c. At least monthly
a. Neuropathy
b. Retinopathy ___ 9. T or F Instruct patients with
c. Poor immune response diabetes to not wear vinyl or
d. All of the above plastic shoes since this type of
shoe does not stretch or
___ 5. In persons with diabetes, gangrene is “breathe.”
typically:
a. Not painful __10. T or F Encourage patients to warm
b. Somewhat painful their feet with a hot water
c. Very painful bottle especially if the
circulation to their toes is
poor.

DaVita has been granted Continuing Education Provider status – CEP12243 - by the California
Board of Nursing (CA BON). This educational activity is approved by all states and specialty
organizations that recognize the CA BON accreditation process.
Please print your CE Certificate and retain it for four years as required by the CA BON!

©2013-2022 DaVita Inc. Page 9 of 9 CEC2165

Orig. Jun 2013
Review: Dec 2022
Revision: Feb 2017, Dec 2019, Dec 2022