2Department of Nursing, West Texas A&M University, Canyon, Texas
The foot or feet may subsequently lose muscle support, eventually converting to deformity. Diagnosis can sometimes be difficult due to the potential of mimicking other conditions like cellulites or deep venous thrombosis, and because diagnosis of a Charcot fracture cannot be made definitively until bone changes occur. Therefore, the focused problem in the project was inconsistency of healthcare providers in the recognition and referral of patients with potential Charcot foot.
This section outlines the process by which an assessment tool was developed, along with implementation and evaluation. No data was collected nor were participants involved as the project involved the development of an assessment tool to further assist NPs in the early detection, identification, and treatment of type 2 diabetic patients at risk of Charcot foot.
The outcomes that were used to determine goal attainment for the project included an evaluation planning step at the end of this DNP Project. The following outcomes were suggested as possible starting points for evaluation planning:
Outcome 1: Healthcare providers will identify, assess, and treat patients with Charcot foot.
Outcome 2: Healthcare providers will refer patients with Charcot foot to appropriate specialty for follow up care.
The detection of patient risks by nurses, which is “the ability of nurses to accurately identify signals can lead to early interventions so that harm to patients is minimized or circumvented” . Nurses and nurse practitioners are at the forefront of patient assessment, which is the first opportunity for detection and intervention of potentially life-threatening illness and injuries. They have a responsibility to patients to be skilled in their assessment abilities and intervene when necessary. Charcot foot, although complex and often difficult to diagnose, is a major complication of diabetes that requires immediate treatment after a detailed and skilled assessment by competent healthcare professionals.
The project design was a qualitative approach, which provided an opportunity for nurse practitioners to share their experiences and challenges when assessing the adult diabetic patient population. “Qualitative methods offer the opportunity to obtain an in-depth understanding of patient experiences and may elicit a deeper understanding of patient’s perceptions and behaviors and the meanings they attach to their experiences” .
Despite the fact that uncontrolled diabetes and loss of proprioception is the main contributing factor leading to Charcot, researchers now believe other predisposing elements may increase the risk such as widespread atherosclerosis, inflammation caused by minor injury, infection, ulceration, or any other disorder in which blood flow is impeded . Discovering the underlying etiology is a crucial aspect in successful treatment. The incidence and prevalence of Charcot is not known exactly but is estimated to affect 0.8-8% of the diabetic population. This number increases to 10% when radiographic studies are used in diabetics with neuropathy. In addition, studies have shown men and women are equally affected and typically in their 5th and 6th decades of life and having had diabetes for at least 10 years or more .
Charcot is a devastating complication of diabetic peripheral neuropathy that may affect a person’s physical appearance and their ability to work and has the potential of having an effect on their mental capabilities as well. Patients are often left with feelings of depression, guilt from financial strains, and isolation. In addition, patients suffering from Charcot experience a high rate of depression and anxiety due to physical mobility restraints and chronic pain. Male patients are at an even greater threat of these complications as a resulting from an inability to work and provide for their families financially .
Finally, studies show that mortality rates of individuals with Charcot arthroplasty are significantly higher than those who have simple diabetic foot ulcerations as well as those with type 2 diabetes lacking foot complications at all. The comparable rates are 28.3, 37.0, and 18.8% .
Accurate assessment of the diabetic foot is a complex process requiring skill, experience, and knowledge of not only the disease but also signs and symptoms of potential complications. The loss of sensation due to peripheral nerve damage makes it difficult for providers to diagnose issues as well as unseen internal problematic issues such as destruction of bone tissue and cartilage as a result of uncontrolled hyperglycemia. It is critical that diabetic patients are adequately censored and made mindful of the possible complications that derive from this disease. Through lessening the percentage of amputations and enhancing quality of life by way of education and consistent monitoring, there will be a decrease in the amount of money spent on the longterm support of the patient with diabetes . However, many clinicians lack experience in the area of Charcot foot assessment and often consider it as simply “a diabetic foot”.
There is a limited amount of scientific literature in regard to treatment protocols and guidelines for management of Charcot foot and ankle deformities and may be in part due to the presence of each individual case of Charcot of the foot and ankle . Whereas many patients pose with obvious deformities, there are a higher number of those who have, little, or vague complaints, which add to the difficulty of accurate diagnosing for the practitioner.
Due to the fact that type 2 diabetics are at risk for numerous multisystem complications, all healthcare personnel, including nurse practitioners, have a responsibility to patients to be knowledgeable and competent in advanced assessment skills in hopes of preventing further complications . The Charcot foot in diabetes poses many clinical challenges in its diagnosis and management. Despite the time that has passed since the first publication on pedal osteoarthropathy in 1883, we have much to learn about the pathophysiology, and little evidence exists on treatments of this disorder” (p. 2123). Identifying this problem in its initial stages is critical to effective treatment. Patients should contact a podiatrist at the earliest onset of symptoms. Occasionally, diagnosis is problematic given this condition is capable of mimicking other major disorders such as cellulitis or deep venous thrombosis, and especially since diagnosis of a Charcot fracture is unable to be made definitively until bone changes occur. The initial indications of the Charcot foot are frequently mild in nature, but can become abundantly more pronounced with unperceived repetitive trauma. Charcot foot typically worsens slowly, with age; rapid progression is uncommon, and should motivate a rapid re-evaluation. Since undiagnosed Charcot can advance considerably to grim outcomes including infection, deformity, amputations, disability, loss of employment, financial and mental strains, and life-long devastating effects, it is crucial for practitioners to be knowledgeable and skilled in assessment and treatment methods.
Diabetic foot complications are key contributors to soaring morbidity and mortality rates. Without obvious signs of inflammation such as warmth, erythema, or function deficit, it is a demanding challenge for healthcare providers to diagnose Charcot foot. “Foot complications in people with diabetes can be difficult to treat and conventional therapies often fail, leading to amputations; thus, prevention of this condition is of paramount importance . Advanced practice nurses must be willing to accept continuous new evidence and tools that will improve patient outcomes as an integral part of their practice. Patients rely on the knowledge and skill of healthcare professionals to ensure their well-being and positive outcomes. Assessment is a key element of the nursing role for all patient populations but more so for those individuals suffering from major diseases such as diabetes or other causes of peripheral neuropathy. According to the American Diabetes Association, 60–70% of people with diabetes acquire peripheral nerve impairment that can expand to Charcot foot and roughly 0.5% of these patients progress to Charcot. This data is especially relevant to nursing practice and advanced assessment skills.
As with many other chronic health conditions, the social and mental aspects of type 2 diabetes can be devastating for patients, families, and care givers alike. Diabetic treatment regimens must be maintained on a daily basis, despite social pressures, economic status, or distracting life events . While type 2 diabetes typically develops or manifests in middle adulthood, this may significantly influence motivation to seek treatment and may require greater efforts or willingness to change. Even in the early phase, subtle complications such as foot calluses may appear to be minor and unimportant for the diabetic patient, thus delay in seeking treatment. Other facets to consider are the costs of medical management of wound care, potential vascular interventions, infection control, wound closure, off-loading, and alternative and adjunctive therapies.
Socioeconomic issues begin with extensive healing. For patients who are unaware of an injury, which progresses to an ulceration, “the average cost of treatment ranges from $3609 to $27, 721” . Regardless of whether a patient is in need of complex therapy over an extended period of time or is simply required to be in some form of offloading device during the acute phase of Charcot foot, the potential for financial strain is inevitable. Complications of diabetic foot conditions are typically debilitating to patients, families, and caregivers alike. Patients are often times unable to continue working and have to rely on others or governmental assistance programs to sustain their daily lives. Others who are permanently disabled are forced to file for long-term social security disability, which is an extremely long and drawn out process that may or may not be approved initially. For those who gain approval, the length of time for their first payment is typically six to seven months. Early detection is vital in advancement to further injury and reduces the incidence of long-term or permanent disability.
Type 2 diabetes is the most common form of diabetes and is defined as a condition in which the body fails to utilize insulin properly, otherwise known as insulin resistance. Typically, the pancreas produces an excess of insulin to accommodate but, over time it is adequately produce the body’s requirement of insulin to maintain blood glucose at normal levels (ada.org, n.d.). Peripheral neuropathy refers to the destruction or dysfunction of peripheral nerves, which are damaged by uncontrolled elevated blood glucose levels, traumatic injuries, infections, metabolic problems and exposure to toxins (mayoclinic.org, n.d.). Charcot- Marie-Tooth (Charcot Foot or CMT) is named for three physicians who were first to describe it in 1886: Jean-Martin Charcot, Pierre Marie, and Howard Henry Tooth [11,12]. It is defined as a serious and potentially life-threatening complication associated with diabetes, which is characterized by various degrees of bone, joint, soft tissue, foot and often ankle involvement and is derived from underlying neuropathy, trauma, and perturbations of bone metabolism and involves inflammation during the acute phase . Podiatric refers to the specialty of a podiatrist who is a doctor of podiatric medicine (DPM), also known as a podiatric physician or surgeon. Podiatrists diagnose and treat conditions of the foot, ankle, and related structures of the leg . Acute is characterized by sharpness or severity, sudden onset, short course, or requiring short-term medical care (as for serious illness or traumatic injury). Inflammatory refers to having to do with the body’s response to either invading foreign substances (such as viruses or bacteria) or to direct injury of body tissue. Deformity is defined as the quality or state of being deformed, disfigured, or misshapen. Amputation is the accidental or intentional removal of a limb or body part. Offloading refers to taking the load off or transfer from one place to another such as reduction of pressure. Removing pressure from one area of the foot to another; effective reduction in pressure.
The Iowa Model for evidence-based practice includes knowledge and problem triggers, which prompt providers to evaluate current practices as well as promoting research when evidence is lacking . “The Iowa Model of Research in Practice infuses research into practice to improve the quality of care, and is an outgrowth of the Quality Assurance Model Using Research (QAMUR). Research utilization is seen as an organizational process. Planned change principles are used to integrate research and practice. The model integrates evidence-based healthcare acknowledges and uses a multidisciplinary team approach” .
The Iowa Model was followed in a before and after design and included 19 baccalaureate nurses working on an endocrinology unit in which the primary patient population consisted of diabetics with chronic leg ulcers . The focus of the study was whether evidence based practice training courses could improve nursing skills. Results indicated trained nurses can prevent significant complications in diabetic patients including amputations and other adverse effects by means of early recognition and treatment interventions.
This model has served as a reference for the project since the primary goal is directed at improving patient health and outcomes by identifying a trigger such as misdiagnosed Charcot foot, then integrating a multidisciplinary team to design an improvement plan such as assessment tool development and review of ADA policy and practice guidelines. “In this model, knowledge- and problem-focused triggers lead staff members to question current nursing practice and whether patient care can be improved through the use of research findings”. Putting evidence into practice can be a complex process but necessary for improvements in healthcare and patient outcomes. The IOWA Model has been a valuable resource in the project by providing a systematic process to identify and address an issue in diabetic health.
From 1999-2008 of patients who underwent either a below or above the knee amputation, 60% suffered from diabetic neuropathy and had some type of trauma, non-healing wound or other complication such as Charcot foot. Based on an exhaustive review and analysis of the study, the primary issue for patients at a heightened chance of foot and ankle problems was the identification and referral to the appropriate specialist . Healthcare professionals, including nurse practitioners, were among those who did not recognize potential issues, which delayed care and led to amputations of the 3,445 patients included in the study.
Symptoms of Charcot foot affect sensory, motor, and autonomic systems of the body. When neuropathy progresses to Charcot Arthropathy, it becomes a serious, potential limb-threatening complication and during the acute phase, is considered to be an inflammatory syndrome. Due to the rarity of this condition, diagnosis and treatment poses a critical issue for healthcare practitioners including nurse practitioners [10,37]. Therefore, an assessment and screening tool for nurse practitioners is needed to assist in the early recognition and treatment of Charcot foot to prevent further complications and possible loss of foot or lower extremity.
A case of Charcot in the Canadian Journal of Medicine in which a 59 year-old male reported complaints of a plantar ulcer for two months but after examination, his healthcare provider discovered that his foot was also deformed; however, the patient had such severe neuropathy that he felt no pain at all . They go on to state early detection is essential and “prevention of disease progression remains the mainstay of treatment, including prompt immobilization, absolute non–weight bearing and professional foot care on a regular basis” (p. 1392). While even the slightest of infection, injury, or minor surgery may trigger the body’s inflammatory response, without the protective barrier of pain being present, diabetic patients with sensory impairment are at greater risk of further injury and early recognition is crucial .
Another valid argument derives from a literature review which discussed suggestions to assist healthcare providers in making early diagnoses of Charcot foot, choosing the appropriate treatment regimen and reducing the incidence of further complications including amputations, sepsis and death . “Charcot neuroarthropathy (CN) continues to be a persistent challenge for clinicians, especially in its acute phase. The report indicated that the diagnosis of CN is missed in as many as 79% of cases and an accurate diagnosis can be delayed up to 29 weeks” (p. 9).
Accurate diagnosis of Charcot can often be challenging . The authors stress the significance of patient and physician awareness in order to gain prompt diagnosis and lessen the burden of foot complications. “Charcot arthro neuropathy is a potentially limb-threatening condition which, beyond the emotional and social burden of physical dysfunction, has been associated with increased mortality” . In addition, the article contains six practical point recommendations for clinicians to aid them in early detection and management and include: Charcot should be considered in every diabetic patient with neuropathy; irrespective of whether the diagnosis is only suspected, immediate offloading should be initiated; if plain x-rays are negative, this should not deter offoading; education to patients and physicians to increase early detection will be beneficial; ulceration or infection in the plantar aspect of the foot should be avoided and; surgical intervention may be required (consult a podiatric specialist). A detailed foot assessment and documentation utilizing a specified assessment tool, which follows ADA guidelines by a skilled practitioner, is recommended for all diabetic patients.
Finally, many diabetic patients with existing neuropathy may present with other distracting issues such as foot ulcerations, swollen extremities, or have no complaints of pain or discomfort at all; clinicians still have the responsibility to perform a thorough examination of the diabetic foot and must be skilled in their assessment techniques . Most complications of Charcot can be avoided with immediate treatment in the acute phase. While it is equally important to exclude other infectious processes or conditions such as DVT, “the overriding goal of treatment is to avoid amputation and prevent further deformity. Good outcomes can be managed with footwear that allows adequate gait and activity, thus sustaining overall quality of life” .
The steps in the course of this project were as follows:
1. Assemble an interdisciplinary project team community of stakeholders to guide the project
2. Review of best practices of diabetic foot assessment as presented in evidence-based literature.
3. Integrate ADA policies and practice guidelines for the assessment, treatment, and referral of the diabetic patient with, or at risk for developing, Charcot foot in conjunction with the project team.
4. Develop an assessment tool of the diabetic foot in conjunction with the project team.
5. Develop an implementation plan in collaboration with the project team
6. Develop an evaluation plan in collaboration with the project team.
Appendix A: Computation of an S-CVI for a 10-Item Scale with Two Expert Raters
Expert Rater No 1
Expert Rater No 2
Items rated 1 or 2
Items rated 3 or 4
S-CVI, content validity index for the scale.
Ratings of 1 = not relevant
Ratings of 2 = somewhat relevant
Ratings of 3 = quite relevant
Ratings of 4 = highly relevant
Monofilament testing for diabetic neuropathy using preferred testing locations colored green
If all sites are tested and the client feels the monofilament in each of the areas; then the score is 10 /10
If the monofilament is not felt in an area on the foot, this indicates loss of protective sensation (LOPS) in that area and requires referral to a podiatrist
-Edema or erythema
-Impaired neurovascular symptoms
-Recent injury or trauma
-Previous foot ulceration or amputation
-Foot deformities or ulcerations
-Erythema or blisters
-Evidence of nonhealing areas
-Dryness, cracking, calluses, or fungal infections
-Recommended of four sites (1st, 3rd, and 5th metatarsal heads and plantar surface of distal hallux) be tested on each foot
-Apply the monofilament along the perimeter of (not on) the ulcer site
-Apply the monofilament to each site three times, including at least one additional
mock application in which no filament is applied
LABORATORY AND RADIOLOGIC TESTING
-ESR and CRP (Erythrocyte Sedimentation Rate and C-Reactive Protein)
-Radiologic exams on affected foot and ankle
TREATMENT OR REFERRAL
-Offloading of affected foot (orthopedic boot)
-Non weightbearing of affected foot (crutches)
-Referral to podiatry if identified as at risk or abnormal findings
-Annual foot examinations of no abnormal findings or risk factors identified
Dissemination of this project included a presentation at the annual nurse practitioner symposium two consecutive years and initially was presented as a project proposal. Throughout the following year, the assessment tool was developed with assistance from my DNP mentor and members of the project team. Final dissemination was conducted via podium presentation, as well as hand out copies of the assessment tool, with question and answer session following. By sharing the project with an area community network of nurse practitioners who are members of a particular region, I contributed to the growth and development of a community organization. This option is frequently overlooked but is an ideal collaboration to improve the overall health and well-being of those patients it serves .
One study conducted by Botek, Anderson & Taylor described a 53 year-old male who was misdiagnosed in the emergency department after presenting with multiple symptoms including pain, redness, and edema to the foot and ankle . This patient was admitted to the hospital and given a course of IV antibiotics, then discharged home with oral antibiotics and instructed to follow up with his primary care physician. After being seen by the PCP 2-3 additional times, the patient was eventually referred to an orthopedic specialist and diagnosed accurately with Charcot foot but the damage suffered to the foot and ankle was irreversible at that point.
It is estimated that 0.1 to 5% of all diabetics will develop Charcot foot at some point during their disease with an increase in odds for those suffering from end-stage neuropathy. Furthermore, those patients with foot ulcerations are more likely to require extremity amputation; therefore, “it is extremely important for the foot and ankle specialist to judiciously approach the Charcot joint” .
As a result of impaired peripheral sensory neuropathy in patients suffering from type 2 diabetes, patients may have no specific recollection of injury. The earliest sign of Charcot foot may include a sudden change in the appearance of the foot or ankle and or discoloration . Therefore, patients often delay seeking medical treatment due to vague symptoms or being unaware they have sustained any type of injury.
The current literature supports the need for further education and assessment tools to aid in the correct diagnosis and treatment referrals for patients who are at high risks for developing Charcot foot. It is imperative that practitioners be given every means of identifying these patients and intervening before life threatening complications occur. Currently, there are various advanced assessment tools available but are directed toward the advanced specialist skills.
Limitations of the project involved an initial negate by one practitioner to accept the terminology of Charcot foot but rather felt it was simply a complication of diabetes and felt it could be treated as such. After further education and the development of the assessment tool, which was presented at the annual nurse practitioner symposium, the project and tool were more widely accepted. Furthermore, various other advanced practice nurses have since voiced an interest in gaining information on how to perform a more structured foot and ankle examination on their diabetic patient population. The interest has been from practitioners within local acute care settings as well as community clinics.
Recommendations for the project were made by members of the area nurse practitioners and consisted of the addition of BMI (body mass index) and specific interpretation of monofilament points to the assessment tool.
If left untreated, Charcot foot may progress to permanent disfigurement or amputations. Early detection and intervention is the key to preventing this serious condition. The development of an assessment and screening tool and following ADA recommendations will assist nurse practitioners and benefit the diabetic population. Currently, there are multiple assessment tools available to specialists in this area such as orthopedics and podiatry but are far more advanced than what is needed for early recognition and referral for advanced practice nurses. After receiving feedback regarding a need from local advanced practice nurses, an assessment and screening tool was developed, along with screening algorithm and assessment and treatment practice guidelines, as a means to assist them in the care of the diabetic patient population who are at risk due to peripheral sensory deficits. In doing so, the goal is for immediate intervention, treatment, and referral to podiatry specialty if warranted and prevent further damage or injury.
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