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Module 5.4: Diabetic Foot

Foot Examination & Monitoring

It is recommended by NICE (2016) that regular (at least annual) visual inspection of a patient’s feet, assessment of foot sensation, and palpation of foot pulses by trained personnel is important for the detection of risk factors for ulceration.

Examination of a patient’s feet should include:

  • Testing of foot sensation using a 10g monofilament or vibration (using biothesiometer or calibrated tuning fork)
  • Palpation of foot pulses
  • Inspection for any foot deformity
  • Inspection of footwear
  • 3-minute diabetic foot exam

(WUWHS, 2016)

3-minute diabetic foot exam

Minute 1: What to Ask

1. Does the patient have a history of:
  • Previous leg/foot ulcer or lower limb amputation/surgery?
  • Prior angioplasty, stent, or leg bypass surgery?
  • Foot wound?
  • Smoking or nicotine use?
  • Diabetes? (If yes, what are the patient’s current control measures?)
2. Does the patient have:
  • Burning or tingling in legs or feet?
  • Leg or foot pain with activity
  • Changes in skin colour, or skin lesions?
  • Loss of lower extremity sensation?
3. Has the patient established regular podiatric care?

Minute 2: What to look for

1. Dermatologic exam:
  • Does the patient have discoloured, ingrown, or elongated nails?
  • Are there signs of fungal infection?
  • Does the patient have discoloured and/or hypertrophic skin lesions, calluses, or corns?
  • Does the patient have open wounds or fissures?
  • Does the patient have interdigital maceration?
2. Neurologic Exam:
  • Is the patient responsive to light touch (protective sensation) on the feet?
3. Musculoskeletal Exam:
  • Does the patient have full range of motion of the joints?
  • Does the patient have obvious deformities? If so, for how long?
  • Is the midfoot hot, red, or inflamed?
4. Vascular Exam:
  • Is the hair growth on the foot dorsum or lower limb decreased?
  • Are the dorsalis pedis AND posterior tibial pulses palpable?
  • Is there a temperature difference between the calves and feet or between the left and right foot?

Minute 3: What to Teach

1. Recommendations for daily foot care:
  • Visually examine both feet, including the sole and between the toes. If the patient can’t do this, have a family member do it.
  • Keep feet dry by regularly changing shoes and socks; dry feet after baths or exercise.
  • Report any new lesions, discolourations, or swelling to a health care professional.
2. Education regarding shoes:
  • Educate the patient on the risks of walking barefoot, even when indoors.
  • Recommend appropriate footwear, and advise against shoes that are too small, tight, or rub against a particular area of the foot.
  • Suggest yearly replacement of shoes— more frequently if they exhibit high wear.
3. Overall health risk management:
  • Recommend smoking cessation (if applicable).
  • Recommend appropriate glycemic control.

Diabetic foot ulcer risk can be classified as:

  • Low current risk (normal sensation, palpable pulses)
  • At increased risk (neuropathy or absent pulses or other risk factor)
  • At high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer)
  • Ulcerated foot

(NICE, 2016, 2022)

ULCERATED FOOT/ FOOT CARE EMERGENCIES

If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the multidisciplinary foot care service (according to local protocols and pathways), so they can be assessed and an individualised treatment plan put in place.

Examples of limb-threatening and life-threatening diabetic foot problems include the following:

  • Ulceration with fever or any signs of sepsis
  • Ulceration with limb ischaemia
  • Clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration)
  • Gangrene (with or without ulceration)

(NICE, 2016, 2022)

The multi-disciplinary foot care team should comprise highly trained specialist podiatrists and orthotists, nurses with training in dressing of diabetic foot wounds and diabetologists with expertise in lower limb complications. They should have unhindered access to suites for managing major wounds, urgent inpatient facilities, antibiotic administration, community nursing, microbiology diagnostic and advisory services, orthopaedic/podiatric surgery, vascular surgery, radiology and orthotics (NICE, 2016, 2022).

All clinicians involved in managing patients with diabetes have a responsibility to provide education and training surrounding foot health. Patients and carers should also be instructed on the importance of maintaining their foot health. This module has outlined the importance of using a system to classify the diabetic foot to ensure that complications are prevented, and where it is not possible to prevent complications, they are managed in the most appropriate manner.

Many diabetic patients are seen frequently by nurses, and they can, therefore, play a key role in the multidisciplinary team that will be managing their diabetic foot problems. It is essential that all nurses who have frequent contact with diabetic patients understand how to assess, classify and manage the diabetic foot so that appropriate care, education and referrals take place in a timely manner.