National Hospital Discharge Survey data for 1994 indicate that 67,000 people with diabetes underwent one or more lower-extremity amputations. Diabetes is the leading cause of amputation of the lower limbs. Yet it is clear that as many as half of these amputations might be prevented through simple but effective foot care practices. The 1993 landmark study, the Diabetes Control and Complications Trial funded by the National Institute of Diabetes and Digestive and Kidney Diseases, conclusively showed that keeping blood glucose as close to normal as possible significantly slows the onset and progression of nerve and vascular complications associated with diabetes.
People with diabetes are vulnerable to nerve and vascular damage that can result in loss of protective sensation in the feet, poor circulation, and poor healing of foot ulcers. All of these conditions contribute to the high amputation rate in people with diabetes. The absence of nerve and vascular symptoms, however, does not mean that a patient's feet are not at risk. Risk of ulceration cannot be assessed without careful examination of the patient's bare feet.
Early identification of foot problems and early intervention to prevent problems from worsening can avert many amputations. Good foot care, therefore, is an essential part of diabetes management -- for patients as well as for health care providers.
This kit is designed for primary care and other health care providers who counsel people with diabetes about preventive health care practices, particularly foot care. "Feet Can Last a Lifetime" is designed to help you implement four basic steps for preventive foot care in your primary care practice.
1. Early identification of high risk feet.
2. Early diagnosis of foot problems.
3. Early intervention to prevent further deterioration that may lead to amputation.
4. Patient education for proper footwear and care of the feet.
The kit includes the tools you need to identify and diagnose diabetes foot problems, to develop a management plan, and to educate your patients.
- A foot screening form and instructions.
- Prescription forms to facilitate Medicare coverage of therapeutic footwear.
- A review of current research.
- A list of additional resources.
- Patient education materials.
Steps for Preventing Diabetes Foot Problems
1. Screen Feet Annually
Conduct a physical exam and a sensory exam using a monofilament.
Assess and document your patient's foot condition.
2. Categorize Your Findings
Low Risk Patient -- All of the following:
- Intact protective sensation
- Pedal pulses present
- No severe deformity
- No prior foot ulcer
- No amputation
High Risk Patient -- One or more of the following:
- Loss of protective sensation
- Absent pedal pulses
- Severe foot deformity
- History of foot ulcer
- Prior amputation
3. Counsel Your Patients or Refer to a Diabetes Educator
Talk with your patients about their risk category.
Demonstrate self-care techniques.
Prescribe appropriate footwear.
Give positive feedback for proper foot care.
Give patients the self-care booklet or tip sheet in this kit.
Counsel about smoking cessation if needed.
4. Follow Up with High Risk Patients
Place "high risk feet" stickers on medical record.
Examine feet at every visit.
Prescribe special inserts and shoes as needed.
Refer to specialists for a risk factor you cannot rectify.
Provide education about self-care.
Ensure that the elderly and blind have help for daily foot care.
Assess metabolic control.
Foot Screening Instructions
Completing the "Foot Screening Instructions" will enable you to:
Quickly identify the patient with current foot problems or a foot at risk for developing problems.
Obtain the information needed to:
- Make an initial diagnosis of a foot problem.
- Develop a treatment plan.
- Identify needs for referral to foot care specialists.
- Schedule follow-up examinations.
Document the level of foot deformity and/or disability.
Determine the need for therapeutic footwear.
Refer for diabetes education.
Compare future examinations with this baseline information.
I. Medical History
Patients who have been diagnosed with any of the medical problems listed are likely to have had diabetes for several years and to be at risk for foot problems. If the patient is unable to feel the 10-gram monofilament on any site on either foot, he or she has peripheral neuropathy.
II. Current History
Question 1: Any change in the foot since the last evaluation?
This question is to determine whether the patient has experienced any change in the strength or sensation in the feet. If this is the patient's first visit, enter N/A unless the patient has noticed a change in the past year.
Question 2: Does the patient have a foot ulcer now or a history of foot ulcer?
A positive history of a foot ulcer places the patient permanently in the high risk category. This person always has an increased risk for developing another foot ulcer, progressive deformity of the foot, and, ultimately, lower limb amputation.
This question is to determine whether the patient experiences intermittent claudication when walking. This pain is an indication of peripheral vascular disease or impaired circulation.
III. Foot Exam
Item 1: Are the nails thick, too long, ingrown or infected with fungal disease?
Thick nails may indicate vascular or fungal disease. If severe nail problems are present, refer the patient to a podiatrist or a nurse foot care specialist.
Item 2: Foot Deformities
Indicate foot deformities listed or specify the type and date of amputation(s). The more serious deformities are illustrated below. Prominent metatarsal heads are evidence of major deformity such as midfoot collapse.
a.Toe Deformities (Hammer/Claw Toes)
b. Bunions (Hallux Valgus)
c. Plantar View of Charcot Joint
Item 3: Pedal Pulses
Check the pedal pulses in both feet and note whether they are present or absent.
Item 4: Skin Condition
Examine each foot and record the problems identified by drawing or labeling the condition on the foot diagram. If there are calluses, pre-ulcerative lesions (a closed lesion, such as a blister or hematoma), or open ulcers, measure and draw them in and use the appropriate symbol to indicate what type of lesion is present. Label areas that are significantly red, warm (warmer than the other parts of the foot or the opposite foot), dry, or macerated (friable, moist, soft tissue).
IV. Sensory Foot Exam
The sensory testing device used to complete a foot exam is a 10-gram (5.07 Semmes-Weinstein) nylon filament mounted on a holder that has been standardized to deliver a 10-gram force when properly applied. Research has shown that a person who can feel the 10-gram filament in the selected sites is at reduced risk for developing ulcers.
- The sensory exam should be done in a quiet and relaxed setting. The patient must not watch while the examiner applies the filament.
- Test the monofilament on the patient's hand so he/she knows what to anticipate.
- The five sites to be tested are indicated on the screening form.
- Apply the monofilament perpendicular to the skin's surface (see diagram A below).
- Apply sufficient force to cause the filament to bend or buckle (see diagram B below).
- The total duration of the approach, skin contact, and departure of the filament should be approximately 1-1/2 seconds.
- Apply the filament along the perimeter and not on an ulcer site, callus, scar or necrotic tissue. Do not allow the filament to slide across the skin or make repetitive contact at the test site.
- Press the filament to the skin such that it buckles at one of two times as you say "time one" or "time two." Have patients identify at which time they were touched. Randomize the sequence of applying the filament throughout the examination.
V. Risk Categorization
Based on the foot exam, determine the patient's risk category. A definition of "low risk" or "high risk" for recurrent ulceration and ultimately, amputation, is provided in the chart below along with minimum suggested management guidelines. Individuals who are identified as "high risk" may require a more comprehensive evaluation.
Risk Category Defined
Low Risk Patients
Conduct an annual foot screening exam.
High Risk Patients
Conduct foot assessment every 3 months.
Management Guidelines for Active Ulcer or Foot Infection
- Never let patients with an open plantar ulcer walk out in their own shoes. Weight relief must be provided.
- Assess/prescribe therapeutic footwear to help modify weight bearing and protect the feet.
- Conduct frequent wound assessment and provide care as indicated.
- Demonstrate preventive self-care of the feet.
- Provide patient education on wound care.
- Refer to specialists and a diabetes educator as indicated.
- Certify Medicare patients for therapeutic footwear benefits (after ulcer heals).
- Place "High Risk Feet" sticker on medical record.
VI. Footwear Assessment
Improper or poorly fitting shoes are major contributors to diabetes foot ulcerations. Counsel patients about appropriate footwear. All patients with diabetes need to pay special attention to the fit and style of their shoes and should avoid pointed-toe shoes or high heels. Properly fitted athletic or walking shoes are recommended for daily wear. If off-the-shelf shoes are used, make sure that there is room to accommodate any deformities.
High risk patients may require therapeutic shoes, depth-inlay shoes, custom-molded inserts (orthoses), or custom-molded shoes depending on the degree of foot deformity and history of ulceration.
- Shoe must protect and support the feet
- Shoe must accommodate foot deformaties
- Shoe shape must match foot shape
Indicate whether the patient has received prior education by checking yes or no in the blank. Patient education is an essential component of preventive care.
VIII. Management Plan
Complete the management plan, indicating actions for patient education, any diagnostic studies, footwear recommendations, referrals, and follow-up care. Note: The management of foot problems may be the responsibility of different health care providers. For example, in some communities, certified nurses provide home health services or practice in primary care or foot care clinics to provide specialized diabetes foot care.