Diabetic Foot Screening

People with diabetes are at a higher risk for foot-related wounds, ulcers and lower limb amputation.  This is because of nerve and circulatory changes (read here) which occur in diabetes.  For this reason, it is important to regularly assess the feet of diabetic clients.

At McDermott Footcare, the tool used for this assessment is Inlow’s 60-Second Diabetic Foot Screen, obtained from the Canadian Association of Wound CareThe screening tool consists of a mono-filament device and accompanying checklist.  The frequency of assessment is determined by the initial and subsequent assessment scores.  The higher the score, the more frequent the assessment.  The quick but thorough assessment covers all important areas.

Visual:

The first part of the assessment involves looking to see the condition of the skin and nails.  Are the skin and nails fungal?  Are there calluses or open ulcers?  Are the nails thickened?  Is footwear appropriate or causing trauma?  Look for Charcot’s Deformity, bunions and previous amputations.

Touch:

Next, the temperature of the foot is recorded.  By touching the feet, a comparison is made of the temperature of both feet.  Are they equal in temperature or is one foot colder/hotter than the other?  Are they colder/hotter in relation to the environment?

The range of motion of the great toe is assessed.  Things to look for include how easily the toe can be moved or is it rigid.  What degree is the rigidity?

Sensation And Other Assessment:

Next comes testing with the mono-filament tool.  10 sites on the foot are touched with the mono-filament and the client’s ability to feel the touch is rated.  The client is also asked whether they feel numbness, tingling, or burning in the feet.  The pedal pulses are felt.  The presence of dependent rubor (redness when the feet are down; pallor when they are elevated) and erythema (reddened areas of the skin) complete the assessment.

Clients respond favourably to Diabetic Foot Screening.  They are advised that it is part of the overall nursing plan of care for keeping their feet healthy.  It is also a good springboard for discussion and health teaching about foot health.  As needed, clients have been advised to see their doctor for further treatment based on the findings of the assessment.

The 60-Second Diabetic Foot Screen is very convenient and quick to complete.  Regular screening gives clients peace of mind that their foot health is monitored appropriately.

Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author

The Importance of Nursing Foot Care for Diabetics

According to a 2009 report by the International Diabetes Federation, 7% of the world’s population has diabetes.  That’s approximately 300 million people worldwide with the majority of cases (85% – 95%) having Type 2 Diabetes.  Type 2 Diabetes is preventable in 60% of cases, according to the IDF.

At McDermott Footcare, almost half of the clientele have Type 2 Diabetes.  All of the clients exhibit neuropathic and circulatory deficits which negatively affect the health of their feet and lower legs.  Read here about neuropathic and circulatory changes.

The following case studies illustrate the importance of regular nursing foot care for diabetics:

Case Study #1

Client A is a nursing home resident.  He was a McDermott Footcare client when he lived at home; at the family’s request, McDermott Footcare has continued his foot care in the nursing home.  On a recent foot care visit, he told me that he had stubbed and cut his toe.  He noticed some discharge coming from the cut.  He did not tell the staff nurses and they did not notice the injury.  On closer inspection, I noticed redness, inflammation and a white discharge when I squeezed the toe, all symptoms indicative of infection.  I cleaned and bandaged the injury site.  I reported the injury to Client A’s family, the Charge Nurse, the Director of Care and requested that my client be seen ASAP by the doctor-on-call.  Within 2 hours, Client A’s family received a phone call informing them that the doctor had just seen their father and antibiotics were now prescribed.  

Case Study #2

When I first saw Client B  12 weeks ago, he exhibited Tinea Pedis (Athlete’s Foot).  The fungal infection completely covered the bottom of both feet, as well as along the sides and top of the feet.  It was starting to spread upwards towards his ankles.  He had large areas of peeling, scaling, redness and itching.  Upon inquiry, I learned that Client B likes to sleep with his socks and shoes on because his feet are extremely cold at night.  During the day, he continues to wear the same shoes.  I discussed a Plan of Care with Client B and his caregivers.  I recommended thick, cotton, breathable diabetic socks for nighttime use and advised my client to stop wearing shoes to bed.  I suggested leather or cloth slippers for daytime use at home.  Athlete’s Foot fungus (read here) thrives in dark, moist places.  Constantly wearing shoes provides the perfect opportunity for the fungus to grow.  I taught the caregivers how to make a vinegar-water foot soak, how to properly dry Client B’s feet and advised Client B to get a prescription anti-fungal medication from his doctor.  6 weeks later, most of the Athlete’s Foot infection was gone, with only a small amount of scaling and peeling on the bottoms of his feet.

Diabetics are at a higher risk for foot-related infections leading to lower limb amputation.  This is because of neuropathy and micro/macroangiopathy.  Since their feet have decreased sensation, diabetics may not realize that they have an infected cut or open sore on the feet.  Decreased eyesight in diabetics means that they may not be able to see the cut or open sore. Poor circulation means that the ability to fight the infection is compromised.

My main concern with both clients was eliminating the infection.  The whitish discharge, redness and inflammation of Client A indicated a bacterial infection in his toe.  Client B’s Athlete’s Foot could have progressed to cellulitis with open sores.  Knowing the appropriate nursing actions and referring both clients to their physician addressed their needs in a timely and effective fashion.

Being in regular contact with both clients, knowing their complete medical history and having up-to-date knowledge in diabetic nursing foot care prevented two situations from worsening.  Regular visits from a certified foot care nurse effectively addresses the needs of diabetics.

On-going nursing assessments during visits are able to identify problem areas that the client and their family are unaware of.  One of these assessments, mono-filament testing for neuropathy, determines changes in the client’s ability to detect sensations in the feet.  Physically checking the client’s feet for abrasions,cuts, sores, blackened areas is important for the nurse to do since diabetic clients have poor eyesight and may not be able to see them.  That is why it is important for diabetic clients and/or their families and caregivers to rely on the skills and knowledge of a certified foot care nurse.

Copyright Terry McDermott. May not be reproduced in whole or in part without permission of author