•Physical Exam •  Skin condition? •  Pressure points? •  Skin temperature? •  Discoloration/swelling? •  Condition of toenails? •  Blood flow sufficient? •  Are foot deformities present? •  Is foot sensation present?

 

Assess skin, hair and nails: Is skin thin, shiny and hairless? This may indicate arterial insufficiency or, in a female patient, postmenopause. Is the skin dry, cracked and fissured? If so, autonomic neuropathy could be the cause and intervention should include the application of emollient to get skin quality back. What does the skin look like between the toes-any signs of maceration which would indicate too much moisture (which could result in tinea pedis)? Once you hear of a person with diabetes having a forefoot amputation secondary to athlete’s foot, you have a new appreciation for the web spaces between toes. Is there evidence of pressure points on the plantar or toe surfaces? Are there corns, calluses, or blisters present? The skin temperature of the foot should be checked and compared right to left. An infrared thermometer can come in handy here to identify temperature spikes that can be indicative of trouble brewing. According to Sanders, any increase in skin temperature of 2 degrees Centrigrade indicates impending Charcot foot or pre-ulcerative inflammation--warranting prompt attention. Local signs and symptoms of inflammation and infection are often muted or completely absent in people with diabetes.  Are there any areas of discoloration or swelling on the foot or leg?

Be sure to check their toenails-are they dry, brittle and crumbling or are they thickened and yellowed? Are they overgrown and cutting into the skin? Do these changes represent a perfusion, infection or age-related issue?

What about blood flow? Palpate the dorsalis pedis and posterior tibial pulses bilaterally. Just because you can palpate pulses doesn’t mean arterial disease is not present. The Ankle Brachial Index, or ABI, is unreliable in the person with diabetes due to their stiff, calcified vessels which are difficult to compress. False high readings may result if used. Lower extremity transcutaneous oxygen tension, or TcPO2, should be used instead of the ABI with diabetics.

Assess the foot for deformities associated with motor neuropathy including hammer toes, cock-up or claw toes, bunions and Charcot foot. All of these represent new pressure points which could ulcerate, as well as challenges related to footwear and off-loading. Look at their shoes and socks-does each foot fit the shoe or does the shoe fit the foot?

Lastly, evaluate for the loss of protective sensation by using the Semmes-Weinstein monofilament as described earlier.

Prevention of Diabetic Foot Wounds

To prevent wounds and amputations, remember the 5 Ps:

•Professional Care •Protective Footwear •Pressure Reduction •Prophylactic Surgery •Patient Education