1. Thomas Hess, Cathy BSN, RN, CWOCN

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About 16 million people in the United States have diabetes, with 798,000 new cases reported annually. Of those with diagnosed and as-yet-undiagnosed diabetes, 15% will develop at least 1 foot ulcer during the chronic state of the disease. The leading risk factor for ulceration is previous ulceration. Diabetes causes 56% to 83% of the estimated 125,000 lower-extremity amputations performed annually.



Clinicians should be proactive when assessing and managing a patient with a diabetic foot structure. To determine the best care plan for a successful outcome, the clinical team needs an in-depth understanding of the patient's medical condition and his or her actual and potential risk factors.


Patient History

A thorough patient history is paramount to the treatment plan. Clinicians must ask specific questions to determine the status of the patient's diabetes, such as:


* When was the patient diagnosed with diabetes?


* What is the medication regimen for this patient?


* Does the patient have a clear understanding of the disease process and potential complications?


* How often does the patient self-monitor his or her blood glucose level?


* Has the patient had a blood test to check the glycosylated hemoglobin levels (a measure of glycemic control) in the past 3 months?


* Has a licensed professional (certified diabetic educator or dietitian) counseled the patient?


* Does the patient complain of lower limb or foot pain-indicative of claudication?


* Has the patient ever experienced foot ulcers?


* Has the patient experienced any known heart disease?



Physical Examination

Obtaining a verbal patient history provides the clinician with only half of the clinical picture-a thorough evaluation of the patient's lower legs, feet, and toes for muscular tone, skin and tissue integrity, and vascular status is also essential. The following physical assessment checklist may be helpful:


* Evaluate the patient's popliteal and pedal pulses.


* Describe the condition of the patient's foot/feet (ie, observing for Charcot foot, healed and/or existing areas of breakdown, nail condition).


* Note the overall status of the skin and presence of any scars from previous ulcers or surgeries.


* Note any other lower-extremity conditions such as venous insufficiency, which may complicate treatment.



Assessment strategies to evaluate the diabetic foot should also include the following:


* Perform the Semmes-Weinstein test.


* Obtain the patient's ankle-brachial index (ABI) to assess blood flow, or refer the patient for more advanced arterial vascular studies. Interpret ABI results with caution in patients with diabetes secondary to a high degree of calcified or stenotic vessels, which give falsely elevated values.


* Examine the patient's feet for ulcers, especially the plantar aspect of the toes, laterally to the foot, between the toes, and the tips of the toes.


* Evaluate the footwear he or she commonly wears. Does it protect the feet, or does it promote rubbing?



Risk Factor Evaluation

Risk factors for patients with diabetes include absent protective sensation; vascular insufficiency; foot deformity causing high-pressure focal points; autonomic neuropathy causing fissure and integument and osseous hyperemia; limited joint mobility; obesity; impaired vision; poor control of blood glucose levels, resulting in advanced glycosylation and impaired wound healing; poorly designed or poorly fitting footwear causing or inadequately protecting the foot from tissue breakdown; history of lower-extremity amputation; and history of foot ulceration.



Key elements of the management regimen developed by the wound care team, which should always include the patient and his family, include preventing future damage, minimizing current damage, and ensuring maximum function and quality of life. This means preventing-or at least reducing-amputations and loss of life typically associated with the diabetic foot.


Source: Hess CT. Clinical Guide: Skin & Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.