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4.2 Obtain a Holistic Comprehensive Patient History and Perform Physical Assessment


RNAO Evidence Level:

Level C: RNAO’s Assessment and Management of Diabetic Foot Ulcers 1

Patients with advanced diabetes may have peripheral arterial disease (see guidelines for PAD).

a. Complete a holistic comprehensive patient history:

  • Medical history including history of diabetes including complications such as retinopathy, nephropathy, neuropathy and sexual dysfunction
  • History of foot ulcer, amputation and past treatments
  • Current treatment of diabetes including other medications
  • Review patient's glucose monitoring and patient's use of data (diary or passport)
  • Review patient's HbA1C results within the last 2-3 months if taken
  • History of episodes of chest pain, hemoptysis or pulmonary embolus
  • History of heart disease, stroke or transient ischemic attack (TIA)
  • Comorbidities (peripheral vascular disease, intermittent claudication, rheumatoid arthritis or Ischemic rest pain)
  • Pain
  • Smoking history
  • History of ulcer and past treatments
  • Current and past medications
  • Nutritional status - eating pattern, meal plan and weight
  • Diabetic education history
  • Allergies
  • Psychosocial status including quality of life
  • Functional, cognitive, emotional status and ability for self-care
  • Lifestyle (activity level, interests, employment, dependents, support system)

b. Complete a comprehensive physical examination including:

  • Blood Pressure, height, weight, BMI, pulses in foot and ankle
  • Review bloodwork that should include the following:
 
   Body Weight     (kg):    
             

     Height (cm):     

     BMI: 

Recent  Weight Loss: Y  /  N Over___ (time)

Intentional Change in Weight Y  /  N

Weight Loss (kg): ___

   Protein-Calorie    Malnutrition
  • Pre-albumin if available (low scores indicate risk for malnutrition)
  • Serum albumin level (<30g/l will delay healing; <20g/l will be non-healable)
  • C-reactive Protein (CRP)
   Check for    anemia   CBC (including       RBC, Hct, Hgb,       MCV, Platelets         etc.)

If anemic, proceed to checking →
  • Serum Iron
  • Total Iron Binding
  • Ferritin
  • Transferrin
  • B12
  • Red blood cell folate level
   Kidney function    (To check    hydration)  
  • BUN
  • Creatinine
  • Potassium
  • Albumin/Urine creatinine ratio
 

Targets for Glycemic Control for Most People with
 Type 1 and Type 2 Diabetes

  • Fasting plasma glucose of 4.0 to 7.0 mmol/L (8.0 for the elderly to prevent chance of hypoglycemia)
  • A1C ≤ 7.0% to reduce the risk of microvascular and macrovascular complications
  • 2-hour postprandial (after meal) plasma glucose targets of 5.0 to l0.0 mmol/L
  • (5.0 to 8.0 mmol/L if A1C targets not being met)
 
As recommended by the Canadian Diabetes Association (CDA) Clinical Practice Guidelines
(CDA CPG Expert Committee, 2008)
 

c. Perform a bilateral lower leg assessment including:

(Level A:  RNAO’s Assessment and Management of Diabetic Foot Ulcers2)

1. ABPI and /TBPI are to be completed as soon as possible. Obtain ABPI and /TBPI results from Most Responsible Physician (MRP) or Vascular Lab if they were done within last 3 months
2. Refer diabetic clients to Vascular Lab for arterial testing. Majority of diabetic clients have calcification of the artery vessels that are nonpliable and stiff leading to falsely high ABPI levels. Therefore as per best practice, diabetic clients must be referred for vascular studies. It is expectation that ABPI and TBPI will still be completed and referred for vascular studies
3. Repeat ABPI and /TBPI assessment every 3 months if healing is not progressing
4. 60 Second diabetic foot screen assessment including monofilament test

(http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-education/professional-resources/60-second-diabetic-foot-screen-tool.pdf)

5. Texas Diabetic Foot Risk Classification score

PDFThe University of Texas Classification System for Diabetic Foot Wounds
OR International Working Group Diabetic Foot Risk Classification score
External siteIWDGF Risk Classification and Associated Interventions

6. Bilateral lower leg assessment that includes:

  • Leg measurements (foot, ankle, calf, thigh)
  • Nail changes (thicker, dry, crumbly, presence of fungal infection, ingrown toe nail)
  • Assess interdigital spaces
  • Presence of callous or corns
  • Presence of varicosities (varicose veins)
  • Ankle flare
  • Drainage on socks

NEUROLOGICAL Bilateral lower leg assessment that includes:

Autonomic Assessment
  • Assess pulses (popliteal – behind knee , dorsalis pedis – top of foot , posterior tibial – medial ankle)
  3
  • Measurement of edema (ankle, calf and thigh)
  • Assess capillary refill (normal less than 3 seconds)
  • Colour (dependent and on elevation)
  • Assess dermatological changes due to impaired blood flow & poor sweat gland function (dry, cracked skin, fissures, maceration and hyperhidrosis – excessive sweating)
  • Presence of hair on lower leg, feet and toes
Motor Assessment
  • Range of motion (ROM) of knee, ankle and foot
  • Proprioception (patient awareness of joint position) of hallux (great toe)
  • Foot deformities (bony and soft tissue changes  Charcot)
  • Gait assessment with appropriate off-loading footwear
  • Examination of footwear (foreign objects, wear pattern, pressure points, presence of wound drainage)
  • Activities of daily living
  • Safety of transfers
Sensory Assessment
  • Monofilament testing ( Monofilament size 5.07 = 10gram)
  • Soft touch (cotton ball)
  • Temperature difference using an infrared thermometer between left and right corresponding sites ( > 2.2 degree Celsius/ > 4 degree Fahrenheit difference indicates possible infection present)
  • Presence of pain i.e intermittent claudication (calf pain) and ischemic pain (pain causing frequent waking at night, or needing to dangle limb for pain relief)

7. Determine Cause of the Wound

Suggested reading:

PDF Diabetes, Healthy Feet and Your Patients. How healthy are YOUR patients’ feet? Brochure (PDF)
External site Link to RNAO Foot Assessment (External site)
External site Link to Diabetic Foot Canada Journal (External site)

Five simple clinical tests (10 –G monofilament, pinprick sensation, ankle reflexes, tuning fork test and vibration perception threshold testing) each with evidence from well-conducted prospective clinical cohort studies, are considered useful in the diagnosis of LOPS in the diabetic foot 45678. The task force agrees that any of the five tests listed could be used by clinicians to identify LOPS, although ideally two of these should be regularly performed during the screening exam—normally the 10-g monofilament and one other test. One or more abnormal tests would suggest LOPS, while at least two normal tests (and no abnormal test) would rule out LOPS. The last test listed, vibration assessment using a biothesiometer or similar instrument, is widely used in the U.S.; however, identification of the patient with LOPS can easily be carried out without this or other expensive equipment.

Monofilaments (size 5.07 = 10gram)

Many prospective studies have confirmed that loss of pressure sensation using the 10-g monofilament is highly predictive of subsequent ulceration 91011. Screening for sensory loss with the 10-g monofilament is in widespread use across the world, and its efficacy in this regard has been confirmed in a number of trials, including the recent Seattle Diabetic Foot Study.12131415

Nylon monofilaments are constructed to buckle when a 10-g force is applied; loss of the ability to detect this pressure at one or more anatomic sites on the plantar surface of the foot has been associated with loss of large-fiber nerve function. It is recommended that ten sites (1st, 3rd, and 5th metatarsal heads and plantar surface of distal hallux) be tested on each foot.

The technique for testing pressure perception with the 10-g monofilament is illustrated below; patients should close their eyes while being tested. Caution is necessary when selecting the brand of monofilament to use, as many commercially available monofilaments have been shown to be inaccurate.

The sensation of pressure using the buckling 10-g monofilament should first be demonstrated to the patient on a proximal site (e.g., upper arm). The sites of the foot may then be examined by asking the patient to respond “yes” or “no” when asked whether the monofilament is being applied to the particular site; the patient should recognize the perception of pressure as well as identify the correct site. Areas of callus should always be avoided when testing for pressure perception.16

 
 

 

Identify and Treat the Cause: 4.2 Assess the Wound and Peri-Wound

 
  1. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  2. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  3. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  4. N, Singh; D, Armstrong; B., Lipsky, "Preventating Foot Ulcers in Patients with Diabetes," JAMA, vol. 193, no. 5, pp. 217-228, 2005.
  5. American Diabetes Society, "Preventative Foot Care in People with Diabetes," Diabetes Care, pp. S78-S79, 2003.
  6. S. E. F. R. A. &. H. S. L. Gardner, "A prospective study of the push tool in diabetic foot ulcers.," in Wound Repair and Regeneration Conference: #20100417 Conference End(var.pagings)., 2009.
  7. Abbott C.; Carrington, A; Ashe, H et al., "The North-West Diabetes Foot Care Study: Incidence of and Risk Factors for New Diabetic Foot Ulceration in the Community Based Patient Cohort," Diabet Med, vol. 19, no. 5, pp. 377-384, 2002.
  8. Gardner, S.E., Frantz, R.A., Bergquist, S. & Shin, C.D. (2005). , "A prospective study of the pressure ulcer scale for healing (PUSH).," The Journals of Gerontology, vol. 60, no. 1, pp. 93-97., 2005.
  9. N, Singh; D, Armstrong; B., Lipsky, "Preventating Foot Ulcers in Patients with Diabetes," JAMA, vol. 193, no. 5, pp. 217-228, 2005.
  10. J, Mayfield; J., Sugarman, "The use of the Semmes- Weinstein Monofilament and Other Threshold Tests for Preventing Foot Ulceration and Amputation in Persons with Diabetes," J Fam Pract (Supl. 11), vol. 49, pp. S17-S29, 2002.
  11. D, Armstrong; L, Lavery; A, Vela; T, Quebedeaux; J., Fleischli, "Choosing a Practical Screening Instrument to Identify Patients at Risk for Diabetic Foot Ulceration," Arch Intern Med, vol. 158, no. 6, pp. 289-292, 2008.
  12. Abbott C.; Carrington, A; Ashe, H et al., "The North-West Diabetes Foot Care Study: Incidence of and Risk Factors for New Diabetic Foot Ulceration in the Community Based Patient Cohort," Diabet Med, vol. 19, no. 5, pp. 377-384, 2002.
  13. J, Mayfield; J., Sugarman, "The use of the Semmes- Weinstein Monofilament and Other Threshold Tests for Preventing Foot Ulceration and Amputation in Persons with Diabetes," J Fam Pract (Supl. 11), vol. 49, pp. S17-S29, 2002.
  14. J, Booth; M., Young, "Differences in the Performance of Commercially Available 10-g Monofilaments," Diabetes Care, vol. 23, pp. 984-988, 2000.
  15. E, Boyko; J, Ahroni; V, Cohen; K, Nelson; P., Heagarty, "Prediction of Diabetic Foot Ulcer Occurence Using Commonly Available Clinical Information: The Seattle Diabetic Foot Study," Diabetes Care, vol. 29, pp. 1202-1207, 2006.
  16. Boulton, A; Armstron, D; Albert, S; R, Frykberg; R, Hellman; D, Kirkman; L, Lavery; J, LeMaster; J, Mills; M, Mueller; D, Sheehan; D., Wukich, "A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists," Diabetes Care, vol. 31, no. 8, p. 1679–1685, 2008.
  17. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.

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