This document discusses foot problems in people with diabetes, including that over 50% of lower extremity amputations are due to diabetes and are often preventable with proper foot care. Neuropathy, peripheral vascular disease, and hyperglycemia can impair wound healing. Daily foot inspections are important to catch injuries or infections early. Preventative care includes foot exams, nail trimming, moisturizing, proper shoes, and treating conditions like calluses.

2. FOOT AND LEG PROBLEMS
 From 50% to 75% of lower extremity amputations are performed on
people with diabetes.
 More than 50% of these amputations are thought to be preventable,
provided patients are taught foot care measures and practice them on a
daily basis.

3.  Complications of diabetes that contribute to the increased risk of foot
infections include:
 Neuropathy:
 Sensory neuropathy leads to loss of pain and pressure sensation, and
autonomic neuropathy leads to increased dryness and fissuring of the
skin (secondary to decreased sweating).
 Motor neuropathy results in muscular atrophy, which may lead to
changes in the shape of the foot.

4.  Peripheral vascular disease:
Poor circulation of the lower extremities contributes to poor wound
healing and the development of gangrene.
 Immunocompromise:
Hyperglycemia impairs the ability of specialized leukocytes to destroy
bacteria.
Thus, in poorly controlled diabetes, there is a lowered resistance to certain
infections.

5.  The typical sequence of events in the development of a diabetic foot
ulcer begins with
 Soft tissue injury of the foot,
 Formation of a fissure between the toes or in an area of dry skin, or
 Formation of a callus.

6.  Injuries are not felt by the patient with an insensitive foot and may be
 Thermal (eg, from using heating pads, walking barefoot on hot
concrete, or testing bath water with the foot)
 Chemical (eg, burning the foot while using caustic agents (Acids)
 Traumatic (eg, injuring skin while cutting nails, walking with an
undetected foreign object in the shoe, or wearing ill-fitting shoes and
socks).

7.  If the patient is not in the habit of thoroughly inspecting both feet on a
daily basis, the injury or fissure may go unnoticed until a serious
infection has developed.
 Drainage, swelling, redness (from cellulitis) of the leg, or gangrene
may be the first sign of foot problems that the patient notices.
 Treatment of foot ulcers involves bed rest, antibiotics, and
debridement.
 In addition, controlling glucose levels, which tend to increase when
infections occur, is important for promoting wound healing.

8.  In patients with peripheral vascular disease, foot ulcers may not heal
because of the decreased ability of oxygen, nutrients, and antibiotics
to reach the injured tissue.
 Amputation may be necessary to prevent the spread of infection.
 Foot assessment and foot care instructions are most important when
caring for patients who are at high risk for developing foot infections.

9. Some of the high-risk characteristics include:
 Duration of diabetes more than 10 years
 Age older than 40 years
 History of smoking
 Decreased peripheral pulses
 Decreased sensation
 Anatomic deformities or pressure areas (eg, bunions, calluses, hammer
toes)
 History of previous foot ulcers or amputation

10.  Calluses- A thickened and hardened part of the skin or soft tissue,
especially in an area that has been subjected to friction.
 Bunions- A painful swelling on the first joint of the big toe.
 Hammer toes

11. Management
 Teaching patients proper foot care is a nursing intervention that can
prevent costly, painful, and debilitating complications.
 Preventive foot care begins with careful daily assessment of the feet.
 The feet must be inspected on a daily basis for any redness, blisters,
fissures, calluses, ulcerations, changes in skin temperature, and the
development of foot deformities (ie, hammer toes, bunions).
 For patients with visual impairment or decreased joint mobility
(especially the elderly), use of a mirror to inspect the bottom of the feet
or the help of a family member in foot inspection may be necessary.

12.  The interior surfaces of shoes should be inspected for any rough spots
or foreign objects.
 In addition to the daily visual and manual inspection of the feet, the
feet should be examined during every health care visit or at least once
per year (more often if there is an increase in the patient’s risk) by a
podiatrist, physician, or nurse.
 Podiatrist-A person who treats the feet and their ailments.

13.  Patients with neuropathy should also undergo evaluation of
neurologic status using a monofilament device by an experienced
examiner.
 Patients with pressure areas, such as calluses, or thick toe nails should
see the podiatrist routinely for treatment of calluses and trimming of
nails.
 Additional aspects of preventive foot care that are taught to the patient
and family include the following:

14.  Properly bathing, drying, and lubricating the feet, taking care not to
allow moisture (water or lotion) to accumulate between the toes.
 Wearing closed-toe shoes that fit well.
 Podiatrists can provide patients with inserts (orthotics) to remove
pressure from pressure points on the foot.
 Orthotics- The branch of medicine that deals with the provision and
use of artificial devices such as splints and braces.

15.  New shoes should be broken in slowly (ie, worn for 1 to 2 hours
initially, with gradual increases in the length of time worn) to avoid
blister formation.
 Patients with bony deformities may need extrawide shoes or extra-
depth shoes.

16.  High-risk behaviors should be avoided, such as walking barefoot,
using heating pads on the feet, wearing open-toed shoes, soaking the
feet, and shaving calluses.
 Trimming toenails straight across and filing sharp corners to follow the
contour of the toe.
 If patients have visual deficits or thickened toenails, a podiatrist
should cut the nails.

17.  Reducing risk factors, such as smoking and elevated blood lipids, that
contribute to peripheral vascular disease.
 Avoiding home remedies or over-the-counter agents or self medicating
to treat foot problems.
 Blood glucose control is important for avoiding decreased resistance to
infections and for preventing diabetic neuropathy.
 The patient may be referred by the physician to a wound care center
for managing persistent wounds of the feet or legs.

18. The monofilament test is used to assess the sensory threshold in patients with diabetes.
The test instrument—a monofilament—is gently applied to about five pressure points on
the foot (as shown in image on left).
(A) This is an example of a monofilament used for advanced quantitative assessment;
(B) Sennes-Weinstein monofilament used by clinicians;
(C) Disposable monofilament used by patients.
The examiner applies the monofilament to the test area to determine if the patient feels
the device.

19.  Many wound care centers provide diabetes education; however, the
patient needs to discuss recommendations for treating wounds with
his or her own physician, as well as raising any questions about
diabetes management.
 Thanking you.