Purpose and Instructions for the Interdisciplinary Diabetic/Neuropathic Foot Ulcer Assessment Form

Purpose The Interdisciplinary Diabetic/Neuropathic Foot Ulcer Assessment Form was developed by members of the SWRWCP as an assessment tool to be used for individuals with peripheral neuropathy +/- diabetes and wounds on their feet. The form is intended to:  Be utilized by health care professionals when assessing and individual with peripheral neuropathy +/- diabetes and an ulcer on their foot  Be completed at the point of entry to the health care system for individuals with peripheral neuropathy +/- diabetes and an ulcer on their foot, or when such a wound is identified in an individual already in the system  Be completed by a generalist health care provider, such as an RN, RPN, etc. or by a Wound Care Specialist or ET Nurse if they are the first person to assess the wound/edema at the time of admission into the health care system  Follow the individual as they move through the health care system, providing all subsequent health care providers access to the initial information

Instructions To be used in addition to the Initial Wound Assessment Screen when a diabetic/neuropathic foot ulcer is identified:  Demographics: Before beginning the tool, ensure the individuals name, ID number (or identifying number) and dates are added to every page (at the top of the first page and the header space of subsequent pages).  Medical History: Document the year the person was diagnosed with diabetes (to the best of the person’s memory). You may consider asking the family for a formal diagnosis and date if needed. Choose the most appropriate eating and physical activity patterns descriptions (may choose more than one) and the most appropriate diabetes education description based on conversation with the person.  Current Diabetes Treatment and Response: Choose the oral and hypoglycemic agents currently used and input medication names and dosages as per labels. Also choose the appropriate glycemic control indicators (more than one may be applicable – NOTE: you may request the most recent HgbA1c from the family physician if the person is unaware or if this information has not been provided by a reliable source).  Frequency of Self-Glucose Monitoring: Review the condition list and choose the most appropriate condition for the person. Investigate if the person has been monitoring their glucose levels as per best practice expectations, choosing yes or no.  Diabetes Related Complications: Review the person’s medical chart, ask them, and if required approach the person’s family physician/nurse practitioner re diagnoses of diabetes related complications, checking the appropriate boxes on the form as South West Regional Wound Care Program

indicated. Considering this information and the information obtained earlier in the form, consider referrals or advocating for referrals to the appropriate health professionals.  Foot Examination: Assess the person’s feet and nails for the following physical characteristics, documenting with a check mark in the appropriate boxes: Descriptor Examples (unless otherwise indicated photos from dermnetnz.org) Hammer toes

From Google Images Claw toes

From Google Images Dropped Metatarsal Heads (MTH)

From Google Images Hallux Valgus

From Google Images

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Dropped Arch

From Google Images Callus – a.k.a. tyloma  An area of hard thickened skin that is most often painless  Caused by friction/shear/repetitive injury over a broad area

Corns – a.k.a. clavus, heloma  A localized area of thickened skin that is often painful and inflamed  Caused by friction/shear/repetitive injury over a very localized area Taylor Bunion

From Google Images Fixed Ankle Joint No image available Hallux Rigidus No image available Fissures – cracks in the heel tissue due to dryness

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Thick Nails:  - Thick hard curved nail plate in the shape of a ram's horn due to aging (image), or trauma  - Thick nail due to psoriasis, trauma, or fungal nail infection Onychogryphosis Oxychauxis Brittle Nails  Typical of fungal infection or psoriasis

Fungal Nails – a.k.a.  Can be due to: o Dermatophytes o Yeasts o Moulds

 Can involve one or many nails Dermatophyte onychomycosis Abnormal Nails, i.e.:  Abnormalities of the nail plate surface: o Pitting – eczema, psoriasis, o Transverse ridging - Consider eczema, , psoriasis, parakeratosis pustulosa, Beau's line o Longitudinal ridging - , psoriasis, fungal Psoriasis of Nails Eczema Beau’s Line nail infection, Darier o Longitudinal groove - Median canaliform dystrophy due to Myxoid or wart o Angel-wing deformity - Nail plate thinning due to lichen planus

o Onychoschizia - Distal lamellar splitting/brittle nails Alopecia areata Median canaliform dystrophy due to water/detergent damage o Longitudinal splitting - An extension of ridging seen in

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psoriasis, fungal nail infection or lichen planus o Distal notching - Consider Darier and lichen planus o Trachyonychia - Rough nails. If all nails affected, known as Twenty Nail Dystrophy, probably due to lichen planus o Erosion - Consider trauma or malignant tumour e.g. SCC or  Nail discoloration: Trachyonychia Nail erosion o Yellow – due to fungal infection, lymphatic obstruction, onychomycosis, psoriasis o Green – pseudomonas o Brown - , external staining, chemotherapy or other medications, renal failure, Benign melanocytic naevus, Laugier-Hunziker Syndrome,

Peutz-Jeghers syndrome Onychomycosis Psedomonas Staining (urea) o White – Vitiligo, trauma to nail, hypoalbuminaemia, chronic renal failure, thyrotoxicosis, liver cirrhosis, arsenic toxicity o Red – liver cirrhosis, trauma, glomus tumor o Blue – systemic medication o Purple/black – hematoma, pseudomonas, Benign

melanocytic naevus. Liver cirrhosis Renal disease Hematoma  Abnormalities of the cuticles and nail folds: o Ragged (connective tissue disease) o Hang nail o Nail fold telangiectases (connective tissue disease) o Distal digital infarcts (vasculitis) o Subungual hyperkeratosis (psoriasis, scabies,

onychomycosis) Melanocytic naevus Melanoma Vasculitis o Pterygium (lichen planus, Stevens-Johnson syndrome)

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o Acute paronychia (staph infection, herpes simplex) o Chronic paronychia (candida or pseudomonas infection) o Retronychia (Embedding of the nail into the nail fold and subsequent )  Abnormalities of nail shape: Lichen planus Acute herpetic Acrodermatitis o Enlarged - Osteoid osteoma (bone tumour) paronychia continua o Long or short o Over curvature o Clubbing - Due to hypertrophic osteoarthropathy or thryoid disease (acropachy) o - Thin spoon-shaped nail associated with iron deficiency anaemia & acitretin treatment o Pachyonychia - Wedge-shaped nails o Onychocryptosis - in-growing nail with granuloma formation. Aggravated by retinoids such as isotretinoin or acitretin

 Loss of nails: Lichen planus Warts Melanocytic naevus o Traumatic o Scarring - Due to tumour or erosive lichen planus o Onychomadesis - Nail shedding may arise in severe or bullous lichen planus or acute and severe systemic illness o Nail patella syndrome

 Lesions around nails: Subungual melanoma Fibroma Cyst o Warts o Melanocytic naevus o Subungual melanoma o Squamous cell carcinoma o Corn o Fibroma

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o Cyst o Onychomatricoma o Subungual exostosis o granuloma

Subungual exostosis Pyrogenic granuloma Ingrown Nails – a.k.a. onychocryptosis  Where the sides or corners of a nail digs into skin  Most commonly caused by ill-fitting shoes, improper nail care, nail injury, and fungal nail infection

 Footwear9: Assess all footwear the person is currently using. Place a check in the most appropriate box(es) on the form. Consider the following properties of good footwear when making your selection:

Shoe Part Property Length  Should be at least ½” between end of longest toe and end of shoe when standing Toe box depth  Toe box should allow toes to wiggle  There should be no stitching inside the toe box rubbing on any part of the foot Width  Widest part of the shoe should fit the widest part of the foot (forefoot) Heel height  ½-1” heel height recommended for walking shoe  Max 2” height for evening or dress shoes  The wider the heel, the better Heel  Should fit snugly or heel may slip  Heels should not be worn down – can throw off gait  If open heel shoe – should have instep strap and sling back strap Heel counter  Should be firm enough to hold foot in place Arch  Should accommodate a high arch  Should not gap on the inner side of the foot

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Material  There should be no wrinkles, loose linings, tacks, ridges between the inner sole and sides of the shoes  Any decorative pattern should not go to the inside of the shoe as it may create a ridges or bulk that could irritate the foot  Leather and suede are recommended  Dyes may cause Soles  Should be flexible but strong and have good gripping surface  Rubber/plastic good for traction, unless you have a shuffling gait, and have shock absorption Closures  Laces, but must be more than three eyelets on each side to be effective  Velcro great for those with poor motor function  Straps (T-bar straps) and buckles good Make sure that the shoe fits its purpose, i.e. does the footwear serve its purpose in a working environment, or if it is to be worn for dancing or evening events, or day-to-day? In addition, write in any information requested on the form, i.e. the age of orthotics/shoes, the date of the last visit to the person’s foot specialist, and the name and designation (and contact information) of any foot specialists involved.  Neuropathy: Assess the person’s loss of protective sensation by conducting a 10-point monofilament test. Insert test results on the form where indicated. In addition, ask questions of the person to elicit responses to signs of autonomic, motor, and sensory neuropathy.  Diabetic Foot Risk Classification: Based on the descriptions provided on the form, select the appropriate foot risk category for each foot.  Diabetic Foot ULCER Classification: Based on the descriptions provided on the form, select the most appropriate grade/stage of the foot ulceration present, and indicate that grade/stage on the form in the appropriate place. Based on this information and information gathered earlier in the form, indicate whether you will be referring to or requesting a referral to a foot specialist for a foot wear assessment/re-assessment or for consideration of an offloading device (in the presence of a plantar diabetic foot ulceration).  Edema: Indicate the date of onset of the edema of each leg and note if the edema is asymmetrical by ticking the appropriate box. Indicate the location of the edema by checking the appropriate box and describe the edema using the following guidelines:

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Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger x 10 – 15 seconds. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema. It is graded based on the depth of the indentation: 1+ = 0 - ¼” 2+ = ¼” – ½” 3+ = ½ - 1” 4+ = takes several minutes to rebound

In non-pitting edema, pressure that is applied to the skin does not result in a persistent indentation. Non-pitting edema can occur in certain disorders of the lymphatic system such as lymphedema, where edema is particularly prominent on the dorsum of the feet and in the toes.

Brawny Induration - Brawny means swollen and hardened, while induration is abnormal firmness of tissues with margins. Palpate where it starts and stops. Induration results in an inability to pinch the tissues.

For edema measurements, using a measuring tape, measure the midfoot, and then the lower leg in increments of 10cm. I.e. with your tape measure at the base of the person’s foot, measure up the person’s leg 10cm and take a circumferential measure. With your tape measure at the base of the person’s foot, measure up the person’s leg 20cm and take a circumferential measure, etc. until you have measured the entire lower leg and upper leg, if edema exists there as well. Further, check the appropriate boxes indicating whether or not the person has previously used compression stockings, if they were adherent to using them, and the age of their current stockings.  Lymphedema Assessment1: Read the descriptors present in the tool and check off all descriptors that apply.  Lipedema Assessment: Read the descriptors present in the tool and check off all descriptors that apply.  Skin and Anatomy2-5: Review the various signs/symptoms of venous and arterial disease listed and check those present in each leg using the following descriptors:

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Signs/Symptoms of Venous Disease Descriptors Examples Varicosities- either small or larger vessels.

Hemosiderin staining- Brown or brownish red pigmentation and purpura caused by extravasation of red blood cells into the dermis.

Chronic Lipodermatosclerosis- lower 1/3 of leg becomes sclerotic and woody. Leg becomes champagne bottle or bowling-pin shaped – ulcers are more difficult to heal.

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Acute lipodermatosclerosis- This presents as a painful and tender condition of the leg. It is frequently misdiagnosed as cellulitis or morphea. It represents a panniculitis associated with venous insufficiency. Ulcers can occur within the lesion, which becomes intensely fibrotic over time.

Photograph used with permission of Dr. V. Falanga.

Stasis or venous dermatitis - erythema, scaling, pruritus, and sometimes weeping- may develop cellulitis through breaks in the skin.

Atrophie blanche - Located on the ankle or foot, ivory white lesions, atrophic plaques. Ulcerations tend to be exquisitely painful. The white lesions represent scarring from previous injuries.

Woody fibrosis - deposits of fibrin in the deep dermis and fat results in a woody induration of the gaiter area of the leg.

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Ankle (submalleolar) flare - Incompetence in perforating vein valve which results in venous hypertension and causes dilation of the venules.

Ulcer base moist with granulation &/or yellow slough/ fibrin.

Ulcer located in gaiter region (lower 1/3 of calf) - Ulceration usually on the medial lower leg superior to malleolus but can be on lateral aspect as well. Ulcerations may encircle the entire ankle; ulcers occurring above mid-calf or on the foot likely have other origins.

Ulcer located superior to the medial malleolus

Scarring from previous ulcer(s)- evidence of previous ulcerations noted.

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Signs/Symptoms of Arterial Disease Descriptors Examples Hairless –little or no hair on the lower legs or feet. No illustration available

Thin- skin appears thin and fragile and pale in color. No illustration available

Shiny skin on legs and feet. No illustration available

Dependent rubor – occurs in the presence of arterial compromise and can mimic cellulitis. The rubor disappears when the foot is elevated, which would not happen with cellulitis. It can be bilateral.

(Gangrene also present) Blanching on elevation -- occurs in the presence of arterial compromise and represents decrease in arterial flow without the gravitational effect of having the foot below the level of the heart. It can be bilateral.

(Gangrene also present) Feet cool/cold/blue—this occurs in the presence of arterial disease, often just No illustration available involving one leg or foot in comparison to the other.

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Toes cool/cold/blue- in this photograph, the 4th toe is becoming ischemic secondary to infection.

Lower temperature in one leg compared to other—one leg feels cooler than the No illustration available corresponding area on the other leg – this generally suggests the presence of PAD in the cooler leg, but can also be from increased temperature in a leg with infection or cellulitis.

Capillary refill time: > 3 seconds Delayed capillary refill time (CFT) is suggestive of peripheral arterial disease. Normal CFT is less than 3 seconds.

Photographs used with permission of myfootshop.com

Ulcer located on foot or toes - often on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude and rub against bed sheets, socks or shoes.

Definition from : http://my.clevelandclinic.org/heart/disorders/vascular/legfootulcer.aspx

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Ulcer base pale and dry &/or contains eschar – the ulcer may initially have grey or purplish tissue that bleeds very little and will turn to eschar if allowed to dry out.

Ulcer round and punched out in appearance –arterial ulcers do not usually have irregular edges and the edges do not slope gently down to the wound bed.

Gangrene dry/wet Dry gangrene (ischemia) may start out red in color and cool to touch, then turn blue or brownish and then becomes black and will desiccate if allowed to dry.

Wet gangrene (infection causing ischemia) starts out with swelling and putrefies, may have foul smelling exudate, fever.

 Pulse Assessment: Palpate the person’s dorsalis-pedis and posterior-tibial pulses and indicate by checking the appropriate box, whether the pulses are present, diminished, or absent.  ABPI Testing7,8: To be completed by a wound care specialist, ET Nurse or in a vascular/diagnostic imaging lab.  Impression: Based on assessments done in this document, input the grade and stage of the diabetic foot ulcer or indicate if the ulcer is a neuropathic foot ulcer (non-diabetic).  Complicated by: Choose all options listed that apply (NOTE: this does not contain extrinsic, intrinsic, and iatrogenic factors affecting healability, rather it is looking for any associated circulatory component).

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 Healability: Based on the information gathered in this assessment and information collected in the Initial Wound Assessment Screen, choose the most appropriate option, knowing that the selection made may vary over time.

References

1 International Society of Lymphology (ISL). Lymphoedema Staging (From International Consensus Document Best Practices for the Management of Lymphoedema). Retrieved from: http://www.lympho.org/mod_turbolead/upload/file/Lympho/Best_practice_20_July.pdf. 2 Hess CT. Venous ulcer checklist. Advances in Skin and Wound Care. 2010;23(8):384. 3 Moloney MC, Grace P. Understanding the underlying causes of chronic leg ulceration. JWC. 13(6):215-218. 4 Coutts et al. RNAO Assessment and Management of Venous Leg Ulcers Guideline supplement. 2007. 5 Dissemond J, Körber A, Grabbe S. Differential diagnosis of leg ulcers. Journal der Deutschen Dermatologischen Gesellschaft. 2006;4:627–634. 6 Vowden P, Vowden K. Doppler assessment and ABPI: Interpretation in the management of the leg ulceration. Worldwide Wounds. 2001. Available at: http://www.worldwidewounds.com/2001/march/Vowden/Doppler-assessment-and-ABPI.html. 7 Suzuki K. How to diagnose Peripheral Arterial Disease. Today. 2007;20(4). 8 Conestoga Collage Institute of Technology and Advanced Learning. School of Health Sciences, Community Services and Bio Technology. Basic Foot Care Student Learning Package. August 2005.

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