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 physician 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 pharmacy 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 SWRWCP: B.8.2_Purpose and Instructions for the Diabetic/Neuropathic Foot Ulcer Assessment Form_Jan_2014 2 South West Regional Wound Care Program 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 SWRWCP: B.8.2_Purpose and Instructions for the Diabetic/Neuropathic Foot Ulcer Assessment Form_Jan_2014 3 South West Regional Wound Care Program Thick Nails: Onychogryphosis - Thick hard curved nail plate in the shape of a ram's horn due to aging (image), psoriasis or trauma Onychauxis - 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. onychomycosis 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, alopecia areata o Transverse ridging - Consider eczema, paronychia, psoriasis, parakeratosis pustulosa, Beau's line o Longitudinal ridging - lichen planus, psoriasis, fungal Psoriasis of Nails Eczema Beau’s Line nail infection, Darier o Longitudinal groove - Median canaliform dystrophy due to Myxoid cyst 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 SWRWCP: B.8.2_Purpose and Instructions for the Diabetic/Neuropathic Foot Ulcer Assessment Form_Jan_2014 4 South West Regional Wound Care Program 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 melanoma Nail discoloration: Trachyonychia Nail erosion o Yellow – due to fungal infection, lymphatic obstruction, onychomycosis, psoriasis o Green – pseudomonas o Brown - onycholysis, 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) SWRWCP: B.8.2_Purpose and Instructions for the Diabetic/Neuropathic Foot Ulcer Assessment Form_Jan_2014 5 South West Regional Wound Care Program 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 inflammation) 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 Koilonychia - 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 SWRWCP: B.8.2_Purpose and Instructions for the Diabetic/Neuropathic Foot Ulcer Assessment Form_Jan_2014 6 South West Regional Wound Care Program 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 SWRWCP: B.8.2_Purpose and Instructions for the Diabetic/Neuropathic Foot Ulcer Assessment Form_Jan_2014 7 South West Regional Wound Care Program Material There should be no wrinkles, loose linings, tacks, ridges between the inner sole and sides of the shoes Any decorative pattern