|
|
 |
|
|
Diabetic Neuropathy is a degenerative disease of the peripheral nerves and a common complication of diabetes. Autonomic, sensory and motor functions may be affected individually or in combination with varying degrees of severity. This nerve damage can create conditions in the foot that produce secondary problems such as deformity and foot ulceration, which may lead to amputation. It is our hope to minimize or eliminate the devastating effects of peripheral neuropathy through careful monitoring of the feet using a foot screen, patient education and appropriate referral to a foot care specialist when needed.
Three levels of screening exist for the diabetic foot depending on the level of expertise of the individual performing the evaluation.
The Level One Leap Foot Screen may be completed by a nurse or health-care professional who is familiar with the foot and able to perform basic strength and sensory testing.
|
Diabetes Foot Screen |
| Name (Last, First, MI) __________________________________ |
Date:______ |
| Fill in the following blanks with a "Y" or "N" to indicate findings in the right or left foot. |
| |
R |
L |
| Is there a history of a foot ulcer? |
_________ |
_________ |
| Is there a foot ulcer now? |
_________ |
_________ |
| Is there a claw toe deformity? |
_________ |
_________ |
| Is there swelling or an abnormal foot shape? |
_________ |
_________ |
| Is there elevated skin temperature? |
_________ |
_________ |
| Is there limited ankle dorsiflexion |
_________ |
_________ |
| Are the toenails long, thick or ingrown? |
_________ |
_________ |
| Is there heavy callous build-up? |
_________ |
_________ |
| Is there foot or ankle muscle weakness? |
_________ |
_________ |
| Is there an absent pedal pulse? |
_________ |
_________ |
| Can the patient see the bottom of their feet? |
_________ |
_________ |
| Are the shoes appropriate in style and fit? |
_________ |
_________ |
| Note the level of sensation in the circles: |
| + = Can feel the 5.07 filament |
- = Can't feel the 5.07 filament |
Skin Conditions on the Foot or Between the Toes
Draw in: Callous, Pre-ulcer, Ulcer (note length and width in
cm)
Label with: R - redness, M - maceration, D
- dryness, T - Tinea
Risk Category
____ 0 No loss of protective sensation.
____ 1 Loss of protective sensation
____ 2 Loss of protective sensation with either high pressure
(callous/deformity), or poor
circulation.
____ 3 History of plantar ulceration, neuropathic fracture (Charcot
foot) or amputation
Performed by ________________________
______________________________
|
|
|
|
|
