Yesterday, I posted about the Diabetic Foot Examination and discussed an overview of what nurse practitioners should keep in mind with assessing the diabetic’s feet. Today, I would like to dive more in detail. Before I get into the individual components, I did make a video that details this so I will link that below if that’s more of your cup of tea.

Let’s get into those key components but keep in mind that this is not an exhaustive list but more so a great starting place. Based on the patient’s history and their current needs, you may find yourself needing to tweak and expand upon this list.

Inspection of the feet, ankle, & lower extremity
This should be considered with every diabetic especially if there is some sensory loss. If they are already complaining of numbness or loss of feeling, you should definitely be looking at those feet with every visit. For those that do not fall into this category, it is still good to have a schedule that you decide to examine each diabetic’s feet. An option could be once every 6 months with an ongoing referral to podiatry.
This is also a great time to access the patient’s shoes and socks. Diabetic shoes and socks are items covered by all insurances, so if they have never had a pair or in need for another this would be the time to address that. Once the shoes and socks are off and aside, give the feet a great look over. Take note of any discoloration or redness. This could alert you to circulatory issues or inflammatory processes occurring with the sign of redness. Look at the nails for suppleness. Some questions to consider: are they well nourished, cracked, brittle, or ingrowing? Assess for calluses, corns, or deformities. This is a sure fire way to know if the patient is wearing well fitting shoes. You also would need to note the hair growth on the lower extremity. The old nursing saying goes: “Hair doesn’t grow where blood doesn’t flow.” If you notice hair loss especially in a man or a woman who hasn’t shaved then start to suspect circulatory issues.
Palpation of the feet
When touching the feet, note the temperature of the extremity. Is it cool or warm? If by chance you note that an area is unusually warmer than expected, this could alert you to inflammation or infection brewing. Also, feel for the pulses and grade them appropriately. The dorsalis pedis on the dorsal side of the foot and the posterior tibial pulse on the inner foot bone are the ones commonly checked. Please note that these pulses can be easily occluded with pressure so lightly place your hand at the site. Assessing for capillary refill on the nail bed and swelling to any degree can be noted during this time as well.
Screening for Peripheral Artery Disease (PAD)
I mentioned a few times earlier circulatory issues. During your history of the patient, if you are alerted of this, I strongly recommend you screening the patient for PAD. There are two primary tests used to screen and diagnose PAD: Quantaflo & Ankle-Brachial Index.
Quantaflo: A sensor is placed on all for extremities (the great toes and index fingers) 15 seconds each so it takes a total of 60 seconds. It is non-invasive and the patient would need to sit with their legs uncrossed, still and quiet. The test measures the blood flow and on the screen you will see waveform that should be active. At the conclusion of the test, your results will be given instantly with a possible diagnosis. The test is not a perfect test so if you find unfavorable results, please follow with an ABI or refer to a lab for the diagnostic testing for PAD. Here’s a great video reference: Quantaflo Test Demo
Ankle-Brachial Index: Also a non-invasive test, the ABI is a blood pressure measurement and comparison of the upper and lower extremities. Once all four BP’s are taken, you divide the ankle BP by the brachial BP and that’s your result. Here’s a good video for reference: ABI screening
See the results chart below:

Image from: https://www.consultant360.com/article/peripheral-arterial-disease-diagnosis-and-treatment

Other items to perform: a monofilament on the bottom and dorsal side of the foot to test for light touch sensation, a tuning fork to the great toe to test for vibratory sensation, and ankle reflexes with a reflex hammer with appropriate grading.

Image from: https://www.researchgate.net/figure/Monofilament-test-for-light-touch-sensation_fig1_320328800/download

Here’s a monofilament video as well: Monofilament Test

For additional resources I’ve provided, browse below:

Ok guys, that’s it! I tried to give you the Overview yesterday with more detail today. I also would recommend looking up how to properly perform ankle reflexes as well as placement of the tuning fork during the exam if you need that extra learning. Again, thank you for reading along and please consider subscribing to my YouTube channel, Kim E. The Diabetes NP, and following me over on Instagram, @thediabetesnp.

Until next time, have a great day!