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The diabetic foot: daily inspection, risk screening and foot-care teaching

  • Assessment

The nurse examines both feet, tests sensation and pulses, sorts the risk of an ulcer and teaches daily foot care.

Updated

What it is

Loss of protective sensation from neuropathy and peripheral artery disease are the two main reasons a person with diabetes gets a foot ulcer, an infection and, in the worst case, an amputation. Many people have no symptoms, so the feet are examined and not just asked about. The International Working Group on the Diabetic Foot (IWGDF) sorts risk into four categories, from very low to high, and each category sets how often the feet are screened. People at risk learn to inspect and wash their feet every day and to seek help quickly for any lesion. Before any surgery on the foot, sensation and arterial status are established.

Reference values

  • Risk 0, very low: no loss of protective sensation and no signs of arterial disease; screen once a year.
  • Risk 1, low: loss of protective sensation or arterial disease; every 6–12 months.
  • Risk 2, moderate: sensory loss plus arterial disease, or either one plus a foot deformity; every 3–6 months.
  • Risk 3, high: sensory loss or arterial disease plus a history of ulcer, amputation or end-stage kidney disease; every 1–3 months.

What you need

  • Good light, a mirror for the sole, gloves.
  • Monofilament (Semmes-Weinstein) or a 128 Hz tuning fork, used as trained.
  • The patient's usual shoes and socks.

How to measure it (and why)

  1. Ask about previous ulcers, amputations, kidney disease, pain on walking or at rest, and numbness: they define the highest risk.
  2. Remove shoes and socks and inspect both feet lying down and standing, including between the toes and the soles.
  3. Look at skin colour, temperature, callus, fissures, oedema, fungal infection and small bleeds under callus: they are pre-ulcer signs.
  4. Look for deformities (claw or hammer toes, prominent bones) and limited joint movement: they create pressure points.
  5. Test protective sensation with the monofilament or the tuning fork; if neither is available, lightly touch the tips of the toes.
  6. Feel the foot pulses and ask about calf pain on walking: absent pulses point to arterial disease.
  7. Check footwear, nail care and whether the person can see and reach their feet: these limit self-care.
  8. Assign the IWGDF risk category, record it and plan the next screening and referrals.
  9. Teach daily foot care and agree who helps if the person cannot inspect their own feet.

How to read it

  • Sensory loss means the person does not feel a stone in the shoe or a burn: inspection replaces sensation.
  • Absent pulses, cold or pale skin and hair loss suggest poor blood flow: wounds heal poorly.
  • Drying and cracked skin or thick yellow nails also need attention; corns and calluses are treated by a trained professional.
  • Foot-care teaching: wash daily in water below 37 °C and dry between the toes; moisturiser but not between the toes; cut nails straight across; seamless socks changed daily; no heaters or hot-water bottles.

Next step: when to call for help

  • Report promptly: any ulcer, blister, cut or skin break, or a red, hot, swollen foot (possible Charcot).
  • Report urgently: signs of infection around a wound, corn or nail (redness, swelling, warmth), or a change in the colour of the foot.
  • Report: new loss of sensation, absent pulses, pain at rest or colour or temperature changes.
  • Refer as planned: a foot-care professional (podiatry) for callus, nails and footwear in high-risk feet.

Test yourself

Think of the answer, then tap the question to see it.

What two findings make a diabetic foot «at risk» in the IWGDF system?

Loss of protective sensation and peripheral artery disease. Either one makes the person at risk; together, or with deformity, a previous ulcer or amputation, the risk rises.

How often is a person in IWGDF risk category 3 screened?

Every 1–3 months. Risk 3 means sensory loss or arterial disease plus a previous ulcer, an amputation or end-stage kidney disease.

How can protective sensation be screened if there is no monofilament or tuning fork?

By lightly touching the tips of the toes with the tip of the index finger for one or two seconds.

What does a red, hot, swollen foot suggest in a person with neuropathy?

Possible active Charcot neuro-osteoarthropathy. It is reported promptly; treatment includes offloading the foot.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update) (International Working Group on the Diabetic Foot (IWGDF), 2023); Your Feet and Diabetes (Centers for Disease Control and Prevention (CDC), 2024); Guía de práctica clínica para el diagnóstico, tratamiento y seguimiento de la diabetes mellitus tipo II en la población mayor de 18 años (GPC-2015-51), versión para pacientes (Ministerio de Salud y Protección Social de Colombia, 2015).

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Representative model, for educational purposes only.