Type 2 diabetes: prevention and management of foot problems continued

Care of people at increased risk of foot ulcers (neuropathy or absent pulses or other risk factor)

• Arrange regular review, 3–6 monthly, by foot protection team
• At each review:
  • inspect patient’s feet
  • consider need for vascular assessment
  • evaluate footwear
  • enhance foot care education

NB If patient has had previous foot ulcer or deformity or skin changes manage as high risk (see below)

Care of people at high risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer)

• Arrange frequent review (1–3 monthly) by foot protection team
• At each review:
  • inspect patient’s feet
  • consider need for vascular assessment
  • evaluate and ensure the appropriate provision of
    • intensified foot care education
    • specialist footwear and insoles
    • skin and nail care
• Ensure special arrangements for those people with disabilities or immobility

Care of people with foot care emergencies and foot ulcers

• Foot care emergency (new ulceration, swelling, discolouration)
  • refer to multidisciplinary foot care team within 24 hours
• Expect that team, as a minimum, to:
  • investigate and treat vascular insufficiency
  • initiate and supervise wound management
    • use dressings and debridement as indicated
    • use systemic antibiotic therapy for cellulitis or bone infection as indicated
  • ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts
  • try to achieve optimal glucose levels and control of risk factors for cardiovascular disease

Type 2 diabetes: prevention and management of foot problems continued

General management approach

• Share decision making with patients
• Adequately train healthcare professionals and other personnel involved in assessment of diabetic feet
• Be extra vigilant in caring for people aged over 70, or who have had diabetes for a long time, have poor vision, smoke, are socially deprived or live alone
• If necessary, make special arrangements for people who are housebound, or live in care or nursing homes
• Encourage patients to inspect their feet and monitor their condition

Patient education

• Make available structured patient education at initial diagnosis and as required, based on a regular, formal assessment of need
• Offer patient education on an ongoing basis
• Use different approaches
• For patients with foot ulcers or previous amputation, consider offering graphic visualisations of the sequelae of disease, and providing clear, repeated reminders about foot care

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG10

National Institute for Health and Clinical Excellence. Quick reference guide Type 2 diabetes: prevention and management of foot problems. January 2004