Diabetes Foot Screening Tool

Patient Name:
Sex: male / female

age:

Date of latest HbA1c ........: mmol/l

Blood Glucose :

Admission Date :

Patient Address:

Medication:

Smoker : Yes/No

Diagnosis:
Wound Type:

History :

Phone No:
Vital sign : Blood pressure :

Occupation :Slightly:

Anticoagulant Therapy: Yes/No

mmHg, RR :

Pulse:

Moderately:

Lower Limb Vascular Assessment

Right Foot

Left Foot

BT:

Heavy :

Doppler: PT: Mono/ Bi/ Tri DP: Mono/ Bi/ Tri

PT: Mono/ DP: Mono/

Bi/ Tri
Bi/ Tri

Right Ankle:

Left ankle:

BrachialIndex:

Brachial Index:

Right Toe

Left Toe:Brachial Index:

ABPI:

TBPI:

Posterior Tibia pulse:

Present/Absent

BrachialIndex:
Dorsal Pedis pulse:
Present/Absent

Posterior Tibia pulse:

Present/Absent

Doral Pedis pulse:

Present/Absent

Int. Claudication : Yes/No Rest Pain: Yes/No

Int. Claudication :
Yes/No

Rest Pain : Yes/No

Oedema Yes/No

Warm : yes/no

Oedema : Yes/No

Warm : yes/no

Diabetes Related
Amputation

Yes/No, if Yes:

Diabetes Related
Amputation

Yes/No, if Yes

Peripheral Sensory Assessment

Right Foot

Left Foot

Vibration Sensation (tuning fork 128HZ):

Vibration Sensation (tuning fork 128HZ):

Monofilament test : normal (0), abnormal (1)

Monofilament test : normal (0), abnormal (1)

Pin Prick : normal (1), abnormal (0)

Pin Prick : normal (1), abnormal (0)

Ankle jerk : present (0), present with

reinforcement (1), absent (2)

Ankle jerk : present (0), present with

reinforcement (1), absent (2)

Temperature perception : normal (0), abnormal (1)

Temperature perception : normal (0),

abnormal (1)

Normal (1)

Normal (1)

Present/Absent

Present/Absent
Abnormal (0)

Abnormal (0)

10g Monofilament: tick circle site if present, cross if not and location of wound

Foot Wounds:
Right
Foot Ulcer

Left:
Yes

No

Foot Ulcer

Yes

No

Previous Foot Ulcer

Yes

No

Previous Foot Ulcer

Yes

No

Foot Deformity:
Right

Left

Bunion

Yes

No

Bunion

Yes

No

Claw Toes

Yes

No

Claw Toes

Yes

No

Skin and Nail Condition:

Right

Left

Skin dry

Yes

No

Skin dry

Yes

No

Plantar Callous

Yes

No

Plantar Callous

Yes

No

Ingrowing Nail(s)

Yes

No

Ingrowing Nail(s)

Yes

No

Thickened Nail(s)

Yes

No

Thickened Nail(s)

Yes

No

Nail onychomycosis

Yes

No

Nail onychomycosis

Yes

No

Corn

Yes

No

Corn

Yes

No

Fissure

Yes

No

Fissure

Yes

No

Footwear Assessment:

Foot Wear: Good Fit

Yes

No

Foot Wear: Good Fit

Yes

No

Foot Wear: Good Shape

Yes

No

Foot Wear: Good Shape

Yes

No

Foot Wear: Lace/Velcro

Yes

No

Foot Wear: Lace/Velcro

Yes

No

(Not too loose/too tight)

Yes

No

(Not too loose/too tight)

Yes

No

(Square box toe not pointed)

Yes

No

(Square box toe not pointed)

Yes

No

(Slip on not appropriate)

Yes

No

(Slip on not appropriate)

Yes

No

Signature:_________________________________ Date:_____/_____/_____
Name:______________________________

_______________________________

PENGKAJIAN PERAWATAN LUKA DIABETES: SIGNTED

Namapasien : TglMasuk:MR :
..
N
o

Nila
i

Parameters
S

S
0
1
2
3
4
5
6
7
I
0
1
2
3
G
0
1
2
3

Size
Tidakada
Ukurankurangdari1 CM2
Ukruranberkisar1 5 CM2
Ukuranberkisar 5 10 CM2
Ukuranberkisar 10 15 CM2
Ukuranberkisar 15 20 CM2
Ukuranberkisar 20 25 cm2
Ukuranlukalebihdari 25 cm2
Inflammation/infection
None
Terdapatbeberapatandainflamasi (hangat, edema , nyeri , dankemerahan)
Terdapatbeberapatandainfeksi (hangat, edema , nyeri , kemerahan, nanah,
indurasi, danbau)
Terdapattandainfeksi (jelas local infeksidanadademam ) danatauinfeksisistemik
Granulation
Kulitutuhataumenyatu
Granular danpenuh/full granulasi
Granular dangranulasisebgaianbesar
Granular dangranulasisetengahnyaluka

4
5

Granular dangranulasisebagiankecil
Granulasibermasalah : (Tidakbergranulardanataudatar, over
granulasidanmudahrapuh, berwarnamerahterang), dantidakadagranulasi
Necrotic tissue
None
Nekrotiklembutdanberwarnasatuataulebih ( kuning, putihdankeabuan)
Nekrotiklembutdanberwarnasatuataulebih ( putih,keabuan,coklat, hitam,
kuning, danhijau )
Nekrotikkombinasikerasdanlembut ( putih,keabuan,coklat, hitam, kuning,
danhijau)
Nekrotikkering/basahdengan 100 % berwarnahitam
Tunneling/undermining
None
Panjangterowongankurang 2 cm
Panjangterowongan 2 4 cm
Panjangterowongan> 4 cm
Wound Edge
Kulitutuh, tepilukajelas, menyatudasardantepiluka
Tepilukamencirikansatuataulebih ; warna pink, kontraksibaik , berbatasjelas,
tepilukadengandasarlukamenyatu
Masalahringansatuatulebih : hyperkeratosis di tepilukadan tipis,
lingkaranmerah /red ring sebagiankecil, rolled/epibole, maserasi di tepiluka,
batastepilukatidakjelas, tidakmenyatu, dankeunguan
Masalahsedangsatuataulebih : hyperkeratosistebal di tepiluka,
lingkaranmerahsebagian, rolled/epibole, maserasisekitartepilua,
batastepilukatidakjelas, tidakmenyatudankeunguaan )
Masalahberatdandominansatuataulebih :hyperkeratosismelebihitepiluka,
lingkaranmerahsebagianbesar, rolled/pibole, maserasiluas,
batastepilukatidakjelas, tidakmenyatudankeunguan).
Depth
Tidakada
Kedalamanpada epidermis dan dermis
Kedalamanmencapai subcutaneous danatauotot
Kedalamansampaike fascia, tendon dantulang

N
0
1
2
3
4
T
0
1
2
3
E
0
1
2

D
0
1
2
3

SKOR

DIABETIC WOUND HEALING ASSESSMENT: SIGNTED

Patients name :... MR:Date admit.... Date check
out:..

SIGNTED
Poin
t
S
0
1
2
3

Parameters

Size
Skin intact
Size less than 1 cm2
Size between 1 - 5 cm2
Size between 5 10 cm2

4
5
6
7
I
0
1
2
3
G
0
1
2
3
4
N
0
1
2
3
4
T
0
1
2
3
E
0
1

D
0
1
2
3

Size between 10 15 cm2

Size between 15 20 cm2
Size between 20 - 25 cm2
Size more than 25 cm2
Inflammation/infection
None
Have some sign of inflammation (warm, swelling, pain, redness,
edema)
Have some sign of local infection ( warm, swelling, pain, redness,
edema, pus, induration, malodorous)
Have sign local infection, fever, osteomyelitis and or systemic
Granulation tissue type
Granular and full granulation and or intact skin
Granular and granulation largely
Granular and granulation partially
Granular and granulation as small
Granulation with problem: overgranulation and fragile and or nongranular/flat
Necrotic tissue type
None
Soft and have color one or more ( yellow, white, and gray)
Soft and have color one or more ( white, gray, brawn, black, yellow,
green)
Combination soft and hard with colors one or more (white, gray,
brawn, black, yellow, green)
Dry/wet necrotic tissue with 100% black color
Tunneling/undermining
None
Less than 2 cm
Length 2 4 cm
Length > 4 cm
Edge of wound (dominant type)
Wound edge pink, defined, attached and or intact skin
Wound edge have slightly one or more : hyperkeratosis, ring red,
rolled/lining, epibole, maseration in edge only, undefined, unattached,
purple
Wound edge have sign moderate one or more : hyperkeratosis, ring red,
rolled/lining, epibole, maceration around wound, undefined,
unattached, purple), purple
Wound edge have heavy one or more : hyperkeratosis, ring red,
rolled/lining, epibole, maceration beyond around wound, undefined,
unattached
Depth
None
Depth included epidermis and dermis
Depth included subcutaneous and muscle
Depth until fascia, tendon and Bone
Total score

Part. 1Competency Diabetic Wound Care Nurse

Diabetic Wound Care Nurse Education Program
Evaluation of Competency Diabetic Wound Care Nurse
The diabetic wound care nurse (DWCN) is a specialized certification in diabetic wound
care. It demonstrates a candidates proficiency and mastery of essential knowledge and

skills of diabetic wound care. Diabetic wound care focuses on overall diabetic wound
care and promotion of an optimal wound healing environment, including prevention,
therapeutic interventions and rehabilitative interventions.
N
o
1

Outcome

Competency
Physical examinationandfoot
Conductinganexamination ofsensationin
patientswithdiabeticfoot: usinga tuning fork, monofilament
andother
To examinetheperipheralcirculationand pulseatthefoot ofthe
anteriorand posteriortibia, femoral, popliteal, andpedal
Perform examination of foot deformity (musculoskletal) in
patientswithdiabetic foot
Perform examinationof skin disorders, nail disorder and skin
color in patientwithdiabetic foot
Perform examination of vascular status using Doppler vascular
to identify ABPI
Perform examination tissue perfusion, transcutaneous oxygen
measurement (if equipment available)
Identify skin temperature: ask the patient to differentiate skin
temperature between the feet
Perform examination of the patient using shoes
Examination of wound Bed
Perform classification of diabetic foot ulcer using texas or
wagner
Identify severity diabetic wound infection : describe clinical sign
of infection
Identify the wound bed : describe characteristic of the wound
bed
Around wound, granulation, slough, type of wound edge,
maceration and so on
Identify the characteristic of exudate
Identify WOUND bed model (TIME)
Wound cleansing
Perform wound cleansing using normal salin, steril water, ringer
lactate, antiseptic solution
Perform wound cleansing from central to out site wound
circularly
Perform wound cleansing gently

No
achiev
ed

Need
practi
ce

Achiev
ed

Perform wound debridement

Shape debridement technic
Mechanical debridement technic
Autolytic debridement technic
Enzimatic debridement technic
Biology debridement technic
5 Using alternative dressing
Choice alternative dressing according to wound bed type or
characteristic of wound bed
Perform bandage wound appropriately
6 Compression therapy if indication
Identify the APBI before perform compression therapy
Perform compression therapy from distal to proximal
appropriately
7 Perform health education :
Drug administration
Diet pattern
Wearing shoes
Control blood sugar, blood pressure, follow up care
Psychological support
Encourage or teach how to inject insulin in some places of the
body (if patient use insulin)
Teach patient how to perform foot care
Limitation of activity and or diabetic fitness
Prevent recurrent of wound occurrence
8 Perform assessment of wound healing progression
9 Identify or evaluation of wound healing: acute/chronic
inflammation, acute/chronic proliferation
Note : no achieved: 0, need practice : 1, achieved : 3. Point : total score x 100/108 =
Date :/../
Name of Student:
Sign:

Name of Supervisor ..
Sign:

Part. 2. Provides effective counseling and referrals for wound care to patient
and family
Achieved
Introduce self and explains the
role of the CDWCN
Establishes a relationship of trust

Assessors validation
comments on evidence

Accept cultural differences and

values
Shows respect for the patient
Maintains
congruent
expressions

facial

Uses appropriate body language

Encourages patient to verbalize
problems
Correctly
identifies
emotions
experienced by the patient
Responds appropriately to the
patients concerns
Allow patient to determine own
solutions
Evaluates progress of patient
towards decision making
Suggests alternative solutions
where appropriate
Refrains from advice giving
Provides appropriate referrals
Terminates
the
consulting
relationship appropriately
Documents appropriately and
accurately
Participant signature
Assessor signature
Date

:
:
:

Part. 3. Provides safe comprehensive and effective nursing care for patients
with fistulae draining wounds

Achieved

Demonstrates a knowledge of the path

physiology of wounds and wound healing
Explains
the
relationship
nutrition and wound healing

between

Assesses the patients wound and general

condition by gathering subjective and
objective data
Liaises with other members of health
care
team
regarding
optimum
management of wound.
Demonstrates
a
knowledge
of
appropriate wound drainage collection
Plans wound drainage containment in
consultation with the patient
Explains
rationale
for
choice
management and containment

of

Implements appropriate care using

principles of asepsis and standard
precautions
Evaluates
effectiveness
of
wound
drainage system and initiates remedial
action if necessary
Documents appropriately and accurately
Demonstrates the ability to educate
other
health
team
members
in
management of appliance
Suggests alternative solutions where
appropriate
Participant signature
:

Assessors
validation
comments on
evidence

Assessor signature

Date

Part. 4. This is blank as it is for students to reflect on their experiences and

progress through the course

Part. 5. Professional Development

Participants
1
1

Identify a teaching approach that consists

in presenting the DWCN students with a
case, putting them in the role of a decision
maker facing a problem
Explore an individual or group of individuals
to clarify and address immediate concerns
by following a systematic problem-solving
process
Explore to enhance a wound care
specialists competencies in a specific skill
area by providing a process of observation,
reflection, and action
Improve professional practice by engaging
in shared inquiry and learning with people
who have a common goal
Demonstrate to solve practical dilemmas
related to intervention or instruction
through participation with other
professionals in practice
Demonstrate to promote an individuals
awareness and refinement of his or her own
professional development by providing and
recommending structured opportunities for
reflection and observation
Identify to support, develop, and ultimately
evaluate the performance of employees
through a process of inquiry that
encourages their understanding and
articulation of the rationale for their own
practices
Identify to assist individuals and their
organization to improve by offering

resources and information, supporting

networking and change efforts
9 Examine how learning occurs and explore
teaching skills relevant to the role of the
wound care specialist
1. Definitely agree
2. Slightly agree
3. Slightly disagree
4. Definitely disagree

Part. 6. Evaluation of Education Program ( Module)

Assessment methods included the use of:
-

Workbooks and pre test

Tests
A major assignment clinical competencies
Presentation
Case study

The pre course reading and workbook were useful tools in preparing
me for the course

Agre
e

5
Disagre
e

The test during the theoretical component helped identify my

knowledge deficits and learning requirements

Agre
e

5
Disagre
e

The major assignment was a useful exercise in professional writing

1
Agre
e

5
Disagre
e

The case study helped my apply theory to practice

1
Agre
e

5
Disagre
e

Thank you for completing this evaluation form, your feedback is

extremely useful to the further development of this course