VOLUME 10 NUMBER 4 • NOVEMBER 2013
137
SA JOURNAL OF DIABETES & VASCULAR DISEASE
EDUCATOR’S FOCUS
C:
Care (i.e. routine preventive foot care)
S:
Structure (i.e. abnormal foot structure).
Foot problems are second only to cardiovascular problems in terms
of healthcare costs and morbidity in patients with diabetes. The foot risk
factors, the ABCS, are important for those over 60 years of age who have
had diabetes for 20 years or more, or who have significant macro- and/or
microvascular complications. Table 1 summarises the ABCS of foot care
and the five As of assessment as a framework for foot care in everyday
practice.
The patient can be classified as being in danger (red light), with im-
paired circulation and reflexes, no pulses, skin breakdown; or to be cau-
tious (amber light) because of abnormal findings such as reduced stimuli,
reflexes and pulses, skin changes or corns and calluses; or having a
healthy foot (green light). Depending on the assessment, appropriate
action should be implemented.
A CONSULTATION APPROACH FOR DIABETES MANAGEMENT
Nigel Stott described a model for a comprehensive and integrative inter-
viewing technique in primary care, which he referred to as the ‘surface
anatomy of the consultation’.
17
This can also be used as an organised
management plan for diabetes care to achieve excellence and success-
ful outcomes and patient satisfaction. The four areas referred to as ABCD
are discussed below.
A:
A patient-centred clinical method is employed in all consultations. This
includes exploring both the disease and the illness experience with re-
gard to the patient’s ideas, feelings concerns, fears and expectations
and knowledge of the disease and family support, understanding the
whole person, enhancing the doctor–patient relationship, finding com-
mon ground with regard to management decisions, being realistic and
taking economic factors into account, and incorporating the family and
community resources to the benefit of the patient.
The choice of medications, dosage and dosage adjustments, and side
effects and lifestyle modifications are discussed and follow-up visits ar-
ranged.
Basic investigations are done, such as HbA
1c
level, full blood count
(FBC), thyroid stimulating hormone (TSH), renal function test, lipid levels,
liver function test, fasting or random blood glucose test, and urine exami-
nation for albumin and ketones. An ECG will be arranged. Appointments
will be made where indicated to the ophthalmologist, podiatrist, dietician
and other specialities.
B:
Behaviour-modifying intervention.This includes modifying help-seeking
behaviour, diabetes education, individualised diet plan and calorie intake,
and modifying lifestyle, especially with regard to an exercise schedule
and active weight loss if overweight or obese. Advice on over-the-counter
preparations and alternate medicines will be discussed.
C:
Continuity of care and monitoring other on-going chronic conditions
and problems related to diabetes or other conditions. This is also the op-
portunity to review all blood results, reports, ECGs and the early detection
of complications and co-morbidities, and to arrange for their treatment
and or referral, especially with regard to cardiovascular and other risk
factor assessments.
Enquire if the patient is on antiretrovirals, as this will need modification
since some of these medications cause hyperglycaemia, hyperlipidae-
mia, insulin resistance, lypodystrophy and neuropathy. It is important to
treat to target with regard to HbA
1c
, blood pressure and lipid levels and to
adjust medications accordingly.
A full foot assessment should be undertaken or arranged with the po-
diatrist. The urine, body mass index and waist circumference are done
at every visit. The follow-up visits are usually arranged every three or six
months, as indicated.
D:
Opportunistic intervention for preventive and promotive healthcare.
This includes lifestyle issues of diet, exercise, weight loss, alcohol con-
sumption and smoking. Enquire about sexual dysfunction and screen for
prostate disorders with PSA estimation. Screen for TB, and advise on
mammogram and PAP smear tests.
THE DIABETES RECORD
To achieve excellence in diabetes and to ensure optimal care, an ad-
equate medical record is essential. In addition to the usual demographic
data, it should also contain the following elements: data on the dura-
tion of diabetes and family history, home glucose monitoring, habits
related to smoking, alcohol, drugs, medications, adherence to lifestyle
issues, especially diet and exercise, past medical and surgical history, the
Table 1.
Summarising the five As assessment and the ABCS of foot care.
16
ABCS of
foot care
Ask about
symptoms
Assess the
signs
Advise
about foot
care and or
foot ware
Arrange
reviews
and or
referrals
Anaesthesia
Any tingling
or numb-
ness?
Sensation Daily foot-
care routine
Inappropri-
ate foot
wear
Podiatry
assessment
and review
action plan
Blood
supply
Any clau-
dication or
cold feet?
Pulses
Daily foot-
care routine
Inappropri-
ate foot
wear
Podiatry
assessment
and review
action plan
Care
What
foot care
routines are
followed?
Nails
and skin
(thicken-
ing, drying,
cracking)
Foot-care
routines
Appropriate
foot wear
Education
on-going
review
Structure
Any foot
soreness?
Foot arches,
angles and
abnormali-
ties when
standing
Special foot
wear
Orthotic,
podiatry and
or physio-
therapy
review
