Diabetic Foot and Skin Assessment Visit SOP

Standardizes diabetic foot and skin integrity assessment, neuropathy screening, wound risk identification, and patient self-care education during home visits.

Steps

• The RN verifies visit purpose and patient readiness
  Confirm the visit is for diabetic foot and skin assessment, verify the patient identity per local policy, and ensure the patient can safely participate in the exam. If the patient is unable to cooperate or the visit purpose is unclear, pause and escalate per facility procedure.
• The RN performs hand hygiene and dons required PPE
  Perform hand hygiene using the organization-approved method, then don gloves and any additional infection-control PPE required by patient condition or isolation precautions before contact with the patient or environment.
• The RN inspects both feet for skin integrity and visible abnormalities
  Inspect all surfaces of both feet, including between toes and around heels, for ulcers, fissures, maceration, redness, swelling, calluses, blisters, drainage, odor, and other visible abnormalities. Document the exact location and appearance of any abnormal finding using measurable descriptors when possible.
• The RN assesses temperature, color, edema, and capillary refill
  Compare both feet for temperature difference, color change, edema, and capillary refill. Note any asymmetry, delayed refill, coolness, warmth, pallor, cyanosis, or unilateral swelling and document the findings in the chart.
• The RN screens for neuropathy and protective sensation loss
  Use the organization-approved 10g Semmes-Weinstein monofilament or equivalent approved neuropathy screening tool on the required plantar sites per local protocol. Document sensation present or absent at each site and escalate if protective sensation is reduced or absent according to facility criteria.
• The RN assesses footwear, socks, and offloading needs
  Inspect footwear and socks for fit, seams, moisture, wear, foreign objects, and pressure points. Determine whether offloading or footwear referral is needed based on observed skin risk or existing lesions.
• The RN measures and documents any wound or suspicious lesion
  Measure any wound or suspicious lesion using a disposable ruler or approved measuring device, then document length, width, depth if applicable, drainage, odor, wound bed appearance, and surrounding skin condition. Escalate immediately if a new ulcer, rapidly worsening wound, necrosis, purulent drainage, or systemic infection signs are present.
• The RN provides patient self-care education and teach-back
  Teach the patient to inspect both feet daily, keep feet clean and dry, moisturize dry skin without applying lotion between toes, trim nails safely per local guidance, wear properly fitting footwear, and report new redness, drainage, odor, pain, or skin breakdown promptly. Confirm understanding using teach-back and document the patient response.
• The RN escalates abnormal findings to the appropriate clinician
  Review the assessment findings and determine whether escalation is required based on open wounds, infection concern, loss of protective sensation, circulation concern, or other abnormal findings. Select the appropriate next step and document the communication and disposition.
• The RN notifies the nurse supervisor, provider, or wound care clinician
  Communicate abnormal findings promptly to the nurse supervisor, provider, or wound care clinician using the organization-approved handoff method. Include the specific abnormal findings, measurements, and any immediate safety concerns, and document the follow-up plan.
• The RN documents assessment findings, education, and follow-up plan
  Document the full assessment, patient education, escalation actions, and follow-up plan in the EHR or approved form. Include measurable findings, patient teach-back results, and any deviations from the SOP.