by Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA

Board Secretary As a Director of Nursing (DON) in a long-term care facility, do you know where the awareness level of diabetes and its complications is for your staff? Do they realize diabetes doesn’t stop? It is 24/7, 365 days a year. Knowing this reality of diabetes and understanding the disease process may assist with preventing serious health problems such as heart disease, stroke, blindness, kidney disease, and nerve damage that can lead to amputation. Education is key. We cannot talk about this enough. Assuming someone knows or that common sense will tell people how to take care of these residents is a huge mistake. I don’t believe in common sense; I believe in common knowledge, but it is only common once it is taught. So, teach about diabetes and the care of residents with diabetes often.

Knowing the Risk of Diabetic Foot Ulcers and Diabetic Peripheral Neuropathy

In 2015, 30.3 million Americans, or 9.4% of the population, had diabetes. Approximately 1.25 million American children and adults have type 1 diabetes. The percentage of Americans age 65 and older remains high, at 25.2%, or 12.0 million seniors (diagnosed and undiagnosed).¹Diabetic foot ulcer (DFU) is the number one risk factor contributing to non-traumatic foot amputations in persons with diabetes. Limb amputations are preceded by DFUs 58% of the time. The primary risk factor for the DFU is loss of protective sensations or diabetic peripheral neuropathy (DPN). DFUs are defined as ulcers caused by the neuropathic and small blood vessel complications of diabetes,² such as ulcerations, infections, and gangrene. DFUs are the most common causes of hospitalization among patients with diabetes. Routine ulcer care, treatment of infections, amputations, and hospitalizations cost billions of dollars every year and place a tremendous burden on the health care system.

DFUs typically occur over the plantar surface of the foot on load-bearing areas such as the ball of the foot. These ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges. The wounds are very regular in shape and the wound edges are even, with a punched-out appearance.³ These wounds are typically not painful because of the peripheral neuropathy, which causes loss of sensation. The totally minute mechanisms of DPN are not completely understood, but we know the neuropathic damage affects sensation, strength, balance, and gait, thus leaving the lower extremity vulnerable to felt dangers.

DPN is caused by high blood glucose, which damages nerves and blood vessels. This is because nerves carry messages back and forth between the brain and other parts of the body, and the small blood vessels provide nerves with nutrients and oxygen required to survive and function. These nerves are extremely sensitive to any change in nutrients and oxygen supply. High blood glucose damages these small blood vessels that feed the nerves. When the vessels are damaged, a sufficient supply of nutrients and oxygen no longer reaches the nerve, thereby causing the nerve to become damaged and eventually die. High blood glucose also damages the outer protective layer of nerves and affects their ability to transmit signals.

So, it is not hard to see that proactively arming caregivers with the skills and tools to prevent damage and ulceration from occurring is considered one of the most important components of care for people with diabetes. Education is not a one-shot deal, nor is it just for the direct caregiver: it includes nurses and family; we can all use reminders. This education has pretty consistent guidelines for all people, but again, it is not one size fits all.

Make sure your assessment of the individual is thorough and includes personal preference in the resident’s routine. On admission, for patients with known diabetes, neurological status can be checked by using the Semmes-Weinstein monofilament test to determine whether the patient has “protective sensation,” which means determining whether the patient is sensate to the 10-g monofilament. Even new admissions without diagnoses of diabetes having this assessment can provide valuable information for the planning of their care. Monitoring the residents’ blood glucose levels in conjunction with the hemoglobin A1c is vital because high blood glucose levels impair healing of existing ulcers or other skin breakdown and are causative factors in diabetic neuropathy.

Proper Foot Care Techniques for Residents with Diabetes

Provide education, instruction, and demonstration on general foot care, which includes daily washing, drying, and moisturizing. Be clear with protocols on washing; first realize the older we get, the less oil our bodies produce in general, and so we want to preserve what natural moisture we have. If the feet are not stinky, sweaty, or filthy, go light on the amount or type of soap. Using moisturizing soaps is advised with older persons, especially if they already have dry feet, which is typical in diabetic patients.

Because we tend to buy economically in long-term care, watch ingredients. Look for those containing lanolin and moisturizing oils. For bedside bathing, I will frequently recommend three drops of baby oil in the bath water as a moisturizer and then a moisturizing lotion after a pat dry all over the body. Complete the wash, dry, and moisturize process rapidly but cautiously to lock in the cellular-level moisture you have applied. What is really important for seniors is then getting dressed for the day or for bed; clothing will easily be pulled over lotioned extremities. Post-washing moisturizing is often a necessity for the whole foot, but not between the toes because this may encourage fungal growth. For persons with extremely sweaty feet, a roll-on antiperspirant applied to the bottom of the feet before applying socks may be very helpful. This application of antiperspirant is preferable to going without socks, or, worse yet, barefoot and completely unprotected. A word about socks, since I brought those up; socks are always recommended.

There are socks made specifically for individuals with diabetes, but the ideal sock is clean, dry, has no elastic and has the ability to wick away moisture from the foot. That may sound contradictory to previous statements about moisturizing the skin; however, this is different moisture. This is moisture of sweating that macerates skin by lying on the surface, not the moisturizing variety for the cells. Be specific in relation to water temperature—the threat of scalding the foot of a patient with diabetes is real! The insensate state increases the risk, and a caregiver using the elbow to test the water isn’t enough. Water for bathing needs to be kept at or below 104 degrees, so you’re going to need a thermometer. There are digital spout-cover thermometers on the market for home use sold to new moms for about $30. I haven’t tested these, but they might be worth a try. Otherwise, lukewarm, no warmer than what you would use for a newborn baby.

Drying the feet of patients with diabetes, if they have neuropathy, can go one of two ways—they won’t feel a thing, or they are extremely sensitive. Point being, pat dry, get in between the toes, cover the entire surface of the foot, take time to observe the topography. Observe for changes in color and contour. This is when having consistent assignments in direct caregivers is most helpful to the continuity of residents’ care. So often visiting facilities I see the residents sitting with only socks on their feet; footwear, whether walking or not, is necessary. For a patient with diabetes, footwear is a protective device. Footwear becomes the barrier between the toes and obstacles the resident can’t see.

Footwear is a support structure and can also be dangerous, so proper fitting is needed, and frequent assessments are required. Wrinkles and foreign objects can cause problems inside a shoe or rigid slipper. Footrests on wheelchairs, another necessity, are often missing. Staff, volunteers, and family start pushing wheelchairs without a care as to where the rider’s feet are, and this is very dangerous. We run the compliance risk factors every day, knowing that upfront investment in DFU prevention is cost efficient. The largest expense lies in education, and the application is simply following through. Establish your protocols facility wide including all disciplines in the education, observation, and reporting. Prevention can happen only if everyone is involved!

References

1. American Diabetes Association. Statistics About Diabetes. http://www.diabetes.org/diabetes-basics/statistics/. Accessed February 14, 2018.

2. Centers for Medicare & Medicaid. CMS RAI Version 3.0 Manual Chapter 3, MDS Section M. https://www.cms.gov. Accessed February 27, 2018.

3. Wound Ostomy and Continence Nurses Society (WOCN). Quick Assessment of Leg Ulcers . Glenview, IL. http://www.wocn.org.

About the Author

Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary, is Wound Care Certified through National Association of Wound Care since 2004. Currently, she consults in LTC and alternate care settings on wounds, skin care, and various other issues. She has been employed in the long-term care setting since 1969, spending 25 years in a long-term care rehabilitation facility where the focus was wound healing therapies. NADONA/LTC has been a leading advocate and educational organization for DONs, ADONs, and nurses in long-term care since 1986. With 40 state chapters, it continues to be the largest organization representing nurses working in both post-acute and long-term care settings. NADONA/LTC offers a wide array of services to its members, including educational materials; conferences; executive fellows program, webinars, scholarships; Nurse Leader, Licensed Practical Nurse and Assisted Living certification programs; a mentoring program; and a quarterly journal, The Director. Through its publications and programs, NADONA/LTC reaches approximately 20,000 nurses who are employed in long-term care. For more information regarding NADONA/LTC, please contact their offices at 800-222-0539 or visit their website at www.nadona.org.