education

Diabetes Foot Care Education

Teaching patients and healthcare professionals how to reduce the risk factors for lower-extremity complications is an important strategy in diabetes management.

Appropriate diabetes self-management education and preventive foot care are known to reduce lower-extremity complications. This knowledge must be transferred to patients with diabetes, since they are the only ones who can translate this information into self-care behaviors.

HOW to teach about foot care

•  Before teaching foot care skills, the educator needs to assess the patient’s present knowledge, behaviors, beliefs, and abilities by asking "What are you doing now to care for your feet?

The challenge for the educator is to provide information that is tailored to the patient’s individual risk level and current foot care practices.

Homelessness or blindness are situations for which the educator must adapt instructions to meet these patients special needs.

Patients need to be given practical and realistic information about foot care that is presented in positive statements as "dos" rather than "don’ts." Give reasons why foot care is important and the purpose of recommendations.

It is helpful for patients to have some written guidelines about foot care to take home.

Provide materials that are appropriate for the patient’s language and literacy level.
WHAT to teach about foot care

Teach patients with diabetes the basic principles of foot care. Patients with neuropathy, vascular disease, or a history of foot ulceration or amputation should periodically be assessed for foot care practices and provided with personalized foot care education.

For high-risk patients, review the principles of foot care at every visit. For low-risk patients, and annual assessment and review is probably sufficient. Encourage patients to remove their shoes and socks at every healthcare visit, even if they are not asked to do so.

Teach and review the following principles of foot care: Look at your feet and interdigital areas daily (e.g., whenever putting on or taking off socks). A magnifying glass, mirror, or magnifying mirror may be helpful in examining the top, bottom, and sides of the feet for color and skin integrity.

Have the patient perform a return demonstration after explaining and demonstrating a foot inspection. Point our areas that need special attention. If the patient is unable to do a demonstration, a family member or other care provider can perform the inspection.

Inspect shoes daily by feeling the inside of the shoe for torn or loose linings, cracks, pebbles, nails, or other loose objects and irregularities that may irritate the skin. Get in the habit of shaking out your shoes before putting them on. Soft leather or canvas shoes that have cushioned insoles and fit well at the time of purchase offer the best protection. Shoes need to match the shape of the foot in both length and width and should be deep enough to accommodate any deformities. Changing shoes during the day can limit repetitive local pressure.

Avoid going barefoot or sock footed. Wear footwear at the poll or beach. Use sunscreen to avoid burns.

Wash and dry the feet thoroughly, especially between the toes.

Use a thin layer of lamb’s wool to separate toes that overlap or touch each other and to prevent maceration.

Caution patient to avoid burns form hot water by checking the water temperature of the bath or shower with the forearm, elbow, or a bath thermometer.

Avoid routine foot soaks: Moisturize dry skin (except between the toes) with an emollient such as lanolin of hand lotion. Hand lotions containing alcohol are not suitable because the alcohol may contribute to drying or cracking of the skin.

Cut toenails straight across and file the sharp corners to match the contour of the toe, making sure that all sharp edges are filed smooth. If the patient does not see well or has difficulty reaching the feet, a family member, nurse, or podiatrist can do this self-care task.

Avoid self-treatment of corns, calluses or ingrown toenails.
Using chemicals, sharp instruments, or razor blades to treat theses problems can lead to ulceration or infection.

A patient or family member may gently buff corns or calluses with an emery board or pumice stone. Emollient lotion or cream should then be applied to keep the corn or callus soft.
Flaky fungal debris can be loosened and removed with a solve nailbrush during regular bathing.

Wear well-fitting, soft cotton, synthetic blend, or wool socks. Avoid using hot water bottles, heating pads, or microwave foot warmers because they can cause burns.

Objetives

Upon completion of this chapter, the learner will be able to

•  Identify the effects of peripheral sensory neuropathy, autonomic neuropathy, and motor neuropathy on the functions of the foot.

Identify the signs of peripheral vascular disease in the lower extremities of people with diabetes.

List the basic elements of a diabetic foot screening examination.

Explain what findings from a foot examination would cause a person with diabetes to be classified as high risk.

Describe treatment plans for a person with high-risk feet or a foot ulcer.

List guidelines for teaching foot care to both low-risk and high-risk individuals.

Lower-Extremity Complicatons

1.  Diabetic foot complications are costly, but beyond the financial concerns are the inevitable social and psychological distresses to patients and their families.

2. Despite many major advances in healthcare delivery over the last decade, foot problems continue to exact a heavy toll on the quality of life of people with diabetes.

3. Lower-extremity complications are a significant cause of hospitalization, disability, morbidity, and mortality among people with diabetes. Improvements in the prevention of diabetes-related foot ulceration and amputation are needed to avoid their considerable medical, social, and economic costs.

Key Educational Considerations

1.  Appropriate diabetes education and preventive care can reduce the risk of foot complications in susceptible patients.

2. Meticulous foot care and proper patient education has been reported to reduce the amputation rate associated with diabetes by 50%.

3. Teaching patients and healthcare professionals ways to reduce risk factors and prevent limb loss due to foot disease is an important strategy in diabetes management and cost reduction.

4. Predicting which patients are at the greatest risk could lead to more efficient use of resources.

5. For people without established end-stage complications of diabetes, better control of blood glucose levels has been shown to reduce the development of neuropathy and slow its progression.

6. According to the strategy of prevention, significantly improving the glycemic control of the entire population of people with diabetes, thus lowering the incidence of risk factors and other complications, is likely to be more effective in preventing foot ulceration and amputation than focusing efforts only on members of the populations already at high risk.
Neuropathy

Sensory, autonomic and motor neuropathies act synergistically to cause diabetic foot complications.

Peripheral sensory polyneuropathy is a major pathophysiologic risk factor for foot ulceration and amputation.

About 50% of people with diabetes of 15 years duration have peripheral sensory neuropathy. Loss of protective sensation allow trauma to go undetected by the patient.

The earliest and most severe damage due to diffuse, somatic, bilateral, distal symmetrical polyneuropathy occurs at the most distal enervated sites in a "stocking and glove" distribution. Loss of protective sensation affects the toes and feet first, although sensorimortor functions of the fingers and hands may also be impaired.

A quick and easy way to identify feet without protective sensation is to evaluate the ability of the patient to perceive the pressure of a 5.07 monofilament applied to the most common sites of potential ulceration. These sites are the plantar surface of the great toe and fifth toe, the plantar metatarsal heads (first and fifth) and the heel.

Autonomic neuropathy causes changes in the nerves that control blood flow, perspiration, skin hydration, and possibly bone composition of the foot.

Peripheral vascular disease causes an inadequate blood supply (ischemia) to the lower limbs, which deprives the tissues of oxygen and nutrients and impairs the removal of waste products.

Edema

Edema, whether from local infection or systemic causes, can adversely affect skin texture, cutaneous circulation, and wound healing. When edema is present it is wise to have the patient examined by a clinician to determine the cause of the edema.

If edema is due to venous insufficiency alone, then compression hose, which can be obtained from a well-stocked pharmacy, drugstore, or medical supply store, may be useful. The patient’s legs should be carefully measured as described on the packaging and the stockings fitted so as not to restrict arterial flow.

If there is arterial insufficiency, compression hose may be contraindicated or the amount of compression may need to be reduced.

Elevating the extremity above the heart may control dependent edema, but diuretics may be required for some patients.

If edema is due to congestive heart failure, it may indicate a need for a change in medication. In the case of heart failure, reducing edema by leg elevation or compression may increase the fluid return and could potentially lead to volume overload.

When arterial flow is severely compromised, patients may not be able to tolerate leg elevation and may even need to sit with the feet dependent to facilitate blood flow to the feet.

Trauma

A 1990 study of 80 amputations revealed that in 69 if the cases, the initial precipitating event was preventable minor trauma leading to skin ulceration. Common sources of trauma include poorly fitting shoes, ingrown toenails, wrinkled stockings foreign objects in the shoe, walking barefoot or sock footed, and inappropriate care of toenails, corns and calluses.

Chemical trauma results when caustic substances such as over-the counter corn and callus removers destroy fragile tissue.

Thermal injuries can occur from hot foot soaks, hot water bottles, heating pads, or walking on hot sand and pavement, resulting in severe burns to the insensate and vascular compromised foot.

Most skin ulcers are caused by minor, repetitive pressure with each step (e.g. walking on a bony, plantar prominence in a show with insufficient insole and sole cushioning) rather than a single episode of identifiable trauma.

Most amputations resulting from trauma can be prevented through patient education and effective self-care that emphasizes properly fitting protective footwear.

Ulceration

A foot ulceration is a full-thickness skin defect below the malleoli that penetrates to the subcutaneous tissue.

Any wound on the foot of a person with diabetes is a cause for serious concern regardless of the depth or size.

Diabetic foot ulceration need not result in infection or amputation. Proper wound management can heal many foot ulcers, and most amputations are preventable.

Infection

The presence of purulence (pus), significant erythema, increased local warmth, tenderness, induration, fluctuance, or drainage indicates infection. If a diabetic foot lesion is infected, appropriate oral or parenteral antimicrobial therapy is prescribed after cultures are obtained, preferably by deep-tissue curettage.

Acute or sub acute infection (of less than 30 days duration) without systemic symptoms, gangrene, or ostomyelitis can effectively be treated using a single oral antibiotic for 2 weeks, with frequent follow-up and daily wound care.

Patients with fever, leukocytosis, severe hyperglycemia, acidosis, hypotension, extensive cellutitis, lymphangitis, deep space infections, gangrene, crepitus, gas in the tissues, evidence of osteomyelitis, or failure of previous courses of therapy need to be admitted to the hospital for parenteral antibiotics and surgical drainage if necessary.

Gangrene

Gangrene is a nonspecific term for tissue death. Microhrombi that develop as a result of infection, arteriosclerosis, or other decreased blood flow, vasculitis, or increased ents to the tissue, resulting in tissue death or necrosis.

Dry gangrene is associated with ischemia. When the gangrenous portion is sharply demarcated and affects only a small area, it may be left untreated but closely observed. In some cases, the affected part, usually to toe tip, will mummify and auto amputate.

A wet or moist gangrenous are is a sign that the process of tissue death is progressive or that infection may be involved. Because of the complete blockage of blood flow to the necrotic are, surgical intervention is usually required.
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