Diabetic Foot Care: the Nurse’s Role in Preventing Diabetic Foot Ulcers

Diabetes is a complex metabolic disorder that if not treated properly, can lead to peripheral neuropathy and peripheral vascular disease creating complications such as foot ulcerations and amputations later on in life. With the increasing numbers of diabetics world wide, it is essential to ensure they are receiving the information they need to properly care for themselves. Because foot ulcers are a debilitating complication of Diabetes Mellitus, nurses must educate diabetics about proper foot care, the importance of routine foot exams, and blood glucose management to prevent them.
Diabetes Mellitus is a chronic systemic disease characterized by either a deficiency of insulin or a decreased ability of the body to use insulin (Black & Hawks, 2007). To control this disease, diabetics take insulin injections or oral medication to control their blood glucose levels. Insulin is a hormone that the body uses to break down glucose. When the body is unable to use insulin or does not produce enough, glucose can build up in the blood causing poor circulation leading to more serious complications (www.mayoclinic.com/health/bloodsugar). When blood glucose levels are not properly monitored, a diabetic’s glucose continues to build up in the circulatory system and eventually leads to such diseases as peripheral neuropathy and peripheral vascular disease. According to Myles (2007), peripheral neuropathy is a complication in which damage to, or degeneration of the nerves can lead to loss of sensation in the feet. Peripheral Vascular Disease, on the other hand, results in ischemia (deficient blood supply, relative to requirements) causing pain to the patient’s feet, and predisposes them to the development of ulcers (Myles, 2007).
One way nurses can help prevent the development of foot ulcers in diabetics is to educate and encourage them to participate in proper foot care. An early intervention can be to teach diabetics about the precursors to foot ulcers, such as red spots on pressure points or calluses. Nurses can educate on the need to wear properly fitting socks and shoes that promote circulation, and reduce pressure points and calluses which could potentially develop into ulcers (Jones, 2006). According to Potter and Perry (2005), diabetics should inspect their feet daily, including the tops and soles of the feet, the heels, and the areas between the toes. Also, they should use a mirror to help inspect the feet thoroughly, or ask a family member to assist them with their daily check. Along with that, Potter and Perry (2005) mention washing the feet daily in lukewarm water (do not soak), and dry feet thoroughly, including between the toes. Diabetics need to know proper nail care as well, like filing the toe nails straight across and square, and to consult a physician for ingrown toenails (Potter & Perry, 2005). By teaching diabetics these fundamental principles, nurses can reduce the number of hospital stays for diabetics with foot ulcerations and possible amputations.
Encouraging diabetics to participate in routine foot exams by their health care provider, is another intervention nurses can implement. A trained practitioner can test for signs and symptoms of foot ulcerations that diabetics themselves are not able to assess, such as assessing for neuropathy by using a monofilament pen. The specialists can also assess the feet for clawing of the toes, distended veins on the dorsum, pedal pulses, the temperature of the feet, capillary refill, edema, decreased pedal hair, and nail atrophy (Evans & Chance, 2005). These can all be signs of peripheral neuropathy or peripheral vascular disease which lead to foot ulcers. Without proper care, diabetics are putting themselves at risk for possible amputations.
Another benefit of participating in routine foot exams is that while examining their feet, the nurse can educate clients on proper blood glucose monitoring to prevent complications. Complications such as diabetic ketoacidosis, hyperglycemia, and hypoglycemia are considered preventable diabetes related problems (Davidson, Ansari & Karlan, 2007). Educating diabetics on keeping their blood glucose levels from fluctuating between highs and lows can potentially decrease the number of diabetics with foot complications. The nurse can help with these problems by teaching diabetics how to monitor their blood sugar using target ranges, such as a reading between 90-130mg/dl before meals, lower than 180mg/dl after meals, and between 110-150mg/dl before bed (www.mayoclinic.com/health/bloodsugar). Along with testing their blood sugars, the nurse should encourage diabetics to participate in proper diet and exercise, and educate on what to eat or what medications to take before exercising to decrease the chances of a sudden drop in their blood sugar level. Fluctuating blood sugar levels greatly contribute to diabetic complications including foot ulcerations, but with proper nursing information and guidance, it can be controlled (Davidson et al, 2007).
The number of diabetics today is on the rise, and hospitals are seeing more and more visits due to diabetic foot complications and amputations. In many of the cases it was found that the foot complications were secondary to a knowledge deficit on proper diabetic care. To put an end to this debilitating complication of diabetes mellitus, nurses must educate diabetics about proper foot care, the importance of routine foot exams, and blood glucose management. Nurses can also send reminders to patients letting them know when their next appointment is, and encourage them to come back. Educating and encouraging patients to get involved in their diabetes care is a big step to reduce diabetes related complications.
Intervention #1

Nurses need to educate diabetics on the importance of routine foot exams.

Disadvantage #1

Routine foot exams are pertinent for diabetics, however, the lack of available, affordable and adequate health care insurance makes this impossible for them. For example, many people do not receive health insurance through there jobs and therefore must attain it themselves, and because of their health status, many times they are considered uninsurable. There are high-risk pools that have been established for individuals who are turned down by private insurers, however, a lot of times they charge higher premiums making it unaffordable. “Studies show that when health coverage is lost, people in poor health are more likely to experience lengthy spells of uninsurance compared with people in good health”( Pollitz, Bangit, Lucia, Kofman, Montgomery and Whelan, 2005). A lot of times people search for health insurance for so long without success that they end up giving up on the system altogether. Nurses need to be aware of this fact and be available to help people with pre-existing diseases seek out suitable health insurance.

Disadvantage #2

There are a limited amount of providers that are qualified to provide foot exams. Not only that, but not all providers make diabetics bare their feet for a proper exam when they come in for check ups. According to Jawaid and Jawaid, “only 14% of doctors treating diabetics ask patients to take off the shoes to examine feet,” (2006). Providers need additional training to manage high-risk foot conditions, as well as additional expertise in footwear modifications, nail and callus care, and surgical management of the foot (American Diabetes Association, 2003). By increasing the number of health care providers that are trained in proper foot examination including nurses, routine foot exams will be more beneficial to the diabetic client.



Intervention #2

Nurses need to educate diabetics on proper blood glucose management.

Disadvantage #1


Blood glucose management is critical to a diabetic’s health, but with limited access to adequate health insurance the supplies needed to do this are unaffordable for most. “Just the routine costs of managing diabetes (to test and control blood glucose levels) can reach hundreds of dollars per month,” ( Pollitz et al., 2005). In one such case involving a 40 year old married woman whose kids have asthma, she puts her kids’ medical needs before her own since they can’t afford them both, and her blood glucose levels got out of control (Pollitz et al., 2005). By advocating for better health insurance policies for diabetics and others with pre-existing conditions, nurses help reduce the occurrence of diabetic foot complications.

Disadvantage #2

Blood glucose monitoring is critical in management of diabetes, however, blood glucose monitoring alone will not do the trick, proper diet is also important in keeping glycosylated hemoglobin levels down. A study using a PDA to track low glycemic index diet daily resulted in decreased glycosylated hemoglobin levels (Ma, Olendzki, Chiriboga, Rosal, Sinagra, Crawford, Hafner, Pagoto, Magner, and Ockene, 2006). With blood glucose (BG) monitoring alone people can still eat foods high in sugar that will send BG levels sky rocketing. When this happens the glycosylated hemoglobin levels go up as well, and are not brought down when insulin is administered like BG levels are. Nurses can educate diabetics about glycosylated hemoglobin and diet management along with blood glucose management to reduce diabetic complications.


References


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Jones, R. (2006). Exploring the complex care of the diabetic foot ulcer. Journal of the American Academy of Physicians Assistants, 19(12), 31-37. Retrieved October 7, 2007 from Expanded Academic ASAP database.
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Myles, J. (2007). Management of diabetic foot ulcers. Practice Nurse, 33(2), 38-42. Retrieved January 16, 2008 from Academic Search Premier database.
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Potter, P.A. & Perry, A.G. (2005). Hygiene. In S. Epstein (Ed.), Fundamentals of Nursing (pp. 1038-1040). Missouri: Mosby.
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