Teaching Diabetic Foot Care Effectively

Abstract

Patient education is a fundamental aspect of the management of foot ulcers in the patient with diabetes mellitus. Preventive measures have to be focused on the individual risk profile of the patient and on the chronology of appearance of symptoms. Teaching issues need to be adapted into the following three stages: A) before: prevention of foot ulceration in the at-risk patient; B) acute: prevention of extension of an existing ulcer; and C) after: prevention of recurrence.

Foot ulceration is a devastating complication of diabetes initiating a chain of events responsible for 50% of all nontraumatic amputations [1]. Despite efforts in prevention and treatment during the last decade, problems with the diabetic foot constitute a major determinant in the quality of life of patients suffering from diabetes and remain one of the most common reasons for hospital admission among diabetic patients [2]. Thus, the rate of lower extremity amputation is 15 times greater in diabetic patients than in age-matched nondiabetic populations [3]. It has been proven that the majority of these amputations are easily preventable through educational programs for patients and caregivers, focusing on the understanding of the causes and increased skills of health care providers to identify the level of risk of each patient and provide prompt and appropriate care [4,5].

Identification of the At-risk Foot

Two main biomedical factors contribute to the level of risk of ulceration a patient with diabetes may encounter: One factor is progressive sensory loss, in particular the loss of pain sensation in lower extremities, secondary to a neuropathic complication. This, in turn, increases the risk of wounds and infections that pass unnoticed and can result in serious lesions. The classical lesion in the neuropathic foot is the ulcer on the plantar aspect, which develops through friction of callosities at pressure points, creating a vesicle under the skin, which, in turn, spreads infection rapidly up to the level of bone [6].

The other factor is peripheral vascular disease, which leads to decrease of blood supply to precarious tissue trophicity. Therefore, the feet are considered at highest risk of foot ulceration; as a consequence to the slightest friction, there is virtually immediate tissue breakdown [7].

On the psychological and motivational levels, the difficulty is that even when the patient is given enough information to recognize the potential risk in the absence of pain, there is no replacement for the loss of the alarm system, which is pain. This insensitivity to pain misleads not only the patient but, above all, physicians into a state of reduced alertness to find immediate solutions to foot injuries. Without pain, the patient does not take small wounds seriously. Physicians often wait for the patient to complain and fail to routinely remove shoes to check the integrity of the foot [8].

Predisposing Factors

Predisposing factors may easily become pivotal and precipitating factors. The fact that a causative factor for foot ulceration can be identified in two out of three cases indicates that most of these events could have been avoided. Several external trigger mechanisms have been identified to precipitate foot ulceration [9]. These are: 1) ill-fitting shoes leading to unnoticed injuries; 2) friction of calluses and increased pressure points; 3) self-care or provider error in foot care; 4) burns; and 5) athlete’s foot. Patients with insensitive feet tend instinctively to seek tight shoes, as normal-fitting shoes do not seem to support their feet sufficiently (absence of feedback). In addition, it is quite common for patients as a consequence of protective sensory loss to be totally unaware of their feet, rendering them even more vulnerable.

Psychological or social factors may also decrease patient alertness and routine of proper self-care of the foot. Examples are: intercurrent illness or surgery of the patient or a close family member; loss of a close family member; unavailability of a care giver; high level of occupation or stress; and any change in daily routine such as travel or hospital admission for other reasons.

Educational Objectives

Educational strategies should be tailored to the individual risk profile of the patient to ensure focused content and optimal use of resources. Essentially, three stages of vulnerability can be differentiated: 1) Before: prevention of foot ulceration in the atrisk patient; 2) Acute: prevention of extension of an existing foot problem and prevention of ulceration in the contralateral foot; and 3) After: relapse prevention after healing of an ulceration or after a toe or leg amputation. The advantage in identifying the last trigger mechanisms is that educational objectives can be oriented at this high-risk behavior of the patient and individually adapted to his or her personal needs.

Topics to Discuss

Level 1 – Before: Prevention of Foot Ulceration in the At-risk Patient

The patient must take special care in choosing shoes. The patient cannot feel the chafing of tight shoes, which may cause lesions and consequent infection. Patients must learn to recognize the potential danger of a protruding nail, or splits in the leather, and even how to buy new shoes, preferably with the help of some family member who also has been taught what to look for. Shoes should be changed during the day, so as not to wear the same pair of shoes the entire day, every day. Shoes should be brought to the medical visits for inspection.

Foot Hygiene

Patients should wash their feet daily and dry them carefully, particularly between the third, fourth, and fifth toes, where interdigital mycosis is most common. Patients should never use scissors to cut nails, but use a file instead. It is recommended that the skin is moisturized every day. Regular follow-up visits (every 6 weeks) by a specialist are helpful. Socks and stockings should be changed daily. A medical examination at each visit should be ensured (frequency determined by the level of risk, but at least every 2 months).

Level 2 – Acute: Prevention of Extension

Patients should examine the skin of their feet daily and note any corns, fungal infection, or other small skin lesions. The existing foot problem should be evaluated daily on severity and progression. Ideally, the plantar aspect of the foot is inspected with a mirror. The dressing should be changed daily and should remain dry the whole day. A wet dressing may macerate the ulceration and help the infection to spread. The patient must know how to identify aggravation of the existing foot lesion and where and how to seek prompt help. Off-loading has to be organized and trained with the patient. Patients should not walk barefoot, particularly on beaches or around swimming pools or at night, eg, when going to the bathroom.

Level 3 – After: Relapse Prevention

Patients should wash and examine the skin of their feet daily and note any corns, fungal infection, or other small skin lesions. They should know how to care for these lesions without using harmful products or instruments such as corrosive chemicals or razor blades. Ideally, the plantar aspect of the foot is inspected with a mirror. Corns should be removed with a pumice stone at least once a week. The patient should be actively trained with this procedure. Any discoloration, edema, blistering, sore, injury, mycoses, ulceration, or callus formation has to be immediately reported to the caregiver for prompt and proper care. The careful choice of shoes as mentioned already at level 1 is mandatory. New shoes are hazards and should not be worn for prolonged periods. A skin check should be made after each time they are worn. Patients must inspect the inside of their shoes for foreign objects before putting the shoes on and must not use electrical heating pads or hot water bottles. Patients are recommended to show their feet regularly to their caregivers even in the absence of any lesion at least once every 2 months.

Conclusion

Recognition that foot amputations are not an inevitable outcome of the progression of diabetes is the main motivational drive to conduct pertinent teaching lessons to the patient [10]. The most effective approach is in this particular situation by a multidisciplinary team who should agree on all teaching objectives. These objectives are oriented on the specific risk profile of the patient taking into account the biomedical and the sociopsychological factors. It is not to be forgotten that the patient with an acute ulcer might not take into account the severity of his or her foot lesion. Insufficient care or even facilitation of aggravation of the lesion by the patient may be the consequence. At the same time, these patients are at risk to potentially develop a new lesion in the contralateral foot.

It is important to analyze the last precipitating factors having finally led to the foot lesion, as they are important markers for planning efficient prevention by health care providers. The patient at the highest risk is the patient after the ulcer or amputation, for whom all effort has to be focused on the prevention of a relapse episode. More than 50% of diabetic amputees need an amputation in the contralateral limb during the first 4 years after the loss of the first leg, stressing the need for effective preventive measures for this particular group of patients [11]. Again, education of specific skills and foot care behavior should be bound to each patient’s trigger mechanisms to help the patient understand the relationship between causality and the foot lesion.

Also, education of patients is fundamentally important. Urgent research is needed to further approach the problem of absence of symptoms, ie, lack of pain as a warning sign. When diabetology masters this aspect of neuropathic diabetes, secondary and tertiary prevention of the ulcer on the plantar aspect will be more efficient.

Education is a lifelong process that together with regular follow-up care can decrease the amputation rate for patients who have to cope with the absence of symptoms. This painlessness can mislead patients and put them at high risk to potentially lose a leg.