The certified foot care nurse (CFCN) plays a significant role in the prevention and treatment of many types of lower-extremity wounds. One of the most significant areas the CFCN can make an impact in the wound care profession is through the prevention of wounds in the diabetic patient through education and assessment. Centers for Disease Control and Prevention statistics (2014) indicate that 7.2 million patients are discharged from the hospital with a diagnosis of diabetes. Of those discharges, 5 out of every 1000 patients had an additional diagnosis related to a lower-extremity amputation. Diabetes is the major cause of nontraumatic amputation. The education the CFCN provides to a patient with diabetes can establish the difference between limb salvage and limb amputation. The following are important teaching points CFCNs should incorporate into their practice:
Daily inspection: Properly inspecting the feet and shoes on a daily basis is one of the most important teaching points the CFCN can provide to the patients with diabetes. Patients should be taught to inspect their feet on a daily basis after removing shoes. The CFCN should teach and instruct the patient to inspect the top of the foot, both sides, in between the toes, and especially the sole of the foot. If patients are unable to inspect their own feet, encourage them to have a caregiver perform the inspection. Long-handled mirrors can also aid in the inspection. Prior to putting on any pair of shoes, patients should be instructed to inspect the insides of the shoes for foreign objects, look for imperfections in the shoes, as well as inspect the shoe inserts. Excessive wear suggests it is time to replace shoes.
Dry skin: The skin of the foot can become dry, causing fissures or cracks to develop. Many people with diabetes do not understand that even minor cracks and dry skin may cause wounds to the feet, which can lead to infection without proper care. It is important for the CFCN to educate about properly cleansing and moisturizing feet on a daily basis.
Daily cleansing: A mild cleanser such as a moisturizing soap and a soft towel are need for good hygiene. Patients should be taught to thoroughly dry the skin, especially between the toes. Soaking the feet is discouraged, as decreased protective sensation from neuropathy often accompanies diabetes leaving the foot "insensate" to water that is too hot, causing burns to the feet.
Neuropathy: Diabetic neuropathy can lead to significant problems with the foot. The lack of protective sensation can allow a wound or injury to go unchecked for many days, resulting in wound infection. Encouraging the patient to perform daily inspection of the feet will decrease the incidence of wounds being undetected and leads to treatment in a timely manner. In addition, advise the patient never to go barefoot, even indoors.
Circulatory issues: Many people with diabetes can develop reduced arterial blood flow related to narrowing and hardening of the vessels that can occur with prolonged or poorly managed diabetes. The combination of vascular insufficiency and diabetes puts the patient at an even higher risk for wounds and amputations. Patients with circulatory disorders should be reminded to protect their lower extremities, as even minor trauma (scratch, bug bite) can initiate a portal of entry for bacteria and other organisms, heightening the potential for infection.
Diabetic foot ulcers (DFUs): These are most frequently caused by some type of pressure such as from an ill-fitting shoe or from an injury that the patient is unaware of until the wound becomes infected. Other problems that might result in DFUs are structural or bony abnormalities, muscle atrophy, and Charcot arthropathy. Treatment by foot, wound, and other specialists should be recommended to patients for any foot ulcer.
Other teaching items: Patients should also be taught to maintain good glycemic control through proper nutrition, daily exercise as tolerated, and blood pressure and cholesterol control. Those who smoke should be advised to stop smoking.
1. American Diabetes Association. Foot complications. http://www.diabetes.org/living-with-diabetes/complications/foot-complications/?l. Published 2019. Accessed June 26, 2019.
2. Boyko EJ, Seelig AD, Ahroni JH. Limb- and person-level risk factors for lower-limb amputation in the prospective Seattle Diabetic Foot Study. Diabetes Care. 2018;41(4):891-898.
3. Burdette-Taylor M, Fong L. Foot and nail care. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:530-554.
4. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2017.
5. Howes-Trammel S, Bryant RA. Foot and nail care. In: Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:263-282.
PRACTICE QUESTIONS
1. A patient with diabetes and neuropathy presents to your clinic with a full-thickness wound to the plantar surface of the hallux. There is no indication of abscess or gangrene. How would you classify this DFU?
a. Wagner grade 1
b. Wagner grade 2
c. Wagner grade 3
d. Wagner grade 4
Content outline: Domain 2, Task 5, 020503
Cognitive level: Recall
ANSWER B:
Rationale: The correct answer is Wagner grade 2. The definition of a Wagner grade 2 ulcer is a full-thickness wound with the absence of gangrene, osteomyelitis, or abscess; however, there can be infection of the soft tissue. Wagner grades 3 and 4 are also full-thickness wounds but are more extensive with grade 3 presenting with abscess, sepsis, or osteomyelitis and grade 4 presenting with localized gangrene. A superficial wound would be graded as a Wagner grade 1.
1. Varnado M. Lower extremity neuropathic disease. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:484.
2. Driver VR, LeBretton JM, Landowski M, Madsen JL. Neuropathic wounds: the diabetic wound. In: Bryant RA, Rolstad BS, eds. Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:239-262.
3. Frykberg RG. Diabetic foot ulcers: pathogenesis and management. Am Family Physician. 2002;66(9):1655-1663. (Classic article for the Wagner scale).
2. A patient with diabetes presents with a superficial wound over the left first plantar metatarsal head. The foot care nurse is able to palpate a strong dorsalis pedis pulse. Which of the following is the best INITIAL treatment of this wound?
a. Offloading
b. Pain control
c. Revascularization
d. Topical antibiotic
Content outline: Domain 2, Task 3, 020302
Cognitive level: Application
ANSWER A:
Rationale: The correct answer is offloading. Many DFUs are caused by some form of pressure, whether it be from a foot abnormality such as a bunion or a hammertoe or from ill-fitting footwear. Diabetic neuropathy does not allow the patient to realize the pressure is causing abnormal friction or pressure, resulting in a wound. For the wound to heal, the source of the pressure should be determined and corrected. The patient should place no pressure on or around the wound such as padding. Antibiotics would not be indicated for a noninfected wound. If the wound is infected, the patient will most likely need oral or parenteral antibiotics instead of a topical antibiotic. Most patients do not typically experience wound pain due to neuropathy. Neuropathic pain should be addressed by the patient's primary care provider. Since the patient has a palpable pulse, this finding would suggest there is no urgent need for a surgical consult; however, if there are other vascular abnormalities such as skin changes (maybe shiny), hair loss, or very dry flaky skin, the patient should see the primary care provider. The arterial flow may be compromised with abnormally high pressures such that the blood vessel has become hardened or the microvascular perfusion has become compromised. The initial action in this case is offloading.
1. Burdette-Taylor M, Fong L. Foot and nail care. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:530-554.
2. Driver VR, LeBretton JM, Landowski M, Madsen JL. Neuropathic wounds: the diabetic wound. In: Bryant RA, Rolstad BS, eds. Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:239-262.
3. Which of the following would indicate correct foot self-care education to the patient?
a. "You should wash your feet every 2-3 days to prevent the skin from drying out."
b. "Apply a moisturizer to the feet and between the toes to prevent cracking of the skin."
c. "You may trim an ingrown toenail if it is causing you problems."
d. "If you cannot see the bottom of your feet, you may use a mirror."
Content outline: Domain 3, Task 1, 030101
Cognitive level: Application
ANSWER D:
Rationale: Patients should be taught to inspect their feet daily to ensure that there are no issues such as pressure areas or callous formation. Some patients may not be able to bend or lift their leg to inspect their feet. These patients can use a mirror to inspect all aspects of the feet. Long-handled mirrors can be purchased from home care suppliers or ordered online. Magnetic backed mirrors that can be placed on the lower end of a refrigerator also work well. Any wound, crack, or fissure should be dressed and reported to the foot care provider for treatment. Patients should wash their feet every day and dry them thoroughly to ensure that there are no injuries. After washing the feet, patients should moisturize the feet, sparing the interdigits, as this can cause excess moisture and can lead to skin breakdown. Patients with diabetes should never attempt to remove or trim ingrown toenails. These should be cared for by a CFCN or other foot care professional.
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