Teach aides how to spot foot problems in diabetics
No health care provider is in a better position to spot infections or other foot problems with diabetic patients than home care aides. They see the feet during bathing and dressing, which means the aides can spot trouble long before either the nurse or physician has the opportunity to examine the patient.
So creating an inservice on patient foot care could save limbs, one education manager says. If an aide fails to spot a foot wound, the patient is put at risk of losing his or her foot. Education is the best way to ensure the aide won’t miss foot trouble signs.
"What we find is the home health aides underestimate the importance of foot care, so they tend to rush through that portion of the visit," says Robin James, RN, MSN, coordinator of continuous quality improvement and clinical education for Interim HealthCare of Western North Carolina in Asheville, NC. The full-service, private for-profit agency serves all of western North Carolina. It’s part of a national company based out of Ft. Lauderdale, FL.
"The bath is the most important part of what they do, and foot care is very important," James adds. "Aides see feet more frequently than the nurses do, and they can pick up on problems sooner."
Although aides could use the foot care techniques with all patients, it’s most important with diabetic patients because their feet typically don’t heal well, James says. "Infections set in more readily, and they can’t feel it, so they don’t know something is wrong."
If a diabetic patient’s foot wound isn’t noticed or cared for properly, gangrene could set in, and the patient could lose the limb.
James discussed the consequences of poor foot care with aides and offered them background information about circulation and tips on proper care in an inservice. She received excellent feedback after the inservice, and the agency soon after had an increase in the number of nursing aides who reported patient foot problems to nurses.
"We don’t think there was any increase in the patients with these problems, but the aides were more aware of what to look for," James explains.
James offers these guidelines on how to set up a foot care inservice and what tips to give aides:
• Collect information from magazines, nursing manuals, and other sources, looking for the latest recommendations and procedures.
James pulled together foot care and bath care information from nursing magazines and nursing manuals, including the Manual of Home Health Nursing Procedures, published by Mosby of Chicago.
James also suggests education managers contact the American Diabetes Association and local experts in the field.
She specifically tried to find answers to such questions as "What kind of patients are compromised?" and "What would their feet look like, and what kind of diagnosis might they have?" and "What kind of treatments might they receive?"
• Explain the basics of circulation anatomy and blood flow, starting with the whys of foot care and progressing to what they can do to improve circulation in the feet.
"We service rural areas, and a lot of people in the mountains don’t have heat, or they live in a little cabin, and cold air is under their homes," James says.
"So they don’t have warm areas for themselves, and the first thing to get cold is their feet."
James tells aides to check the temperature of patients’ feet before they are immersed in warm water. "If they’re consistently cold, the aide must teach the patient how to keep the feet warmer to increase the blood flow."
A change in footwear
The solution could be as simple as encouraging the patient to wear well-insulated slippers. The best footwear around the house would be slippers with rubber bottoms and dry, loose-fitting socks. Then the patients should keep themselves warm with blankets.
Also, education managers can ask aides to describe what the patient’s foot looks like, focusing on these details, which could offer clues as to whether the patient’s foot is receiving adequate blood flow:
Is there hair loss on the toes and lower extremities? James explains that hair follicles need a consistent blood supply, so the lack of hair could mean poor blood flow.
Is the foot’s skin dry, taut, and shiny? This could be a sign of cellulitis, which is indicative of poor blood flow, James says.
When the aide touches the patient’s foot, does it feel callused? "If they have poor blood flow and the foot is injured with a pressure sore or ulcer, then because of the poor blood flow, it will not heal as quickly," James says.
• Discuss nerve damage and normal recovery from foot injuries vs. abnormal reactions that could lead to more serious problems.
"If you stub your toe, your first instinct is to rub it, and you might favor that foot. Or if you wore a new pair of shoes and got a blister on your heel, it would cause pain, and you wouldn’t put your shoe back on your foot," James explains. "But a person with nerve damage can’t feel the injury, so that person tends to re-injure the same area, and the healing process doesn’t take place."
The problem is compounded because the person doesn’t favor the injured foot through limping and redistributing the weight on the foot.
"Consistently in diabetic patients you see both poor blood flow and nerve damage," James says.
Some common signs and symptoms of nerve damage include numbness, burning sensation, and tingling.
James suggests aides talk with the patient while touching the foot, asking the patient, "Do you feel this? Do you feel what I’m doing? Do you feel my fingernail? Do you feel this pressure?"
Aides can write down any problems on the aide progress notes and then contact the nurse who is handling the case, she adds.
"Early detection is very important," James notes.
• Teach aides the signs and symptoms of skin breakdown.
Look for changes in shape, color, and texture of toe nails, James says.
"Sometimes they could turn purplish or bluish if there’s no blood flow. Or yellow. The normal color is pink," she says.
Toe nails that are streaked could indicate poor nutrition or shoes that fit improperly.
Aides should take notes
The skin typically turns red, becomes dry, and develops blisters as it breaks down.
Another clue to problems is if the patient is extremely immobile because the less the patient moves around, the more likely the skin will break down, developing wounds, James says.
• Discuss the techniques of good, safe skin care.
James says Interim HealthCare’s aides are encouraged to file and shape patients’ toe nails, but they are not allowed to cut them because this could injure the foot.
"If the patient is vascularly compromised, then the nurses might not cut the toenails either and might refer the patient to a podiatrist," she says.
"We teach them to handle the feet kind of gently," James says. "If you rub them intensely, it can cause tears."
For this reason, aides must be extremely careful when touching the feet.
Before bathing patients, the aide should test the water because if the nerve is damaged, the patient won’t know whether the water is too hot, James says. "Sometimes when diabetic patients are bathing themselves they can burn their feet if the water is too hot and they didn’t realize that when they stuck their feet in the water."
Also, James advises aides not to soak the patient’s feet for more than 5-10 minutes because a long soak could allow bacteria to get into any sores on the feet. Likewise, the aide shouldn’t put hot water pads or heating bottles on patients’ feet because these also can burn them.
But she encourages them to soak the feet a little because this makes it easier for the aide to clean the feet and check the skin and toes.
• Have aides give patients some tips on properly caring for their own feet.
Aides can check to see whether the patient has been changing his or her socks regularly. "If the feet are moist and the patient doesn’t change socks every day, then they can get a fungus infection," James says. "Also, if they don’t change socks every day, they increase the risk of bacteriological infection."
No bare feet allowed
Similarly, the patient should change shoes at least twice a day to prevent the shoes from causing pressure sores. Different shoes will put pressure on the foot in different spots, so by switching the shoes regularly, the patient can prevent a sore from developing.
Another tip is to have the patient make sure the socks have no lumps or bumps in them, including the common stitching ridge across the toes, James suggests.
"Sometimes the socks have a ridge across the top of the toes. If a patient doesn’t have the ability to feel that, and the patient keeps the shoe on tight all day, then that’s enough pressure to actually cause a sore."
Also, Interim HealthCare recommends that patients never walk barefoot because they could easily injure their feet by stepping on glass or other objects.
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