Finding Time for Foot Care.

Vigilance helps prevent complications with diabetic residents' feet

Mrs. Smith just had an accident while seated on one of the sofas in the living room. Mr. Brown is in the hallway looking for his cat which, in reality, has been gone for 50 years now. Mr. Thomas, a "wanderer," is attempting to convince an arriving group of visitors to take him to the store. It's time for Miss Jones to be accompanied to her physical therapy session. The therapy dog, usually placid and obedient, is running down the corridor dragging Mrs. Simpson's cane behind him, and Mrs. Simpson (not a big dog lover) is expressing (loudly) that she's not pleased. Oh, and on top of everything else, it's almost time for the noon meal and (by the way) the state surveyor has just arrived.

Although perhaps exaggerated a bit, this description of a "day in the life" of a skilled nursing facility isn't all that much of a stretch. There's no way to anticipate every crisis, major or minor, that could occur at any moment on any given day, placing additional demands on caregiving staff who are already hard pressed to keep up with the basics of daily resident care.

Some needs of residents are more obvious than other needs. For example, if residents didn't have their hair washed frequently enough or receive regular assistance with bathing, it soon would become evident. Feet, on the other hand, could easily be overlooked. For those diabetic residents who are at high risk of developing pressure ulcers on their feet, this oversight could be critical. The need for routine foot care, if ignored, could quickly escalate into the need for wound treatment.

Diabetics living in the community are encouraged by their physicians to follow a rather extensive list of self-care guidelines, including daily inspection of their feet and the inside of their shoes, daily foot washing and, if needed, moisturizing, but many diabetics living in nursing homes are not physically or cognitively able to follow these guidelines.

Some residents, for example, lack the joint flexibility required for a thorough foot inspection. Others simply forget to look at their feet or can't see well enough to identify potential problems- problems that they perhaps can't feel because of peripheral neuropathy. These individuals need help from caregivers. How can the already-overburdened staffs of nursing homes keep up with routine foot care for these residents?

Jean DeCamp, RNC, director of nursing at Village North Health Center in St. Louis, says the foundation for good foot care for these residents starts early.

"We do a thorough, full-body assessment at the time of admission, including a foot assessment," she says. "We look for foot deformities and assess the condition of the toes and toenails, making sure there is no infection in or around the nail bed. We also note if the feet are excessively dry or have calluses, swelling, redness, bruising, ulcerations or pre-ulcerations. If we find any of these things, we notify the attending physician and obtain orders for a podiatrist, so that treatment can be started right away and problems avoided."

DeCamp points out that, once admitted, residents with diabetes have the condition of their feet monitored by the caregivers who bathe them, each time they are bathed. She says that to try to follow the guidelines for community-dwelling diabetics--such as daily foot inspection-simply isn't practical or necessary in the nursing home setting.

"People in long-term care facilities are in a protective environment," explains DeCamp. "They're less vulnerable to trauma to their feet, such as burning them while walking on a hot beach or experiencing a puncture wound from stepping on a nail while walking around outside without shoes. Therefore, the regular foot monitoring we provide has been more than sufficient to prevent problems."

She notes that in order to provide every diabetic resident with daily foot washing and inspection would require a complete re-evaluation of staffing patterns and, most likely, an increase in the number of staff.

"We've never had a problem with this level of care," DeCamp says. "If we were to suddenly find ourselves with a large number of residents at especially high risk of developing diabetic foot ulcers, perhaps we'd have to reassess our approach.

"Educating staff is a high priority when you're trying to deliver quality care," she says, "and it helps a great deal to have a good relationship with your podiatrist. When ours is here treating residents, she is also providing continuous, ongoing education to our CNAs, which helps them realize that they are an integral part of the care team. She's great with our staff."

DeCamp adds, "Foot care takes an interdisciplinary approach, just as any other type of care does. In addition to our staff podiatrist--who reviews any concerns we have about potential complications, makes regular visits to our facility and is on call to help with any problems that arise--we also have a consultant dietitian and certified dietary manager who are involved. They do a total nutritional review shortly after admission, and then they continue to monitor residents' diets. The dietitian also reviews the monthly reports of pressure sores, to see what adjustments these and other residents might need.

"Another essential part of the team is rehab, who determine whether a diabetic resident needs prosthetic devices or special shoes.

"The important thing to keep in mind in all this is that elderly residents with diabetes or peripheral neuropathy or vascular disease are always at high risk of developing foot complications. We have to make sure staff are trained and skilled in performing the regular assessments of residents, so that we can prevent problems."

Jean DeCamp, RNC, is director of nursing at Village North Health Center in St. Louis. She has been a DON for 18 years and has been involved with long-term care for 24 years.