It may not be the most glamorous thing to talk about, but wound care is front and center at long-term care facilities around the country. Why? Because 23 percent of people 60 and older are diabetics and managing diabetic complications in residential facilities can be daunting.¹

Some of the most prevalent diabetic complications are foot lesions, which send more diabetics to the hospital than any other problem. About 15 percent of diabetic patients will eventually develop foot ulcers.²And 12 to 24 percent of diabetics with foot ulcers will require lower-limb amputation.³

Foot Ulcers
Foot ulcers, which are open sores or wounds on the bony aspects of the dorsum or on the plantar foot, are the most common form of skin alterations. They're easily identified by the thick callous formation surrounding them.

Diabetics are particularly at high risk for skin ulcers if they have neuropathy, poor circulation, uncontrolled blood sugar, a foot deformity such as a bunion or hammer toe, or wear ill-fitting shoes. Healing these wounds can be difficult and time consuming because diabetics are predisposed to slow healing. The recurrence rate is high.  

Prevention
Diabetics who are insulin dependent are at higher risk of developing kidney, eye and heart disease than people who do not have diabetes. Smoking, obesity and drinking alcohol add to diabetic complications, particularly skin lesions. What can we do to prevent and control diabetic complications in our residents? 

Here are some specific instructions for residents and caregivers:

• Wash feet daily.

• Inspect feet and toes daily.

• Maintain or obtain a healthy weight.

• Wear proper fitting shoes.

• Wear thick, light colored, soft socks.

• Don't go barefoot.

• Stop smoking/provide quit-smoking programs.

• Cut toenails straight across.

• Exercise.

While the number of people being diagnosed with diabetes is sharply increasing,⁴LTC facilities are fighting back by creating medical teams trained to identify, treat and counsel residents and families on diabetic complications.

The team usually includes a doctor, nurse manager/wound care specialist, dietician, medical specialists, if indicated (vascular surgeon, orthopedist, podiatrist), physical and/or occupational therapists, social worker and family members.

Each team member plays an important role. Social workers address the resident's lifestyle issues, offering support for the residents and families. Physical and occupational therapists provide appropriate devices and equipment ranging from foot or leg braces and shoes to proper cushions for seats. They also plan, encourage and provide physical activities that help improve blood circulation and help residents to reach an appropriate weight.

The nurse manager may use the following numerical scale to assess the risk of developing foot ulcers:

0: no loss of protective sensation

1: loss of protective sensation with no weakness, deformity, callus, pre-ulcer, history of ulceration

2: loss of protective sensation with weakness, deformity, pre-ulcer or callus, but no history of ulceration; or ischemic index <0.45.  

For residents who have already developed foot ulcers, nurses generally include the following details in their initial assessment and update the information as indicated: location of ulcer, description of tissue destruction, description of drainage, any signs of infection, description of condition of surrounding skin, length of time ulcer has been present, information on past treatment.

Each team members' assessment contributes to the individual plan for the resident's overall care and can help reduce diabetic complications.

Managing Skin Alterations
Following the risk assessment and evaluation of existing wounds, the entire medical team aggressively addresses the resident's needs.

For example, a podiatrist may be asked to trim a resident's nails or perform surgical procedures. A vascular surgeon may address poor blood circulation and test for peripheral vascular disease in the lower extremities. A dietician will evaluate a resident's nutritional needs to help the resident maintain or obtain a healthy weight and control blood sugar.

Additional treatment includes:

• preventing and treating infection

• off-loading or taking pressure off the ­portion of the foot with the ulcer

• debriding

• applying medication or dressings to the ulcer

• managing blood glucose and other health-related problems

• addressing the physical and psychological affects on the resident and family. As mentioned earlier, diabetic foot ulcers may lead to amputations, which dramatically alter the person's self image, physical ability and the body's hemodynamic responses.

Education
As healthcare professionals, educating our residents, their families, friends and the community at large is our responsibility. We must meet with religious groups, senior centers, housing developments and anywhere else people will listen on how to live a healthier life. We can provide local help-lines in our facilities, our communities or refer people to the American Diabetes Association.

And, for our residents who already have diabetes with all its life-altering complications, we must double our efforts to reach out to them, their families, friends and clergy. Our goal must be to provide everyone with accurate and current information on how people with diabetes can manage this disease and best live their lives.

References

1. American Diabetes Association. National ­Diabetes Fact Sheet. Retrieved from www.diabetes.org on Aug. 3, 2009.

2. American College of Foot and Ankle Surgeons. Foot Ulcers Affect 15 Percent of All Diabetic Patients. Retrieved from www.footphysicians.com/diabetes/diabetes_foot_ulcers.htm on Aug. 4, 2009.

3. Stillman R. Diabetic Ulcers. eMedicine June 30, 2008. Retrieved from emedicine.­medscape.com/article/460282-overview on Aug. 3, 2009.

4. Centers for Disease Control and Prevention. Fact Sheet: Diabetes at Work. Retrieved from www.cdc.gov/diabetes/pubs/factsheets/atwork.htm on Aug. 3, 2009.

Alecia Blake is a wound care nurse at Beth Abraham Health Services, New York. Juanita Reyes-Tineo is a certified wound care specialist/medical practice nurse and day health center nurse for Comprehensive Care Management, a member of Beth Abraham Family of Health Services.