“It’s all about attitude for diabetic patients to have good education and strong wound care management on their own,” she said.
At the outpatient clinic where Villar sees patients, she combines evidence-based practice with compassion and understanding of diabetic patients’ knowledge levels and fears about managing their wounds, most of which are on the feet.
“The gold standard is offloading,” she said. Used to relieve pressure on the wound area, offloading might mean using a total contact cast that is especially effective if the wound is on the plantar aspect of the foot or diabetic shoes.
Nancy Morgan, BSN, MBA, RN, WOCN, WCC, agreed that a cast is the best avenue for wound management. “The big gap we’re seeing is that not many people are doing [them.]. Clinicians don’t know how to do it, and it also may be a reimbursement issue. But hands down, it should happen.”Nancy Morgan, RN
Shoes in general must be evaluated to prevent foot ulcers, Morgan said. Nurses can assess the fit of shoes, teaching patients to be more aware of how shoes are affecting their extremities. “As we age, our feet shrink. A lot of patients aren’t updating their shoes,” Morgan said.
Prevention is best medicine
Preventing chronic wounds is the best overall strategy for diabetic individuals, and education is essential. Patients need to understand that over time, diabetes results in impaired circulation and neuropathy, which predisposes individuals to wounds and delayed healing. Morgan advises nurses to look for — and teach patients to look for — early signs such as skin discoloration, inflammation and deformity.
New guidelines for prevention and treatment of pressure ulcers, released in 2014 by the National Pressure Ulcer Advisory Panel provide nurses with material to use in practice and to disseminate to patients who must observe their own skin and take action when integrity is compromised, according to Morgan.
Patient education essential
While overall patient education is essential, it also must include careful blood glucose management, said Traci Mancuso, MSN, ARNP, FNP, WCC.
“The downstream effects of high blood glucose bring microvascular changes, which increase the risk for reduced wound healing,” Mancuso said.
“Diabetic patients are more susceptible to chronic wounds, especially below the knee, and if they have a comorbidity, such as obesity, with their extra weight, they end up with lower extremity edema that further compromises circulation. The healing power comes from the blood, so if the extremities can get blood, they get healing,” she said.
Elevated blood glucose also negatively affects skin integrity. Villar said high glucose in the bloodstream attracts water, which is spilled in urine. This loss of fluid results in a loss of moisture to the skin; the resultant drying and cracking are predisposing conditions for infection. Wounds have difficulty healing, then due to loss of sensation, there’s trauma to the wound and it becomes bigger and deeper.
Patients must be given information to assess their wounds and know when to report their observations, all three nurses concurred. Morgan advocates patient teaching, which includes monitoring the temperature and color of the skin, dimensions of the wound, the amount and type of drainage and any signs of infection. “When a patient changes his dressing, have him note the color and amount of drainage, using a percentage,” Morgan said.
Mancuso said patients with a vascular compromise — whether edema or peripheral vascular disease — need to know they should be elevating their feet a few times a day to get fluid back into the circulatory system.
Villar said patients often end up with chronic wounds as a result of noncompliance with their treatment plan. “They may not understand their plan, or feel they don’t have any control over it and fear sets in,” Villar said. Nurses must explore reasons for noncompliance, which might range from lack of understanding of the treatment plan to unavailability of transportation to medical appointments or lack of money for supplies.
“The nurse needs to explain the whole process of treatment to them,” Villar said. “Lower their fear factor; teach them the risks of being noncompliant. Give them the confidence that you’re doing this treatment plan together.”