Diabetes and Wound Healing - Literature review Example

Diabetes and Wound Healing Diabetes and wound healing is treated by tissue viability nurses by keeping in view the latest researches and techniques. The focal point of their care is providing specialist advice for treating acute wounds. Nursing and holistic care treatments deal with diabetic patients by assessing the nature of their disease and its associated complications by keeping in view their medical history and the probable causes. Genetically inherited diabetes is the most common cause followed by obesity, older age, physical inactivity and certain ethnicities like African-Americans, Mexican-Americans and Pacific Islanders. Treating patients with diabetes requires expertise and intensive knowledge regarding wound healing. The most common form of diabetes is type 2, and children and adolescents are mostly reported to have this form of disease. Diabetes prohibits wound healing in a number of ways. It influences the immune system of the human body and ordinary wounds can convert into ulcers. The most common problems arise in case of diabetic foot ulcers. Various approaches are adopted in the treatment of such ulcers. Glycemic control is an important aspect in wound healing complications. Glycemic control refers to the glucose levels in the blood. Hyperglycemic condition in patients suffering from diabetes mellitus can trigger infections and hinder wound healing. The effect of diabetes on wound healing is a very complex issue that continues to leave many unanswered questions. There continues to be an empiric fact that diabetic patients are at increased risk for the development of infection and impaired wound healing. The precise underlying defect(s) continue to be a focus of research; however, it is generally agreed that improved glycemic control plays a significant role in lowering the risk of wound healing complications. Diabetic patients need to pay special attention to their diabetes care in general as well as to the critical illness, wound, or ulcer that has brought them to our care. (Meyer 1996, pp. 195-201) The treatment of chronic wounds also becomes critical as a result of other multiple factors hindering wound healing in diabetic patients. ‘...diabetic foot ulcers, like all chronic wounds, will heal only if the underlying pathology is corrected...However, the recurrence rates are quite high’. (Joslin & Kahn 2005, p.1139) While dealing with insulin deficiency and changing lifestyle habits form the basis of treating diabetic patients, however, some medications have also proved to be effective for the treatment of wounds. ‘Of all the preclinical growth factor trials, only one agent has been approved for the topical treatment of chronic wounds. Recombinant-PDGF(Regranex[Becaplermin]; Ortho-Mcneil) has been approved for the treatment of diabetic ulcers’. (DiPietro & Burns 2003, p.187) Studies have associated diabetes with other complications- particularly, wound healing. In fact, delayed healing of wounds is an indication that the person might be suffering from diabetes. Even minor wounds should not be ignored, and all problems associated with skin should be taken seriously. ‘...diabetes affects all facets of wound healing and wound management. ...Wound healing is more difficult with older people with diabetes. Treat the cause and take a multidisciplinary approach...wounds must be regularly evaluated and documented with defined goals of treatment.’ (Dunning 2005, p.177) Having defined goals mean that the progress of given treatment should be monitored on regular basis. Obesity can lead to cardiovascular diseases and diabetes mellitus as evident from research. The relationship between adipose tissue and diabetes can greatly help in understanding their effects on wound healing. The classical perception of adipose tissue as a storage place of fatty acids has been replaced over the last years by the notion that adipose tissue has a central role in lipid and glucose metabolism and produces a large number of hormones and cytokines, e.g. tumour necrosis factor-α, interleukin-6, adiponectin, leptin, and plasminogen activator inhibitor-1. The increased prevalence of excessive visceral obesity and obesity-related cardiovascular risk factors is closely associated with the rising incidence of cardiovascular diseases and type 2 diabetes mellitus. (European Heart Journal 2008, pp. 2959-2971) Malnutrition has also been found to play important roles in triggering the diabetes. Insulin deficiency is sometimes related to malnutrition. ‘The precise mechanism of abnormal wound strength in diabetes remains to be studied further, but careful control of diabetes, maintenance of nutrition, and treatment of systemic illness are important factors in the promotion of wound healing.” (Yue et al. 1987, pp. 295-299) Certain skin diseases like ischemia aggravate wound healing, particularly in foot ulcers. ‘Patients with infection and ischemia were nearly 90 times more likely to receive a mid-foot or higher amputation compared with patients in less advanced wound stages.’(Armstrong, Lavery & Harkless 1998, pp. 855-859) The skin conditions of diabetic patients change and it becomes numb, dry, cracked. It is important to note that ischemia in itself is not a risk factor for the development of a foot ulcer. Instead, ischemia complicates and slows wound healing, as a result of insufficient blood flow... Recent investigation into the microcirculation of the diabetic foot has revealed significant structural and functional changes that may contribute to impaired wound healing observed in diabetic foot ulcers. (Mantzoros 2006, p.354) The implications of the findings on nursing practice are providing better care to the patients and educating them to cope with such issues on their own. The holistic approach also demands that nurses should impart knowledge about factors to consider for their well being. Stress and other anxiety disorders aggravate chronic wounds like foot ulcers. Training the patients to cope and manage foot ulcers is a vital part of the nursing practice. Removal of dead and infected tissues and culturing the wound may lead to better and accurate treatment. Initially, a neuropathic ulcer of the foot must be assessed for infection, debrided of devitalized tissue, and examined by radiography to detect foreign bodies, soft-tissue gas, or bony abnormalities. Effective treatment requires that weight bearing be eliminated 20,21. Foot ulcers commonly fail to heal simply because patients continue to put weight on their feet. Because a prolonged period with no weight put on the affected foot (i.e., strict bed rest) is usually unrealistic, devices are required that reduce pressure at the site of the ulcer while allowing ambulation22-24. Small, shallow ulcers have been treated successfully with felted foam inserts.’ (Caputo, Cavanagh, Gibbons & Karchmer 1994, pp. 854-860) Tissue viability nurses are trained to adopt modern strategies of treating ulcers. Recent studies suggest the soaking of feet in tap water brings tremendous relief to the patient. Patients arrive at clinics with anecdotes of how their feet have not been placed in water for years because a professional has told them ‘not to get their leg ulcer wet’ and yet these same professionals are happy to squirt saline at the wound – thereby ‘wetting’ the ulcer. Many progressive clinics now hold buckets for the purpose of soaking the patient’s leg ulcers. The buckets are lined with bin-bags and filled with tap water. (Hampton & Collins 2005, p.148) Education of out-patients by nurses regarding the after-care of ulcer removal is also important. Special shoes, braces, or casts should be recommended for such patients, to assist wound healing and inhibit its recurrence. Poor circulation in the feet can delay wound healing and makes it prone to infections. Numbness or neuropathy lessens the ability to feel heat, pain and even cold. Foot care and patient education are a vital part of the holistic care that should be offered to all people with diabetes, irrespective of age or length of diagnosis. Foot disorders in diabetes: Foot problems in people with diabetes develop for a number of reasons. The main contributing factors, however, are peripheral neuropathy, peripheral vascular disease and infection. (Shilling 2003, pp. 61-68) Encouraging the patients to quit smoking and make efforts for regular exercise can help a great deal in wound healing. One should avoid walking too much or applying pressure on feet by standing for long hours. This deepens the wounds and exacerbates it. ‘It has been explored, investigated and recognised that high standard, individually tailored, psychosocially orientated patient education will have beneficial, clinical and cost-effective results on disease and quality of life (QoL) outcomes.’ (Gillibrand 2010, pp. 113-114) Studies have proved the vitality of centuries-old Chinese medicine to bring relief to diabetic patients. ‘The centuries-old traditional Chinese medicine practice of qigong, has potential to improve perceptions of healthiness, as well as physiologic measurements of health, among women at risk for type 2 diabetes.’ (Gates & Mick 2010, pp. 345-354) In a shared-decision-making environment, nurses can effectively help the patients in understanding their unique and individual problems regarding wound healing and other complications. The framework indicates the practitioner's role in diagnosing the problem, providing options, and screening for decisional conflict. Decision coaching involves assessing factors influencing patients' decisional conflict, providing support to address decisional needs, monitoring progress in decision making, and screening for factors influencing implementation. Informed patients share their values and preferences shaped by their personal situation. (Worldviews on Evidence-Based Nursing 2008, pp. 25-35) The slow wound healing in diabetes becomes a cause of unrest, irritation, and hindrance in carrying out everyday chores. As most of such cases are reported in older persons, therefore they are most likely to get into depression, mood disorders or hopelessness. Warren Gillibrand and Phil Holdich explain how practice nurses can help diabetics deal with stress or depressive illness. (2010, pp. 362-365) Wound healing is a slow, costly, and time consuming task. Therefore it becomes imperative to detect signs of recovery after a few weeks of treatment. This shall enable the health provider whether his/her approach is yielding the desired results or not. According to a study, within 4-weeks, it can be assessed, whether the ulcer is treatable or not. The treatment of diabetic ulcers is complex. The fundamentals of good clinical care include adequate off-loading, frequent debridement, moist wound care, treatment of infection, and revascularization of ischemic limbs (9). Even when properly managed, the wounds may not heal in a timely fashion. Foot ulcers that do not heal in an expedient amount of time are expected to be more likely to become complicated by intervening infection, hospitalization, and amputation and, thus, to be more costly because of the increased utilization of healthcare resources. (Sheehan, Jones, Caselli, Giurini & Veves 2003, pp. 1879-1882) Sometimes, amputation becomes imminent- Researchers have tried to find out such cases in which ulcers are not likely to be healed and thus amputation may be required. (Margolis, Taylor, Hoffstad & Berlin 2003, pp. 627-631) As more and more people are being diagnosed with diabetes, the role of the nurses has also been expanded. It has become one of the top most issues for public health sectors to promote awareness and initiate prevention programmes. The global research that has been carried out regarding diabetes and wound healing needs to be implemented and incorporated in the nursing practice. Preventing type 2 diabetes is now a public health priority. Nurses will be at the forefront of implementing and running future diabetes prevention initiatives. This article gives an overview of the evidence from evaluated diabetes prevention programmes, reviews different strategies for identifying high risk groups and highlights key strategies for communicating risk and promoting lifestyle change. (Yates, Jarvis, Troughton & Davies 2009, pp. 4-10) While the nature and intensity of wounds vary, nurses need to assess the individual requirements of treatment. Foot ulcers remain the main problem area and it needs to be dealt with according to the patient’s medical background, lifestyle, eating habits and age. Nurses should teach the patients to keep their wounds clean and protected. Open wounds are exposed to infections that shall further deteriorate its condition. The cost incurred on treating patients with diabetes and consequent wounds in the developed countries is sky-rocketing day by day. Foot ulceration is a common complication of diabetes. Gradual loss of sensation renders the foot susceptible to even minor trauma. Susceptibility to infection and peripheral vascular disease inhibit healing once injury has occurred and may lead to gangrene and amputation. The age-adjusted rate of lower-limb amputation is estimated to be 15 times higher in individuals with diabetes than in the general population (Armstrong et al, 1997). In the UK it is conservatively estimated that there are around 64,000 individuals with active foot ulceration at any time and 2,600 amputations annually in patients with a foot ulcer (Gordois et al, 2003). The cost to the NHS is around £300m per year. (Possnet 2008, pp.44-45) A study was conducted to assess the economical downside of diabetic patients with chronic wounds. Medical and pharmaceutical insurance claims associated with lower extremity diabetic ulcers were examined retrospectively to better understand the costs and duration of treatment in clinical practice. The study population consisted of working-age individuals (18 to 64 years old) with health care benefits provided through private employer-sponsored insurance plans. Diagnostic information contained in the claims database was used to identify the severity of the ulcers, and the charges associated with treatment were based on claims data. Claims for lower extremity ulcers were found in 5.1% of individuals with diabetes. Although many lower extremity ulcers heal with standard treatment, some are more resistant to treatment and require costly ongoing medical care. Almost half of these cases were associated with deep infection, osteomyelitis, or amputation. Total payments for treatment of lower extremity ulcers in this population averaged $2687 per patient per year, or $4595 per ulcer episode, with inpatient expenditures accounting for more than 80% of these costs. Costs were significantly higher for patients with more severe ulcers or with inadequate vascular status in the affected limb. We concluded that lower extremity ulcers occur in a large number of working-age people with diabetes and contribute significantly to the morbidity associated with this disease. The high cost of treating diabetic foot ulcers suggested by this analysis argues for the development of better treatment strategies and outcomes assessments for these patients. (Holzer, Camerota, Martens, Cuerdon, Crystal-Peters & Zagari 1998, pp. 169-181) . Slow wound healing can affect the long-term health and medical conditions of a person. Naturally, it also affects relationships and hinders professional and social commitments. Nursing practice should encompass all problem areas- physiological, psychological and behavioural. The slow or impaired wound healing negatively influences performance levels and achievement of goals, in personal, communal and professional lives. Having to live as an amputee is a nightmare for anyone. If a nurse detects that the wound is not responding to the treatment, the strategies should be changed. If it still does not show any sign of recovery, amputation may be needed. It is incumbent upon the nurse to inform the patient about the possibilities. By preparing the patient mentally, he/she would be enabling the patient to look beyond his immediate condition and rethink his/her future plans. A psychological approach in nursing practice can particularly help patients with diabetic wounds. Summing it up, the causes of diabetes are mostly genetic; or some medical, physical, psychological, environmental, or ethnic factors may also make a person diabetic. The treatment of diabetes is based on controlling glycemal levels that refer to the blood sugar. This is done by treating insulin deficiency. Though there are no specific medications for the treatment of wounds, only one agent has proven to be clinically effective: Recombinant-PDGF (Regranex[Becaplermin]; Ortho-Mcneil). Patients usually have to visit the health care providers for the treatment, dressing or removal of ulcers. Nurses have to deal with each patient according to the nature, intensity and the depth of infections. While most wounds are curable in a slow pattern, some are incurable to the extent that the limbs have to be imputed. Caring for chronic wounds is not only a lengthy procedure- it is costly as well. Though patients are required to visit hospitals or clinics for their follow up treatment, yet they should be imparted the basic knowledge about keeping their wounds clean and inspecting for further complications. Chronic wounds like foot ulcers require proper care like resting, and keeping off pressure from the affected limbs. Prolonged standing or walking can deepen the infection and worsen its condition. It might also prolong its healing. Such patients are recommended special shoes, casts etc. to support their affected limb(s) and carry out their daily activities. At each follow up visit, the nurse should inspect the wound closely and maintain its history. Optimally, a wound should start showing signs of recovery within 2 weeks. If this is not happening, then either the treatment should be modified or further examination should be made to find out whether it is curable or not. It is therefore, of utmost importance to monitor the condition of the patient according to the treatment and the changes in diet and lifestyle that he/she is making. Regular exercise is advised to diabetics, as obesity is another major cause of this disease. In case of wounds, walk or other exercise becomes difficult. Applying pressure on the legs and feet would worsen the ulcer; therefore, such activities need to be conducted upon the advice of medical experts. Minor skin problems may be symptoms of developing a wound, later on- hence they should not be ignored. Ischemia is not caused by diabetes but can aggravate as the skin of diabetic patients becomes excessively dry and cracked due to the non-functioning of the oil glands in the feet. Therefore, it is vital for such patients to keep their skin clean and moisturized. Leaving behind excess moisture should be avoided because moisture breeds infection. Foot soaking in normal tap water brings great relief to the patients with foot ulcers. The role of nurses is paramount in teaching the patients how to take care of their wounds and in deciding the mode of treatment. Patients usually find it very hard to make decisions pertaining to their treatment. By explaining the pros and cons of the recommended treatments, they can understand the nature of their disease. The training programmes being launched for the awareness of diabetes are mostly led by nurses. Communication with the people who are at higher risks of getting diabetes can prevent the widespread of this disease. Children and adolescents need to be made part of the prevention programmes in which they should be educated about diabetes and its complications. The psychological side effects are also tremendous and have to be addressed. The overall health and well being of individuals and the respective roles they play in their personal, social and professional lives are all affected by this medical condition. References Armstrong DJ, Lavery LA & LB, 1998, ‘Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation’, Diabetes Care, vol. 21 no. 5, pp. 855-859. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW & Karchmer AW, 1994, ‘Assessment and management of foot disease in patients with diabetes’, N Engl J Med, vol. 331, pp. 854-860 Di pietro LA & Burns AL 2003, Wound healing: methods and protocols. Humana press, New Meyer JS 1996, ‘Diabetes and wound healing’, Crit Care Nurs Clin North Am. Vol.8 no.2, pp. 195-201. Dunning T 2005, Nursing care of older people with diabetes, Blackwell publishing, India. 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