Foot Problem Found in Diabetes Type 2 - Essay Example

Nursing case study assignment Of an A 72 year old male with a forefoot amputation associated with diabetes type 2 Foot problem found in diabetes type 2 – An introduction: The diabetic foot problem is one of the major complications found to occur in a larger fraction in diabetic clinical practice, with the development of foot ulcer contributing to greater percentage of hospital admission among patient the with diabetes. (Reiber etal., 1998) The global prevalence of diabetes by 2003 was estimated to be 194 million that is predicted to be 366 million by 2030. With more than half of limb amputation occurs in diabetic patient, 7 to 20% of diabetic foot patient undergoing amputation.(Frykberg,1998) Additionally it is noted that diabetes induced limb amputation that results in 5 years mortality of rate of 39% to 62%, with an additional reflection on the patient’s lifestyle- quality of life and survival rate.(American Diabetes Association,1999) In nutshell, the term "diabetic foot disease" (DFD) could be accounted for a spectrum of diseases, that would encompasses components of the tissues that involves the foot of a patient with diabetes. This includes structures as the skin, the soft tissues, and the osseous structures of the foot. Further, it requires the patients with diabetes to routinely undergo assessment for the presence of subtle or overt foot disease. The diabetes related foot amputation of 72 years old male would definitely have an impact on his life style, starting from mental dilemma to asking for help to effectively do his every day’s activity. The context of care in this case would be palliative care setting – comfort care, given with the goal to provide both cure and comfort to maintain the highest possible quality of life for as long as the life remains. In modern terms care of persons ages above 65 encompasses palliative care and geriatric care depending on the patients conditions as an interdisciplinary approach. This can be provided in both home care settings, given that the old man has an at tender at home who can attend to him round the clock or in hospital setting – that would be in the outpatient clinic. He decision also further depends on the patient’s physical status if he is prone for further complication and if there is a feeling that home care would not be effective in containing then palliative hospital care setting would be more advantages. So the overall care team in the hospital would involve physical practitioner, nurse practitioner and other technicians. The nurse practitioner in this scenario has a range of activities from attending to the physical treatment and providing mental stability. (Boulton, 1997) (Ramsey etal, 1999) Pathophysiology and symptoms: It is well known fact that the diabetic food syndrome is a consequence of long standing diabetes – a chronic complication of peripheral neuropathy and peripheral vascular disease effecting lower limps. (Murray & Boulton, 1995)The peripheral neuropathy for instance brings about the complications by diminishing the sensitivity to external trauma thus exposing boning prominences to high pressure, which eventually leads to chronic food ulceration. The peripheral vascular disease in turn interferes with the healing process of ulcer by diminishing the amount of tissue oxygen and nutrients thus lengthening the healing time. The ischemic ulcer is further prone to bacterial colonization that further complicates the superficial or deep infection into osteomyelites. Thus these 3 components – Peripheral neuropathy, PVD, infection added with the trauma leads to the progression of pathology from non ulcerated condition to acute syndrome of diabetic food ulcer that on ultimate stage results in amputation. (Abbot etal2000) (D’Ambrogi etal, 2003) (Giacomozzi etal., 2002) Diagnosis and ongoing tests: It is a common finding that 15% of patients with diabetes develop DFS at least once in the lifetime. Of this, peripheral neuropathy accounts to 50% of patients and PVD to 40% of patients. In reference to international consensus guideline, the risk profile for diabetic food ulcer is neuropathy, vascular sufficiency, presence of deformities and previous amputation or ulcer. The various findings at the level 1, Medical history – duration of diabetes, management other complication, social habits, ulcer history – location duration, recurrence, infection, previous foot trauma or surgery. Dermatological – Erythema, warmth, cellulitis, ulcer, tropic changes. Musculo skeletal – Swelling, deformity, joint mobility and joint dislocation. Neurological – Degree of neuropathy assessed by Semmes – Weinstein monofilaments, vibratory, propreoseption. (McKenly etal.,1995) This step helps to find the level of sensitivity of monofilament to the pressure thus identifying the level of risks. The same concept is applicable to vibratory perception threshold also. The tests helps in evaluating the effects of therapy’s and also in predicting the evaluation of pathology, as it is possible that the fibers that are responsible for vibratory component of sensation, that is more myelinited and involves in metabolic derangements – the typical nature of diabetic neuropathy. Vascular – Absent are Asymmetric pedal pulse, dependent rubor, Gangrene. The peripheral vascular disease that is assessed by testing peripheral’s pulses are also at time quantified by measuring toe and ankle pressure, to calculate the ankle/brachial pressure index (ABPI) a ratio between highest systolic pressure at ankle and systolic brachial pressure. A value greater that .9 indicates a normal condition where as value between .9 to .5 indicates presence of PBD and value less that .5 indicates critical limb ischemia suggest an amputation. (Young etal., 1994) Non-invasive vascular studies – Arterial Doppler and transcutaneous oxygen tension – a precise evaluation of concentration of oxygen present in the determined area that in turn depends on the amount of blood in the area. When the pressure is less than 60 mmHg is indicative local ischemia and values less than 40 mmHg indicative of critical ischemia. Laboratory test – Complete blood count with differential ESR, CRP, blood glucose, HbA1c. Diagnostic imaging – Plain radiograph, imaging studies, CD, MRI, bone scan. Radiographic findings – Bone density, joints bones involved, deformity, osteolysis, fracture, dislocation, soft tissue edema, and vascular calcification. The deformity of the foot present or not present is an indicator of ischemia the degree of motion of joints tested also shows whether the bone and joints can withstand the hyper pressure thus showing the ulceration risks stage. Based on these tests ulcerative risk score according to the international guide lines laid, there are 4 different class as 0 (no risks) to 3 (very risk), the patients with higher risks follows more closely. These tests as explained are the tests to be done to assess the state of ischemia and diabetic ulceration seen in the patient. (Cavannah etal., 1994) Developmental consideration for the patient in the above case study: With almost half of all lower leg amputation performed in patient in that test, most amputation are found to cause its effect physically, mentally, psychologically and socially.( Lakartidningen,1999) According to the theory of Erickson’s model of psychosocial quality is very essential and significant and meaningful concept. Erickson in his psychosocial theory developed 8 stages of human being effectively describing their psychological – mined and social – relationship attributes. He believed that psychosocial principle is genetically inevitable in shaping human development. He divided his stages as syntonic (trust) versus dystonic (mistrust). On reference to the Erickson’s psychosocial model the 72 years old male patient falls in this stage 8 where integrity versus the despair is the stage, the late adult life stage. The relationship involves 2 levels with society, the world and life. The issues they have among them is searching for meaning and purpose of the life they have lived, at the same time going through the achievements in their life. The basic virtue and strength in this stage is wisdom and renunciation. The mal adaptation or malignancy – the negative outcome in this stages resumption and disdain. To assess how the person would pass though each crisis successfully could be assessed by calculating the healthy ratio or balanced between to opposing disposition that represents each crisis. In this stage the patient goes through the opposing phase of integrity and despair. As a part of integrity the patient might have wisdom and renunciation as calmness, tolerance, appropriate emotion detachment, no regrets, peace of mind, non-judgmental, spiritual, and acceptance of facts – self actualization. on the negative side the patient might undergo stage of perception – despair and distain as unrealistic and uncaring deluded spoilt, conceited, pompous, arrogant resulting in miserable un fulfilled and blaming condition. Thus by effectively interacting with the patient nurse practitioner can understand in what phase of psychosocial crises stage the patient is undergoing as either syntonic or dystonic. The duty of nurse practitioner would be strike at the right balance between the conflicting extremes and focusing on the idle or preferable situation. Erickson describes this stage as a review or closing stage with integrity feeling peace if they look back their life positively and disgust if they feel they have wasted their life. (Erickson etal., 1983) (ADA, 1999) Ongoing Nursing Care and management of the disease: When treating diabetic foot ulcer, awareness of natural history is very important. The diabetic foot can be of 5 stages from normal, high risk, ulcerated, infected and necrotic foot. The management of all the 5 stages especially from 3 to 5 demands urgent, aggressive multi disciplinary management to control mechanical, wound, micro biological, vascular, metabolic and educational aspect. Achieving good metabolic control of blood glucose lipids and blood pressure is preliminary important with an education to teach proper foot care. The intervention in each stage would be different in stage. In stage 3 relief of pressure – mechanical control and sharp debridement and dressing (wound control) and vascular control being important, in stage 4 microbial controls is crucial, treatment with intravenous antibacterial. In stage 5 if necrosis is wet, it would require intra venous anti bacterial and surgical debrediment. In uncontrolled stages, amputation results. The patient would be given drug therapy to control the infection and necrosis stage, aetiological diagnosis of each patient, assessment by physician and nurse, all above described diagnostic search, reduction of pressure etc. apart from this now there is growing awareness of considering individual patients own perspective, leading to psychodynamic treatment. researches have proved that physical illness is a important stress factor and a number of factors have to be consider experienced by patient, relation of degree of depression rd before intervention as how the patient perceives his illness, impact of illness on patients life. A research undertaken by Nazaime Kocaman etal showed that, in daily clinical practice of patients with physical illness, the negative perception of the illness to be addressed with psychosocial support. (Rubin, Peyrot, 1999) The collaborative care- role of nurse practitioner: In treating the patient, nurses apart from the regular, diagnostic procedure, treatment regimens etc in case of a hospital care setting, the nurses can also concentrate on the psycho social aspect. Essentially the management team would include a diabetologist, podiatrist, anesthetists, laboratory technician, nurses and health professionals. The nursing intervention in those cases would mainly be On routine base Establishment of standardized assessment and document tools for diabetic foot ulcers Dressing choices for local wound care Effectiveness of adjunctive therapies to promote wound healing Effectiveness of various devices utilized for pressure redistribution/offloading Health delivery issues (government support and funding of programs and treatment for diabetic foot ulcer management, cultural beliefs, high risk patient populations) Impact of sharp/surgical debridement on wound healing Impact of education on healthcare provider and specific patient outcomes (ulcer healing/reoccurrence) On psycho social nature: Facilitation: Helping client identify, mobilize and develop personal strengths in moving toward health. Nurturance: Gently supporting and encouraging client to integrate all biophysical, cognitive and affective processes in movement toward health Unconditional Acceptance: Using empathy to fully accept person as worthy with no strings attached. Build Trust: Through nurse-client relationship; keep promises, meet basic physical and safety needs through being truthful and trustworthy; use touch and boost esteem needs, through affirming comments about strengths. Promote Positive Orientation: In other words, accept client as worthwhile and facilitate ability to project oneself into a positive future through making comments about events that might occur next week, etc. Promote Control: In other words, perceived control is the key; ask what client needs and how you can help; offer options in plan of care; recognize small accomplishments such as breathing evenly, control bleeding. Affirm and Promote Strengths: Comment on small strengths, e.g., strong pulse, ability to void, to walk from bed to chair. Set Mutual, Health-Directed Goals: Involve client in developing health directed interventions that fit within his or her model of the world The patient may require several sessions of supportive psychotherapy and education to help him accept his illness, the need for treatment, and the importance of developing a compliance plan. In this case, treatment of the patient’s depression, helplessness, and overwhelming anxiety lead to an increase in motivation for treatment, improved compliance, and hopefully resulted in a better long-term outcome Preparing for future course, by discussing how to live with amputation and providing tips and practices. References: 1. Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg. 1998;176(2A Suppl):5S-10S. 2. Frykberg RG . Diabetic foot ulcers: current concepts. J Foot Ankle Surg. 1998;37:440-446. 3. 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Giacomozzi C, Caselli A, Macellari V, Giurato L, Lardieri L, Uccioli L. Walking strategy in diabetic patients with peripheral neuropathy. Diabetes Care. 2002;25(8):1451-1457. 10. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999;341(1):738-746. 11. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol. 1994;130(4):489-493. . McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Diabetes Care. 1995;18(2):216-219. 12. McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Diabetes Care. 1995;18(2):216-219. 13. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. 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Diabetes Metab Res Rev 1999;15(3):205-218. 20. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care 2001;24(6):1069-1078 Read More