Nursing Management of Diabetic Foot

This article discusses the nursing management and dressing of diabetic foot.

Introduction

Reports from the World Health Organisation (WHO) indicate that by 2000, the number of patients suffering from diabetes had reached 171 million, with the figure being prospected to escalate to 380 million by 2025 (WHO, 2016). Existing evidence demonstrates the sub-sequential consequences that have prevailed on the patients, healthcare providers, and the community. To patients, for instance, Diabetes malady leads to excess glucose (a type of sugar) in their blood. As time moves by, the surplus content of glucose in the blood damages the body’s organs. Conceivable impediments include damage to small (microvascular) and large (macrovascular) blood vessels, contributing to stroke, heart attack, and complications with the gums, nerves, feet, kidneys, and eyes. Therefore, the solution to this menace can only be attained through close interrelationships between people and health systems. Previous studies have also gone further into proving that of all diabetic patients, 15% of them will suffer from diabetic foot ulcers throughout their entire life. Diabetic patients find this type of ulcer the most common cause of hospitalization.

It is worth noting that whenever adequate care is not availed for diabetic foot ulcers, severe conditions, which include gangrene, other infections, amputations, and even death, may result (McDermott, 2016). Risk factors associated with the progress of diabetic foot ulcers are older age, cigarette smoking, infection, poor glycemic control, ischemia of small and large blood vessels, previous foot ulcerations or amputations, diabetic neuropathy, and peripheral vascular disease. Previous antiquity of foot  disease, foot malformations which create a strangely weakened ability to look after personal care (for example, visual impairment), renal  failure, oedema, and high-pressure forces are further risk factors concomitant with diabetic foot ulcers. It has been documented that the amputation rate of the lower limbs in non-diabetic patients is generally 30 times lower than that of diabetic patients; it has again been proven that diabetes results in one leg being amputated every thirty seconds worldwide. Generally, the patient is at a 50% risk of undergoing a second amputation two years after the first amputation. About three years after the lower limb amputation, death occurs in more than 50% of the patients.

Benner Novice Theory

Dr. Patricia Benner, a nursing theorist, formulated a model of the stages for clinical competence (Benner, 2001) as documented in her book, “From Novice to Expert: Excellence and Power in Clinical Nursing Practice.” This is what later adopted the name Benner Novice Theory. The first stage is referred to as Novice. Usually, the student here is in his/her first year of education. Such students have very limited potential to predict the possible outcomes of patients in particular situations. Such a student can recognize complex signs and symptoms, including mental status variations, only after exposure to patients with similar signs. In the second stage, the student graduates to an advanced beginner. Here, they have already gained relevant and adequate experience to distinguish meaningful and recurrent compositions of a patient’s situation. However, although they have already grasped substantial amounts of knowledge and knowledge, they are still in a deficit of adequate in-depth experience (Utley, 2010).

In the third stage, they must acquire relevant competency (Siviter, 2013). Though the student is now sailing towards nursing excellence, the main hindering block at this stage is the lack of flexibility and speed required by a proficient nurse. They have, however, mastered relevant skills in the art of advanced organisation and planning. However, they need to recognize the nature and patterns of clinical situations quicker to distinguish themselves from advanced beginners. The student now becomes proficient in the fourth stage. Here, they can integrate situations wholly rather than partly (Fitzpatrick & Wallace, 2006). Proficient nurses can make modifications to plans as a way of responding to different situations. At the same time, they can tell the events that are to occur based on past experiences.

The fifth and final stage is where the students become experts in the field. Here, the nurse can attain his/her goals by recognizing the demands and resources to apply in particular situations. Such a nurse knows exactly what is supposed to be done and, therefore, no longer relies on rules for guidance whenever taking action in any situation (Masters, 2014). Based on their deep experience and knowledge, they have already grasped the go about any kind of situation that may prevail. They have again learned to focus on situations that are of great relevance while at the same time dedicating less focus on irrelevant situations. Whenever they are in a deficit of experience, most probably due to the occurrence of a new event, or when events occur contrary to expectations, expert nurses embrace the use of analytical tools to get the way forward in terms of the directions to adopt in such a situation (DeLaune, Ladner, McTier, Tollefson, & Lawrence, 2016).

Clinical project for Nursing Management of Diabetic Foot

 The main aim of this project was to identify the various factors that cause foot infections in diabetic patients. Also studied are the various factors that are the chief drivers of the development of diabetic foot ulcers. Various prevention methods were identified, and patient education was identified as the most effective way of caring for the diabetic foot. Appropriate resources were reviewed to develop relevant information to boost the project’s success. In connection to this, the reviewed articles were Wells, C. (2015, September). Orchestrating Healing: a Grounded Theory of Registered Nurses Caring for Patients with Diabetic Foot Ulcers, McDermott, A. (2016). Diabetes and amputation. Healthline, amongst other books.

For any person suffering from diabetes, the blood sugar or blood glucose levels are too high (Ruhl, 2017). With time, such high levels cause damage to blood vessels or nerves. Diabetes-instigated nerve damage causes one to lose feeling in their feet completely, and as a result, such individuals may not feel a sore, blister, or even a cut (Holt, 2009). Such foot injuries are the key causal factors of infections and ulcers. It is of great significance for individuals and, more precisely, diabetes patients to seek medical intervention upon noticing such sores, as serious cases would even result in amputation of the limbs. Damage caused by blood vessels also means there is no proper circulation of oxygen and blood; hence healing of the foot may prove hard. Treatment efforts are also rendered fruitless as poor blood circulation sees to it that antibiotics ingested do not get to the infection site. Once a person has developed such diabetic foot problems, it is of great significance that they receive intensive nursing care to propel the healing of their condition in relation to quality nursing care.

There are several key compelling factors towards diabetic foot problems, the key being the type of footwear an individual uses (Nather, 2008). Poorly fitting shoes are the leading factors towards the same. With blisters, corns, sore spots, consistent pain, calluses, and red spots in the legs, with the pre-mentioned being directly attributable to poor footwear, new shoes that are properly fitting must be obtained immediately. Poorly controlled diabetes, which could be long-standing, greatly increases the risks of such individuals suffering from peripheral neuropathy. Many infections also trigger diabetic foot problems (Edmonds, Foster, & Sanders, 2008). Serious bacterial infections, just a fungal infection, could emanate from Athlete’s foot. Toenail fungus should be treated with immediate effect and is to be avoided by involving a foot specialist in handling ingrown toenails. It is also worth noting that any form of tobacco that is smoked damages blood vessels in the legs.

Observations have been made that in the prevention of lower limb amputation and, generally, foot ulcers resulting from diabetic conditions, nurses play an important and equally effective role by running educational intervention programs, screening people deemed to be at higher risks, and provision of health care. It is of great significance that all diabetic patients and more-so those at higher risk of acquiring foot ulcers familiarize themselves with the necessary basics of good foot care. Research has shown that nurse-provided patient education regarding adequate foot care has effectively managed diabetic foot (Bulechek, Butcher, Dochterman, & Wagner, 2013). Nurses can therefore offer teachings on conducting daily feet examination and care. Nurses also must encourage diabetic patients to routinely clean their feet and carry out continued care on their skin and nails. Nurses are, however, supposed to evaluate the specific requirements of individual patients and, as a result, design specified educational programs to offer to the patient in question and their families. They can additionally induce the patient’s family members to actively participate in the education program to capture the essence of visiting the clinic regularly, taking blood tests at regular intervals, and how to prevent diabetes complications (Wells, 2015). The table below outlines the basic diabetic foot care principles gained through nurse education to patients.

Table 1: Basic principles of diabetic foot management

ü  Daily examination of feet for swellings, discoloration of the skin surface, cracks on the skin, numbness, and pain.

ü Implement self-help techniques such as using mirrors to aid in examining feet.

ü  Maintaining proper foot hygiene by washing feet and then drying them properly between the fingers daily.

ü Regulate the water temperature to ensure it’s appropriate before dipping the foot in for washing.

ü  To always wear socks before wearing shoes and avoid walking bear footed.

ü  To make choices of shoes that are fitting. The afternoon is the most appropriate time for making purchases of shoes.

ü  Fingernails are to be cut directly and regularly.

ü  Foot lesions, e.g., corn, should not be manipulated at all costs.

ü  Creams rich in moisture should be applied on dry surfaces to keep them moist but exempting between the fingers.

ü  Whenever they note any reduction in visual acuity, they should seek professional help.

 

There are three major contributors to diabetic foot ulcers: peripheral vascular disease, infections, and peripheral neuropathy (Latov, 2006). The pre-mentioned factors are the major causes of amputations and gangrene. 80% of diabetic foot ulcers are, however, solely caused by peripheral neuropathy (Lavery, Peters, & Bush, 2010). Therefore, nurses in the foot care specialty are involved beginning from the early stages of treatment and care. Some major roles they indulge in include offering education, examination & screening, and wound dressing. Screening is primarily aimed at detecting diabetic foot problems early, identifying those at risk of foot ulcers, and reducing the overall number of patients. The table below outlines the steps to dressing a diabetic foot ulcer (Shai & Maibach, 2004).

Table 2: Dressing of a diabetic foot ulcer.

        i.  Prepare a whirlpool bath and dip the foot in it.

      ii. Using a catheter and syringe, wash away the dead tissue in the ulcer.

    iii.  Apply wetness to dry cotton wool and use it to remove dead tissue from the ulcer.

    iv. Apply enzymes on the ulcer to help dissolve dead tissue found on the wound.

    v. On the ulcer, apply special maggots that will eat away only the dead skin and simultaneously produce chemical substances to aid in healing the culture.

    vi.   Dress the wound using a clean and treated bandage.

  vii.    The dressing should be changed at least twice per day.

 From the above studies, it prevailed that a change process was necessary to effect appropriate care. The most significant change that ought to be implemented with immediate effect was to offer additional education by means of introducing short courses to nurses directly involved in the nursing care of patients with diabetic foot ulcers. Additionally, nurses should embark on home-to-home visits for diabetic patients to educate them on the basic management practices for diabetic foot. Home-to-home visits will prove more effective as the nurses involved will reach out to most patients, including those who previously never attended clinics.

Conclusion

Diabetic foot, the main trigger of hospitalization of diabetic patients, has been identified as a major concern in the health care systems. Individuals suffering from this disease frequently develop diabetic neuropathy owing to numerous neurovascular and metabolic factors. Peripheral neuropathy leads to loss of feeling or pain in the feet, legs, arms, and toes because of low blood flow and distal nerve impairment. Sores and blisters appear on numb sections of the legs and feet, such as metatarsophalangeal intersections and heel part. Consequently, injury or pressure goes unobserved and becomes the entry gateway for infection and bacteria. In addition to playing their role in public education, health care, management of health systems, improvement of life quality, and caring for patients, nurses who are members of the team involved with diabetes care should fully attend specialized training. This will help them embark on the implementation of the latest instructions concerning diabetic foot care in a bid to enhance the effectiveness of their services in the promotion of the health of diabetic patients. This, therefore, calls for short-term training courses to educate nurses on how to enforce algorithms and clinical guidelines for diabetic care in hospitals and clinics.

Bibliography

Benner, P. E. (2001). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Prentice Hall.

Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. (2013). Nursing Interventions Classification (NIC)6: Nursing Interventions Classification (NIC) (Revised ed.). Elsevier Health Sciences.

DeLaune, S. C., Ladner, P. K., McTier, L., Tollefson, J., & Lawrence, J. (2016). Fundamentals of Nursing: Australia & NZ (Revised ed.). Cengage AU.

Edmonds, M. E., Foster, A. M., & Sanders, L. (2008). A Practical Manual of Diabetic Foot Care (2 ed.). John Wiley & Sons.

Fitzpatrick, J. J., & Wallace, M. (2006). Encyclopedia of Nursing Research. Springer Publishing Company.

Holt, P. (2009). Diabetes in Hospital: A Practical Approach for Healthcare Professionals. John Wiley & Sons.

Latov, N. (2006). Peripheral Neuropathy: When the Numbness, Weakness, and Pain Won’t Stop. Demos Medical Publishing.

Lavery, L. A., Peters, E. J., & Bush, R. (2010). High-Risk Diabetic Foot: Treatment and Prevention (Illustrated ed.). CRC Press.

Masters, K. (2014). Nursing Theories: a Framework for Professional Practice. Jones & Bartlett Publishers.

McDermott, A. (2016). Diabetes and amputation. Healthline. Retrieved 06 07, 2018, from https://www.healthline.com/health/diabetes/diabetes-amputation

Nather, A. (2008). Diabetic Foot Problems. World Scientific.

Ruhl, J. (2017). Blood Sugar 101: What They Don’t Tell You About Diabetes (Vol. 1). Pronoun.

Shai, A., & Maibach, H. I. (2004). Wound Healing and Ulcers of the Skin: Diagnosis and Therapy – The Practical Approach. Springer Science & Business Media.

Siviter, B. (2013). The Student Nurse Handbook3: The Student Nurse Handbook. Elsevier Health Sciences.

Utley, R. (2010). Theory and Research for Academic Nurse Educators: Application to Practice. Jones & Bartlett Learning.

Wells, C. (2015, September). Orchestrating Healing: a Grounded Theory of Registered Nurses Caring for Patients with Diabetic Foot Ulcers. ResearchGate. Retrieved 06 07, 2018, from https://www.researchgate.net/publication/281971866_Orchestrating_Healing_a_Grounded_Theory_of_Registered_Nurses_Caring_for_Patients_with_Diabetic_Foot_Ulcers

WHO. (2016, 04 07). Diabetes: Global Report on Diabetes. Retrieved from World Health Organisation: http://www.who.int/diabetes/global-report/en/