Currently I am working in a nursing home where the elderly residents have various illnesses including the after effects of strokes and dementia. Due to their age and particular care needs the education for health support workers, senior carers and nurses who are at the centre of this care provision is fundamentally important. The aim of this assignment will therefore be the appraisal of this education, meaning their training and ongoing monitored development, with a specific focus on the prevention of foot ulcers in patients who suffer from diabetes mellitus.
This is an important area for consideration because at the moment health care support workers have no formal education in the prevention of foot ulcers in diabetes patients and can be ignorant of its symptoms. As with nurses it is reasonable to expect that they should have attained a certain level of knowledge in this area as the consequences of foot ulcers can be very serious and in cases can lead to amputation. This ultimately has a significant impact on the quality of life of the diabetes sufferer and the carer therefore has a duty of care to protect their patient against this preventable outcome. It should be noted that 85% of cases which end in amputation can avoided (Garay- Sevilla et al., 2002, 81-86).
In order to carry out this critical appraisal the first step is to consider the causes of diabetic foot ulcers, it signs and symptoms, treatment and prevention. The assessment of these factors is necessary because it deconstructs the knowledge required by health care workers and subsequently allows the provision of education to be accordingly evaluated for its accuracy and comprehensiveness. The next point to discuss is the current state of education on offer. This will be assessed in terms of how far it provides the level of knowledge needed by people who are in the position of diagnose and treat diabetic foot ulcers. Recommendations for best practice will then be make.
Causes of diabetic foot ulcer
One of the effects of diabetes is decreased immunity and poor wound healing. In the absence of normal blood flow specific lesions of the arteries, particularly in the extremities, can occur. Diabetic foot syndrome is one such complication and occurs in 15% of all patients with diabetes. These changes are a consequence of the existence of diabetic neuropathy. Motor neuropathy in diabetes leads to muscle atrophy and impaired co-flexors and extensors whilst also effecting deformation rate. Sensory neuropathy, sensory disturbance of pain by temperature and touch, increases the risk of injury which in turn contributes to the formation of ulcers. Autonomic neuropathy results in the formation of arterial venous fistulas and impaired blood oxygenation which leads to disorders affecting the trophic ulcers (Rubin & Peyrot, 1998, 81–87). The syndrome occurs in the later stages of the disease and is one of its most severe complications as it can lead to death. It manifests itself in complex changes in the joints and foot nerves, limb deformation, and deep tissue damage. It is also associated with damage to blood vessels, nerves, skin and bones. The initial abnormality takes the form of a pressure point which can be caused by, for example, ill-fitting shoes which cause blistering, cuts, and bites caused by foreign bodies. Vascular disease, resulting in decreased blood flow, contributes to poor healing and infections can be caused by numerous microorganisms (Manson & Spelsberg, 2004, 172–184). Patients who experience sensory disturbances find that pain is suppressed and consequently they might not recognize the seriousness of their situation leading to a delay in treatment. The treatment that is required must be prompt and responsible but it can also be protracted (Lustman et al., 2000, 934–943). Foot problems can affect anyone who has Diabetes regardless of whether they are being treated with insulin, non-insulin, tablets, injections, a controlled diet or physical activity.
Signs and symptoms of diabetic foot ulcer
In order that treatment is successful it is necessary that health care professionals and care workers can recognize the signs and symptoms of diabetic foot ulcers especially when caring for the elderly who are unable to detect the signs and symptoms. The main features of the disease include explicit sores, prolonged healing sores, changes in the shape of limbs, and, in later stages, gangrene. In the early stages symptoms usually coincide with complaints of fatigue which is accelerated by walking and standing, a sense of gravity, and freezing feet due to the deformation problems with wearing familiar footwear.
One of the most pressing reasons for a good standard of education in diabetic foot ulcers is the variety of forms it might take. This means that the health care worker must be able to recognize the condition in different scenarios. The neuropathic foot is the most common form with 70% of cases of diabetic foot falling into this category. It takes the form of a hot pink color with a palpable pulse and impaired deep sensation (Wysocki & Buckloh, 2002, 65–99). Another form is known as ischemic. This condition is caused by peripheral vascular occlusive. Diagnosis includes history (hypertension, hypercholesterolemia, smoking) and intermittent claudication. The foot assumes a cold bluish tinge and has no palpable pulse. The sufferer experiences a pain in motion and severe pain at rest (Lustman et al., 2000, 934–943). The final form is neuropatyczno-ischemic. This is characterized by the worst prognosis (Morisaki et al., 2004, 142–145).
The main course of action is to preserve the integrity of the skin. This is because the main danger lies in the wounds and fractures where if infection takes hold the result will be purulent inflammation and necrosis. Severe pain or numbness, sores, blisters, and peeling require the most urgent medical intervention because these can lead to gangrene and ultimately amputation of the affected limb. As the only quantifiable sign of inflammation, which indicates tissue lesions, is skin temperature it is necessary to used infrared thermometers. These can be used to determine the temperature of the skin in different areas of the foot. Dermal thermometers are also useful in the interpretation of the different phases of Charcot foot and in determining the most appropriate orthopodologic treatment in each phase. However, these are specialised tools and are unsuitable for carers to use nursing homes.
There is very particular method which should be implemented for assessing the health of a diabetes suffer’s feet. It is this type of information which should be included in an educative strategy used to train health care workers. Before measuring the temperature of the skin in the feet, the patient should be barefoot for at least five minutes before the examination to avoid a rise in temperature due to footwear or hosiery. The result should then be recorded. The next step is to repeat the measurement in the same area of the contralateral foot and compare the results obtained. This should be done for all the high risk areas. A difference in temperature of less than 2? c can be considered normal. Once infection has been ruled out, differences greaterthan2? C in diabetic patients are highly suggestive of Charcot activity. When the examination is done in a patient with Charcot foot and the difference is less than 2? C it shows that the acute period has come to an end. If the patient observes a difference in temperature greater than 2?C in self-examination on two consecutive days, he or she should contact a healthcare professional to determine the cause of the difference (www.diabeticfootjornal.net). Unfortunately there is no effective treatment for diabetic ulcers but reducing the load on the feet does offer hope of saving the affected limb. Alternative treatments can involve the use of hydrotherapy and ulcer surgery to remove necrotic tissue. Algorithm for the treatment of infected feet includes glycemic control (insulin), strain rates (shoe inserts, crutches, plaster casts), antibiotics and surgical procedures (drainage, incision, removal of dead tissue).
Prevention of diabetic foot ulcer
One of the most effective treatments is preventative. All patients with Diabetes Mellitus should be screened when there is a sensation of numbness or pain exists even if there are no visible lesions or ulcers (Morisaki et al., 2004, 142–145). The education of health care workers in foot ulcers therefore needs also to take into account prevention. Inspection of the stop should be performed as often as possible. If the skin of the foot shows sign of a scratch or crack you cannot use adhesive, alcohol or fat-containing ointments as these tools lead to further irritation. Redness or paleness, the presence of edema, blunting of the sensitivity, fungal lesions, and the overall deformation of the foot should be examined for deviations from the norm. If identified treatment should start immediately. In addition, from time to time, it is desirable to perform a neurological examination to determine the tactile, thermal, and vibration sensation of the foot. Angiographic diagnosis of vascular leg reveals the presence of thrombus. Basic steps can also be taken to prevent the occurrence of gangrene. These include the maintenance of desired blood sugar levels, the monitoring of the hygiene of the feet, making regular visits to an endocrinologist and follow their recommendations. (Clement, 1995, 1204–1214).
Good foot care
Education is important because good foot care has lots of pitfalls. Using the wrong cream, overcutting toe nails, walking barefoot, wearing the wrong shoes or socks can increase the chances of foot ulcers. It is necessary that the carer should be able to advise diabetes sufferers in all the dos and don’ts when it comes to looking after their feet in the proper manner to decrease the chances of contracting a foot ulcer in the first place (www.patient.co.uk). Some of these dos and don’ts are as follows;
In contrast to what might seem like common sense it is vital to avoid using items such as moisturising oils or cream designed for dry skin and the prevention of cracking.
Look out for athletes foot (common minor skin infection) as it can cause flaky and cracked skin
The space between toes can become sore and can become infected. It is essential to monitor this.
Cut your nails by following the shape of the end of the nail. Do not cut down the sides of the nails as this may cause damage or lead the nails to develop an ingrown nail.
It is important to wash feet regularly and dry them carefully, especially between toes.
Do not walk barefoot even at home
You right treads
Always wear sole or shoes or other footwear however don’t wear too tight socks around the ankle as they may affect circulation
Shoes, trainers and other foot wear should;
Fit well to make into accounts any awkward shapes or deformities
Have broad front and plenty of room for toes
Heels to avoid pressure on toes.
Have good laces, buckles to prevent movement and rubbing of feet in the toes
When you buy shoes, wear the type of socks that you usually wear
Avoid slip on shoes, shoes with pointed toes, sandals, or flip flops.
Always feel inside foot wear before you put footwear on to check for stores, rough edges etc.
Tips include avoiding food burns and water burns – checking the bath temperature with your hand before stepping in to it
It important to avoid using items such as hot water bottles, electric blankets or foot spas.
Do not sit too close to fires.
Further measures include looking very carefully at the feet each day including between the toes. This involves examining the area for reduced sensation in order to not miss any vital signs of the inset of a foot ulcer. It is also necessary to look for any cuts, abrasions, bruises, blisters, redness or bleeding. If any of these symptoms are spotted carers should immediately inform the nurse who is in charge who should in turn carry contact a podiatrist or similar specialist.
Existing education provision
To date education in diabetic foot ulcers takes several forms. NICE recommends that all people with diabetes should be offered structured education as an integral part of their diabetes management (www.nice.co.uk). The purpose of this is to raise awareness of the side-effects and complications of diabetes in those who suffer with it. This increases the chance for early identification of foot ulcer symptoms. The XPERT Programme was launched in 2007 to provide education to all health care professionals across Wales so they are able to give structured advice to patients with type2 diabetes. In addition the National Service Framework (NSF) (2001) for diabetes set out a ten year programme for change. It outlined evidence-based standards for the planning, organising, and delivery of diabetes services. This programme represents the Welsh Assembly’s strategy for improving diabetes and through the progressive implementation of the NSF the quality of care and treatment for those living with diabetes (www.wales.gov.uk). However within this long-term plan there is little direct reference to patients in residential or nursing homes. This is also the case with the Desmond, Dafne and Bertie programmes which have little relevance for the care of the elderly. Clearly there is a significant gap within the education of health care professionals.
This gap is apparent in the nursing home where I work as none of the staff have received any particular training specifically related to diabetes mellitus. This clearly puts the residents of the home in an at risk category because the chances of their carers recognising the early symptoms of foot ulcers are substantially reduced. Within the nursing home and home care system however there does exist a health care specialist with the expertise to assist in raising awareness about the causes and prevention of foot ulcers; the podiatrist. The work of a podiatrist is overseen by the Chiropody Code Of Conduct which states that chiropodists and podiatrists must be able to work, where appropriate, in partnership with other professional support staff, service users and their relatives and carers. They should also ‘be able to demonstrate effective and appropriate skills in communicating information, advice, instruction and professional opinion to colleagues, service users, their relatives and carers’ (Standards of proficiency, Health Professions Council, 2009). However, in practice this is frequently not the case. The health support workers are not currently included in visits and are not given the opportunity to learn or ask questions when the podiatrists are called to review residents. Neither do they pass on information about their findings to staff on duty. Evidently there is an issue of communication.
The podiatrist is not the only person with a professional duty to assist health care workers with their treatment of foot ulcers. The NMC code of conduct states that nurses should work with others to protect and promote the health and wellbeing of those in their care, their families and carers and the wider community. Therefore, the nurse in charge should ensure that learning opportunities are facilitated and that staff have feedback from these specialist visits which help to inform and improve the care delivered to residents.
Education – best practice
The current provision of education demonstrates that the education of health workers is largely at the discretion of their employers. If individual employers do decide to provide their staff with training there is little in the way of advice to follow and this can result in poorly informed, ill-conceived or simply inadequate education. At the same time it creates a situation whereby health care workers have to rely on experience gained on the job to identify the symptoms of foot ulcers or their own inclination to acquire further knowledge. For new members of the staff who lack experience there might exist a worrying amount of ignorance on the subject. There is however much potential to improve this situation.
In best practice education takes a variety of forms. This may include formal study sessions, workplace booklets or posters and online education programmes. Therefore there is potential for foot ulcer education to be flexible and made to suit the particular needs of a workplace. At my workplace none of these options have been made available. Ideally the best situation would be a formal study session where the expert knowledge of a specialist can be imparted and where full training can be given. The information gained should then be reinforced at the workplace through posters or leaflets.
Conclusively it is very important that diabetic foot ulcers are prevented at all times while treating patients with diabetes, especially in the elderly who might for other reasons associated with dementia and impaired movement find it harder to care for themselves. Education of health care professionals is key in achieving this. They should have the necessary knowledge to help prevent foot ulcers, to recognise the first symptoms of one, and to provide effective treatment. They must also be able to advise the diabetes sufferer on how to care for their feet and how to avoid the contraction of a foot ulcer in the first instance. Despite this clear need for knowledgeable clinicians the situation as it currently stands fails to provide health care workers who look after the elderly with the training they require to the provide the best standard of service possible. Whilst measures are in place for the education of both diabetic sufferers and nurses, more work needs to be done on identifying the educational requirements of those who care for elderly patients. Best practice in education should be drawn upon and formal training sessions organised alongside the better provision of information within the workplace. The expertise of specialists such as podiatrists should also utilised more effectively so that staff within the nursing home are well informed and understand the treatment their patients are undergoing and their specific needs. Communication is at the heart of this.