This paper will critically analyse the care of a patient with an acute exacerbation of a long term condition. It will address the importance of carrying out a holistic assessment and will seek to justify the care plan put in place to manage the patient’s condition. Confidentiality has been maintained in accordance with the Nursing and Midwifery guidelines (NMC 2008).
Tom is a 72 year old gentleman who was diagnosed with type 2 diabetes 15 years ago. He was started on medication to manage his diabetes 7 years ago but due to his worsening blood glucose control he has since been converted to insulin one year ago. Tom had been independent with the management of his diabetes with support from his local GP surgery. Recently he developed an ulcer on his right foot with resultant wound infection which made him unable to attend his surgery. Due to the wound infection he had been finding it difficult to keep his blood sugar levels within acceptable limits so he was referred to my caseload for diabetes and wound management.
Managing long term conditions has become a priority in healthcare particularly due to the increasing prevalence of diseases such as diabetes which requires a heavy use of resources (DoH 2007a, Singh & Armstrong 2005). There is a need to encourage patients to be as active as possible in their care which will help reduce the need for hospital admission through empowering patients and promoting self care. There is evidence that patients who understand their condition through support from healthcare professionals and are allowed to contribute fully in their care will result in less incidence of acute exacerbation (DoH 2006). However there has been difficulty in providing the on-going support and care co-ordination in the community that could prevent crisis events from occurring in the first place. This has lead to a key focus on the ways that this can be achieved in practice through such services as community matrons, rapid response and 24 hour district nursing services (DoH 2007b).
Relating this specifically to diabetes; the implementation of expert patient programmes and DESMOND (Diabetes education and self management for ongoing and newly diagnosed) have sought to reduce the incidence of acute exacerbations and diabetes related complications through patient education and empowerment (NHS Choices 2011a, DoH 2001a).
The government have placed the care required for those with long term conditions into three main groups; case management, disease management and self care (DoH 2007b). In this case, Tom required disease management of his diabetes and self care interventions.
Acute exacerbation can be defined as a medical crisis of a chronic illness (Strauss et al 1984). More recently it has been described as an acute presentation of an existing major illness (The Kings Fund 2010). In this situation Tom’s existing illness was diabetes and the acute presentation was the development of a diabetic foot ulcer that had become infected and affected his blood sugar control.
Recent statistics show that the number of people with diabetes has risen from 1.4 million to 2.9 million since 1996 and it is expected to rise significantly over the next 15 years (Diabetes UK 2011). The research also shows that diabetic foot problems account for more hospital stays than all other diabetic related problems put together and affect between 4-10% of diabetics (NHS Diabetes 2012, DoH 2001). Preventing foot problems in diabetics has been a priority in the UK over the past 10 years which has been highlighted in government publications such as NICE guidance and the National Service Framework for Diabetes (NICE 2008, NICE 2004, DoH 2001a). Despite these publications a survey carried out in 2007 found that 23% of diabetics did not receive a foot check which has contributed to the introduction of the ‘Putting Feet First’ Framework emphasising the need for appropriate assessment and management of diabetic feet (Diabetes UK 2011b).
Mason et al (1999) indicate that patients who are at high risk of foot complications must be identified. The National Service Framework for Diabetes supports this view and indicates that patients must have annual foot checks and access to specialist foot care clinics with timely referrals (DoH 2001b). In my area of practice we have an integrated care pathway in place for diabetic foot wounds that aims to provide the patient with optimal care. An integrated care pathway involves a multidisciplinary approach for a specific condition that aims to ensure a seamless approach to care and helps healthcare professionals make clinical decisions (Middleton, Barnett & Reeves 2001).
As soon as Tom was under my caseload, I referred him straight away to the local diabetic foot clinic as the NICE guidance for foot care states that patients with an ulcer should be referred within 24 hours (NICE 2004). It was important that Tom received specialist input quickly as he currently had a localised infection which placed him at risk of systemic infection and amputation if the infection was not resolved (Edmonds & Foster 2006). The foot clinic consisted of a team of podiatrists, Clinical Nurse Specialists in Diabetes, a Dietician and a Diabetologist. When Tom came back from his first appointment, he had already started on the integrated care pathway which we used as our primary documentation between services. This benefited Tom’s care as it improved the continuity and quality of the documentation (Roberts & Middleton 2000, Renholm, Leion-Kilpi & Suominen 2002). Also, due to having diabetes nurse specialists at the clinic this meant that his medication regime could be reviewed as well as receiving specialist foot care. The aim was to reduce his blood sugar levels as the hyperglycaemia was preventing his ulcer from healing and there is a general consensus that improving glycaemic control improves wound healing and prevents the risk of acute complications (Mcintoish 2007, Meyer 1996). Through Tom seeing the multidisciplinary team in one environment and by utilising the ICP, this prevented his care from becoming fragmented. Also due to having access to specialist clinicians in the field of diabetic foot management this enabled him to receive expert advice and care. This was evident in the management of his wound infection where judicious prescribing of antibiotics took place by specialist clinicians (Timmons et al 2009). This was vital in preventing any further deterioration in Tom’s health and managing the acute exacerbation.
Tom visited the foot clinic once a week and a wound care plan was constructed until a review needed to be carried out. This is where the importance of a holistic assessment took place taking into consideration the social, physical and psychological factors that impacted on the situation (Higgleton et al 1999). The research also indicates that the quality of holistic assessment is enhanced by ensuring the patient participates at all times (RCN 2004). By allowing Tom to contribute to the assessment process it enabled the care provided to become personalised and reflected his needs and not what we assumed them to be.
Firstly it was vital that we carried out a physical wound assessment on each visit to Tom using the assessment tool in the integrated care pathway. It was important that we used the same assessment tool with an effective understanding of its use as studies have shown that nurses fail to assess wounds effectively (Dowsett 2009, Mcintosh & Ousey 2008). Through using the integrated pathway it meant that all nursing staff were using the same assessment tools which ensured effective continuity of care.
Nixon et al (2006) found that those who had a diabetic foot ulcer were 5.1 times more likely to have been wearing poorly fitting shoes and this was evident in Tom’s assessment with the Podiatrist. In the integrated pathway it was documented that he had a high degree of peripheral neuropathy after an assessment was carried out and his shoes were ill fitting. The presence of neuropathy had contributed to the formation of the ulcer as Tom was not able to feel the damaging pressure on his foot caused by inappropriate footwear. This situation needed intervention so he had full assessment of his feet and given choices on available footwear that took into account his preferences. Holistic assessment was a key factor in ensuring concordance as the footwear that the Podiatrist wanted him to wear may not have been agreeable to Tom and he may have refrained from wearing them continuously as directed. This would have lead to a further deterioration in the ulcer condition but through effective partnership working they were able to come to a joint decision that was acceptable to Tom and the Podiatrist. This ensured that the assessment took into account his physical, social and psychological needs.
Preventing deterioration in the foot ulcer had started with the assessment of his feet and footwear but it required more intervention in the form of patient education. Valk et al (2005) found that providing patients with information and education positively influences their behaviour to take responsibility for their foot health. This meant ensuring that Tom carried out things such as regular skin care and nail care and empowered him to take ownership of his care (DoH 2001).The only difficulty with checking his feet daily was that he was unable to bend down to apply any moisturising cream to his feet which was dealt with by assessing his social support network. He did not have any close relatives but he made the decision to obtain a private carer to help him with this twice a week. Tom’s current active foot ulcer and increased education from the multi-disciplinary team on the high risk of amputation had enabled him to make an informed decision to prevent further deterioration.
Central to promoting the healing of diabetic foot ulcers is ensuring adequate nutrition (Thompson & Furhrman 2005) but often the quality of nutritional assessments carried out in practice are poor (Johnstone 2006, Cartwright 2002). NICE guidance clearly states that diabetics with foot problems should receive specialist dietary advice (NICE 2008). In the foot clinic Tom was able to be seen by a dietician who was able to carry out a comprehensive assessment and plan of care that would help improve his dietary lifestyle with the aim to improve his blood sugar control. A significant factor in the nutritional assessment was that it was ongoing whereby he would see the dietician every other week to determine his progress.
Tom had been managing his diabetes independently prior to his foot ulceration and it was vital that he carried on doing so where possible. Promoting self care was not simply providing Tom with relevant information and education about his condition; it was also about increasing his confidence (DoH 2009). Due to the uncontrolled blood sugars he had to be started on new insulin and he felt that he needed some support and supervision. A survey found that only 38% of diabetics received any psychological support during their care (DoH 2008) so it was at this point that we needed to provide him with the psychological and social support to sustain his self care. Together we were able to form a care plan that would be reviewed on a weekly basis. The district nursing team would visit him when his insulin was due to provide support and ensure he was injecting correctly.
The support given to Tom needed to be tailored to his requirements by ensuring that information was given in the correct format (Mcintosh 2008). Those patients who have lived with diabetes for many years often have some form of reduced eyesight secondary to diabetic retinopathy or maculopathy (NHS choices 2011b). In Tom’s care he had reduced eyesight but he was still able to read with prescription glasses. This assessment showed that he would benefit from written leaflets but this needed to be followed up with verbal consultations. I gave him the necessary leaflets on diabetic foot care but ensured that we enabled him to ask questions if he felt this was necessary when we visited him at home. The primary aim was to meet his needs effectively and create optimal self care through education and empowerment.
This assignment has critically examined the management of an acute exacerbation of diabetes with the assistance of a specialist foot clinic. Through timely referral processes, multidisciplinary input and the use of an integrated pathway it allowed the exacerbation to be controlled and managed in the community without the need for hospital care. This is particularly pertinent when the research describes the prevalence of diabetes and the intensive resources it frequently requires from secondary care to manage the acute complications of this condition. This episode of care has shown the positive effects of a specialist diabetic foot clinic which emphasises the need standardised care and access to this service across the UK. It has demonstrated how ‘joined up care’ in the community helps to ensure a seamless approach to patient care in relation to a long term condition.
This paper has also identified the importance of holistic assessment in the management of diabetic foot ulceration which ensures patient’s needs are fully addressed and assists them in achieving optimal self care. There needs to be an emphasis on educating and empowering patients but this must be provided in the correct format taking into account the patient’s requirements and literacy needs at all times.