Diabetic Foot Ulcers in a Smoker Patient - Assignment Example

Diabetic Foot Ulcers in a Smoker Patient Abstract Diabetic foot is one of the common yet preventable complications of diabetes that shows increased risk of development because of the presence of certain risk factors. These risk factors include smoking as the highest contributing factor, due to the negative effect on the vascularity of the body. Identification and proper prevention and treatment are essential in the prevention of diabetic foot. Also routine checkups and awareness programs are needed in order to prevent such rates from increasing. There is an expected increase in the future cases of diabetes around the world and concomitantly the complications associated with diabetes. This makes the prevention of further cases all the more important due to the increased morbidity and mortality rate associated with it. Part one: Factors Affecting Health of a Diabetic as Well as a Smoker Patient with a Diabetic Foot Diabetes is one of the most common and most serious types of disease known to man. It is also one of the most costly diseases in the world because of lack of definite treatments and life long modifications in the patients’ life. Up to this date, there is no treatment for diabetes. Diabetes can only be prevented or, if diagnosed, directs to lifelong medications. Refraining from carbohydrate rich diets are also recommended. Patients of diabetes are more prone to diseases as their overall immunity decreases significantly and normal illnesses can become significantly complicated should a careful planning not take place. Many complications of diabetes are entirely preventable, provided that proper treatment regimes and preventive techniques are followed through. There are many risk factors that can lead to diabetes in patients. Diabetes in turn can lead to significant changes in a person’s life style, and can cause conditions such as cardiovascular disease, renal disease and retinopathy among the few. There are 1.4 million diagnosed cases of diabetes in the UK alone. The life expectancy of the patients can reduce between 10 to 20 years depending upon the risk factors added in the patient’s lifestyle and the effects due to poor management of the condition. (PSNC, 2002) The number of cases is expected to grow with time, as more and more people are opting for a more sedentary lifestyle along with reduction of exercise. The most common risk factor for diabetes is obesity, which is followed by alcohol and cigarette smoking. Obesity affects the production of insulin production as the pancreas is not able to produce adequate quantities for the entire body. Also obesity increases the resistance of insulin uptake and utilization. The increase in the body weight along with contributing factors such as hypertension, alcoholism, and poor quality of life, increase the risks of diabetes many folds. Smoking and diabetes is a lethal combination. Even greater risks are involved in this combination. Patients with diabetes constantly put an effort to manage their blood glucose, blood pressure, and cholesterol in order to stop complications. Unfortunately, smoking reverses all the processes and further decreases life expectancy and quality of life. Some of the health risks of smoking, which already are associated with diabetes, are: Heart attack, as smoking reduces the availability of oxygen and patients with diabetes who smoke are three time more likely to suffer from heart attack or stroke; smoking raises blood sugar, blood pressure, and cholesterol levels; it can also affect kidneys and nerves. But most importantly it causes damage and constriction of blood vessels. This damage leads to foot ulcers, peripheral vascular disease and leg and foot infections. Our blood vessels are coated with a thin layer of cells that ensure smooth blood flow. Carbon monoxide from smoking costs this important layer of cells, allowing fats and plaque to fasten to vessel walls. When nicotine reaches the brain immediately stored fats are released. These fats stick to vessels walls damaged by toxic carbon monoxide and cause Peripheral vascular disease. And, diabetes multiplies it. Peripheral vascular disease is a movement disorder. Sequentially, it takes longer for infections to heal and due to this lack of blood risks for developing ulcers or gangrene increases. Diabetic foot is one of the most serious and at times life threatening conditions that is entirely preventable if proper prevention care is given. Usually, this area of healthcare instruction goes unexplained. This may be due to the lack of knowledge about the condition on the patient’s behalf or the erroneous assumption on the physician’s behalf that the patient already knows about the potential complication. Only and only prevention and care can ensure that diabetic foot does not occur. Therefore such patients are constantly advised to keep watch on any changes that seem to be taking place in the foot and that are out of character. Mostly the complications and types of clinical presentations are divided in to two broad categories; the neuropathic foot and the ischaemic or neuroischaemic foot. Presentations for each show variation, but most common signs include redness and swelling of the foot, pain, discoloration, crepitus, or a painful, pulse less foot. All these presentations warrant emergency admission and surgery. Immediate surgery can save the patients foot from amputation in lesser cases, and may even save his or her life in serious life threatening cases. (Peter J, Watkins, 2003) The decrease in blood supply and the decrease in the neurological transmission complicate and slow any wound healing process that may take place in the foot. This is one of the main reasons why diabetic foot must be dealt with as soon as possible. The development of diabetic foot ulcer, although considered as a less frequent complication of diabetes, is not so infrequent at all. Around 10% of the diabetic patients around the world are expected to suffer from diabetic foot, therefore, the problem is not only an economical issue for the healthcare facilities around the world, but also mean significant morbidity and mortality risks, along with serious changes in the life style of the patient, which may not be a happy state for him or her. Also, the concern is increasing as patients who have experienced one episode of diabetic foot may undergo repeated problems time and again, whether due to the same wound or due to a new one. The aggravation for the patient is very hard to describe in words. (Newrick, 2000) The effect of smoking on the wound healing of a diabetic patient has been extensively documented. The two effects that smoking causes on the wound healing are hypoxemia and hypoxia. Many of the components in the smoke are toxic for platelets and cause inhibition of the cellular metabolic processes. These components include nicotine, carbon monoxide, and hydrogen cyanide. (Millington et.al, 2000) Researches have now proven that smoking increases and complicates the problems of the diabetic patients, and mainly leads to macro and micro vascular complications in patients. Such patients are at a bigger risk of developing complications, and reports show that currently every one in five diabetics is a smoker as well. Smoking cessation is one of the most hard endeavours that a person may undertake, and is one of the most common substances one turns to when anxious.”People keep smoking for two reasons. First, nicotine is highly addictive. Often, a person who quits smoking goes through withdrawal. Symptoms of withdrawal include: being irritable, sweating, having headaches, diarrhea, or constipation, as well as feeling restless, tired, or dizzy. Second, many people become psychologically tied to smoking. It is part of their daily ritual. It helps them wake up in the morning, comforts them when they are upset, and rewards them for a job well done. Smoking also has pleasurable physical effects. It relaxes people and perks them up”. (http://www.iconocast.com/dinner-movie/Smoking_diabetes.htm) These factors make it simple to smoke and hard to leave. However, the understanding of the dependence that the patient has for smoking is the first step in helping him or her quitting it. Smokers in diabetics show extremely alarming rates of complications. Diabetics who smoke have twice the risk of dying with cardiovascular disease. This rate can increase up to 8 times should other factors such as hypertension or elevated cholesterol levels are present. The chances of neuropathy and microalbuminurea become double in such cases. Smoking therefore is one of the first initiatives that a diabetic person can take to show his dedication towards self. (PSNC, 2002) Part Two: Strategies to Maximise Health Benefits of Such Patients. Diabetes is a condition that the patient acquires for a life time. Therefore in such patients the treatment is also life long. Such a treatment requires extreme dedication and interest on the patient’s behalf if he or she wants to live a near to healthy and normal life. Interventions, treatment plans, awareness programs and therapies are therefore a very important part of the overall treatment. It is imperative that patients with diabetes when they come in for their health checkups should have a complete examination done, including a proper examination of the feet. This is especially in the cases of chronic diabetics, as generally the risks of getting a diabetic foot in such cases are high. The examination of feet must include the areas of callus formation, deformities including various bony prominences, and other structural changes. Diabetic patients are usually advised orthotic footwear to ensure minimal risks of diabetic foot from footwear injuries. Such care becomes more frequent and more important for those who do show any particular changes in their feet. Patients are advised not to walk barefoot, and care should be taken to avoid too much pressure loads on the feet. Diabetic foot first presents itself as an ulcer, and therefore, if it is seen on the patient’s feet, it warrants urgent and extensive treatment. Concurrent with this care is the maintenance of the patient’s treatment plan and ensuring the patient is complying with it. (Vijan et al, 1997) The foot problems are presented by ulcerations, which could be superficial, deep with or without exposure of bones, muscles, ligament, and tendons; bone inflammation or Ostetis; bone infection or Osteomyelitis; or, Gangrene of toes and foot. All of these should be carefully observed while examining the patient’s foot. In many of the diabetic foot cases, the wound can become infected. The most common infection causing bacteria include the gram positive cocci, namely Staphylococcus aureus. In infected cases a proper culture is important to help in deciding the right antibiotic regime. Antibiotic therapy is a cornerstone in a successful handling of a foot ulcer. The problem lies in the decreased vascularity that is commonly seen in the diabetic feet, which reduces penetration of the antibiotic in sufficient quantities from the blood stream in to the wound. In such cases, a concomitant introduction of local antibiotics is highly recommended. These can include antibiotic beads, impregnated sponges etc. which can be directly applied at site to achieve maximum results. (Armstrong et al, 2004) Diabetes with smoking invites extreme trouble and a lot of hard work for the health care professionals. It is particularly emphasized that doctors should help and encourage their patients to stop or quit smoking. It is recommended that continuous assessment of patient’s smoking history, counseling of the patient, and proper training of delivering smoking cessation systems should be practiced for better results. Patients do get frustrating and exhibit intolerant behavior sometimes. However, doctors and physician ignore this kind of behavior and continue to influence their patients to quit smoking. They do this by educating them about the benefits of as well as the methods their patients can opt for successfully quitting smoking. They also provide their patients with material and recourses to put forward practical answers to their questions. Also, many success stories can give them a push towards a healthier path. Cases of smoking in diabetic patients warrant serious investigations about their overall mental health status and well being. For such cases, active investigation about possible depression and prompt delivery of appropriate help are essential for the long term survival of the patient. Concurrent diabetic and antidepressant therapies have shown improved results in both the areas of patient’s health. (Solberg et al, 2004) Also since such patients are more likely to be negligent towards their diabetic regime, they can be held in close observation, with frequent healthcare visits and follow-ups to ensure proper following of the regime. Many of the patients are not adequately informed about the hazardous and complications of smoking in diabetic conditions. Many of the macrovascular and microvascular complications require the patient’s interest in their own well being. Only proper education and awareness in different levels of social service can ensure that these patients seriously consider smoking cessation. This advice and education should be augmented with the introduction of quit smoking schemes for diabetic patients, which will not only keep the motivation levels high, but through review methods will be able to chart progress. (Solberg et al, 2004) The best strategy in the care of diabetic foot is the prevention strategy. Modification of various risk factors can help in the prevention of diabetic complications as well as improvement in the lifestyle of the patients. These include vigilant blood glucose and blood pressure levels monitoring, and dislipidemia and smoking reduction. (Ferreira, 2004) The introduction of learning resources for the patients as well as the healthcare professionals is also a very important part in increasing awareness about diabetes. It is a successful method by which diabetic patients can learn about handling of their condition and identifying complications should they arise. Such resources include posters and leaflets, promotion health units, national and local campaigns, support programs and surveys, display areas large and small and local training initiatives for healthcare professionals. (PSNC, 2002) smoking cessation services include intensive one to one support schemes through pharmaceutical approaches and group therapy clinics for smokers. (PSNC, 2002) (Diabetes Management Guidance, 2003) As health care professional, proper care should be provided to the patient. Most important for him/her is to recognize the people with a high risk. Health care professional should be extra careful with them. High risk patients includes: “patients who walk barefoot, patients with diabetic neuropathy (nerve damage), patients with significant diabetic peripheral vascular disease (damage to vessels supplying the limbs), patients who smoke or use tobacco in any form, [patients] with a foot deformity, Diabetics with a history of previous ulcers or foot infections, patients with abnormal gait (walk in unbalanced manner), those with significant skin and nail infections or deformities, blind/partially sighted persons (increase chances of repeated injuries to foot), elderly patients; especially those living alone, diabetics with chronic renal failure, patients with high alcohol intake.” (http://www.geocities.com/diabetesjain/diabetic_fooot.htm) Health care professionals can also perform some screening tests for diabetic foot problems. These include physical inspection that is performed for any evidence “of dry, or excessively moist, skin, hair and nail abnormalities corns, calluses and infection,” or “deformities, heel spurs, flat arches, etc.” Sensations are tested for any sign of numbness or its related symptoms diagnosing nerve damage. Large nerve fiber function tests are done for vibratory sensations, light touch and position sense. Whereas, small nerve fiber function tests are done for temperature and pain perception. Vascular inquiries consist of “deformities, heel spurs, flat arches, etc.; Palpation of pedal pulses; Brachial to ankle systolic pressure ratio; and, proximal pulses (popliteal and femoral).” (http://www.geocities.com/diabetesjain/diabetic_fooot.htm) Plain X-ray should be the first test for evaluations patients with foot ulcers. X-rays helps in excluding the infections of soft-tissues and bones. If gas is present in the soft tissues, it implies the presence of anaerobic organisms. This should be drained immediately. If the X-ray showed changes in the bony tissue, the patient should be treated for osteomyelitis. “A three-phase bone scan may be helpful in identifying areas of osteomyelitis. Another test, magnetic resonance imaging (MRI), may be helpful in selected patients to identify occult soft-tissue infections, particularly in those with a Charcot's foot. Recent studies have shown that an MRI may be a more sensitive test than a bone scan in patients with diabetic foot problems. Often, a combination of these tests is used to make an accurate diagnosis of osteomyelitis.” (Epstein, 2001) The very last option is surgery. Surgeries are performed in cases of gangrene. If gangrene does not get treatment in time, the foot is amputated to save the rest. Gangrene is a serious infection, commonly seen in diabetic foot. It develops from a small cut or blister that is infected. The cut or blister may or may not be felt by the patient due to nerve damage and poor blood circulation. Diabetic foot is one of the most disturbing and dangerous outcomes of diabetes. The problems of life long loss of a limb with concomitant limitation in mobility are only one aspect, since recurrence rates are known to be high in the already afflicted cases. It is also a very significant and disturbing loss for the patient, who may already be not happy with his diseased condition. The human factor is often neglected in the routine care and there are very few interventions that are present to help patients recover from these episodes. Understanding this human need and providing comfort, understanding and guidance to these patients should be considered a routine part for their optimal health. Only by treating the patient as a whole can we achieve good results in diabetic care and prevention. References David Armstrong and Benjamin A Lipsky, 2004. Advances in the Treatment of Diabetic Foot Infections. Vol 6 No.2: 167-177. David A. Epstein, MD, John D. Corson, MB, ChB, FRCS (Eng), FRCS (Ed) FACS. 2001. Surgical Perspective in Treatment of Diabetic Foot Ulcers. Health Management Publications, Inc. http://www.medscape.com/viewarticle/403557_print DIABETIC FOOT http://www.geocities.com/diabetesjain/diabetic_fooot.htm Accessed, March, 9 2007 Diabetic Foot Ulcer Assessment, 2006. Site last accessed on March 3rd, 2007 from http://www.wrha.mb.ca/staff/woundcare/files/Manual_07_FootUlcer.pdf Accessed, March, 7 2007 Diabetic Patients Who Smoke; Are They Different. Annals of Family Medicine. 2:26-32 Diabetes Management Guidance, Harrow Primary Care Trust and NWLH Trust, 2003. Eric B Rimm, June Chan,Meir J Stampfer, Graham A Colditz, and Walter C Willet,1995. Prospective Study of Cigarrette Smoking, Alcohol Use, and the Risk of Diabetes in Men. BMJ 1995. 310: 555-559 J. Thomas Millington and Thomas W. Norris, 2000. Effective Treatment Strategies for Diabetic Foot Wounds.Journal of Family Practice. Site last accessed on March 3rd, 2007 from www.findarticles.com Accessed, March, 7 2007 Leif I Solberg, Jay R Desai, Patrick J O Conner, Donald B Bishop and Heather M Devlin, 2004. Paul Newrick, 2000. Book Review, International Consensus on the Diabetic Foot. BMJ, 321:642. PSNC Diabetes Services: A Guide for Community Pharmacists, 2002. Peter J. Watkins, 2003. ABC of Diabetes, the Diabetic Foot. BMJ2003. 326:977-979 Sandeep Vijan, Deryth L. Stevens, William H Herman, Martha M Funnel and Connie J Standiford, 1997. Screening, Preventing, Counselling, and Treatment for the Complcations of Type II Diabetes Mellitus. Journal of General Internal Medicine, 12(9):567-580. Smoking http://www.iconocast.com/dinner-movie/Smoking_diabetes.htm Accessed, March, 7 2007 Victor Ferreira, 2004. Diabetes Mellitis, Descriptive Epidemiology, Barking and Dagenham Primary Care Trust, Public Health Directorate. Read More