A Case Study And Ethical Considerations In Podiatric

Introduction

I am a podiatrist working for the National Health Service (NHS), and I have my private practice. My role professionally, involves assisting patients that suffer from diabetic foot ulcer. I assist them to manage their diabetic foot problems by providing sufficient education, as well as proper treatment of diabetic foot ulcer.

NMC considers all allegations associated with misconduct to practice. As such, in this case study, the aim of the NMC code of conduct is demonstrated, and as such, the patient involved in the case study will be referred to as Mr. T. Mr. T, suffers from diabetes foot ulcer, in his medial plantar surface, rooted on his right hallux. He is 45 years of age and he is his family’s breadwinner. The MDT has significantly provided him with sufficient education, as well as advice regarding the management of diabetic foot ulcer. Contrary to the expectation that he should heed to these pieces of advice given to him, Mr. T has failed to put into practice, the recommendations provided to him, which have health benefits and which if put into daily practice, can significantly aid in the healing of his wound. It has been noted that Mr. T practices behaviors, which are of high risk and which have consequently prevented his wound from healing. The high-risk behaviors include wearing ill-fitting shoes that lead to subsequent ulcerations because it mounts pressure to the wound.

Secondly, he has developed a negative attitude in his eating habits and that interferes with his glucose level stability. He practices improper foot-care, as he fails to redress his foot in every week. It is evident that despite having been given enough follow up and support by the MDT team, Mr. T has proven to be unwilling to change behaviors. As such, this assignment purposes to put into analytical scrutiny, the case of Mr. T, who has complex health needs, and as such, it will critically analyze his integrated care needs, provide a discussion of the nursing care that needs to be provided. In line with this, the paper will compare the nursing service provision with the recommendation in policy and research findings, thereby linking it to partnership and inter-professional working.

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In the UK, the multi-disciplinary team assists patients in managing their diabetic foot ulcer. Although, it is noted that there are less podiatrists that assist in aiding to manage the complications, associated with their condition (Baillie et al., 2017). In this regard, these patients seek out for assistance from private sectors, in order to get the assistance from the podiatrists that work in those sectors. Those podiatrists are known not to be competent enough in carrying out foot assessment, as well as management. As such, it is evident that the patients visiting the private sectors do not often get better assistance (Lu & McLaren, 2017). In addition, community nurses, as well as clinics that deal with diabetes offer secondary care to various patients that suffer from diabetes foot ulcers. It is worth noting that patients suffering from diabetes foot ulcer are usually well cared for, especially in the UK, and as such, the NHS purposes to ensure that they receive proper management, with the assistance of podiatrists, thereby, aiding to provide sufficient education, which is in line with proper treatment of their problems (Lipsky et al., 2015).

There are various problems, which hindered the healing of Mr. T’s wound, and these include the following: unfavorable attitude: it is clear that Mr. T was provided with sufficient and appropriate education that involved handling his foot. However, he has negative attitude, owing to the fact that he is not willing to change his behavior, whilst on the contrary, he prefers to maintain his inappropriate lifestyle. In accordance with the writings of Herber et al. (2007), this acts as a barrier that prevents his wound from healing, which then causes his frustration. Moreover, scholars such as Spilsbury et al. (2007) and Pun et al. (2009) indicate that unfavorable attitude prevents behavior change, which consequently prolongs a wound’s healing process. Due to the fact that Mr. T had not shown a sign of improvement, he developed traumatic frustration, which in turn led to the development of diabetic neuropathy, and also the loss of protective sensation, thus making him to be prone to injuries. Neuropathy manifests itself in the sensory, motor, as well as autonomic elements that are in the nervous system. According to the Nice guideline (2015), the reversal process then becomes difficult, which then leads to the development of ulcerations.

Another problem that prevents the healing of the wound is the instability of the glucose level, in which case, Nathan et al. (2009) point out that the instability of the glucose levels makes the patient to develop hyperglycemia, which consequently results in delayed healing of the wound and compromised conditions associated with chemotaxis and phagocytosis. According to Prompers et al. (2008), high levels of glucose in the body leads to malfunctions, especially in the white blood cells and that makes the wound to be susceptible to various infections.

Ill-fitting shoes is also noted to be a problems that prevents Mr. T’s foot from healing as it increases the risks such as skin breakdown, which consequently interferes with the wound’s healing process and also causes bony deformities like toe clawing. Additionally, Vileikyte (2008) points out that pressure is caused due to wearing ill-fitting shoes and that results to tissue injury and also prevents the closure of open wounds. Overall, it is also clear that owing to the fact that Mr. T prevents the NHS from caring for his wound, it then implies that he does not receive the appropriate healthcare. Additionally, he does not have a general practitioner, who would have assisted in treating his wound. Most importantly, he lack sufficient knowledge on risks that are associated with non-healing wounds and also the benefits accompanied with self-management, as well as care for a diabetic foot ulcer wound. These have also acted as potential hindrances in the achievement of effective care practice (Baillie et al., 2017; cited in Yazdanpanah et al., 2015).

In accordance with the provisions of the International Working Group on the Diabetic Foot (2003), it is mandated that national, as well as international guideline standards recommend that all patients need to be educated in enhancing an appropriate care management to diabetes foot ulcers, in order to promote a preventive behaviour, thus, avoiding ulcerations. Additionally, the provisions of Wounds International (2012) also point out that there is a valuable significance associated with education, which consequently bring forth a cost-effective measure in the management of diabetes foot ulcers. The national, as well as international guideline also emphasize that educational therapy poses as the most effective method that the MDT use in providing knowledge and skills to diabetes foot patients, for their daily practice (Zinman 2009; cited in Pun et al. 2009).

The MDT that would assist Mr. T to manage his diabetes foot ulcers comprise of a podiatrist, a nurse, a microbiologists, plastic surgeons, interventional radiologists, an orthotist, and an diabetologist. As such, it is significant to note that the MDT purposes to care for the patient while in the clinic and upon admission to the hospital. After the initial assessment, as well as intervention, the MDT follow up, in order to ensure that he is in good condition, and this includes the emphasis of education that relate to problem recognition, effective foot care, and surveillance. As relating to education, the MDT is obligated to educate their patients regarding proper eating habits, which consequently assists them to regulate their blood sugar levels. Moreover, the education assists the patient to care for their foot, in which case, Mr. T will be made aware of the appropriate footwear, will be able to develop a positive hygiene and attitude (Knight et al., 2006; cited in Formosa et al., 2017).

In this regard, it is evident that the MDT will be able to ensure early detection of amputation, management of the diabetes foot ulcer, as well as prevention of other complications. Mr. T should receive a day-to-day treatment, as well as assessment by the MDT, comprising of nurses, podiatrists, diabetologists, and the orthotists. The wide range of treatment includes podiatry, specialist footwear, amongst others (Siersma et al., 2017). Moreover, the nurses need to conduct a domiciliary intervention on antibiotics program. It is evident that the national UK policy mandates that the NHS podiatrists, working with the MDT should be obligated to care for a patient’s wound (Prompers et al. 2008). There is need for a local wound debridement to reduce the bacteria that are present in the wound that would consequently infect the wound. Moreover, the patient should undergo offloading to reduce the wound pressure and there should be regular dressing to quicken the healing of the wound (Nathan et al. 2009).

Plastic surgeons should be obligated to exercise a regular role of providing clinical assessment and investigations whenever there is need for urgent treatment. On the other hand, vascular scientist should carry out non-invasive imaging, referred to as Doppler ultrasonography, and also conduct a program associated with graft surveillance (Lu & McLaren, 2017). Moreover, interventional radiologists play a significant role of providing sufficient advice on the appropriate imaging, conducting regular multi-disciplinary vascular radiology meetings, and also making joint decisions, on the appropriate form of intervention with the patient’s MDT. Owing to the fact that Mr. T has a severe foot problem, he needs to be admitted to the hospital, and receive care from appropriate clinicians such as the diabetologists and surgeons. However, during this time, he needs to be managed by the other MDT as well. The diabetic foot practitioners need to coordinate all the care for all the inpatients, which includes the wound microbiology, metabolic, and vascular aspects. These significantly assist in the prevention of complications for the patient (Siersma et al., 2017).

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Conclusion

It is significant to take note of the fact that a multi-disciplinary team approach is significant in the management of patients with diabetes foot ulcers, especially when there is need to achieve optimal management and prevent the associated complications. Collectively, this team focuses its effort in restoring and also maintaining a lower extremity of ulcer, which focuses on the functional limb savage, as its ultimate goal. During the process of managing Mr. T’s condition, it was evident that without the MDT, he had limited chances of receiving appropriate treatment. It was also noted that he needed to incorporate the knowledge that was provided to him through sufficient education from the MDT, in order to change his lifestyle and exercise appropriate self-care on his foot. It is evident that Mr. T needed to be monitored and cared for and not left to dress his wound alone. Although the team provided him with sufficient pieces of advice, regarding the management of his foot, which could assist him in changing his lifestyle, and consequently have a quick healing of his wound, he did not heed to the advice. This assignment brings forth the following recommendations, which if put into practice, could aid in effective management of diabetes foot ulcer. They are as follows:

  • Collaboration amongst various specialists need to be extended to include the creation of consensus documents, as well as structured educational programs, which emphasize on the concept of interdisciplinary care to patients suffering from diabetes foot ulcers.
  • Legislative advocacy needs to be enforced, to ensure that there are adequate and sufficient healthcare resources that significantly assist is supporting the guidelines that can prove to be effective, especially when multiple specialty groups are collectively heard as one.
  • Moreover, there is need for diabetes care providers to reduce the increasing rate of diabetes foot ulcer by enhancing education, in order to facilitate the idea of self-care practice. In line with this, they should be obligated to provide a frequent evaluation to patients’ diabetic foot. In this regard, it is significant to note that whilst increasing the knowledge regarding diabetes foot ulcers to patients, the risk associated with amputation is consequently reduced. Moreover, healthcare providers also need to ensure that their patients receive an annual foot examination, in order to identify certain high risks that may be associated with it.

References

  • Baillie, C., Rahman, S., Youssief, A., Khaleel, A., & Bargery, C. (2017). Multidisciplinary Approach to the Management of Diabetic Foot Complications: Impact on Hospital Admissions, Limb Salvage and Amputation Rates. Endocrinol Metab Int J, 5(2), 00119.
  • Formosa, C., Alfred, G., & Nachiappan, C. (2017). Outcomes of educational interventions in type 2 diabetes: WEKA data-mining analysis Retrieved from
  • Herber OR, Schnepp W, Reger MA (2007) A systematic review on the impact of leg ulceration on patient’s quality of life. Heath and Quality of Life Outcomes, 5, (44)
  • Knight, K. M., Dornan, T., & Bundy, C. (2006). The diabetes educator: trying hard, but must concentrate more on behavior. Diabetic Medicine, 23(5), 485-501
  • Lipsky, B. A., Apelqvist, J., Bakker, K., Van Netten, J. J., & Schaper, N. C. (2015). Diabetic foot disease: moving from roadmap to journey. The Lancet Diabetes & Endocrinology, 3(9), 674-675.
  • Lu, S. H., & McLaren, A. M. (2017). Wound healing outcomes in a diabetic foot ulcer outpatient clinic at an acute care hospital: a retrospective study. Journal of wound care, 26(Sup10), S4-S11.
  • Nathan, D. M., Buse, J. B., Davidson, M. B., Ferrannini, E., Holman, R. R., Sherwin, R., & Zinman, B. (2009). Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Clinical Diabetes, 27(1), 4-16
  • NICE guideline (2015). Diabetic foot problems and management nice.org.uk/guidance/ng19 Retrieved
  • Prompers, L., Huijberts, M., Apelqvist, J., Jude, E., Piaggesi, A., Bakker, K. et al. (2008). Delivery of care to diabetic patients with foot ulcers in daily practice: results of the eurodiale study. Diabetic Medicine, 25(6), 700-707
  • Pun,S P., Coates. V, Benzie.I FF. (2009). Barriers to the self-care of type 2 diabetes from both patients’ and providers’ perspectives: literature review, Journal of Mursing and Healthcare of Chronic Illess. Wiley online library. Retrieved from [Online]
  • Siersma, V., Thorsen, H., Holstein, P. E., Kars, M., Apelqvist, J., Jude, E. B., ... & Mauricio, D. (2017). Diabetic complications do not hamper improvement of health-related quality of life over the course of treatment of diabetic foot ulcers–the Eurodiale study. Journal of diabetes and its complications, 31(7), 1145-1151.
  • Spilsbury K, Nelson EA, Cullum C, et al. (2007). Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs;57:494–504
  • Vileikyte L.(2008) Psychosocial and behavioral aspects of diabetic foot lesions. Current Diabeties Reports. 8(2):119-25
  • Wounds International. (2012). Optimising wellbeing in people living with a wound. An international consensus. Wounds International
  • Yazdanpanah, L., Nasiri, M., & Adarvishi, S. (2015). Literature review on the management of diabetic foot ulcer. World journal of diabetes, 6(1), 37.
  • Zinman, B. (2009). Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Clinical Diabetes, 27(1), 4-16.

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