Study of a Diabetic with Type Two Diabetes and a Leg-Ulcer
This essay will focus on a type two diabetic patient with leg ulcer as the effect of the complications of diabetes. Limited mobility caused by leg ulcer will be discussed as the health deviation. My patient is Mrs B, 54 years old who was diagnosed with type two diabetes 13 years ago and lives with her husband and two daughters’ ages 18 and 16.
She works as a senior staff for a beauty company. I chose this client because my sister died of complications of foot ulcer and my grand father died of diabetes. I came from a country where health services are not free and due to poverty, my sister was not diagnosed till she died and my grand father was only diagnosed in his old age when intervention was too late. Herbal medication was used for both my grandfather and my sister but failed due to lack of knowledge of the condition (Yodar 1989). All confidentiality will be maintained and informed consent form is included in the appendix. This health deviation was also chosen because it is a costly problem in the UK with an increasing prevalence. National Health Service (NHS) spent approximately ?400 million a year on treatment on leg ulcers (www.journalofwoundcare.com). Andrew et al (2010) estimated that by 2025, people suffering from diabetes mellitus would have rapidly increased from 2.6 million at present to 4million. The understanding of this condition and how it impacts on individual will prepare me for the future as I will be in a position to care for people with diabetes and also to educate them on the impact the illness can have on their well being.
Type 2 diabetes is accompanied by peripheral resistance to insulin in muscle cells, increased production of glucose by the liver and altered pancreatic insulin secretion (Steven and Michael 2008). Increased tissue resistance to insulin generally occurs first and is eventually followed by impaired insulin secretion. Looking at the pathophysiology of Mrs B’s leg ulcer which resulted in limited mobility. Insulin is produced by the pancreas but could not be used due to inhibition of insulin resistance. This results in accumulation of glucose in her bloodstream not being used by target cells thereby leading to hyperglycaemia. Leg ulcer is caused by poor diabetic management and can either be venous or arterial (Tim and Sudhesh 2010). According to Mustoe (2004), accumulation of glucose in Mrs B’s bloodstream over a period of time causes increase in blood viscosity and leads to blockage and damage of the small vessels and peripheral nerves. This then lead to decrease in circulation to her peripheral vessels and causing the pressure in her vein to increase (venous hypertension). Arteries loose their normal higher pressure due to venous hypertension and this allows inflammatory exudates to escape into the subcutaneous tissues of the crus subsequently breaks down the tissue. Walking barefoot at home is part of Mrs B’s upbringing. In addition to the pressure in her foot, she hit her foot against her daughter’s scooter and the skin break down. Venous hypertension stretches the veins and result into leakage of blood protein into the extra vascular space and leaving out the extracellular matrix molecules (venous insufficiency). Venous insufficiency causes build-ups of white blood cell (leukocytes) in smaller blood vessels which plug the vessel and contributes to ischemia in the limbs. Leukocytes can also release inflammatory factor, further contributing to chronic wound formation (Mustoe 2004). Diabetic mellitus is characterised by autonomic, sensory and motor neuropathies. There are various complications for client with diabetes mellitus (type 2) due to inability of retaining control of their blood glucose (Palfreyman 2008). Mrs B developed a reduced mobility due to damaged peripheral vessels and nerves caused by decrease circulation as a result of increase glucose level in the blood. Reduced mobility can have a great impact on day to day activities as this also reduces the individuals independent and control of ones life. Mrs B as the bread-winner in her family now finds it extremely difficult to cope and to provide for her family since her husband also has a heart condition which prevents him from working. This is also distressing due to her children’s needs not being met and her inability to function effectively as a mother because of reduced mobility.
Mrs B is on insulin, lansoprazole for prevention of gastric acid and fentanyl patch for pain killer (www.diabetes.co.uk/treatment and bnf)
Leg ulcer cost NHS approximately ?400m a year of which community nursing services accounts for. Research has shown that 80-85% of client with leg ulcer are venous leg ulcers whilst 10-20% are arterial leg ulcers (www.journalofwoundcare.com). According to Simon et al (2004), leg ulcers are on rapid increase in the UK and have a huge impact on NHS budget. Immobility is also on increase because of inadequate bed in the hospital to admit such client for close monitoring. This results in district nurses spending more time on caring for client with ulcer in the community and yet most patients do not receive appropriate care. Chapman (2008) states that about 1.2%-3.2% in 1000 people suffers from chronic leg ulcer, which means 80,000-198,000 people in the UK suffers from venous leg ulcer. A UK study examined the prevalence of venous ulcer and it was 0.4/1,000 in men and 0.6/1,000 in women. The increase of leg ulcer is related to age. Same study shows that in men over 85 years old, the rates were 8.29/1,000 and 8.06/1,000 in women and 55% of patient had leg ulcer for more than one year (Moffatt et al, 2004). Research in Canada estimated that 2.0/1000 Canadian suffers from leg ulcer, of which 40% are homebound due to immobility caused by chronic leg ulcer and this has been a huge cost to the Ministry of Health (MOH). Approximately, $5,868 is spent on each client under standard community care thus, coming up to $511 million spent annually by the MOH on leg ulcers (Shannon 2007)
Mrs B often becomes have low mood and becomes tearful because of the state of her health. According to Rotter (1965) cited in Mamlin et al (2001), it is believed that the client has an external locust of control. This is related with depression, fear and inability to cope with stress.
Mrs B’s diabetes was diagnosed 13 years ago following her admission in St George’s hospital for a removal of gall stone. During her observation, the health care assistant informed the nurse that her blood glucose reads 19.4mmol/L. The nurse did a fasting glucose level test on her and it reads 10.9mmol/L. Her urine was tested and glucose was present in it. It was also noticed during her stay in the hospital, her increase in thirst was alarming. Random blood glucose tests, fasting blood glucose tests, urinary analysis for glucose and ketones, Hba1c level and formal glucose tolerance tests such as plasma glucose are procedures carried out to confirm the diabetes state of client. Eye test is also checked to confirm diabetic retinopathy whilst other cardiac investigations to rule out or recognise the presence of cardiac diseases (www.doh.gov.uk). Mrs B does not require surgery and does not fall in the categories of people who go through referral because her diagnosis was confirmed in the hospital. Her General Practitioner (GP) will also be informed so that h/she can refer her for follow up. Patient with diabetic type 11 will normally be referred by their to their local GP within 8 weeks to external bodies like out-patient where they will be able to see a diabetes specialist nurse for follow up (www.doh.gov.uk).
Diabetes research in the UK is funded by the Juvenile Diabetes Research Foundation, the charity Diabetes UK and other private companies sectors. Diabetes specialist nurse specialised primarily with clients with diabetes and their aim is to educate, help client understand, control and manage their diabetes; and also provides physicians care for them (David 2010).
The client was met on her admission to the ward for advance medical treatment for her leg ulcer which is also limiting her mobility. Mrs B is now finding her activities of daily living very hard to keep up with and has to depend on her husband who also suffers from heart condition and panic attack for her care. Her reduced mobility has become a challenge and concern for her as she is unable to meet the needs of her children and this stress is worsening the husband’s condition. According to National Institute for Health and Clinical Excellence (NICE), a consultant’s visit from GP’s referral should be within 9 week at best and at least, 18months (www.nice.org.uk/Gps).
Health care professionals are undergoing stress, whilst NHS are target driven rather than effective treatment and consultants are trying to meet these target (www.doh.gov.uk). Palfreyman (2008) interviewed 266 people with the history of leg ulcer and identify the huge impact it has on ones quality of life even the ones with healed leg ulcer has a lower quality of life in comparison with people who has no history of leg ulcer. According Briggs and Fleming (2007) 8O% of patient with leg ulcer caused by complications of diabetes type 11 have excruciating pain, 75% of them have exudates, 65% of them suffer from depression, 56% of them have an offensive smell and 65% insomnia. Mrs B is experiencing reduced quality of life. The weight of bandage on her leg and exudates is burdensome. The smell is intimidating and embarrasing and leads to the client being withdrawn and hiding themselves. The pain is also mentally and emotionally disturbing which is also putting strain on her physical movement (reduced mobility); also her being overweight is worsening her reduced mobility.
Limited mobility has been the focus of concern for Mrs B. As the breadwinner of her family, anxiety, fear of the unknown and depression has increase rapidly in her life as she is experiencing extreme difficulties in mobilizing and in carrying our her day to day activities. According to Gavard et al (1993), “Depression occurs frequently in people with diabetes, especially in those with complications”. The Quality and Outcome Framework (2010) has introduced depression screening into regular diabetes surveillance (www.nhsemployers.org). Mrs. Book’s relationship with her husband and two daughters is affected as she gradually deteriorated and lost her independent. Her dependence is now on her husband who cannot engage in stressful work due to his heart condition and also the children are having problems with socializing because they have to rush home after school to help their mother. Mrs. Book condition has had great impact on her children as they struggle to maintain previous level of performance in their education. Limited mobility has leaded a strained relationship between Mrs. Book’s and her children. She cannot spend much time with them as she use to; taking them to the park, cinemas, shopping and holiday has also reduced. The weight of the bandage on her leg is burdensome at she often have to change the bandage when it is wet. She conceives her despair and was afraid to engage her husband because stressful situation can trigger his panic attack. This often led to conflict between her and her husband as the husband struggles to understand her.
Research shows that supportive families can help client with chronic illness cope with behavioral or psychological disorder that may occur as a result of the illness. Same research shows that open expression of emotion such as crying might make the family member to empathize (Hanson et al 1992). On the contrary, this can be argued depending on the level of maturity of the family member. In Mrs. B’s case, open expression of emotions might not be appropriate in the presence of her children. Her children ages 18 and 16 years old fall in the 5th stage of Eric Erickson’s psychosocial theory of Human development (identity v Role confusion). This adolescent’s stage is when they start resolving identity and direction and also becoming a grown-up (http://www.businessballs.com/erik_erikson_psychosocial_theory.htm). Open expression of emotion of can be stressful to Mrs. B’s children in addition to the stress adolescent experience due to hormonal changes in their body (Seiffge-Krenke 2001).
Mrs B’s finance is also affected. As a senior staff of a growing beauty company, she finds it hard to return to work as she is unable to move around to assist customers as her job demand. Abiding with her company’s uniform conduct is also a problem for her, although the manager has agreed for her to wear a trouser instead of a skirt, yet she has to take breaks often to change the bandage when it’s wet. She also has to wear a special shoe because she wasn’t fitting in her normal shoes because of the extent of the bandage on her ankle. Her condition contradicts her working environment. This might cause stereotyping and make her feel odd. Mrs B felt she is loosing control of her life as she is also not free to wear any clothing she want and has to wear clothing’s that covers her leg. As a result of her limited mobility, she feels guilty and sees herself as a failure for letting herself and family down. A study/ statistics was carried out by (Murray and Fortinberry 2005) in Australian and it shows that problems encountered by the patient are comparable to those of the US and UK.
This essay has improved my knowledge on complications of type 2 diabetes on individuals life and how it can ruin once career. I have lived with people with diabetes and got few friends with diabetes type 2, yet my understanding of their condition was shallow which I believe it has limited me in a way i should have help them. I have also come to the realisation of the strain leg ulcer can place on individual. Although I have nursed few patients with leg ulcer caused by their diabetes, I have not provided them with appropriate emotional and psychological support they might have needed due to my limited depth of the condition. Finally, I have deepened my understanding on how culture, upbringing and religion can affect a client’s view of their conditions. In future, when dealing with a patient with leg ulcer, I will put into consideration their culture, religion, job and environment where they live. This will help me to make an appropriate referral to a local group available in their area where they can meet other people with the same condition and moreover, people of the same culture. This will give them the opportunity to interact with others and see how they deal with it since they have the same culture.
This essay was based on limited mobility caused by leg ulcer in type 2 diabetes patient. Pathophysiology of the health deviation and its effect on the client was discussed, the impact of the health deviation on client’s journey through health care and potential influences of the health deviation on the long term well being of client and family/ significant was also discussed in details.
Andrew, S. P. and Anthony P. C (2010) The treatment of diabetic foot infections: Pathogenesis of diabetic foot disease 26, (7).
Briggs, M. and Fleming, K. (2007) Living with leg ulceration: a synthesis of qualitative research. Journal of Advanced Nursing; 59: 4, 319-328. [online] Available at http://www.nursingtimes.net/assessing-the-impact-of-venous-ulceration-on-quality-of-life/1896181.article. (Accessed 16 Nov, 2010)
C.J Currie., C.L Morgan., and J.R Peters (2008). The epidemiology and cost of inpatient care for peripheral vascular disease, infection, neuropathy, and ulceration in diabetes. Nursing Times 6(110) 42-44.7
Chapman. R (2008) Chronic Wound Pain. [online] Available at: http://www.painconcern.org.uk/pages/page78.php ( Accessed: 19 Feb 2010)
David Uregbula (2010), The Role of a Diabetes Specialist Nurse. [online] Available at: http://www.ehow.com/about_5201899_role-diabetes-specialist-nurse.html#ixzz1DIN4J4hF. (Accesssed:26 Jan 2010)
Deborah, A .S., Francis P.D. and Charles N.M (2004). Management of Venous Leg Ulcers. [Online] Available at: http://www.bmj.com/content/328/7452/1358.full
(Accessed: 10 January 2011)
Gavard J., Lustman P. and Clouse R (1993) Prevalence of depression in adults with diabetes: An epidemiological evaluation. [online] Available at: http://care.diabetesjournals.org/content/16/8/1167
INGE SEIFFGE-KRENKE (2001) Diabetic Adolescents and Their Families: Stress, Coping and Adaptation. USA: CambridgeUniversity press
Journal of Wound Care (2006): Venous Leg Ulcer. [online] Available at: http://www.journalofwoundcare.com/JWC/Supplements/206 ( (Accessed 15 Jan 2011)
Mamlin N., Harris, K.R. and Case, L.P. (2001). A methological Analysis in Research of Locust of Control and Learning Disabilities: Rethinking a Common Assumption [online] Available at: www.findarticles.com/cf_o/moHDF/4_3476157546/p1/article.jhtm1. (Assesed: 23 January 2011)
Moffatt, C.J. et al (2004) Prevalence of leg ulceration in a London population. [online] Available at: http://www.nursingtimes.net/the-burden-of-chronic-wounds-in-the-uk/527138.article QJM; 97: 7, 431–437: (Accessed on 18th Feb 2010)
Murray B. and Fortinberry A (2005). Depression Facts and Stats. [online] Available at http://www.upliftprogram.com/depression_stats.html#statistics, (Accessed: 23 Feb, 2010)
Mustoe T (2004). “Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy”. Am. J. Surg. 187 (5A): 65–70
National Institute for Health and Clinical Excellence (2008). [online] Available at:www.nice.org.uk/Gps. (Accessed 15 Jan 2011)
Palfreyman, S.J. et al (2007b) Impact of intravenous drug use on quality of life for patients with venous ulcers. Journal of Advanced Nursing; 58: 5, 458-467.
Palfreyman, S. (2008) Assessing the impact of venous ulceration on quality of life. Journal of Advanced Nursing; 104:41, 34-37.
Ronald J. Shannon (2007) A Cost-utility Evaluation of Best Practice Implementation of Leg and Foot Ulcer Care in the Ontario Community.[online] Available at: http://www.cawc.net/images/uploads/wcc/5-1-Cost-utility_Evaluation.pdf (Accessed on 23 Feb 2011)
Stephen R. Baker, and Michael C. Stacey. Article first published online: 21 JAN 2008
The Quality and Outcome Framework (2010) Depression screening into regular diabetes surveillance. [online] Available at: www.nhsemployers.org ( Accessed: 12 Feb 2011)
Tim Holt and Sudhesh Kumar (2010). ABC of Diabetes (6th ed). UK. Wiley-Blackwell
Yoder RA. Are people willing and able to pay for health servicesSoc Sci Med 1989; 29(1):35-42. [online] Available at: http://www.ispub.com/journal/the_internet_journal_of_health/volume_8_number_2_12/article/user_fees_in_health_services_in_nigeria_the_health_policy_implications.html. (Accessed on 21 Feb. 2010)