Treating diabetic foot ulcers

The aspect of professional practice I choose related to my role as an adult nurse was diabetic foot ulcers. I choose this topic because it is ofte

Introduction

Alcoholism is defined as a disease that is persistent, progressive and often fatal. It is not a symptom of other diseases or emotional problems; it is its own disorder. Alcohol affects every part of the body even the brain which will eventually adapt to the alcohol use by becoming dependent on it after prolonged use. Genetics and environment are factors that are influenced by this disease.

Drinking can reduce life expectancy by 10-12 years and next to smoking is the second most common preventable cause of death in America. The earlier a person starts drinking, the greater their chance is of developing serious illness later on. Once dependant on alcohol, it’s very difficult to quit.

The cause of alcoholism is unknown. Just drinking gradually and consistently over time can produce alcohol dependence and cause withdrawal symptoms during periods of abstinence, but this is not the only cause of alcoholism. To develop alcohol dependence several other factors typically come into play, like genetics, culture and psychology.

The signs of alcoholism or a dependence on alcohol vary from person to person and depend on how much the person drinks or how the person drinks. The definition of alcohol use and abuse ranges from moderate drinking, which is defined as equal to or less then two drinks a day for men and equal to or less then one drink a day for women. Hazardous or heavy drinking would be defined as more then 14 drinks per week or 4-5 drinks at one sitting for men or more then 7 drinks a week or 3 drinks in one setting for women or frequent intoxication in either gender. Harmful drinking is when alcohol consumption has actually caused physical or psychological harm or alcohol consumption has persisted for at least a month or has occurred consistently for a year. Alcohol abuse is used when the person either can’t fulfill work or personal obligation’s and/or has recurrent problems with the law. Alcohol dependence is used for people that three or more alcohol related problems in a period of one year that includes increased amount of alcohol needed to produce an effect earlier obtained with less alcohol, experiences withdrawal symptoms or drinks to avoid withdrawal symptoms, drinks more then intended, unsuccessfully attempting to cut down or quit, gives up hobbies or leisure activities to drink.

Summary

Emotional and behavior problems such as depression and anxiety put people at a high risk for alcoholism and often are the reason the elderly turn to alcohol. Problem drinking in this case can be a way to self medicate. People may also use alcohol to become less inhibited in public situations that for some may be a source of great anxiety. Those that have impulsive personalities are also at a great risk for developing dependence to alcohol, due to the fact that they have low impulse control.

Alcoholism affects every part of the body causing illness, cancer and with long term consumption can even cause death. Frequent, heavy drinking is associated with a higher risk of death to injury, violence and medical disorders, like pancreatitis, upper gastrointestinal bleeding, nerve damage and even impotence. As people age it takes few drinks to become intoxicated and organs are damaged by smaller amounts of alcohol then younger people. Those that require surgery also have an increased risk of postoperative complications, including infections, bleeding and decreased heart and lung functions, along with wound healing problems. If withdrawal symptoms are present can inflict further stress on the body and delay healing.

Neurological or mental disorders can be caused from binge drinking which can cause memory impairment and problems thinking and concentrating. Nerve damage from severe vitamin deficiencies can impair mental function and memory and cause emotion disorders and even psychosis, like Wernicke-Korsakoff Syndrome, that causes loss of balance, confusion and memory loss and can lead to permanent brain damage and even death.

Diagnosing alcoholism can be hard, since nearly always people deny the problem. But for most, denial may be the first warning sign that their drinking is out of hand. There are tests to screen for alcoholism, most are short and allow the person to take them on his or her own time. Because people deny their problem or attempt to hide it, the questions relate to problems associated with drinking, rather then the amount of liquor consumed. The quickest test is the CAGE test and is an acronym for: 1. Attempts to CUT (C) down on drinking. 2. ANNOYANCE (A) with criticisms about drinking. 3. GUILT (G) about drinking. 4. Use of alcohol as an EYE-OPENER (E) in the morning. This test is called a Self Administered Alcoholism Screening Test (SAAST) and appears to be the most useful in detecting alcoholism in white middle aged males. Alcoholism, hard to detect in elderly women is sometimes diagnosed as depression and prescribed anti-anxiety drugs that can have dangerous effects when mixed with alcohol

conclusion

Treatments for alcoholism vary, but the overall goal in treatment is total abstinence, since those that abstain have better success rates then those that don’t. Treatment should also, include replacing addictive patterns with satisfying, time filling, behaviors which are able to fill the void in daily activities when drinking has stopped. Because alcoholism is so difficult to treat, most doctors will choose to treat alcoholism as a chronic disease that include relapses and remission periods.

Inpatient and outpatient treatments are available to those that would benefit most from these types of treatments. Those with co-existing medical or mental disorders or those that might harm themselves have greater success with inpatient treatments at a psychiatric hospital or alcohol center. Outpatient treatments work best with people that have a good support system and are able to take medications for mild to moderate withdrawal symptoms.

Psychotherapy treatments focus on Psychotherapeutic approaches and include cognitive-behavior therapy is used for severe alcoholism and gives people the opportunity to learn to cope and control their behavior, by changing the way they think about drinking and Interactional group psychotherapy that includes group based therapy like Alcoholics Anonymous or AA, 12-step program.

Alcoholism is a very real and serious disease that requires medical treatment and those suffering will require lifelong care and support.

n seen and treated by nurses and so understanding the treatments available and the effect living with diabetic foot ulcers has on individuals in very important.

The first article I am going to discuss and evaluate is the ‘short report: the effect of topical phenytoin in healing diabetic foot ulcers: a randomised control trial’. This was located from the Diabetes UK website. This article explores how the use of a topical treatment for treating diabetic foot ulcers may be more conducive for the healing process as it contradicts the need for medical intervention as well as minimising patient caused to the individual. This study concludes that there were no changes in the diabetic foot ulcers being assessed between the two trail groups. This implies that the study doesn’t support the use of phenytoin in the treatment of diabetic foot ulcers.

In relation to the hierarchy of evidence, this article falls under randomized controlled trials, which is the second from the top on the hierarchy. The National Institute for Clinical Excellence (NICE) defines a randomized control study as ‘A study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or treatment. One group (the experimental group) receives the treatment being tested; the other (the comparison orcontrol group) receives an alternative treatment, a dummy treatment (placebo) or no treatment at all. The groups are followed up to see how effective theexperimental treatmentwas. Outcomesare measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reducebias.’ (NICE 2013). According to the British Medical Journal (BMJ), randomised controlled trails are the most thorough and precise technique of assessing if the participant is reacting positively to the treatment they have been administered. This also contributes towards managing the monetary value of the study and its effectiveness. The BMJ states that this method of evidence can come with some ethical issues one being, ‘exposing patients to intervention believed to be inferior to current treatment.’ (1998). They also express that although not all studies conducted by this means may be unethical, the validity of using this method may be unreliable, one of the main reason for this is due to the struggle to get the population to sign up to be a participant in the trail. In a case study directed by Wootton R. (2000), it can be argued that although treatment offered in RCTs may be inferior to current treatment, it can work for the benefit of the participant and when it does the results are more desirable than what was seen from current treatment.

The second article I am going to discuss and evaluate is ‘debridement of diabetic foot ulcers’. This article was located in the Cochrane library. This article studies the debridement of foot ulcers and what impact it has on healing the diabetic foot ulcer. It also explores the use of dressings on the wound and what dressings apart from the standard gauze had a positive impact on the healing process. The findings of this study showed that the dressing that was being trailed had a positive impact on healing DFU and in an increased time compared to the standard gauze. From this article it Is clear that debridement as well as the other dressing which was trailed has a profound effect on the healing of DFU’s which may have a direct impact on the variations of dressings nurses have to treat diabetic patients. In accordance to the hierarchy of evidence, this article is a systematic review which comes at the very top of the hierarchy. The Cochrane Collaboration agree systematic reviews are the most reliable if they are carried out correctly because ‘Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making.’ (2013). This definition has been demonstarted in the article which has been chosen as they have managed to keep to the strict methods used to eliminate bias. One of them being randomised controlled trails. This type of trial ensures that all participants are randomly put in control groups where they would receive a placebo or the actual drug. This trail is strictly confidential as only those people conducting the study not assisting know which group is receiving what drug. All results obtained from the trail are ‘assessed by rigorous comparison of rates of disease, death, recovery, or other appropriate outcome in the study and control groups.’ (The Centre For Evidence Based Medicine. 2013). Leibovici L and Reeves D also hold systematic review in high esteem describing it as a ‘powerful tool deployed in the pursuit of evidence based practice.’ (2005). They argue that systematic reviews do not just focus on the drug or treatment in question but highlight questions which are important to patients from the point of view that the patients well -being is the primary outcome of the study. Whereas in some clinical trails the primary outcome would reflect the need to save resources or to attempt to claim that certain treatments have an advantage which isn’t always the case.

Despite systematic reviews appearing to cover all areas, some researchers have conflicting views on the expenses involved to run a study using individual patient data (IPD). According to Stern and Simmes (1997) IPD is much more expensive and time consuming than other research methods. However it is argued that due to the advancement of technology obtaining patient data is not as time consuming or expensive than in the 90’s.

The final article I am going to discuss and evaluate is “Whatever I do is a lost cause.’ The emotional and behavioural experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers’. I obtained this article from the online Wiley Library. The article is relevant to my discipline as nurses treat many patients who currently have or have had diabetic foot ulcers in the past. This article gives and in depth picture of the fears of those who have had successful treatment for their DFU but are afraid of them returning. This article homes in on the feelings of the patients and how different aspects of DFU and the possible consequences affect their lives and how they approach the condition. However it doesn’t acknowledge how beneficial the treatments they received were. And the effects it had on them emotionally and physically if any.

This article is qualitative study which according to the hierarchy comes at the bottom under the heading expert opinion. The Office of National Statistics use Ritchie and Lewis (2003) definition of qualitative study which is, ‘a naturalistic, interpretative approach concerned with understanding the meanings which people attach to actions, decisions, beliefs, values and the like within their social world, and understanding the mental mapping process that respondents use to make sense of and interpret the world around them’. The National office for statistics continues on the say that qualitative research offers an extended understanding of the subject and information related to it. Moreover it explains reasons for certain findings, evaluate how effective the study was and how it would aid their research.

According to Ewe Flick the need for qualitative research has increased in the last few decades due to the rapid changes of society. He refers to it as a means to keep up to date with the current situations. Although qualitative research has been a fundamental study for the past couple decades, there are many defects in this method. Becker and Geer (1960) highlighted the fact that although the interviewer and participant speak the same language, there may be some discrepancies with the interpretation, which in effect may leave the interviewer without information he needs/ wanted. According to Beaker and Geer another reason it may be difficult for the participant to open up about certain issues which are bought up. This again may be another factor which prevents the researcher getting all the information they need. There also positives to this research method. Qualitative research is also known as going out on the field because the researcher has to find the participants and in some cases has to meet in an environment that suits them. The advantage of this is that if a participant who is being interviewed about a sensitive subject is in the comfort of their own home then they may feel more able to talk about the issues raised as Crabtree and Miller (1991) suggested.

References

Leibovici L & Reeves D. (2005) Systematic reviews and meta- analysis. Journal of antimicrobial chemotherapy. Page 803. Volume 56.

The Cochrane Library. (2013) http://www.thecochranelibrary.com/view/0/AboutCochraneSystematicReviews.html

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Sage Publications (2002) http://ehp.sagepub.com/content/25/1/76.full.pdf+html

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Flick U. (2009). Introduction to Qualitative Research. 4^th edition. London. Sage Publications

Office for National Statistics-

http://www.ons.gov.uk/ons/guide-method/method-quality/general-methodology/data-collection-methodology/what-is-qualitative-research-/index.html

last accessed 12th January 2014

National Institute for Health and Care Excellence (2011) http://www.nice.org.uk/website/glossary/glossary.jsp?alpha=R

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British Medical Journal (1998)

http://www.bmj.com/content/316/7126/201

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British medical Journal (2000)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27370/

Last accessed 12th January 2014