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Patient Education: Diabetic Foot CareJulia L. MontaltoClinical Judgement in NursingProfessor SimontonApril 13, 2014Introduction Health promotion and education is an important aspect of nursing care. Patients of all ages should be involved in adopting a healthy lifestyle to improve their quality of life. Social cognitive theory identifies factors (behavior, cognition and other person factors, and the environment) that influence how and to what extent people are able to change old behaviors and adopt new ones. Psychosocial factors also play a role in the ability to change a behavior. Stress and anxiety regarding disease tend to be one of the largest learning inhibitors. Finally, the educational plan MUST be tailored to fit with the patient’s values just like any other nursing care. During clinical I was presented with an opportunity to educate one of my patients. This patient had been admitted to the hospital for an exacerbation of unmanaged diabetes. Upon assessment, it was noted that he had a decently sized foot wound that looked to be infected. He was unaware of the severity of the wound and possible consequences if not taken care of. According to one study, the majority of the participants had poor knowledge regarding diabetic diet, exercise and foot care (Jain, 2010). People with diabetes can develop many different foot problems. Even the smallest of them can lead to serious complications. These problems most often happen when there is nerve damage, also called neuropathy, which results in loss of feeling in the feet. Poor blood flow or changes in the shape of your feet or toes may also cause detrimental issues. Although it can hurt, diabetic nerve damage can also lessen a person’s ability to feel pain, heat, and cold. A stone in a shoe or a blister could lead to skin break down which could lead to infection. If a patient has no feeling of this, they will not catch the foot injury until it is in its later stages of infection. (Foot Complications: ADA 2014) Patient Demographic Information and History?Initials: DT Age: 54 Sex: M Primary medical diagnosis: Diabetes Mellitus Type II?Presented to ED with SOB, vomiting, chest pressure, anorexia, and an infected, slow-healing foot wound. Blood glucose was 579 mg/dL and BUN was 21. Was admitted with exacerbation of unmanaged diabetes mellitus, diabetic ketoacidosis, and gastritis r/t excess aspirin intake.?Past Medical history: Essential HTN, hyperlipidemia, hypercholesterolemia, GERD, DVT, & neuralgia. Surgical debridement of foot wound on 9/25.?Medications: Insulin glargine 40 units qhs blood glucose management?Novolin-R sliding scale ac & hs blood glucose management?Avandia 4 mg bid blood glucose management?Ampicillin 3g q6h tx of foot infection?Ceftriaxone 1 g q24h tx of foot infection?Aspirin 81 mg qd prevention of MI?Lipitor 10 mg qhs lower blood cholesterol?Lovenox 40 mg q24h prevent thromboses?Neurontin 300 mg q12h relieve neuralgia?Metoprolol 25 mg qd manage HTN?Valsartan 80 mg qd manage HTN?Pantoprazole 40 mg q24h prevent acid reflux?Tramadol 50 mg qd relieve pain r/t foot wound?Dilaudid 3 mg q4h prn relieve pain r/t foot wound?Prescribed diet: 1800 calorie diabetic diet?1. T: 97.2 P: 76 R: 16 BP: 97/63 O2: 99% Pain: 7, left foot?2. A&O to person, place, & time. Cooperative & able to follow commands. Slightly fatigued.?3. Wound in left foot. 2.5 cm long X 1 cm deep. No current symptoms of infection. Small amt. serosanguinous drainage on dressing change.?4. Blood glucose: 98.?5. Pedal pulse weak bilat.?6. 2+ edema in feet bilat.?7. Ready for enhanced learning. Time limitations r/t pain & fatigue.?Identification of Learning NeedsDT has been admitted to the hospital on multiple occasions for a diabetic exacerbation. Currently, there needs to be reinforcement of severity of the disease process and consequences of lack of management. The patient needs to leave the hospital having a better understanding of how to manage his chronic illness and the tools and support he can use to help with this. I would like to address mainly diabetic foot care and the importance of it. Also the use of his sliding scale Novalog insulin. I have decided that the focus should be on his foot care and sliding scale insulin because they are two major contributing factors to hospital readmission. The patient wanted to learn about the importance of foot care because he had never really thought that it was a necessary daily assessment with diabetes. This had been one of many admissions for diabetic ketoacidosis so the patient seemed perceptive to the idea of carefully monitoring blood glucose and using his sliding scale insulin. We agreed to talk about these care plans during my shift and if the patient was still there next week, we would address other needs of the patient. Student BackgroundMy name is Julia and I am a student nurse from the University of New Hampshire. This is my third year of nursing and I am well equipped with the knowledge and information for educating this patient on diabetic foot care and usage of sliding scale insulin. Throughout the past two years I have been taking classes on the pathophysiology of diabetes and medications that are used to help manage the disease. I have found brochures and print outs at the hospital and online on how to care for your feet if you are a diabetic. I also plan on showing him exactly what he needs to do when assessing his feet. I plan on giving him a pocket size sliding scale BG/Insulin handout that he can keep on him at all times. I will also show him the types of socks he needs to wear and a company that makes shoes specifically for patients with diabetes. Client Learner Assessment Prior to providing teaching, it is important to assess the clients readiness to learn, the type of learner, any barriers or impairments, prior knowledge, and support of family or friends. It is important to gather a basic understanding of your patients learning needs so that you can identify the goals of the education plan. The patient understands the basic pathophysiology of the diabetic disease process. Until this hospitalization, he was unaware of some of the potential complications associated with diabetes mellitus.?He believed that he could manage his diabetes by taking his daily dose of Avandia. He did not previously see the necessity of managing his diet, exercising, or monitoring blood glucose.?The patient is African-American. He enjoys a high fat, high sugar diet. Although many stereotypes attribute this sort of diet to African-Americans, it is truly common amongst most cultures in the southern United States. Giving up certain foods may be seen as a large cultural sacrifice. He is a high school graduate. He is cognitively capable of understanding all aspects of the plan.?Pain and fatigue will make long teaching sessions impossible. However, he displays readiness for enhanced learning and has already made efforts to learn more about managing his disease. Teaching should be accomplished in brief, frequent sessions of no longer than 15 minutes each. He is married. His wife has been to visit him daily during his hospitalization, but was not in attendance when I was with the patient. The patient states that she is interested and will be assisting him with his care.?The patient also stated that he is willing to consider support groups and communities that share the same disease. GoalsThe patient stated that he would like to be able to describe the basic pathophysiology of diabetic foot problems. He would also like to be able to demonstrate how to identify the correct amount of units to be administered based on a given blood glucose reading. Given that the patient is in pain and fatigued, it is likely that these education pieces will be done in intervals with frequent periods of rest. These educational interventions will be done in his hospital room with the help of another nurse and wound care. He will verbalize and/or perform the following:Behavioral Objectives Daily foot inspection: Cognitive, psychomotor- Patient will understand the need to check his feet daily for any alteration in skin integrity Check for blisters, cuts, scratches, foreign objects, and discoloration.Foot injury interventions: Cognitive- The patient currently has a foot wound which will be seen by wound care, therefor he will not be providing care with me, but perhaps with the wound nurse. The patient will participate in the care of his ulcer with the wound nurse. Cleanse breaks in skin with soap & water. Do not use alcohol, iodine, etc.?Call health care professional immediately if injury does occur. Daily foot cleansing: Cognitive, psychomotor- patient will wash his feet in front of me and/or another nurse. We will confirm the temperature of the water that he has chosen to use. a. Wash with mild soap in medium temperature water. Test the temperature with an unaffected extremity or a thermometer. b. Dry by patting feet, ensuring spaces between toes are completely dry. Regular foot care: cognitive, psychomotor- patient will perform and verbalize these acts of care in front of me or nurse who will validate his correct approach. a. Apply lanolin to dry feet, but do NOT put any lotion between toes.?b. Use mild powder for sweating, but do NOT powder shoes.?c. Soak feet in warm water before cutting toenails & cut straight across Contraindicated items: cognitive- patient will verbalize his new understanding of what to avoida. Commercial remedies for corn/ callous removal?b. Tight shoes?c. Tight clothing?d. Colored, non-cotton, or dirty socks?e. Hot water bottles or heating pads?f. Cold weather Administration of NovaLog? FlexPen?Cognitive, psychomotor- patient will verbalize his understanding of the use of sliding scale insulin. Patient will also self-administer prior to meal with a nurse. Take blood glucose level prior to meals Administer pen 5-10 minutes before eating, DO NOT administer if you are not planning to eat within 10 minutes Based on blood glucose, match it will the providers order of sliding scale View the “How to use your NovoLog FlexPen” hand out with another nurse Administer medication prior to a meal with nurse present Teaching Strategies1. Explain the etiology of diabetic neuropathy and physiology in non-technical language.?2. Use visual aids to show what injuries requiring special attention will look like3. Demonstrate wound cleansing & explain necessity for immediate medical intervention. Assist patient in creating a list of phone numbers to call for emergency & non-emergency care.4. Demonstrate a thorough foot cleansing, and have patient give a return demonstration5. Demonstrate appropriate foot care & have pt. give return demonstration.?6. Provide a list of contraindicated items and explain the dangers of using each.?7. Provide handout with instructions on how to use NovaLog? FlexPen?8. Have patient administer sliding scale insulin Teaching Plan Outcomes?Upon completion of the instructional sessions the patient will:?1. Describe the reasons that diabetics are more likely to develop foot problems.?2. Describe the types of foot injuries that will require attention.?3. Demonstrate appropriate wound cleansing, and identify whom he will call in the event of foot injury.?4. Demonstrate proper foot cleansing technique.?5. Demonstrate and verbalize appropriate foot care.?6. Verbalize understanding of contraindicated items.7. Correctly administer insulin using sliding scale prior to meal ?Prior to providing any education to the patient, I decided that it is most effective to do the “teach-back method.” The teach-back procedure has been suggested by several experts in health literacy as a method that can be used to assess and promote patient understanding (Wilson, 2008) Patients often receive information and instructions from health care providers, but it is not really known what they understand or if they are able to act on that information to promote their health. The teach-back method allows patients to articulate, in their own words, their understanding of what they were taught by providers. It allows the patients to restate the key elements from patient teaching and provides the health care professional with insight about areas that need supplemental instructions or demonstrations. The teach-back method also provides the health care professional with a gauge of how successful their education was based on the client’s verbalization and actions of what they believe is correct. To measure the clients understanding, I would encourage him to explain his necessary foot care and insulin regimen to his wife. I would be present during this conversation and intervene or provide any further clarification if necessary. Evaluation of Outcomes I was able to provide basic instruction in foot care and administration of sliding scale insulin. I provided a brochure and went over the finer points of foot inspection and cleansing as well as the NovaLog handout. I was unable to meet every objective due to time constraints and interruptions. Given the limited time, I felt successful in the teaching of proper daily foot checks and washing techniques.?I feel that the patient had a greater appreciation for the significance of taking care of his feet. Prior to teaching, he did not understand how seriously diabetes could affect foot health. He is much more likely to take proper care of his feet in the future.?I would like to have had more time for visuals of complications of diabetic neuropathy. I believe seeing the consequences would have more of an impact on the patient.?I was not able to watch the patient administer his insulin, but I had relayed my education plan to the nurse I was working with. I asked open-ended questions to identify the patient’s education level & teaching needs. I was sure to explain the pathophysiology in layman’s terms and allowed for the patient to verbalize his understanding and ask questions. I took great care in being nonjudgmental about previous medical non-compliance.?The hospital environment is not the optimal one for teaching. The busy atmosphere, beeping machines, shared room, and IV lines are distracting and obtrusive. Choosing a less busy time when nothing is infusing in the patients IV would be most advantageous for instruction as well as allowing enough time for the patient to have breaks while also including everything you planned on teaching.As I carried out this assignment I began to realize the importance of assessment prior to educating any patient. It is pertinent to evaluate the needs of the patient prior to beginning any type of teaching. Also, having the correct tools, knowledge, and strategies when developing a teaching plan can greatly improve the overall outcome. Conclusion Patient education is one of the most overlooked tasks of a nurse. With the busy and stressful workload of a nurse, it can be difficult to take quality time to educate your patient on their illness or disease. Furthermore, if nurses do spend time making sure the patient understands everything needed, it can prevent future admissions and save lives!?Work Cited Foot Care: American Diabetes Association??. (n.d.).?American Diabetes Association. Retrieved April 13, 2014, from Complications - American Diabetes Association??. (n.d.).?American Diabetes Association. Retrieved April 14, 2014, from Jain, P. (2012). Knowledge & Attitude of Diabetic Patients Regarding Diabetic diet, Exercise and Foot care.?International Journal Of Nursing Education,?4(2), 141-145.Moyet, L. J. (2009).?Nursing care plans & documentation: nursing diagnoses and collaborative problems?(5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.NovaLog Handout Wilson, Feleta L., Lynda M. Baker, Cheryl K. Nordstrom, and Carol Legwand. "Using the Teach-Back and Orem's Self-Care Deficit Nursing Theory to Increase Childhood Immunization Communication Among Low-Income Mothers."?Issues in Comprehensive Pediatric Nursing?31.1 (2008): 7-22. Print. ................
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