Offloading the Diabetic Foot: Implementing Orem S Self-Care Deficit Theory

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Offloading the Diabetic foot: Implementing Orem’s Self-Care Deficit Theory

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Running Head: OFFLOADING THE DIABETIC FOOT: IMPLEMENTING OREM’S SELF-CARE DEFICIT THEORY

Offloading the Diabetic Foot: Implementing Orem’s Self-Care Deficit Theory

Merri M. Wolff, RN, MSN, APRN, CWS

University of Alabama

November 11, 2012

Abstract

The current global epidemic of type 2 diabetes mellitus has led to an accompanying increase in both foot ulceration and amputations, which pose significant health problems to populations worldwide. It is estimated that up to 80% of amputations are preceded by untreated ulcers (Sheridan, 2012). Current literature suggests that this can be prevented through education that advocates self-care towards better patient compliance for the prevention and treatment of diabetic foot ulcers and amputation. Patient compliance with offloading, which calls for limited mobility, is one of the key components for healing. This has been suggested to be the biggest challenge for clinicians dealing with diabetic foot ulcers because of its negative impact on social, psychological, physical, and economic domains. Providing patients with some control of the medical decision-making has proven to increase adherence to medical regime (Przybylski, 2011). This paper will explore Orem’s Self Care Deficit Theory and its implication for nursing practice relating to compliance with offloading and pressure relief when caring for patients with diabetic foot ulcers at high risk for amputation.

According to the Healthy People 2010 Database, the aging population is expected to increase from 40 million in 2010 to 70 million by 2030 with more people coping with chronic illnesses such as diabetes (Simmons, 2009). The American Diabetes Association (ADA) estimates that a million people are being diagnosed with diabetes every year (Kumar, 2007). There are over 180 million people worldwide with diabetes and this number is expected to double by 2030 as diabetes spirals out of control. In the United States, diabetes mellitus is also associated with foot ulcers and is the leading cause of non-traumatic lower extremity amputations. More than 68,000 non-traumatic lower extremity amputations were performed on patients with diabetes in 2009, a rate that is eight times higher in patients with diabetes than in those who do not have diabetes (CDC, 2012). According to the U.S. Department of Health and Human Services, (2010) this adds up to 3.5 of every 1000 diabetic patients with the survival rate one-year post amputation at 65%, 45% after the second year, 18% after the third year, and 5% after four years (Cornell & Steinberg, 2009). The leading cause of lower extremity amputations is foot ulcers. In 2007, the treatment of diabetes and its complications in the United States was at least $116 billion with at least 33% of these costs linked to the treatment of foot ulcer (Vickie et al., 2010).

Pressure offloading through the use of both medical devices and the making of appropriate lifestyle changes is a crucial element in the treatment of diabetic foot ulcers.

Quality of life issues in patients with chronic diabetic foot wounds is an essential aspect of total health care. It is important for healthcare providers to recognize and appreciate

the difficulties these patients face on a daily basis (Armstrong, 2008).

Issue Identified: Offloading Complexity

One of the key aspects of diabetic wound healing involves the use of pressure reduction or offloading to redistribute pressure from the wound site. Because many diabetics have foot deformities combined with peripheral neuropathy, they loose their protective mechanism in the insensate foot. If proper offloading is not achieved, an increase in plantar pedal pressure occurs causing ulcers to become susceptible to deterioration, infection with risk of limb amputation. Most clinicians lack the knowledge or skill to appropriately educate patients on proper medical devices for offloading and often do not consider the patient’s individual needs in this decision. This unfortunately has led to poor ulcer-healing success, which has negatively impacted quality of life. Offloading the diabetic foot is a complex phenomenon. It not only involves the use of medical devices but also must take into consideration other variables such as patient’s age, lifestyle, socioeconomic position, belief system, health status and social support to achieve compliance (Howard, 2012).

Practically, offloading is too rarely used or used in an inadequate way. In a recent study by Dumont (2010), diabetic foot clinics showed a lack of offloading in 24% of

patients, the use of orthopedic shoes in 32%, of “Scotch Cast boot” in 7% and of total contact casting in 3%, crutches were prescribed in 2% of patients, a wheelchair in 5% and in the remaining 27%, the offloading consisted of bed rest (Dumont, et al, 2010).

Orem’s Self-Care Deficit Theory

Recent evidence in diabetes care suggests a need for healthcare professionals to assess and empower individuals in the area of self-care when dealing with this chronic illness and its limb or life threatening complications, citing that patient noncompliance is his/her way of trying to gain some control. (Kumar, 2007). Dorthea Orem believed that people naturally migrate towards self-care, and nursing should focus on affecting that ability (Simmons, 2009). Orem’s theory of nursing describes self-care as activities that individuals undertake in order to maintain their health, life, and general wellbeing (Pearson, 2008). This includes voluntary activities such as eating a balanced diet, getting regular exercise, adequate sleep and avoidance of high risk activities such as smoking. When a person becomes critically ill or injured, this scope of self-care can dramatically change. A person’s ability to adapt to these changes and manage his/her own health and to regain optimal level of health and function is dependent on several related factors. Orem refers to these as basic conditioning factors. These include age, gender, health status, state of development, family support, environment, health care system, resources available, and pattern of living (Alspaugh, 2011). When an individual’s health prohibits him/her from meeting his/her own self-care demands, an imbalance occurs, and this is termed self-care deficit. In such a case, Orem’s model suggests that nurses become self-care agents to help these patients cope and meet these self-care deficits by (a) reducing the self-care demand so that the patient is able to manage his/her own needs, or eliminating the self-care deficit; (b) allowing the patient or his/her meaningful support to provide some level of independent care if total self-care is not possible; (c) and if it is impossible for the patient or meaningful other to provide any level of self-care, the nurse will directly assume the role of meeting the individual’s self-care (Pearson, 2008).

Outcome Measurements

Diabetic foot ulcer outcomes must be strictly measurable, patient-oriented and monitored on an ongoing basis in order to ensure successful treatment. The following describes three of the tools currently used today to measure outcomes for diabetic foot ulcers and for purposes of this paper, successful offloading:

1.  The outcome most widely recommended as crucial to wound healing rate predictions as well as monitoring are wound surface area (length and width) and wound depth (Santamaria et al., 2012).

2.  Health Related Quality of Life Measures (HRQoL). This tool measures not only clinical outcomes but those variables that assess subjective experience for the individual patient such as: (a) physical function, or the ability to carry out functions of daily living while managing a diabetic foot ulcer; (b) psychological well-being regarding, depression or anxiety associated with living with a chronic wound; (c) social functioning and the ability to maintain relationships in the context of chronic wound demands; and (d) somatic sensation related to wound pain (Ribu et al.,2007).

3.  The Bates-Jenson Wound Assessment Tool (BWAT). The BWAT contains 13 items that assess wound size, depth, edges, undermining, necrotic tissue type, amount of necrotic, granulation and epithelialization tissue, exudate type and amount, surrounding skin color, edema, and induration. These are rated using a score of 1 indicating the healthiest and 5 indicating the unhealthiest attribute for each characteristic (Harris, et al, 2010).

Reducing the Theory Practice Gap

The literature has identified several theory-guided methods that can successfully be used to guide practice when dealing with patients with diabetic foot ulcers that require offloading and pressure relief. They include (a) building a trusting relationship with the patient and family; (b) education directly related to diabetic foot ulcers and foot care, particularly proper off-loading, proper foot wear and pressure relief that is continuously reinforced with verbal and written information; (c) assuring that the patient environment promotes learning; (d) allowing patient to demonstrate self-care actions such as foot inspections and offloading techniques; (e) encouragement to sustain self-care efforts by involving patients in periodic wound measuring that demonstrates healing while setting realistic goals for the healing process that reflect the patient’s concerns; (f) setting reasonable goals for offloading while maintaining quality of life to avoid failure by utilizing offloading devices that meet the needs of the individual patient, such as total contact casting for the ambulatory patient, or leg elevation and heel floating for the nonambulatory patient; (g) promoting family involvement when indicated; and (h) being a liaison between patient and provider (Simmons, 2009).

Summary

Dorthea Orem's Self Care Deficit Theory is one of the general theories that guides nursing practice and can be applied to multiple settings in practice. The area of diabetic foot ulcers is one area of nursing practice in which the application of this theory is appropriate because it is crucial for patients to be actively involved in self-care. Orem believed that people have a natural ability for self-care and that nursing should focus on affecting that ability (Simmons, 2009). The goal of nursing practice is to assist patients to become adequately prepared to engage in their own care, thereby improving patient outcomes and quality of life. In the diabetic ulcer patient, this is accomplished by establishing a trusting nurse-patient relationship, providing support and education, allowing patients some control of their situation by participating in decision making, and encouraging them to actively participate in their treatment and offloading decisions, thereby improving ulcer healing outcomes and quality of life.

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