￼ The Wound, Ostomy, and Continence Nurses Society’s (WOCN) guideline for “patients with lower-extremity neuropathic disease (LEND) with or at risk for wounds” states their goal to “support clinical practice by providing consistent, research-based information with the goal of improved cost-effective patient outcomes as well as to stimulate increased wound research” (WOCN, 2012).The intent of this paper is to examine this guideline and evaluate the parameters of its content. Diabetes is a metabolic disease that is characterized by high blood glucose levels resulting from the body’s inability to produce and/or use insulin. According to the National Institute for Clinical and Health Care Excellence [NICE], Between 20-40% of people with diabetes have neuropathy and 50% of diabetics may develop a foot ulcer (Fitzpatrick, 2013). Neuropathy is a microvasuclar vascular disease which causes a loss of sensation, although painful sensations are still reported. (Holt, 2013). Diabetic neuropathy is the leading cause of non healing ulcers in diabetics with amputations (Masson, 2011), and linked to 62% of non-healing ulcers (as cites in Hampton 2006 p.S22).
Approximately half of all diabetic patients are affected by neuropathy (as cited in Fitzpatrick 2013, p. 228). Evidence suggests that the “control of associated risk factors can delay or prevent such complications” and should be made priority (Hill, 2009). Ulceration develops with high pressures, such as tight fitting shoes or other foot wounds. Through the effects on peripheral nerves and arteries, diabetes can lead to foot ulcers and infection (Hill, 2009). Managing an infection is somewhat challenging for diabetics as blood glucose levels are elevated during times of stress, the ill diabetic is a rich environment to a host of bacteria. “When the blood glucose level remains high for an extended period of time it increases the potential for protein destruction to occur and the continued interference with the protein function will eventually lead to destruction of cellular function and the well-recognized tissue injuries that are related to diabetes’ (as cited in Hampton, 2006, S22-S24). Diabetics who do not manage their blood glucose levels are at a much higher risk for developing ulcerations related to diabetic neuropathy. WOCN recommend “referral to lab markers that may indicate infection including complete blood count (CBC), procalcitonin, C-reactive protein, and blood glucose to recognize and treat infections early on” (WOCN, 2012).
Neuropathies are often difficult to diagnose. Symptoms can be vague and are often overlooked. It is important that the nurse be vigilant in identifying the signs and progression of neuropathy. (Hill, 2011) Peripheral neuropathy is most likely to occur within 5 years of onset of the disease (as cited in Hampton, 2006 p. S22), therefore early patient education on foot examination and injury prevention is key. The WOCN emphasize patient teaching should include daily cleansing, moisturizing, self-foot exam and investing in indoor and outdoor shoes; as well as smoking cessation and counseling, adapting a customized fitness program, targeted nutritional therapy, and providing vitamin supplementation to support blood sugar control Although the WOCN guidelines are extensive in their research, ranging from specific offloading procedures to debridement for ulcers, however there is no strategical implementation of protocol, nor any accounting for the majority population that suffers from diabetic wound.
Many of the diabetics who develop an ulcer related to neuropathy are elderly, poor and do not have good control of their glucose or any means to do so. Masson points out that diabetic amputation rates have a positive correlation with high incidence of “socio-economically deprived backgrounds and attention should be paid to the vulnerability of this population” (as cited in Masson, 2011, p. 641). In conclusion, consistent glucose management is the best prevention for microvascular diseases such as diabetic neuropathy and the associated risks of ulcer or amputation occurring. Nurses should teach all diabetic patients to pay careful attention to glucose management and foot care, especially during illness. Healthy lifestyle factors and thorough yearly checkups contribute to the successful management of all diabetic complications.