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An international cruise conference on nursing problems.

Late August on board of some Russian river cruise ship took place an interesting conference. About 20 American &

Eugenia P. Ananieva

Experience of new approach to  nursing aid to the patients with diabetic foot syndrome.

Diabetic foot syndrome is an anatomo-functional disorder, leading to the development of ulcerous striking foots, festering and necrotic complications, bone deformation and destruction and after all to breaking the supporting functions of limb.

Persons with diabetes are at significant risk for lower extremity amputations; such procedures are 15 times more common among persons with diabetes than among those without diabetes. Yet if patients whose feet are particularly at risk are aggressively sought out and treated, up to 50% of amputations can be prevented.

The amputation of the lower extremity, especially in hip level, leads to the fast death of these patients. 50% of operated patients dies during the first 3 years after amputation and 50% of persons with diabetes who undergo a lower extremity amputation have an amputation of the contra lateral leg within a few years. This occurs not only because of peripheral neuropathy and peripheral vascular disease but also because the remaining foot bears increased pressure and frequently develops ulceration and infection. The risk is greater for patients over 40 years old who have had diabetes for more than 10 years. Have to remember that about a half of patients after the first amputation loose the ability to move.

There is more than 11 thousand amputation of the shank due to diabetic foot syndrome. Really this number is higher because there is not the registration by nosology.

So, the prevention of diabetic foot syndrome development is very important. For the realization of this special program the City Centers of Diabetes and Diabetic Foot were established on the base of Chelyabinsk Medical Academy Clinic (the Diabetic Foot Center) and on the base of Clinical Hospital № 1 (Diabetes Center).

Medical workers, rendering aid elderly sick complicated by diabetes must have both knowledge of special care and clinical manifestations of glucose metabolism and its complications, skill to render an emergency help and ensure an interaction with relatives of sick and organs of social protection. It is most reasonable to prepare such specialists from nurses, as far as they are put on shoe bases of general care.

City Diabetes Center works about 2 years and its activities consist of:

·        School for diabetic patients;

·        Consultations of endocrinologist, ophthalmologist, nephrologist etc;

·        Podiatric service.

The staff of this center includes 2 nurses and 2 doctors. Coordinator of the school for patients is chief nurse (nurse manager). The number of the patients in one group is 10. People in the group are of same age, interest or education, if possible. The study cycle is 16 hour in 4 days. The study day consists of the lectures with breaks. Educators (endocrinologist, podiatrist, podiatric nurse) tell about diet, special food item for suffers from diabetes which are produced by local plants, about modern sugar reducing medicine and insulin therapy, about physical activity and exercise, about podiatric care, about signs of worry (hyperglycemia or its long-term complications). Educators help the patients understand and accept the seriousness of his disease and the importance of daily self-care. They assess, update, and reinforce their patient's self-care skills; for example, insulin injection, planning meals, and foot care. Regular follow-up is encouraged: feet and legs should be examined at each health care visit and patient should have annual dilated-eye examinations.

 Podiatric service carries out foot care and diagnostic help. All patients with diabetes should be given a complete foot examination at each visit (or at least four times a year). Saving the diabetic foot and preventing amputation requires the following:

·        Identification of feet at risk.

·        Prevention of foot ulcers.

·        Treatment of foot ulcers.

·        Prevention of recurrence of foot ulcers.

Patient Education Principles:

·        Instruct patients on the importance of regular foot care.

·        Inform patients about the relationship between neuropathy, peripheral vascular disease, and foot ulcers.

·        Urge patients to avoid risk factors associated with worsening of neuropathy.

·        Urge patients not to smoke - particularly if they have peripheral vascular disease.

·        Inform patients about special shoes for preventing or treating foot problems.

·        Refer patients to a certified pedorthist if they have foot deformities or otherwise need special shoes.

·        Inform patients about the availability of podiatric services; encourage patients to use these services.

Furniture, computer and technique with help of pharmaceutical company equipped school for patients. The podiatrist service works at base of surgical outpatient department. There are some problems in the work of Chelyabinsk City Diabetic center. First of all, it's a physician priority in prophylactic field. As I said, we consider that  nurses have to prevent diabetes complication, to educate patients and their relatives.

The second, there are not enough visual aids for patients' education such as Blood Glucose Meters, Non-invasive Blood Glucose Meters, Test Strips for Visual Reading, Syringes and Injection Products, Urine Testing Products. We have not possibility to use any software in spite of we have a computer at study. We have not any special software product for diabetes patient, for example, Computerized Meal Planning, Controlling Diabetes at the Keyboard, Computerizing Your Meter.

The third, patients have podiatric care only at podiatrist room  at the polyclinic or, if it needs, at the in-patient surgical department. They have not qualified help at own homes.

This problem we try to decide at special Chelyabinsk City’s Diabetic Foot Center. We master by practice a model of  the complex nurses' crews. The crew consists from

·        Nurse manager

·        Patronage nurse

·        Manipulation nurse

·        Doctors as consultants (podiatrist, endocrinologist and others)

The goals of this crew are:

1.     Care at the pre- and post-hospital treatment

2.     Education of patients

3.     Monitoring for patients with Diabetic foot syndrome

4.     Making doctors' prescription and procedures

5.     Social and psychological help for patients

6.     Interaction with social service

7.     Conducting of medical documentation

8.     Integration of activity with activity of the Diabetic foot center

The main problems are:

·        Shortage of staff  (there are only one crew - 2 nurses - for … patients)

·        Insufficient material equipment (there is a shortage of dressing and antiseptics even)

·        Lack of special educated nurses (at Chelyabinsk State Medical Academy have been worked up a program of podiatric nurses and nurse managers education)

We consider that worthy adapting principles of the care on Russian ground lead to the developing of complex nurses' crews, which would be dispensary helpful for patients with diabetic foot syndrome. We have many problems, especially financial and material. But we have a wish to help our patients.

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