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Neuro Behavioral Med 3 > 43 - Behavioral Implications in Diabetic Patients > Flashcards

43 - Behavioral Implications in Diabetic Patients Flashcards

1
Q

What are “the big three” dreaded complications of diabetes?

A
  • Blindness
  • Kidney failure
  • Foot and leg amputation
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2
Q

Describe which areas of quality of life are decreased in those with diabetic foot ulcers

A
  • Social
  • Psychological
  • Physical
  • Economic
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3
Q

Describe the level of quality of life reduction in diabetics with ulceration

A
  • Some studies report quality of life reduced by 10 to 40% in diabetic patients with ulcer versus diabetic patients without ulcers
  • Further impairment for persons advancing to amputations
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4
Q

Why is the quality of life reduced in diabetics with ULCERS?

A
  • Reduced mobility
  • Change in lifestyle of individual and family (frequent doctor visits)
  • Loss of social role
  • Unemployment
  • Reduce social activities (odors of wound vac, dressings)
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5
Q

How many US citizens in the US are diabetic?

A
  1. 1 million people
    - 9.3% of the total population
    - 14.6 million people diagnosed
    - 6.2 million people undiagnosed

CHANGED NUMBERS - LOOK AT RECORDING

Those who are UNdiagnosed have no medical treatment for their disease, poor skin care, no precautions, form ulcers even before there

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6
Q

Describe the distribution of

A

s

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7
Q

What are the statistics of diabetes in the US

A

x

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8
Q

What is the “bad news” of foot complications for diabetics?

A
  • Foot ulcers associated with significant morbidity and mortality
  • Treatment of ulcers range from simple to complex
  • High rate of recurrence
  • Leading cause of amputation

Any time you have a break in the skin, the patient is at risk for infection and diabetics are immunocompromised, so the risk for infection is high

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9
Q

What is the most common precursor for lower extremity amputation?

A

Ulceration

“Foot ulcerations are the most common single precursor to lower extremity amputations among persons with diabetes.”

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10
Q

Why are patients with a small amputation at higher risk for further amputation?

A
  • Once a diabetic has a partial or complete foot amputation, he or she is at high risk for further breakdown
  • This is because the biomechanics of gait is changed
  • They start to favor the adjacent leg, making risk of amputation of that leg increased
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11
Q

What are further areas of complication with amputation?

A
  • Rehabilitation of an BKA or AKA with a prosthetic in a diabetic can be extremely difficult (especially when the patient is OLDER*)
  • Below knee and above knee amputations put significant stress on the heart and lungs
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12
Q

What is the five year mortality rate for new onset diabetic foot ulceration?

A

Five year mortality rates after new onset of diabetic foot ulceration reported as 43 to 55% and up to 74% with lower extremity amputation

KNOW THESE NUMBERS **

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13
Q

There is a higher level of mortality associated with ulceration and amputation than which common cancers?

A
  • Prostate
  • Breast
  • Colon
  • Hodgkins disease
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14
Q

What is the major culprit of mortality in this disease?

A
  • Cardiovascular disease is major culprit for mortality
  • New-onset diabetic foot ulcer should be considered a marker for significant risk of increased mortality
  • Needs to be managed locally, systemically and psychologically
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15
Q

What are the some of the stages of dealing with an ulcer?

A
  • Diagnosis and Denial
  • Many patients are in denial of the seriousness of ulcer
  • “Non-compliance” is extremely common
  • Difficult for patients to accept need to change lifestyle
  • Commonly can lead to depression and continued denial
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16
Q

Describe non-compliance of dealing with an ulcer

A
  • Continue weight bearing

- Missed appointments

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17
Q

Describe how depression results from ulceration and continued denial

A
  • Many times patients will be pleasant to doctor without indication of symptoms of depression
  • Common for family members to express concern about patient
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18
Q

What is important in counseling patients with diabetes and ulceration

A

Nutritional and exercise control of diabetes

This is all of our responsibilities to educate patients

Portion control, importance of healthy eating

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19
Q

What factor increases the chance of negative patient behavior

A

Time –> The longer the ulcer is present the more chance of negative patient behavior

  • Sense of hopelessness
  • Diminished quality of life
  • Depression and anxiety
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20
Q

Describe how honesty is relevant in treating ulceration

A
  • Need to be consistent and honest with patient

- If ulcer care is not effective need to progress to more advanced techniques to heal ulcer

21
Q

Describe the consequence of ulceration that reaches bone

A

When you have a chronic wound that probes the bone, it is an indication that there could be osteomyelitis (bone infection) - 99% of the time you need to take them to surgery and remove the infected bone. Some of the time antibiotics alone can be effective, but relapse is common.

22
Q

What are the principles of ulcer management

A
  • Infection
  • Vascular Supply
  • Debridement
  • Off loading
  • Wound Management
  • Wound Closure
  • Management of medical comorbidities
23
Q

Describe a study by Winkley in 2009

A

“Quality of Life in Persons with Their First Diabetic Foot Ulcer”

  • Prospective study of 253 diabetics with first ulcer and quality of life
  • Used a short form health survey at 18 months follow-up

Results

  • 40 deaths
  • 36 amputations
  • 99 recurrences
  • 52 non-healing ulcers

5 to 6 point deterioration of patients who did not heal or had recurrent ulcers

Conclusion
- “Quality of life deteriorates in people with diabetes whose first foot ulcer re-occurs or does not heal within 18 months.”

24
Q

Describe the main points of diabetic ulcer management

A
  • Successful management needs to address patients mental status as well as the ulcer management
  • If things are progressing well express to patient and congratulate him or her
  • If not going well, need to be up front and honest and be clear of treatment plan
  • Consider professional psychological help if significant signs of anxiety and depression
25
Q

What are three things that are required for “successful” amputations?

A

1 - “Remove all necrotic, painful, or infected tissue.”

2 - “Must be able to fit amputation stump with a functional and easily applied prosthesis.” (least important of the three, but do need to evaluate)

3 - “Blood supply at the level of the proposed amputation must be sufficient to allow primary skin healing.”

If you can’t feel pulses, consult vascular for healing potential - A BKA may be more effective to increase chances of healing due to better blood flow.

26
Q

What are the major factors to consider when determining the level of amputation

A

Medical and mental status of the patient
- Is the patient medically and mentally stable enough for multiple procedures if needed?

Infection
- Infection needs to be controlled before definitive amputation, unless proximal amputation is being performed at safe anatomic site

27
Q

What are the different amputation levels?

A

Toes

  • Partial
  • Complete

Partial rays

  • 1st ray
  • Middle rays
  • 5th ray

Others

  • Transmetatarsal
  • Lisfranc’s
  • Choparts
  • Boyd’s
  • Symes
  • Calcanectomy
  • Below Knee (BKA)
  • Above Knee (AKA)

LISTEN FOR DEFINITIONS

28
Q

Describe toe amputations

A

x

29
Q

Describe partial ray amputations

A

x

30
Q

Describe transmetatarsal amputation

A

x

31
Q

Describe Lisfranc’s amputation

A

x

32
Q

Describe Choparts amputation

A

x

33
Q

Describe Boyd’s amputation

A

x

34
Q

Describe Symes amputation

A

x

35
Q

Describe Calcanectomy amputation

A

x

36
Q

Describe BKA and AKA amputations

A

x

37
Q

Describe amputation as a treatment option

A
  • Not always considered a failure
  • For many patients it can be relief to pain and suffering
  • Many patients are ready for a definitive procedure versus potential for prolonged treatment course
  • However, for many considered a major loss, even if it is a minor amputation (i.e. toe)
38
Q

Describe the amputee’s reaction to new BKA amputation

A
  • Has been 18 hours since amputation
  • Surprising, shocking
  • Not a lot of pain in the amputated leg (numbed)
  • They will taper the numbing medication over the next 6 hours
  • She will be going home in a couple days, which seems soon to her
  • Strange, but getting ready to go home and get used to the new life with one leg
  • It is going to be much better in the future and is thankful for the one good leg
  • Doesn’t want people to feel uncomfortable around her, feel free to ask questions
  • Happy to explain how it got to this point and why, etc.
  • Complex regional pain syndrome caused the amputation
39
Q

What are common phases that amputations go through

** this is important **

A
  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance
  • Recovery
40
Q

Describe the denial phase

A

This happens either before or after the amputation. Pre-amputation often involves the person trying to convince themselves that their situation will get better, which actually could make them worse off. After is normally more traumatic and will often involve the person denying that the loss has any impact on their life.

41
Q

Describe the anger phase

A

This can be either inward or outward. The patient will blame themselves, the doctors, and even their family. It is necessary for the patient not to repress their anger, but experience it while it is happening to deal with it.

Anger can be directed anywhere, including the physician. Why didn’t you warn me? Why didn’t you force me to do better? Can also be mad at themselves since they realize they could have prevented this

42
Q

Describe the bargaining phase

A

In this situation, this step is normally out of order and coincides with denial. The important thing to try and remember is that amputation is always a last resort, and if it were not necessary, it would not be happening.

Can occur “out of order” - can occur up with denial when they are trying to avoid the problem

43
Q

Describe the depression phase

A

This is believed to be the most complicated stage for amputees. They are not only faced with the sadness of their loss of limb, but they come to worry about losses that will happen because of it

MOST COMPLICATED STAGE ***

44
Q

Describe the acceptance phase

A

The main point of acceptance for an amputee is to accept that the limb is gone and not coming back. This is where they have to take control of what will happen in their life from this point on.

Like in the video clip… The limb is not coming back, you start to realize you need to move forward. They are still the same person, but some things will change.

45
Q

Describe the recovery phase

A

Physical, social ,and psychological rehabilitation and counseling.

Counseling can be very beneficial

46
Q

What can be done to help the patient cope?

A

There are psychological and coping strategies associated with complications for amputees

47
Q

What are some emotions and coping strategies associated with amputation?

A
  • Catastrophizing (making it seem worse than it actually is - do better once they realize it isn’t that bad)
  • Vulnerability (seek more attention)
  • Avoidance (ignore the problem)
  • Helplessness

You will see a lot of this

48
Q

Describe a summary of diabetic amputation management

A
  • Successful management needs to address patients mental status as well as the amputation management
  • If things are progressing well express to patient and congratulate him or her
  • If not going well, need to be up front and honest and be clear of treatment plan
  • Consider professional psychological help if significant signs of anxiety and depression

Neuro Behavioral Med 3 (16 decks)

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