Placement Assignment on Medical Care

The increasing prevalence of diabetes in different parts of the world is well documented
as having reached near pandemic proportions (Kahn, Cooper & Del Prato 2014; World Health
Organization [WHO] 2015). It is equally well-documented that the South Asian population has a
higher risk of diabetes and kidney complications due to genetic, lifestyle or access factors (Tan,
Davis & Davis 2013; Wium, Gulseth, Eriksen & Birkeland 2013). Apart from these, national
surveys show that in the United States, 25.9% or 11.8 million of the senior population have
diabetes, diagnosed or diagnosed (ADA 2015). Meanwhile, lower-extremity ulcers are a common
and challenging problem for people with diabetes and healthcare professionals who take care of
them (Sharp & Clark 2011; Sussman & McLennan 2014; Veldhoen, Nube, Molyneaux & Twigg
2014). Ulceration tends to negatively impact the quality of life of the sufferer dues to factors
such as pain, exudate, odour and social isolation (Wilkinson, Randhawa & Singh 2014).
Especially when a patient has multiple risk factors such as ethnicity and senior age, it is of
utmost importance that wound care and health management be done using the holistic approach
(Popoola 2003). Through the holistic approach, there are improved chances that ulceration will
not significantly impact the quality of life of the diabetic sufferer. This paper presents a
discussion on the holistic care of a diabetic patient with a chronic wound. Attention is provided
to theory-driven care planning and delivery.
Medical Care Scenario
Jane is a 70-year old woman with South Asian roots diagnosed with type 2 diabetes 25
years ago. However, instead of taking medications upon diagnosis, she insisted on using
alternative medicine instead. Nevertheless, she was started on medication for the management of
her diabetes 17 years ago but because of her worsening blood glucose control, her physician
shifted her to insulin five years ago. Jane has been residing at a nursing care facility for he past
12 months. ane has always been the feisty and active type of person, with a love for the
outdoors. However, she has been generally careless about adhering with the management of her
diabetes which is why her glucose has been poorly managed. A year before Jane shifted to
insulin, she developed a wound on her heel. Her ordeal began with a new pair of shoes which she
taught would be comfortable to wear. In an outing to a theme park together with her family, Jane
had already been feeling pain in her right heel at the middle of the day but thought that her new
pair of shoes simply needed breaking in.
However, when she got home, she found that has heel had begun to blister. Jane
attempted to treat her wound on her own, with iodine and dressing. She went to great lengths in
order to hide her wound, oftentimes wearing thick socks. She managed to infect her
wound further until the nurses can no longer ignore her limping and asked to look at Janes foot.
Immediately, she was taken to her GP. At the GPs office,
Because of her neglectfulness, Janes wound infection continued. In turn, Jane was
finding it difficult to manage her blood sugar levels within acceptable limits because of her heel
infection. Janes ordeal with her chronic heel wound persisted for more than five years.
Presently, she requires surgery for her foot as the infection has spread. Jane is aware that her
stubbornness and failure to adhere with her medications have been keys to her worsening wound.
At this point in time, she regrets hiding the worsening of her wound from her physician. Jane has

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been struggling with feelings of frustrations due to the non-healing of her wound, fear that her
foot would be amputated, and resentment at her condition. She had considerable self-blame for
her previous behavior. Consequently, she has become distracted, lost her appetite, has not been
sleeping well, moody, and her preoccupation on fears making her miss out on her medications.
Holistic Care
Wounds can and do heal in patients with diabetes, but healing may take longer due to an
impaired process in this population (Harman 2014). It cannot be emphasized enough that a
non-healing wound is prone to complications, including, infection and trauma, that could delay
healing even more. When this happens, the patient could suffer from adverse consequences,
including their families and carers, in light of increased patient morbidity and mortality as well
as the economic effects of becoming ill (Armstrong, Lavery, Wrobel & Vileikyte 2008).
Indeed, researchers have shown that when a diabetic patient has an active foot ulceration,
he or she experiences general decline in health, physical functioning, physical role as well as
vitality (Sharp & Clark 2011). On the other hand, healing of wounds among diabetic patients
lead to enhanced quality of life (Nabuurs-Franssen, Huijberts, Nieuwenhuijzen Kruseman,
Willems & Schaper 2005). Notably, over 50% of patients who have had a non-traumatic limb
amputation have diabetes, the majority of amputations had been preceded by an ulcer or nonhealing wound (Sharp & Clark 2011).
Janes chronic wound and health in general should be assessed in the contexts of her
overall physical and psychosocial health (Timmons 2003). As with any chronic disease process,
Janes chronic wound needs intervention by multiple health care disciplines to address the many
conditions and co-morbidities that could impact her wound healing (Batista, Magalhes, Gamba,
Nery & Cardoso 2010; Ukay, Gariani, Pataky & Lipsky 2014; Hellingman & Smeets 2008). As
seen in Janes case, the development and worsening of her wound has been multifactorial,
thereby indicating that the multidisciplinary process is essential, in which an interdisciplinary
team approach must be used. For Jane, considering that she is an elderly, Asian patient with
diabetes residing at home with a chronic ulcer at her heel, a disciplinary team would comprise of
a certified wound specialist who would take care of debridement, dressing selection and patient
education; an orthotist for recommendations on pressure relief footwear; a physical therapist for
gait training and home modification; a nutritionist to monitor her diet and improve overall
nutritional status; a vascular surgeon to evaluate patency of blood vessels; a primary care
physician to manage glycemic control and other co-morbidities; an infectious disease specialist
for evaluation of her wound osteomyelitis; a podiatrist for possible surgical intervention; a
counselor for her emotional issues; and, a temporary home care nurse (Association for the
Advancement of Wound Care [AAWC] 2011). The care to be delivered by this multidisciplinary
team will be coordinated in care settings across the continuum.
The holistic approach to be used for Janes wound management harnesses an
integrated care pathway (ICP) in order to provide optimal care (Manton & Boogaerts 2010).
Yarwood-Ross & Randall 2013). To note, this ICP establishes the multidisciplinary approach for
a specific condition in order to deliver a seamless approach to care aside fro facilitating decision
making among professionals. Janes assessment encompasses her physiological, emotional,

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psychosocial, economical, spiritual and cultural dimensions. Physiologically, Jane has diabetes
and is of senior age. Diabetes, as exacerbated by Janes age and South Asian roots, is a
multidimensional illness that can lead to complications such as hypertension, poor vision, and
kidney failure, among others. Emotionally, Jane has been feeling frustrated, resentful, fearful and
moody. Janes psychosocial contexts had been limited to her family and close visiting friends
because her heel wound prevents her from moving about. Economically, Jane is covered by basic
insurance but this does not provide certain types of medicine and home nursing care. Politically,
had not Janes daughter consulted a nephrologist who advised her to change insurance, there
would be future problems in the even that Jane would need dialysis treatments (Yarwood-Ross &
Randall 2013). Spiritually, Jane had converted to Catholicism but no longer attends church
because of the disability. Culturally, Jane is among the population that is at higher risk for
diabetes and her Asian background sometimes interferes with her trust in the American
healthcare system. The use of the ICP will facilitate consistent continuity of care (Yarwood-Ross
& Randall 2013). It must be noted that the process of assessment should be based on the theory
of developed by Roper, Logan and Tierney (1983) Activities of Daily Living (ADL) (also known
as the RLT model). The discussion on assessment and care plan based on the ADL will be
discussed in the next section because they occur according to a continuum.
Holistic Assessment and Care Plan
Janes assessment and care plan would be underpinned by the ADL, which seeks to define
the meaning of living. The goal of interventions based on the ADL is to achieve optimal
independence for patients (Roper, Logan & Tierney 1983). Notably, the ADL has also been used
in assessing a patient's relative independence and potential for independence in terms of
activities undertaken on a daily basis. Based on the ADL, Janes independence will be considered
in her care plan, according to a continuum ranging from complete dependence to absolute
independence. The use of the ADL will help Janes multidisciplinary team in determining which
interventions will lead to enhanced independence as well as further supports needed in order for
Jane to eliminate dependencies that persist. Although the ADL looks like a checklist, it should
not be used as one.
Instead, the model should be regarded as a cognitive approach for developing a care plan
for patients. All throughout the care and evaluation, dependence and independence must be
regularly reviewed. By checking the changes in the dependence-independence continuum, the
team can determine whether Jane is improving or not, and in the process, make modifications
based on evidence. Table 1 below is the care plan for Jane, which will also serve as her
evaluation plan. The goals of Janes care plan are to prevent wound deterioration and promote
self-care.
Table 1: Janes Care Plan
Topic

Problem

Plan (Physical)

Plan
(Psychological)

Plan (Social)

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Maintaining a
safe environment

Janes chronic
wound is prone
to infections

Jane should live

in an
environment that
is clean and
sanitized, and her
home nurse can
facilitate this.
The environment
should be stressfree due to her
emotional issues
and her physical
therapist can
facilitate home
modification

The environment
should be stressfree due to her
emotional issues
and her physical
therapist can
facilitate home
modification

Jane needs to explore the

development of her
social support networks,
such as, friends,
families, fellow residents
at the facility or even
church members,

Breathing

Janes breathing
may be affected
by side effects
of the
medications she
is taking, as well
as her age.

As a person ages,
conditions that
constrain the
ability to breath
may increase
because of
declining lung
function. My
involvement here
was to regularly
check for signs
indicating
problems such as
dyspnea,
shortness of
breath, blood
gases, abnormal
arteries, cyanosis,
closed lip
breathing,
retraction of the
respiratory
muscles during
breathing and
superficial
breathing.

Intense pain as
well as emotional
disturbances may
interfere with
Janes breathing.
Her emotional
distress may
cause breathing
problems

Little social relevance.

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Communication

Jane has the

tendency to
conceal her
feelings, as well
as the worsening
of her wound

Janes mental
health
professional
should encourage
her to express her
feelings. Her
primary care
physician should
continually
educate her
during her
healing process.
Her podiatrist,
infectious disease
specialist, and
vascular surgeon
should keep her
updated about
her condition.

Daily
communication
facilitates the
formation of
social bonds and
relationships.
However, aside
from her GP, it
seems as if Jane
does not feel
comfortable in
communication
with other
members of her
health team. ,

There is consensus among

scholars that
communication is the
backbone relationships.
What Jane badly needs at
this point in time, is to have
smoother communication
skills between her and her
health team. Through
smoothly flowing
communication protocols
and processes, it is highly
likely that Janes
intervention will obtaon
enhanced production

Mobilization

Jane cannot
move around
because of her
wound

Janes physical
therapist should
provide her with
the appropriate
exercises

Mobilization is
one of Janes
problems
because of her
wound. An
assessment of
Jane reveals that
she is highly
frustrated by not
being able to
move about.

Jane requires education

about mobilization. She
needs to understand that due
to the aging process, many
changes are occurring in her
body that could hamper her
mobilization.

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Eating and
Drinking

Jane has to
manage her
blood sugar
level

Janes nutritionist
should monitor
her diet and
improve overall
nutritional status.
Notably, Janes
proper eating and
drinking ,
promotes,
preserves and
recovers her
health. However,
as of the time of
her assessment,
Janes eating and
drinking were far
from optimal.
Due to the
significance of
eating and
drinking, her
entire team will
provide each
their insights
regarding these
daily activities,

behavioral and
psychological
changes will
unfold in Jane as
she ages.
However, a
dilemma at hand
is that the said
changes also
affect the give
senses of an
aging person
such that food
does not seem
too appealing.

Jane should learn the

different ways through
which she can manage her
eating and drinking in
public places.

Elimination

Jane does not

seem to have
problems with
elimination
except in terms
of getting help
into and out of
the bathroom

Janes home
nurse should
assist her, and her
physical therapist
should facilitate
modifications so
that Jane can
eventually move
about
independently

As a person
becomes older,
he or she starts
suffering from
stomach
problems
because the
digestive system
somewhat
weakens and
experience
atrophy.

Jane needs to be prepared

socially so that she will not
embarrass herself publicly,

Personal cleaning
and dressing

Jane needs help

for her hygiene,
as well as the
dressing of her
wound

Janes home
nurse can educate
her about how to
be independent.

One of the
greatest
participation that
I had was in
terms of Janes
personal hygiene
and dressing up.
I suggest that out
mental health
counselor listen
to Janes fears of
becoming fully
dependent on

One thing that bodes well

for Jane is that in spite of
her immobility, she can look
attractive especially since
garments sold in malls for
senior ladies have become
more fashionable as ever.

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others in the
future.

Maintaining
body temperature

Jane is taking
many
medications that
could interfere
with her body
temperature

Janes general
physician should
regularly check
factors that could
change Janes
body
temperature,
including,
medications. Her
home nurse
should ascertain
that the
temperature in
Janes room is
regulated

Working and
playing

Jane wants to go
outdoors but her
wound is
causing her pain

Janes physical
therapist should
arrange for
outdoor activities
with the use of a
wheelchair and
other assistive
devices. Her
podiatrist,
infectious disease
specialist, and
vascular surgeon
should manage
her pain and
involve Jane in
her pain
management

Sleeping

Jane cannot
sleep because of
the discomforts
of her wound

Janes
multidisciplinary
team should meet
with Jane so that
she could
manage her
sleeping well.

Jane has already

reached her
senior years. Her
mental health
counselor needs
to discuss with
Jane any sense of
loss that she may
have experienced
retirement.
Perhaps a
continuation of
this query would
be how Jane
perceives play in
the context of
quality if life.

Among many adults,

employment or work is the
activity that represents
notions of maturity, and
being grownup. Therefore ,
it is not surprising that work
facilitates identity formation
among members .

Multidisciplinary Collaboration
It is of utmost importance that the members of Janes team use a collaborative approach
(Batista, Magalhes, Gamba, Nery & Cardoso 2010). The team members should work closely

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together according with diabetic foot protocols and guidelines so that they could collaborate in
the management of Janes wound. As discussed earlier, Jane should be part of this collaboration,
starting on the day of her assessment. The collaboration should occur throughout the continuum
of care for Jane, with the professionals sharing updated information about the patient in order to
deliver efficient yet timely care. The team members should also collaborate in providing patient
education on proper foot care in light of Janes diabetes. Communication is a crucial process in
this team collaboration, to be facilitated by technologies such as electronic health records.
Moreover, trust and respect should be the underlying values of communication between team
members.
Patient Anonymity and Confidentiality
In delivering holistic care to Jane, her team should respect her confidentiality and privacy
at all times. None of her personal health information should be disclosed to unauthorized parties,
and should be stored in secure and safe databases. None of the team members will use Jane as a
subject for studies to which she had not given consent.
Conclusion
Presented in this paper is a holistic multidisciplinary approach to providing care for Jane
in light of her diabetes and chronic wound. A holistic approach is necessary because care for
diabetes should be in a continuum. This is to ensure that the treatment regimen is complementary
in all aspects. The treatment should also be private and confidential to respect the patients rights.
The ADL model will be useful in her assessment and development of care plan. Apart
from these, Jane will also be encouraged to participate in the development of her care plan based
on the rationale that this will increase her commitment to its success since she knows about the
plan and helped to form it. Overall, the multidisciplinary team should take a collaborative
approach in delivering holistic care to Jane.
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