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In order to implement NICE guideline, an audit was conducted on diabetic at risk foot.

It showed that over 60% of patients audited had some form of foot problem, and most were not seen by professionals to treat them or were not given any form of advice. The diabetes team therefore, decided that, an assessment tool be formulated for the use of the ward nurses to identify diabetic foot problems. Diabetes is known to be the leading cause of neuropathy; or rather neuropathy is the most common complication of diabetes. It is a known fact that more than fifty percent of nontraumatic lower limb amputation occurs in diabetics; and to further backs the notion of Boulton et al, (2005) that, up to four percent of diabetics have foot ulcer every year. Diabetes UK (2010) supports the above by suggesting that, 1 in 20 diabetics will develop foot ulcer in a year and more than 10 foot ulcers developed into amputation. Hyperglycaemia is largely the commonest risk factor for developing diabetic neuropathy. If so then there is a very necessary need for limiting hyperglycaemia developing in patients through structured education. Diabetes UK (2010) published a guide call Putting feet first encouraged healthcare organizations to identify a designated person for foot assessment and referral or treatment for patients coming to hospital and for that matter attending clinics have their feet examined at diagnosis and ongoing care thereafter. In the DCCT (Diabetes Control and Complications Trial, 1995) study, the annual incidence of neuropathy was 2% per year, but dropped to 0.56% with intensive treatment of Type 1 diabetics. The progression of neuropathy is dependent on the degree of glycaemic control in both Type 1 and Type 2 diabetes. Pathogenesis of diabetic foot disease is so complex and sub divided that I would generalize it and made it simple. Hyperglycaemia in tissues and blood vessels cause capillary membrane thickening and endothelial hyperplasia resulting in hypoxia and tissue damage leading at times to ischaemia. (LO 1&5) Hyperglycaemia also causes excessive osmotic pressure on cell membranes and glycation which results in accumulation of metabolites. It further helps in activating Protein kinase C which acts on sensory nerve to contract causing nerve damage. (Mazze et al, 2004; Williams et al 2002). To diagnose diabetic neuropathic foot, it is essential for patients to have regular checks by trained professional like podiatrist, doctors with interest in the subjects and other healthcare professionals whose interest lies with the field of foot diseases. Why so? Take for example, a nurse who is interested in foot disorders will make sure that her patients receive timely assessment and intervention to prevent and treat

their foot problem as opposed to the nurse who is not interested in food disorders. At best a nurse might refer the patient to the podiatrist, and leave it at that, where as the interested one will follow up the patient to make sure that they are receiving the proper and timely intervention. Or she might do the assessment and the intervention herself; because she had taken the needed time to do research and educated herself in order to help her patients. One would argue that, it is not necessary for a nurse to go to such a length in caring for a patient as all she has to do is refer to the podiatrist, and her job is done. That might be true to some extent; however, to limit the cost of hospital stay for patients who unfortunately required hospitalization due to foot problems, the nurse could assess the patient and if appropriately treat infected foot in time which will in turn minimize recurrent admission. The above argument highlighted a statement from Holman and Young (2011) that, 15.3% of people with foot problems revisit hospital four or more times in three years of their study. However, researchers from the diabetic division announced significant drop in rates of non-traumatic lower limb amputation among newly diagnosed US diabetic adults, but said more work is needed to reduce the disparities among some populations. (CDC 2012). Dr Lind, (CDC 2012) expert in foot medicine concurred that, Hopefully it is a sign that professional are doing better job of preventing and treating peripheral vascular disease, lower limb ulcers and infections more aggressively and timely before they get to devastating stage of requiring amputation.

From the above arguments, you would agree with me that, there is a need for developing a tool for nurses to use in identifying at risk foot of the diabetics during hospitalization for whatever reason. Further, nurses will be educated and taught how to use this tool competently and with confident to address the following: To help all diabetic patients under their care to agree on glycaemic target. To actively educate all diabetic patients on foot care. Diabetic patients should be assessed for possible neuropathic signs. To timely refer suspected patients to the podiatrist for early intervention. For every newly diagnosed diabetes foot care plan should be agreed with. To incorporate foot education into the Think Glucose Project