As a certified wound, ostomy and continence nurse who is currently employed full-time as a nursing instructor in an associate degree program, I read the Getting Ready for Certification section in the July/August 2010 issue of our journal JWOCN with great interest. Since my wound care experiences are currently limited to the patients I encounter with my students on medical surgical units, I found the multiple-choice questions a needed content review. I do, however, have a comment about one of the questions. Perhaps I am "reading into the question" and suffering the same fate as my nursing students who then answer the question incorrectly. Question 3 states: A WOC nurse is providing teaching to a diabetic patient. Which is the most important aspect to emphasize?

1. Insulin administration

2. Foot care

3. Blood sugar regulation

4. Skin care

According to the author, the correct answer is foot care. As I read this question, I kept asking myself, should I only be concerned with my role as a wound care nurse (foot care), or should my greater responsibility to the patient impact my answer? I also thought about the strategy I teach my students to use when answering priority questions. I tell them, pretend it is 3:15 PM on a busy medical surgical unit, you are scheduled to leave at 3:30 PM; what is the single most important thing you can do for your patient; or what will ultimately solve the problem or save the patient's life? When I used my own standard, I answered blood sugar regulation. The main goal of diabetes management is the normalization of blood glucose levels. Using the same reference cited by the section author, I researched the chapter about neuropathic and diabetic wounds, and it reinforced my answer, as I remembered information linking neuropathy incidence to poor glycemic control.1 In addition, the American Diabetes Association has called glycemic control "fundamental to the management of diabetes" and their 2009 guidelines recommend tight glycemic control for the reduction of macrovascular and neuropathic disease.2

I also remind my students not to use the "real world" when answering nursing questions, but as I read this question; one of my more difficult diabetic patients came to mind. A few years ago, I was asked to suggest topical therapy for a nonhealing diabetic neuropathic wound. As I reviewed the chart, I noted that the patient was prescribed only an oral hypoglycemic agent, and blood sugar levels were not well controlled or managed. When I interviewed the patient, he told me that he was not willing to self-inject insulin and refused any assistance. He was adamant that he would only "take pills." Each day, the nursing staff provided excellent foot care and evidence-based wound care, but without needed insulin, the wound never healed, and ultimately the patient required a transmetatarsal amputation.

I agree that foot care is paramount, and an important and fundamental aspect of diabetic teaching. However, patients can check their feet each day and follow strict protocols, yet, if their blood sugars are not well managed, they place themselves at risk for neuropathy, peripheral vascular disease, macrovascular disease, immunocompromise, infection, and amputation.3 Poor blood sugar regulation leads to the ultimate complication, death. Therefore, as a nurse, I believe the more important intervention is glycemic control. If I were told I could teach only one aspect of diabetes management to a room full of newly diagnosed diabetic patients, I would have to select blood sugar regulation. Managing blood sugar is no longer limited to diabetic patients as evidence links strict glycemic control to better outcomes in critically ill patients as well.4 Checking the feet daily and assisting the patient to perform foot care definitely assist diabetic patients to recognize problems early and intervene quickly, but, in the long run, doesn't glycemic control help prevent these same problems in the first place and go to the heart of diabetes management?

References