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...investigated the aim of developing an understanding of the wider factors associated with diabetic foot ulcers.
Key words
- Stress
- Wound healing
- Social support
- Coping strategies
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Mr B, a 50-year-old man, was diagnosed with diabetes 11 years ago. He developed a diabetic foot ulcer (DFU) that failed to heal and 5 months after its development, an amputation of his left hallux was planned owing to the development of osteomyelitis. Prior to his DFU, Mr B was a self-employed truck driver. However, owing to the ulcer and its treatment, he has been unable to work and has been struggling to claim sick pay. At this time, Mr B was also going through the divorce court where his wife was contesting his claim to half their assets. Consequently, Mr B was residing with his elderly mother. It was evident at his wound clinic appointments that Mr B was very low in mood and frequently became tearful. Clearly, he has many issues requiring consideration, including his non-healing DFU, divorce and the loss of his job and income.
Ways of looking at stress
Numerous models have been developed for assessing stress, and their use provides a means of understanding the individual's persepective. Selye (1956), one of the first to describe stress, discussed the General Adaptation Syndrome. He suggested this occurs in three stages:
* alarm reaction
* resistance
* exhaustion.
Selye (1956) believed that regardless of the source of stress, this physiological response pattern proceeds.
Ten years later, Lazarus (1966) described a model of stress contrived of two sections:
* stress appraisal
* coping mechanisms.
In contrast to Selye's, this model considers the interaction between individual and environment. Rather than, as Selye's model suggests, Mr B definitely reacting in a set manner to the stressors placed upon him, Lazarus' model suggests that the severity of his reaction will depend upon his perception of the stress.
Holmes and Rahe (1967) developed the Social Readjustment Rating Scale (SRRS). Scores were calculated for various life events in order to rate the relative degree of necessary readjustment. Not all listed events are negative, but all are considered to require some form of readjustment that leads to stress. Mr B would probably score moderately high on the SRRS and this could partly explain why his foot ulcer and subsequent bone infection occurred when it did (Holmes and Rahe, 1967). However, there have been criticisms of this scale. It is difficult to distinguish between some of the listed life events as they are interlinked. Krantz et al (1985) suggested that if the frequency of all events is considered alone, unique interactions might be missed. As with the General Adaptation Syndrome, the SRRS assumes that all individuals perceive equal levels of stress.
It is important to note that there does not appear to be any one model that best applies to every individual. However, Lazarus' model appears to best consider individuality.
Effects of stress on health and wounds
The rapid stress response, commonly known as flight or fight, can be triggered by physical or psychological dangers or by emotional distress (Krantz et al, 1985). While the resulting increase in hormones, amino acids and glucose may be valuable when a physical threat is present, this arousal can be counterproductive when a physical response is not required (Niven, 1989).
During the body's slow stress response, the enzymes released remain functioning for longer than the hormones...
NOTE: All illustrations and photos
have been removed from this article.
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