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An-Najah National University
Deanship of the Faculty of Medical and Health
Sciences Nursing &Midwifery Department
Evaluation the Nursing Practice of Diabetic Foot
Ulcer Care in UNRWA Health clinics
A qualitative descriptive study
Submitted by: Khawla Bani Oudeh, Deema Al-Haqash, Shatha Yahiya
Supervised by: Miss Fatima Hirzalla
This Thesis is Submitted in Partial Fulfilment of the
Requirements for the Degree of Baccalaureate, at Faculty of
medical and health Sciences, Nursing & Midwifery Department at
An-Najah National University, Nablus, Palestine.
2011
2
Evaluation the Nursing Practice of Diabetic Foot Ulcer Care In
UNRWA Health Clinics
A qualitative descriptive study
Authors: Khawla Bani Oudeh, Deema Al-Haqash, Shatha Yahiya
3
ACKNOWLEDGEMENTS
First, we give all the glory to God, the source of our strength, for granting us both the
mental and physical endurance to complete this monumental task. Then, we would
like to thank our entire families, especially our loving parents, for their love,
understanding, and support.
We give special thanks to president of An-Najah National University, Prof. Rami
Hamdallah for his continued support to scientific researches and to nursing college.
We would like to extend a very special thanks to Dr. Aidah Alkaissi for believing in
us and for her continued support and encouragement throughout this process.
To Miss. Fatima Herzallah, our advisor, we extend special thanks and gratitude to
you for your assistance, encouragement, and support.
To everyone who gave us the financial and moral support for the completion of this
task, Thank you.
4
Table of content
No Content Page Number
Acknowledgment 3
List of Tables 6
Abbreviations 7
Abstract 9
Chapter One Introduction
1.1 Introduction 11
Chapter Tow Background
2.1 Definition of diabetic foot ulcer 14
2.2 Pathogeneses, signs and symptoms 14
2.3 Assessment of diabetic foot 15
2.4 Classification of diabetic foot ulcer 16
2.5 Problem statement 17
2.6 Study significance 17
Chapter Three Literature review
3.1 Literature review 19
3.2 Objectives 22
3.3 Research question 22
Chapter Four Research Methodology
4.1 Participant 24
4.2 Selection of Sample 24
4.3 Data collection 25
4.4 Pilot experiment 26
Chapter Five Analysis
5.1 Analysis 28
5.2 Ethical Considerations 29
5
Chapter Six Result
6.1 Structural analysis 31
Patient history and quality of life 36
Diabetic foot assessment 37
Laboratory screening test 37
Diabetic foot treatment 38
6.2 Interpreted whole 40
Chapter Seven Discussion
7.1 Method Discussion 42
7.2 Result Discussion 43
7.3 Conclusion 45
7.4 Study Limitations 45
7.5 Recommendations 45
7.6 Study Budget 46
Chapter Eight References
8.1 References List of 48
Chapter Nine Appendix
9.1 Appendix One 52
9.2 Appendix Two 53
6
List of tables:
No Name Page
One Abbreviations 7
Two Signs and symptoms to the etiology of
(DFUs)
15
Three Wagner Ulcer Classification System 16
Four Themes and subtheme 31
Five Meaning bearing unit, condensation, code, subtheme, and theme.
32
7
Table: list of abbreviations
DFU Diabetic Foot Ulcer
UNRWA United Nations Relief and Works Agency
FBS Fasting Blood Sugar
RBS Random Blood Sugar
LDL Low Density Lipoprotein
HDL High Density Lipoprotein
TBI Toe Brachial Index
ABI Ankle Brachial Index
PN Peripheral Neuropathy
TCC Total Contact Casting
RCT Random Control Trial
ABPI Ankle Brachial Pressure Index
U/A Urine Analysis
CBC Complete Blood Count
CRT Control Randomized trial
RFT Renal Function Test
WHO World Health Organization
DM Diabetes Mellitus
9
Abstract:
Background: Diabetes is reaching epidemic proportions and with it carries the risk of
complications disease of the foot is among one of the most feared complications of
diabetes. The ultimate endpoint of diabetic foot ulcer disease is amputation, which is
associated with significant morbidity and mortality, besides having immense social,
psychological and financial consequences.
Aims: the major aim of the study to describe the contents of nurses´ skills and
practices associated with the management of diabetic foot ulcer (DFU).
Setting: three primary health clinics which is UNRWA health clinics (Balata camp,
Asker camp, and Al- ain ), Nablus city in Palestine
Sample: 12 registered nurses (five nurses from Balata, three nurses from Asker and
four nurses from AL-ain health center) who has at least 5 years experience in the
primary health clinics and work with diabetic foot ulcer management clinics.
Research methodological design: Using qualitative methodology, descriptive
approach, semi-structured interviews were guided by a script which included a series
of both open-ended and pop questions.
Results: the nurses' experiences and practice on diabetic foot ulcer management
divided
Into four themes: patient history and quality of life, diabetic foot assessment,
laboratory screening test, and diabetic foot ulcer (DFU) treatment.
Conclusion: Nurses' experiences of maintaining the quality of practice is important in
the context of today's safety and quality agenda. Practical nurses have substantially
more malpractice in managing diabetic foot ulcer. Increase the competency of nurses
by providing training programs can reduce (DFU) complication and improve the
quality of care.
Key words: diabetic foot ulcer, content analysis, amputation, Charcot neuroarthropathy.
Primary health clinic
11
1.1: Introduction Diabetes is reaching epidemic proportions and with it carries the risk of
complications. The worldwide prevalence of diabetes is expected to rise from 2.8% in
2000 to 4.4% in 2030, which means that 366 million people will be affected (Johannes
et al, 2010).
Disease of the foot is among one of the most feared complications of diabetes. The
ultimate endpoint of diabetic foot disease is amputation, which is associated with
significant morbidity and mortality, besides having immense social, psychological
and financial consequences (Khanolkar et al, 2008)
The term ‘Diabetic Foot’ consists of a mix of pathologies including diabetic
neuropathy, peripheral vascular disease, charcot’s neuroarthropathy, foot ulceration,
osteomyelitis and the potentially preventable endpoint, limb amputation (Khanolkaret
al, 2008)
Diabetic foot problems are also likely to harbour other associated complications of
diabetes such as nephropathy, retinopathy, ischaemic heart disease and
cerebrovascular disease (Khanolkar et al, 2008)
Estimates show that foot ulceration may occur in up to 15% of diabetic patients
during their lifetime. The relationship between diabetic neuropathy, the insensitive
foot, and foot ulceration was recognized by Pryce, a British surgeon, over a century
ago. He stated that, "It was abundantly evident that the actual cause of the perforating
ulcer was peripheral nerve degeneration and that diabetes itself played an active part
in the causation of the perforating ulcer" (Marvinet al, 2004).
The diabetic foot is especially vulnerable to amputation because of the frequent
complications of peripheral neuropathy (PN), infection and peripheral alarterial
disease (PAD). A combination of this triad leads to the final cataclysmic events,
gangrene and amputation (Marvin et al, 2004).
12
Successful management of the diabetic foot ulcer needs the expertise of a
multidisciplinary team which should include physician, podiatrist, nurse, orthotist,
radiologist, and surgeon working closely together, within the focus of a diabetic foot
clinic and the provision of specialty footwear in the long-term management of patients
with a history of foot ulceration (Loretta et al 1999; Luigi, 2011).
We have undertaken a descriptive study to evaluate nurses the practice of diabetic
foot ulcer care in primary clinics were the comprehensive diabetic foot management
take place while the hospitals focus on treatment. This evaluation through comparison
nurses practice with general guideline DFU.
14
2. Background
Diabetic foot problems occur in both type 1 and type 2 diabetes mellitus. They are
more common in men and in patients over 60 years of age
2.1 Definition of diabetic foot ulcer
The word health organization (WHO) defines DFU Lesion on the surface of the skin
of the foot, usually accompanied by inflammation. The lesion may become infected
or necrotic and is frequently associated with diabetes.
2.2 Pathogenesis, signs and symptoms
In the pathogenesis of diabetic foot ulcers (DFUs), neuropathy, angiopathy
(ischaemia), foot deformity and limited joint mobility are central risk factors. With
regard to the etiology of foot ulceration, 45–60% of ulceration is thought to be purely
neuropathic, 10% purely ischaemic and 25–40% mixed neuroischaemic. People in
developed countries tend to be more often neuroischaemic
Neuropathy Impaired nerve function in the foot is common in people with diabetes although the
person themselves may be unaware of its presence. All types of nerve fibers can be
involved including motor, sensory and autonomic nerves and the associated
functions affected ( Jude et al, 2010; Hau et al, 2000).
Sensory neuropathy
Damage to the nerves carrying signals from the foot renders the foot insensitive to
temperature, vibration, pressure and pain .The loss of sensation means that small
injuries often go undetected.
15
Motor neuropathy
Motor neuropathy leads to atrophic changes in the foot musculature that cause foot
deformity and decreased joint mobility and redistribution of foot pressures which
eventually predispose the foot to ulcerate
Autonomic neuropathy
Autonomic neuropathy results in loss of sweating, with the resultant dry skin being
predisposed to callus and fissures. Callus is defined as a build up of keratinized skin,
in reaction to persistent pressure, and will itself exert pressure.
Table2: Signs and symptoms to the etiology of (DFUs) Neuropathic Ischemic
Related to pressure Related to ischaemia
Located at high-pressure areas Located at end-arteries
Painless or burning pain Painful
Callus Callus Gangrene
2.3 Assessment of the ‘diabetic foot’ The diabetic foot assessment should include a thorough neuropathic,
structural and vascular assessment at least on an annual basis (Khanolkar, et al 2008).
Neuropathic assessment which include history to include neuropathic symptoms
testing pressure sensation by 10 g monofilament, testing vibration sensation by
128
Hz tuning fork.
Structural assessment which include Identifying structural abnormalities such as
calluses, Bunions, hammer toes, claw toes and flat foot, Identifying Charcot
neuroarthropathy.
Vascular assessment which include history to include claudication symptoms,
16
Identifying cutaneous trophic changes such as corns, calluses, ulcers or frank
digital gangrene, palpating pedal pulses, ABPI/ TBI/ Arterial Doppler in selected
cases.
While several wound classification systems are available, the widely implemented
system by health care providers is Wagner Ulcer Classification System, which uses
six wound grades (scored 0-5) to assess ulcer depth and defines wounds by the depth
of ulceration and the extent of gangrene (Robert et al, 2002).
2.4 Classification of diabetic foot ulcer
Management is based on the simple principles of eliminating infection, debridement,
cleansing and the use of dressings to maintain a moist wound bed, and offloading.
Debridement is the removal of devitalised, contaminated or foreign material from
within or adjacent to a wound, until surrounding healthy tissue is exposed and it is
widely practised in diabetic foot care. There are many methods for debridement such
as surgical/sharp, enzematic, outolytic, mechanical (wet to dry dressing) and
biologic(larval) ( Jude et al, 2010).
TABLE 3
Wagner Ulcer Classification System
Grade Lesion
0 No open lesions; may have deformity or cellulitis
1 Superficial diabetic ulcer (partial or full thickness)
2 Ulcer extension to ligament, tendon, joint capsule, or deep fascia without
abscess or osteomyelitis
3 Deep ulcer with abscess, osteomyelitis, or joint sepsis
4 Gangrene localized to portion of forefoot or heel
5 Extensive gangrenous involvement of the entire foot
Adapted with permission from Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163-72.
17
From 50% to 75% of lower extremity amputations are performed on people with
diabetes. Prompt and aggressive treatment of diabetic foot ulcers can often prevent
exacerbation of the problem and eliminate the potential for amputation. The aim of
therapy should be early intervention to allow prompt healing of the lesion and prevent
recurrence once it is healed (Hinchliffe et al, 2008)
2.5 Problem statement
The outcome of management of diabetic foot ulcers is poor and there
is uncertainty concerning optimal approaches to management in our city . We have
undertaken a qualitative descriptive study to identify nurses practices and
interventions for which there is evidence of effectiveness.
2.6 Study significance
Since diabetic foot ulcers are common and serious complication of diabetes mellitus
and consider major challenge to health care providers in the worldwide .
Thus the significant of the study will be able to evaluate nurses practice associated
with DFU management, and with deep understanding of nurses experiences to
determine strong in addition to weak point. Finally to develop strategies that help
nurses to improve there practices.
19
3 Literature review
The significant morbidity and mortality associated with diabetes is well known. A
recent 10- year prospective, population based study found a history of DFU to be a
significant independent predictor of mortality in patient with diabetes. This study found
patients with diabetes with a history of DFU had a 47 % increased risk of mortality in
comparison to patients with diabetes who didn’t have a history of DFU (Robert et al,
2010).
Neuropathy and peripheral vascular disease have been identified as major risk factors
for diabetic foot ulceration and amputation. In a cross-sectional, population-based study
the proportion of the lesions were Neuropathic ulcers55% of total diabetic foot ulcers
Ischemic ulcers 10% and neuro-ischaemic ulcers 34% of total diabetic foot
ulcer(Khanolkar et al, 2
008)
Charcot neuroarthropathy is a non-infective process occurring in a well-perfused and
insensitive foot. It is characterized by bone and joint destruction, fragmentation and
remodeling (Khanolkar et al, 2008)
There are several techniques that can be used sensory function during neuropathy
screening. The current recommendation supported the use of the 10-gmonofilament
(is an objective, simple instrument used in screening the diabetic foot for loss of
protective sensation (Booth et al, 2000) in addition to the one of the following
techniques: pinkprick sensation, vibration perception with a 128-Hz tunning fork,
ankle deep reflexes or vibration perception threshold testing.
Studies have shown the monofilament test to identify persons at increased risk of foot
ulceration with a sensitivity of 66–91% (Robert et al, 2010).
There are several tools used to assess vascular status such as Ankle brachial pressure
index (ABPI) is the ratio of systolic blood pressure at the ankle to the systolic
Blood pressure at the brachial artery and is used to detect the presence of peripheral
vascular disease. While, an ABPI of 0.90 or less suggests presence of peripheral
vascular disease, an ABPI greater than 1.1 may represent a falsely elevated pressure
caused by
medial arterial calcification(Khanolkar et al, 2008).
20
Doppler arterial waveform is another non-invasive tool used to assess the vascular
status. The normal arterial waveform is pulsatile with a positive forward flow in
systole, followed by a short reverse flow and a further forward flow in diastole.
“49-85% of all diabetic foot related problems are preventable.This can be achieved
through a combination of good foot care, provided by an interprofessional
diabetes care team, and appropriate education for people with diabetes (Bakker et
al, 2005)
Successful management of diabetic foot ulcers requires close collaboration between
many different groups in primary care and in the hospital service, and this
Collaboration might not be easy to establish while traditional barriers between health-
care professionals remain in place (William et al, 2003)
Typically, conventional care techniques for the treatment of DFUs have focused on
four major concepts: debridement of necrotic or devitalized tissue, controlling
infection, offloading, and maintaining a moist wound environment.. (Howard et al,
2011; Andrew et el, 2004)
There is little data from randomized trials to guide the use of antibiotic therapy and
hence the initial regime is usually selected empirically based upon clinical experience
and local preferences. Commonly used oral antibiotic regimes include amoxicillin–
clavulanic acid, ciprofloxacin, cephalexin and clindamycin. Topical antibiotics may
often be effective in mildly infected ulcers, whilst the presence of severe infection
may warrant use of parenteral antibiotics (William et al, 2003; Khanolkar et al, 2008)
The best time-tested and evidence-based offloading technique is total contact casting
(TCC) because compliance is assured and the bulk and weight of the cast
reduces patient activities(Robert et al, 2010).
Studies have confirmed that regular weekly sharp debridement is associated with
more
rapid wound healing (Khanolkar et al, 2008; Robert et al, 2010 ; Jude et al, 2010 ).
Saline-moistened gauze has been determined to be the standard of care by the
21
American Diabetes Association. The ulcer was covered with a layer of saline
moistened
Tegapore that completely covered the ulcer and was secured by hypoallergenic tape.
This primary dressing was then covered with a layer of saline moistened gauze,
followed by a layer of dry gauze and a layer of petrolatum gauze, and wrapped with a
layer of Kling (Aristidis et el, 2000).
The importance of dressing wounds is well established, although the optimal type of
dressing still remains unclear. Dressings commonly used are the standard wet and dry
saline dressings, but they do not provide a sufficiently moist environment and may
lead to non-selective tissue destruction (William et al, 2003)
Controversy currently exists in published literature on the use of hydrocolloid
dressings on DFUs with some sources reporting adverse events while others support
their use. It is suggested that hydrocolloids can be used safely on DFUs, providing
that they are used on appropriate wounds after a thorough patient assessment the
wound is superficial with
no signs of infection, there is low to moderate exudate and dressings are changed
frequently (Gill et al, 1999)
Promogran, a wound dressing consisting. of collagen and oxidized regenerated
cellulose, is more effective that standard care in treating chronic diabetic plantar
ulcers( Aristidis et al, 2001).
Application of Graftskin for a maximum of 4 weeks results in a higher
healing rate when compared with state-of-the-art currently available treatment and is
not associated with any significant side effects. Graftskin may be a very useful
adjunct for the management of diabetic foot ulcers that are resistant to the currently
available standard of care(Aristidis et al, 2001)
22
Collagen-based products and extracellular matrix products are considered alternative
dressings because they provide collagen to the wound. While they can be beneficial to
some patients they have not demonstrated faster closure than wet-dry dressings
(Howard et al, 2011)
No significant effect on either wound area or rate of healing was found with a
collagen-alginate dressing product, compared to a saline-moistened gauze in a non-
blinded RCT. An alginate appeared no better than vaseline gauze in a second RCT
(Hinchliffe et al, 2008l)
3.2 Objectives of the study
Describe the contents of nurses´ skills and practices associated with the
management of DFU.
Investigate nurses experience related to diabetic foot ulcer management
Evaluate nurse's practice of DFU management according to the general
guideline for the optimal DFU care
3.3 Research Questions
What are the effects of nursing practice in the management of DFU?
What are the nurses experience related to diabetic foot complications?
Are the multidisciplinary team approach to assessment and treatment of DFU
applicable in the UNRWA health clinics?
24
Research Methodological design
Qualitative approach
To study the practice of nursing care of DFU, was chosen a qualitative approach with
the method open interviews. The choice of qualitative approach was made to obtain a
description of the experience and skills that nurses has in work and the strategies for
knowledge.
4.1 Participant
The study was conducted by interviewing 12(female nurses), employees at three UNRWA Health Centres in Palestine. Two test interviews were conducted, which
contained useful data, and guide researcher to pick up the most appropriate question
for other interviews,12 interviewees are females because the most employees in the
primary health clinics are female nurses with an average working length in 10 years.
4.2 Selection of sample
convenience samples is one that is readily accessible to the investigator. Since not all
subject have a chance of being selected, its not probability (or random) sample.
Including criteria which are:
- RN's ( PN ,BSA)
- Had experience in primary health clinics at least 5 years and work with diabetic
foot management
Excluding criteria which are:
nurses experience in the primary health clinics less than5 five years. And didn’t work
with DFU management
Setting: UNRWA Health Centers which include Balata camp, Asker camp, and Al-
aim in Nablus City.
Period: : a period of four months which is, from September to December
25
4.3 Data Collection
The interviewer's approach was defined which is open –ended questions that allows
the respondent to answer questions in any way she or he see fit so that the same
statements and tones are used with all research subjects. It is neither practical nor
desirable to require that exactly the same wording be used throughout an interview.
One advantage of the interview process is that the interviewer can follow up on
specific information given by different subjects in different ways(Thomas, 1990).
Sequence is important in devising formal interview guide, usually called an interview
schedule. First we explained the project and asked whether the subject has any
questions about it. In addition the rapport with subject was established..
Balanced information were sought before sensitive questions were posed. No more
detail was elicited than will be used. We implemented 12 semi structured individual
interviews which are about an 30 minutes in duration .
The interviews recorded on tape. The interviews conducted in a separate meeting
room in the department, where the nurse works. In the interview situation is only the
informant and the interviewer, who is the current researcher
The audio-taped interviews will be guided by a set of trigger questions designed to
reveal the participants behavior, meanings, ways of thinking and emotions. Interviews
transcribed for analysis, with additional information from field notes, which helped
triangulate data sources. The interview’s a preliminary questions are "
How many years do you work in the clinic?
What are nurses practice In management of DFU?
This question posed to all nurses as it would be allowed to speak freely about what
they considered important. Another questions used "What your experience related to
the diabetic foot care?" , "What are the standard care of diabetic foot that nurses
follow in the primary clinic?", "Can you tell us about your experience with diabetic
foot dressing?"
26
Interviewing techniques frequently used to make control over the interview and to
handle the subject experience exactly. At the end of a meeting, we summarize the
main issues brought up, also we the subject ask for additional comments. Then we
Thank the subject and let her/him know that their ideas have been a valuable
contribution and will be used in the proposed research or interventions.
4.4 Pilot experiment
A pilot experiment was conducted by interviewing two participant who are females
one of them had one month experience and other participant had three month
experience in diabetic foot ulcer care . Both of these interviews were used to test the
design of the full-scale experiment, which then can be adjusted. Also its provided
chance to added any missing information and help authors on recheck formulated
interview questions .
28
5.1 Analysis
The data material was analyzed by content analysis . Content analysis is a
summarising, quantitative analysis of messages that relies on the scientific method
(including attention to objectivity, intersubjectivity, a priori design, reliability,
validity, generalisability, replicability, and hypothesis testing) . The aims of content
analysis is to organize a mass of information into meaningful classes, generally with
some degree of quantification. (Thomas, 1990)
One characteristic of qualitative content analysis is that the method, to a great extent,
focuses on the subject and context, and emphasizes differences between and
similarities within codes and categories. Another characteristic is that the method
deals with manifest as well as latent content in a text. The manifest content, Analysis
of what the text says deals with the content aspectand describes the visible, obvious
components, In contrast, analysis of what the text talks about deals with the
relationship aspect and involves an interpretation of the underlying meaning of the
text, referred to as the latent content
Both manifest and latent content deal with interpretation but the interpretations vary
in depth and level of abstraction (Graneheim et al, 2003).
Text was sorted into four content areas: experiences related to the patient history and
patient quality of life; diabetic foot examination; lab investigations and diabetic foot
treatment. Experiences related to diabetic foot management were evoked by asking:
"Please tell me about your experiences of diabetic foot ulcer management."
The interviews were read through several times to obtain a sense of the whole. Then
the text about the participants’ experiences of diabetic foot management was extracted
and brought together into one text, which constituted the unit of analysis. The text was
divided into meaning units that were condensed. The condensed meaning units were
abstracted and labeled with a code.
29
The whole context was considered when condensing and labeling meaning units with
codes. The various codes were compared based on differences and similarities and
sorted into ten sub-themes and four themes, which constitute the manifest content.
In qualitative research the concepts credibility, dependability and transferability have
been used to describe various aspects of trustworthiness.
Credibility deals with the focus of the research and refers to confidence in how well
data and processes of analysis address the intended focus (Graneheim et al, 2003). In
our research paper we Choosing participants with various experiences and have long
been dealing with diabetic foot ulcer.
To increases the possibility of shedding light on the research we select the most
suitable meaning unit.
5.2 Research Ethical considerations
Approach was to first get the approval of the UNRWA Health Clinics Director, After
this approval we take permission of the gate keeper of clinics (Balata camp, Asker
camp, and Al- aim camp) to collect data from nurses who work with diabetic foot and
finally, All participants informed by the interviewer both verbally and written for the
purpose of the interview and study.
The agreement was obtained on the time of the interview also participant was
informed that the study was voluntary and that the authorization of the respondent
was required to study would begin. The participant informed that interview will be
conducted in a private room which just the informant and the interviewer present and
the interview recorded by tape recorder and that no individuals can be identified after
text processing.
Although details were included on the interview could be terminated if the respondent
did not wish to continue and that all material treated as confidential and kept locked
up.
Collection of information only be used for research and not for commercial purposes
or other scientific purposes
Consent form obtained from participant who agree to participate (Annex1)
31
Result:
6.1 Structural analysis
The interviews were printed shortly after the interview and the material has been read
through several times. If repeated through readings have units that were meaningful
and relevant to the issues identified and then written in the margin scheme to get a
reduced data set. The meaning-bearing units appeared as a special pattern and have
been grouped and from this pattern appeared indicative themes.
Statements from respondents were initially seen in several themes. Each theme was
then analyzed for itself through repeated reading and the themes that emerged could
describe content. A periodic reading of the description of the subjects were checked
for the relevance of content description
The text of abstracts then formulated into subthemes and finally into themes (Table
4). The results presented in the meaning of the four themes.
Table 4: Themes and subtheme
Themes Subthemes
1. Nursing practice of patient history
and quality of life
Patient history
Quality of life
2. Diabetic foot ulcer assessment
Structural assessment
3. Laboratory investigations/
screening
Periodic tests (monthly):
RBS, Urine analysis
Periodic tests (yearly):
FBS, lipids profile (HDL, LDL , triglyceride
and cholesterol)
4. Diabetic foot ulcer treatment Deressing
Infection control
Table 4: Meaning bearing unit, condensation, code, subtheme, and theme.
32
Meaning bearing
unit
Condensation
Code
Subtheme
Theme
During the first visit of
diabetic duration and
patient history recorded
on the patient file.
Assessing patient for
presence of another
disease as a
complications of DM
I ask patient about
previous foot
ulcerations and '
duration of healing
Assessing patient of
DFU presence
Assessing diabetic
patient for smoking
because that lead to
Diabetic duration and
family history
recorded on patient
file
Presence of another diseases as complication
previous foot
ulcerations and '
duration of healing
Assessing DFU
presence
Smoking lead to
more complications
Diabetic
duration, family
history
Diabetes mellitus complication
foot ulcerations
and ' duration of
healing
DFU presence
Smoking
Patient history
Nursing
experience of
patient history
and quality of
life
33
more complications
Giving education about
importance of physical
activity
Giving instruction
about nutrition for the
patient
Assessing patient daily
activity and I direct
them to walk daily
Education about
importance of
physical activity
Instruction about
nutrition for the
patient
patient daily activity
and I direct them to
walk daily
Physical activity
Nutrition
daily activity
Quality of life
34
Checking on the
presence of fissures
and fungus.
Drying between the
toes and look if
there’s a drought in
the foot.
While performing
dressing I assess leg
temperature as
assigns of infection
Each month routine screening of a random blood sugar two hours after eating, and urine analysis.
Each year diabetic
client has
comprehensive
screening tests: FBS,
Cholesterol,
Triglyceride, LDL,
HDL, Creatinine
The most treatment
presence of fissures
and fungus
Presence of drought foot
Assess leg temperature as assigns of infection
Monthly screening tests: RBS, U/A
Yearly screening tests: FBS, Cholesterol, Triglyceride, LDL, HDL, Creatinine
N/S commonly used, povadine rarely
fissures and
fungus
Dry foot
Temperature as assigns of infection Monthly : RBS, U/A
Yearly: FBS, Lipid profile, RFT
Foot examination
Periodic tests
(monthly):
RBS, Urine
analysis
Periodic tests
(yearly):
FBS, lipids profile (HDL, LDL, triglyceride cholesterol
Foot ulcer
assessment
Lab
investigation
35
used for DFU is N/S, but povadine rarely used for treating it.
N/S used for irrigating and cleaning ulcer, povadine used for sterilizing area around the ulcer
Using antiseptic-solutions according to their availability at health center.
Antibiotics such as Neomycin ointment
used.
N/S for irrigating and cleaning ulcer, povadine for sterilizing area around ulcer.
Usage of antiseptic
solutions as available
Usage of Neomycin
Ointment for treating
ulcers
N/S commonly, Povadine rarely.
N/S: irrigation, cleaning ulcer. Povadine: sterilizing around ulcer.
According to availability
Neomycin
ointment.
Dressing
Infection control
Diabetic foot
ulcer
treatment
Structural analysis was thematic; themes were identified and formulated from the text.
The four themes are presented below with the respective sub-themes, which presented
with short summaries of the interviews.
36
Them 1: Patient history and quality of life
Under this theme, two sub-themes were emerged as illustrated below
1. Patient history
Nurses considered many factors in taking patient history which include: duration of
diabetes, degree of glycemic control controlled or un-controlled ststus, presence of
diabetes associated illness that may affect wound repair such as cardiovascular
disease, renal disease, cerebrovascular disease, and review of family history, and past
history of foot ulceration that all recorded in the overall medical assessment sheet for
each client.
"The first visit for diabetic patient we take family history 0f the client which include
type of diabetes date of diagnosis and place of diagnosis in clinics or other places
"(N9), (N1), (N4), (N6)
"The first thing we ask patient if discovered the diabetes in the this clinic or in the
outside clinic because if discovered in the clinic we called new diagnosis but if
discovered in other health clinic we called registration"(N6), (N3)
2. Quality of life
Nurses considered some factors had effect on the patients diabetic control and wound
healing such as obesity (BMI>25), smoking, and physical activity.
"We take patient weight to resume his or her status because some of them eat and
remain sleep without performing activity" (N10)
"When the patient visit clinic for the first time I ask hem are you smoker?" (N5)
"If the patient had acceptance to listen I advise him to walk every day to maintain
body weight in the normal level" (N8)
Them 2: Diabetic foot ulcer assessment
Under these them one sub-them emerge as follow:
37
1. Diabetic foot examination
Little of the interviews shown that some of nurses experienced examining the feet for
structural abnormalities such as calluses, fissures, corns, and fungus between nails
before dressing was while other nurses considered this assessment was performed by
the physiotherapist.
"When the patient had dressing first Thing I check on the presence of fissures or
dryness and I offer advice to use lubricant in order to reduce dryness of the foot"
"Some type of shoes leads to presence layer of dead tissue in specific point of foot so
I check on the presence f this layer during the dressing"
Them 3: Laboratory screening
Under this theme, two sub-themes were emerged as illustrated below
1. Monthly screening test
Nurses explained that diabetic patient had every month routinely screening test
which includes random blood sugar, and urine analysis especially concern albumin
reading.. This screening test performed every three months' when the patient had a
control over the glucose level in other term control diabetic patient.
"Every month patient with diabetes has postprandial test (random blood sugar two
hours after eating) and urine analysis" (N3), (N2)
"We explained to the diabetic patient every month comes to the clinic to perform
screening test and if you're diabetic level controlled you should come every three
month" (N7)
" All patients with diabetic had postprandial test two hour after eating and urine
analysis and albumin to ensure that kidney function well" (N8)
38
2. Annual screening test
Nurses explained that the annual screening tests which include: FBS, cholesterol,
triglyceride, LDL, HDL, and Creatinine in order to make baseline evaluation for the
patient with diabetes.
"Every year patient with diabetes had comprehensive test which include screening of
diabetic foot and FBS, LDL, HDL, and Creatinine"(N1), (N8)
"Yearly screening tests often preformed for every diabetic patient that include
triglyceride, FBS, LDL, HDL, creatinine and cholesterol to ensure the pt in safe side"
(N4)
Theme 4: Diabetic foot ulcer treatment:
Science prolonged healing times increase the risk for morbidities, infections,
hospitalization and amputation, expeditious wound closure is the primary goal in the
DFU treatment.
The experience of nurses in treating diabetic foot ulcer was discussed, which revealed
presence of gap between nurses’ practices and standard diabetic foot management
guideline concerning treatment.
Under this theme, three sub-themes were emerged as illustrated below:
- Dressing
Dressing plays a vital role in reduction of diabetic foot ulcer complications.
“The most common used is N/S in dressing of diabetic foot ulcer but povadine used
only around ulcer and not used in open wound” (N1)
“The important anti-septic solution is N/S but povadine rarely used according to the
doctor instructions” (N4)
“I use povadine for treating DFU, because I feel it’s sterile and the best antiseptic
solution for ulcer” (N6)
39
- Infection control
The nurse's experience returned to infection control, there is a lack of adequate
knowledge among nurses about infection control method.
“If patient condition bad and complicated I refer him to the doctor who describe
appropriate antibiotic for the patient” (N5)
“Some patient with diabetic foot ulcer I note if there is a discharge of bus from the
wound and there is redness around the wound I use Neomycin ointment” (N10)
"The patients with diabetic foot ulcer were simple cases had no infection didn’t need
antibiotic"(N9)
6.2 Interpreted whole
Nurses' practice of diabetic foot ulcer management in the UNRWA health clinics
We found from nurse’s practice of the diabetic foot ulcer management had tow
important part, the first part was initial assessment and the second part was diabetic
foot ulcer treatment
The first part which was initial assessment divided into sub-group that patient history
and quality of life, diabetic foot examinations, and laboratory screening test. The
nurses had awareness regarding to complete history which must be performed as part
diabetic patient evaluation, also they had alertness to laboratory screening test for
patient with diabetic foot ulcer since wound healing can be delayed by complications
such as renal insufficiency.
With deep understanding of nurses experience of diabetic foot assessment the gap was
emerge were nurses had inadequate knowledge and skills or practices neither vascular
assessment nor neuropathic assessment while some of them practice foot examination
The second part which is treatment of diabetic foot ulcer also nurses expressed lack of
knowledge and competence skills, regarding to infection control, debridement how to
40
do it? what are the method of debridement?, and they considered diabetic foot
treatment mainly dressing
The underlying causes that contribute to poor nursing practice regarding to DFU:
Lack of adequate knowledge and skills concerning DFU management in general,
specifically its screening test
Absence of general guideline of DFU management that applied at the clinics.
Nurses considered diabetic foot assessment as a physiotherapist responsibility.
Lack of training programs offered to primary nurses to improve their skills and
practices regarding to diabetic foot ulcer assessment and treatment.
42
7.1 Method Discussion
A qualitative approach with open interviews were chosen to get a glimpse of nurse
work while able to converse with the respondent.
A conversation is an interaction between the interviewer and respondent that the
interviewer's purpose is to gather information.
The interviewer's interest is to discover and obtain description of structures in nurse
work that is unknown or not sufficiently known (Svensson & Starrin, 1996).
To find out the experiences, thoughts and perceptions Malterud (1998) and Dahlberg
(1997) produce the qualitative approach as a more understanding than explanatory
model and away to describe the world as human experience it. The differences
between qualitative and quantitative research are questioner its design as Bryman
(2002) and Trost (2001).
Questions which asked how many or how plain, suitable for a quantitative study,
while trying to understand or find patterns is qualitative studies most useful.
Since the aim is to describe competency of nurses work, a qualitative approach was
selected with the desire to understand and describe nursing practice and skills in the
primary health clinics.
7.1.1 Validity and credibility
Through the interviews had been applied for a description of respondents' job content
and how they perceives it. The selection of interviewees was not as difficult as there
are many nurses employed at clinics. The selection from the start was made with
given a temporally feasible area geographically. For the validity criteria was for
participating respondents to be employed at the hospital for at least 5 years and
worked with foot complication in diabetes disease.
Interview subjects' participation was voluntary and could be exited at any time. (Polit,
Beck et el, 2001) believes that concepts such as validity and reliability are not used
within qualitative research, but concepts such as validity and credibility instead
utilized. The credibility of the study's results provided by the description of data
collection, selection and analysis process
43
7.2 Result discussion
We found the poor practices of diabetic foot ulcer management mostly caused by
practical nurses. Lack of adequate knowledge and training program considered as the
main factor of developing poor management of DFU.
Nursing workshops, seminars and short-term training opportunities should be
available from colleges. Colleges and universities typically hold seminars lasting one
or more hours that focus on specific issues within nursing practice of diabetic foot
management. Seminars should be focused on practical nursing strategies or more
abstract nursing theories.
Understanding knowledge use in everyday nursing practice is important to the quality
in health care. Studies show that experienced nurses use multiple sources of
knowledge to guide their practice (Rycroft-Malone et al, 2004; Bonner, 2007; Mantzoukas
and Jasper, 2008 ).
We summarized from the interviews that nurses had insufficient knowledge related to
diabetic foot management generally and specifically in diabetic foot ulcer assessment
and treatment. Nurses considered diabetic foot ulcer as a physiotherapist
responsibility who is available in clinics only two days per week. We wonder is that
time limit of the physiotherapist is sufficient to cover all diabetic cases?! Did
physiotherapist work to treat patients with diabetes enrich nurses to learn more about
assessment of diabetic foot ulcer?! All of these factors lead to nursing negligence and
malpractice in neuropathic assessment, which include a thorough history of
neuropathic symptoms such as burning, tingling, numbness and nocturnal leg pains.
Examination should comprise of careful inspection for muscle wasting, foot
deformities such as claw toes, loss of hair and
trophic changes.
Based on Khanolkar et al, (2008).
Pressure sensation is usually assessed by using the 10 g nylon Semmes–Weinstein
monofilament. Vibration sensation is tested using a 128 Hz tuning fork applied on the
bony prominence of the great toe, gradually moving upwards if there is any
impairment noted.
44
Malpractice in vascular assessment, the panel recommends a tiered testing approach
to assist in evaluation DFU. At screening one or more measures should be used these
include palpation of pulses, ankle brachial index (ABI) and toe brachial index (TBI).
Palpation of pulses. Palpation of peripheral pulses, including the femoral, popliteal
and pedeal vessels (dorsalis pedis and posterior tibial), should be a part of the routine
physical examination. In this regard, palpation of pulses is an inadequate screening
tool for PAD in patients with diabetes in setting in which pulses present or absent.
Ankle brachial index (ANI). The panel recommends the ABI as producible and
quantitative test for vascular evaluation.
According to Khanolkar et al, (2008) toe brachial index (TBI) is being increasingly
used as an effective alternative screening tool in diabetics as it is less influenced
by arterial calcification than ABP.
The vascular assessment was performed by the physician and physiotherapist
which based on palpation of pulses such as dorsalis pedis pulse and poseteior tibial
pulse. While the nurses had no knowledge or skills in the vascular assessment.
General management comprises of cleansing the wound, debriding any necrotic
material and probing with a blunt sterile instrument to identify any foreign bodies or
exposed bone.
Debridement is a crucially important process of this phase and includes the removal
of necrotic, unhealthy and infected tissue from the wound bed. This is commonly
achieved by sharp debridement, which is usually carried out by using a scalpel and
forceps.
Studies have confirmed that regular weekly sharp debridement is associated with
more rapid wound healing.
7.3 conclusion
Diabetic foot complication is considered as a major health problem word-wide.
Nurses' experiences of maintaining the quality of practice is important in the context
of today's safety and quality agenda. The method for identifying deficiencies and
redesigning faulty systems appears to be a promising way to propose strategies to
45
prevent diabetic foot complication. Practical nurses have substantially more
malpractice in managing diabetic foot ulcer. Increase the competency of nurses by
providing training programs and the number of registered nurse can reduce diabetes
complication and improve the quality of care. The availability of standard guideline of
diabetic foot management promote the quality of care provided by nursing team.
7.4 Study limitation
- The study was conducted only at UNRWA health clinics, while other governmental
clinics not included due to limitation of research study time.
- Small sample size that make the study result difficult to be generalized on other
primary health clinics.
- Unavailability of specialist nurses in diabetic foot ulcer management
- Nurses discomfort regarding to the use of audiotape during interviwe
7.5 Recommendation
1) Develop screening and educational programmes for nurses in primary health
clinics about DFU management in order to improve their practice and improve
quality of health care .
2) Construct general guideline for diabetic foot management to reduce
complications
3) Psychological, sociological, epidemiological and economic studies to determine
the incidence, prevalence and burden of DFU in Palestine
4) Developing and exploring the efficacy of simple, reusable, inexpensive modes
of offloading that are acceptable to, and consistently used by, individuals with
DFUS
46
5) Developing and exploring the efficacy of DFU dressing materials and skin-care
formulations that optimize healing while protecting DFUS from foreign body
contamination or invasion by microbial or parasitic organisms
Study Budget
This study will carry out in three primary UNRWA health clinics which was Balata
camp , Asker camp, and Al- ain camp clinics.
The cost of the study self funded as a group as follow :
Phone calls 60 NIS
Transportation cost for each clinics 70 NIS
Printing of study copies 50 NIS
Total 180 NIS
48
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the standard of care for treating neuropathic foot ulcer in patient with diabetes.
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for diabetic foot ulceration. Diabetes care.23, 606-607.
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monofilaments. Diabetes Care.23, 984-988.
Andrew, J. Boulton, M. et al. 2004. Neuropathic diabetic foot ulcers. Massachusetts
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Hinchliffe, J. Jeffcoate, J. Bakker, K.et al . 2008. A systematic review of the
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Jeffcoate, W. Harding, K. 2003. Diabetic foot ulcers.
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51
Appendix one : Consent Form
Consent Form
Consent for participation in the study of Evaluation nurses practice of diabetic foot
ulcer care in UNRWA health clinics
I have received both written and verbal information about the study and had the
opportunity to questions.
I am aware that participation in this study is voluntary and that I may at any time and
without providing any reason to cancel my participation in the study.
I hereby give my consent to participate in the interview study.
Signature Date
52
Appendix Two: Interview Guide
Open questions
How many year did you work in the clinics?
What are nurses practice in the management of diabetic foot ulcer?
The pop questions which asked during the interview :
What are laboratory investigations for patient with diabetic foot ulcer ?
What is diabetic foot assessment ?
What are nurses practices of diabetic foot ulcer treatment ?
What are the most common complications of DFU?
Can you tell us about your experience with diabetic foot dressing?
Question At the end of the interview:
What is your evaluation to DFU management in the clinics?
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