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
52
Embed
fmhs.najah.edu · ulcer was peripheral nerve degeneration and that diabetes itself played an active part ... hammer toes, claw toes and flat foot, Identifying Charcot neuroarthropathy.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
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.
18
Chapter 3
Literature review
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?
23
Chapter 4
Research methodology
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 .
27
Chapter 5
Qualitative analysis
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)
30
Chapter 6
Study result
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.