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Diabetic Foot Screening for Ulcer. [email protected]
Diabetic Foot Screening for Ulcer Detection: Suggested Customized Nursing
Guideline at a University Hospital-Egypt
By *Dr. Zeinab M. El-Sayed
1 & Dr. Safaa M. Abdel Motaleb I. Hassanein
2
(D.N.Sc, Lecturers; Medical-Surgical Nursing Department, Faculty of Nursing, Cairo University-Egypt)
Abstract:
Background: Diabetes Mellitus is a common chronic disease requiring lifelong behavioral and life
style changes. It is a complex disorder which progresses in severity over time, and considers a leading
cause of new cases of foot or leg amputation. So people with diabetes require careful monitoring of
their foot on regular basis. Therefore foot assessment and foot care instructions are most important in
early detection of foot complications. The nurse as one of the health team members; has an important
role in assessing, caring, teaching and counseling those patients. The aim of the current study was to
detect foot ulcer using diabetic foot screen: suggested customized nursing guideline at a University
Hospital-Egypt. Research Questions: Q1: What are the screening periodical recommendations for
diabetic patient? Q2: Is Inlow’s 60-second Diabetic Foot Screen assist in determining patient risk? Q3:
Is there a correlation between patient’s left and right foot total score & Body Mass Index as well as
indicators of diabetic problems? Q4: What are the predictors of getting foot problems in the future?
Design: A descriptive exploratory design was utilized to guide and to achieve the aim of the current
research. Tools: I) 1-Demographic data & 2- Medical data pertinent to medical diagnosis, BMI,
duration of disease, blood glucose level…...etc. II) 1-Inlow’s 60 second diabetic foot screen. 2-
International working group on the diabetic foot (IWGDF)-risk classification system. Setting: The
study was conducted in the medical departments (19, 31 & 6) and outpatient clinics at El-Manial
University Hospital; affiliated to Cairo-University -Egypt. Results: 40% of the study sample their age
was between 50 and less than 60 years old. 52% was female. The study highlighted that 30% of the
sample was overweight with Mean+SD=24.87+12.81 while 32% had diabetes between 5 and less than
10 years ago with Mean+SD= 9.60+6.96. Between 60 to 70% of the sample needed screening yearly
and only 6% needed screening every 3 months. There was a correlation between indicators of
discovering diabetes' total score & patients' foot condition= 0.39 & 0.37 for Lt & Rt foot respectively.
Regression test predicted relation between indicators of discovering diabetes' total score & patients foot
condition in the future=0.40 & 0.38 Lt & Rt foot respectively. Conclusion: The more diabetic patients
became aged the more foot care is required. Frequent foot screening is needed to prevent diabetes
related complications in the future. Recommendation of the study: 1-All diabetic patients with either
type I or type II need to be scheduled on foot assessment. 2- Replication of the study on large sample
and follow up patient’s foot condition after taking the Customized Nursing Guideline of foot care.
Key words: Inlow's 60-second Diabetic Foot Screen, Diabetic foot ulcer, diabetic foot ulcer
detection, nursing role in care of diabetic foot problems.
Introduction:
Diabetes mellitus (DM) is a
chronic progressive metabolic disorder
characterized by hyperglycemia. It is a
major public health problem
worldwide (Shrivastava, Shrivastava
& Ramasamy, 2013). It can lead to many
health problems because of changes in
microvascular and macrovascular in
tissues and organs. Its complications
cause many devastating health
problems. Chronic hyperglycemia
cause irreversible structural changes
resulting in basement membrane
thickening in microcirculatory
branches causes connective tissue
hypoxia and microischemia
(Ignatavicius & Workman, 2012 ).
Amputation of lower limb is a
devastating complication for patients
with diabetes (Ignatavicius &
Workman, 2012). In USA, patients
with diabetes have an increased risk of
lower-limb amputation (Schofield et
al., 2012). There are approximately 18
million Americans with diabetes and
25% develop foot related problems as a
result of the disease, an estimated
600,000 American diabetics suffer
from foot ulcers, and undergo 80,000
amputations of legs every year because
of the foot ulcers (Armstrong 2008).
Agyemang, (2013) found that, in Egypt
diabetes prevalence ranged from 2.6%
in rural Sudan to 20.0% in urban
Diabetic Foot Screening for Ulcer. [email protected]
Egypt. Diabetes prevalence was
significantly higher in urban areas than
in rural areas. The prevalence of
chronic diabetes complications ranged
from 8.1% to 41.5% for retinopathy,
21% to 22% for albuminuria, 6.7% to
46.3% for nephropathy and 21.9% to
60% for neuropathy.
The foot is a frequent site for
complications in patients with diabetes
and for this reason foot care is
particularly important. The foot related
problems are sometimes referred to as
peripheral diabetic neuropathy (Lavery,
et al., 2008). The symptoms of
neuropathy include numbness and loss
of feeling. Researchers believe that the
process of nerve damage is related to
high glucose concentrations in the
blood that could cause chemical
damage to the nerves, disrupting
normal neural sensory function.
Numbness and loss of feeling in the
feet make it difficult for a diabetic to
identify a disease process such as
infection which could become
ulcerated and necrotic if treatment is
delayed. Increasing skin temperature
may be an early warning for potential
infections (Windsor, 2008 & Lavery, et
al., 2007). Diabetic foot lesions are
responsible for more hospitalizations
than any other complication of
diabetes. Among patients with
diabetes, 15% develop a foot ulcer, and
12 - 24% of individuals with a foot
ulcer require amputation (Armstrong,
2008). Diabetic persons confer the
greatest risk of foot ulceration because
of microvascular disease and
suboptimal glycemic control. Poor
circulation of the lower extremities
contributes to poor wound healing and
development of gangrene. The typical
sequence of events in the development
of a diabetic foot ulcer begins with a
soft tissue injury of the foot, formation
of a fissure between the toes or in an
area of dry skin, or formation of a
callus (Richard & Stillman 2008).
Inflammation is one of the earliest
signs of tissue injury and ulceration.
However, the clinical signs of
inflammation are usually too subtle to
be detected by patients or even by
trained health care providers
(Houghton, Bower & Chant, 2013).
Foot ulceration occurs as a result of
trauma in the presence of neuropathy
and peripheral vascular disease.
Complications of foot ulcers are a
leading cause of hospitalization and
amputation in diabetic patients
(Vuorisalo, Venermo & Lepäntalo,
2009). A slight increase in the
temperature of toes or any part of the
foot is a warning sign of a developing
foot ulcer in diabetics that could lead
to amputation of the lower extremity
(Windsor, 2008). Unnoticed excessive
heat or cold, pressure from a poorly
fitting shoe, or damage from a blunt or
sharp object inadvertently left in the
shoe may cause blistering and
ulceration. These factors, combined
with poor arterial inflow, confer a high
risk of limb loss on the patient with
diabetes (Poncelet, 2009 & Windsor,
2008). Peripheral arterial disease
(PAD) is a component cause in
approximately one-third of foot ulcers
and is often a significant risk factor
associated with recurrent wounds
(Lavery,
et al., 2008).
Diabetes is a complex disorder
which progresses in severity with time,
so people with diabetes should be seen
at regular intervals for the remainder of
their lives (Alastair Innes, 2012). It is
best managed with a team approach to
empower the patient to successfully
manage the disease in order to promote
health and wellbeing. The nurse as one
of this team has an important role in
assessing, caring, teaching and
counseling those patients. Nurses are
health care providers who actively
Diabetic Foot Screening for Ulcer. [email protected]
involved in prevention and early
detection of diabetes and its
complications. The nurses' role could
be in health care, community
education, health systems
management, patient care and
improving the quality of life. Diabetes
Nurses play their educating role in the
field of prevention of diabetic foot,
foot care and preventing from foot
injury (Aalaa,
Malazy, Sanjari, Peimani
&Mohajeri,2012).
Foot assessment and foot care
instructions are most important nursing
role when caring for patients who are
at high risk for developing foot
infections. Such risk factors have been
used collectively to determine a global
risk for individual patients (Suzanne,
Smeltzer, Bare, Hinkle & Cheever,
2010). In addition to the daily visual
and manual inspection of the feet, the
feet should be examined during every
health care visit or at least once per
year (more often if there is an increase
in the patient’s risk) by a podiatrist,
physician, or nurse (Boyko et al.,
2006). Screening for neuropathy in the
diabetes clinic is therefore justified for
diagnosis, patient education, the
provision of further impetus for
optimization of glycemic control, and
the institution of improved foot care
for the reduction of lower-extremity
complications (Kluding & Gajewski,
2009). From 50% to 75% of lower
extremity amputations are performed
on people with diabetes. More than
50% of these amputations are thought
to be preventable, provided patients are
taught foot care measures and practice
them on a daily basis (International
Diabetes Federation,2007).
One of the nursing roles is foot
screening which should be performed
as early as possible to detect "At-Risk"
feet and prevent the development of
diabetic foot complications, thereby
further reducing the risk of major
amputations (Nather, Chionh, Tay,
Aziz, Teng, Rajeswari, Erasmus
& Nambiar, 2010). Therefore the aim
of the current study was to detect foot
ulcer using diabetic foot screen:
suggested customized nursing
guideline at a University Hospital-
Egypt.
Significance of the study:
World Health Organization
estimates that more than 346 million
people worldwide have diabetes
mellitus (DM). This number is likely to
be more than the double by 2030
without any intervention (World health
organization 2012). Diabetes is the
third leading cause of death by disease,
primarily because of the high rate of
cardiovascular disease (myocardial
infarction, stroke, and peripheral
vascular disease) among people with
diabetes (International Diabetes
Federation- World Diabetes Day
2014).
The prevalence of diabetes is
increasing, and health care resources
for foot problems are often inadequate.
Thus it has become useful to direct
resources toward patients who are at
the greatest risk of foot ulceration, as
ulceration is the usual precursor of
amputation. Screening of people with
diabetes for high risk status is an
essential component of comprehensive
diabetes care. As it reduces workload
and identifies unrecognized ulcers at
an early stage. In other word screening
and patient education that change
behavior, are essential to prevent most
diabetic foot ulcers. Lately diabetes
considered one of the main diseases all
over the world and it has drawback on
patients' general condition as it acts as
primary cause of secondary diseases as
hypertension, cerebro-vascular stroke,
thrombosis….etc. Also on the long
term for patients who have
Diabetic Foot Screening for Ulcer. [email protected]
uncontrolled Diabetes Mellitus they
might develop neuropathy and
vasculature change which affects
directly on sensation and healing
process. Moreover one of the most
dramatic problems is diabetic foot; but
early detection might play a crucial
role to control diabetic foot problems
and its progression.
By using assessment of high risk
diabetic foot it would give an indicator
about the foot condition of the diabetic
patient and also gives them guidance of
the follow up timing. Also by giving
them a brochure which rich of pictures
and simple directed points in order to
guide them about how to care for their
feet is value the prevention plan for
diabetic patient. Thus the aim of the
current study was to detect foot ulcer
using diabetic foot screen: suggested
customized nursing guideline at a
University Hospital-Egypt.
Material & Methods:
The Aim:
The aim of the current study
was to detect foot ulcer using diabetic
foot screen: suggested customized
nursing guideline at a University
Hospital-Egypt.
Research Questions:
Q1: What are the screening periodical
recommendations for diabetic patient?
Q2: Is Inlow’s 60-second Diabetic
Foot Screen assist in determining
patient risk. Q3: Is there a correlation
between patient’s left and right foot
total score & body
mass index as well as indicators of
diabetic problems?
Q4: What are the predictors of getting
foot problems in the future?
Research design
A descriptive exploratory
design was utilized to guide and to
achieve the aim of the current research.
Setting
The study was conducted at
medical departments (19, 31 & 6) and
the out patient clinic at Kasr Al-Aini
Educational Hospital; affiliated to
Cairo-University -Egypt.
Subjects: A convenient sample of 50
adult male & female patients was
recruited in the current study.
Inclusion criteria: Patients with either
type I or type II diabetes mellitus and
recently without foot ulcers or
amputation related to diabetic disease.
Tools
In order to achieve the purpose
of the research two tools were utilized
to gather data pertinent to the study
variables as follows:
Tool I: Personal data which
consisted of two parts: Part I:
Demographic data which covers items
seeking information about the
background of the subjects such as age,
gender, marital status, occupation.
Part II: Medical data pertinent to
medical diagnosis, BMI, duration of
disease, blood glucose level…...etc.
Tool II: Included two parts:
Part I: Inlow’s 60 second diabetic foot
screen by the Canadian Association of
Wound (2004). It is designed to assist
in screening persons with diabetes to
prevent or treat diabetes-related foot
ulcers and/or limb-threatening
complications. It included 12
parameters each parameter consists of
2, 3 or 4 items accordingly and its
score ranged between 0-1, 0-2, 0-3 or
0-4. The overall score ranged from 0 to
25 for each foot; the higher the score,
the more frequent the screening
recommended. The highest score from
either foot; determines the
recommended reassessment intervals:
Its interpretation is as follow: Score=0-
6 means recommended screening
yearly. Score=7-12 means
recommended screening every 6
Diabetic Foot Screening for Ulcer. [email protected]
months. Score=13-19 means
recommended screening every 3
months. While score=20-25 means
recommended screening every 1 to 3
month. In addition Part II:
International working group on the
diabetic foot (IWGDF) – Risk
classification system. (IWGDF)
categorization is as follows: (0)
Normal; means no neuropathy. (1)
Means loss of protective sensation. (2)
Stands for a LOPS and deformity. (2b)
reflects that the patient has peripheral
arterial disease. While (3a) means
patient has a previous/sensation
parameters changes. While (3b) means
that the patient has boney parameters
changes). Lavery, Peters, Williams,
Murdoch, Hudson & Lavery, (2008).
Reliability was achieved with 95%
confidence intervals as alpha test=0.96
for the right foot, & 0.97 for the left
foot (Murphy, Laforet, Da
Rosa, Tabamo & Woodbury, 2012).
Ethical consideration:
An official permission was
taken from the hospital administrators.
Each participant was informed about
the nature and purpose of the study.
Then consent was obtained from all
patients for participation in the study.
The researchers emphasized that
participation in the study is entirely
voluntary; anonymity and
confidentiality are assured though
coding the data.
Pilot study
Once permission was granted
to proceed with the proposed study, a
pilot study was carried out before
starting data collection on 6 of targeted
patients to evaluate the clarity,
feasibility and applicability of the tools
as well as estimate the time needed to
collect data. Data which obtained from
the pilot study was excluded from the
study results.
Also panel of juries' expertise
were reviewed the utilized tools for its
validity; few modification was
performed on the socio-demographic
data sheet to make it more
comprehensive. Also they have been
reviewed both the English and Arabic
developed version diabetic guidance
booklet which was based on both
Nanda guidelines and extensive review
of literature.
Procedure
Once official permission was
granted from the head of the
department to proceed the study, the
researchers initiated data collection.
Patients who fulfill the inclusion
criteria were interviewed individually
starting by demographic and medical
data. The researchers started by giving
fully explanation about the nature of
the research. Each patient received the
following instructions: General
instructions: This tool is designed to
assist in screening persons with
diabetes to prevent or treat diabetes-
related foot ulcers and/or limb
threatening complications. The screen
should be completed on admission of
patients with diabetes.
Specific instructions: Explain
screening to each patient and ask them
to remove their shoes, socks from both
feet. Remove any devices (if present)
that impair the screening. Review each
of the parameters for each foot. Then
by the end of the screening the
researchers calculated the total score of
(A 60-Second tool) & (IWGDF) for
each foot separately and interpreted
based on the tool scores and
description. Once the screen is
completed the researchers determine
care recommendations by using the
suggested Customized Nursing
Guideline based on patient's needs as
researchers gave and explain each
shared patient in the study the brochure
Diabetic Foot Screening for Ulcer. [email protected]
of the Customized Nursing Guideline
for the diabetic patient and simplified
the uses of the endorsed instructions
which were according to each patient’s
score. Finally; the researchers used the
highest score from either the left or the
right foot to determine recommended
screening intervals.
Operational definition:
-Indicators of diabetic
problems: There are theoretical factors
which were founded related to the
future problems for the diabetic
patients and the researchers utilized as
vital indicators of foot problems as
follows: (age, BMI, duration of having
diabetes mellitus indicators of
discovering diabetes mellitus, activity
of daily living (ADL) & healing period
of old foot injury).
-Indicators of discovering
diabetes mellitus: Which are the
factors which let each patient
discovered that he has diabetes
mellitus as follows: (polyphagia,
polydepsia, polyuria, insomnia,
malaise, drowsiness, loss of
consciousness, periodical check-up and
accidently check-up).
-Customized Nursing
Guideline: It is the nursing brochure
which designed based on both 1-the
affiliated guidance of the (Inlow's 60
second diabetic foot screening) 2-
Extensive reading of Nanda guideline
and literature review. Also it reflects
the nursing activities or instructions
that provided for each patient
individually according to his/her
results which depended on the used
tools.
Suggested Customized Nursing
Guideline (Headlines): Contact the researchers for the
comprehensive guideline:
1-Self Care Parameters:
High scores in parameters 1, 2 and
4: Indicative of self care deficit that
need to:
a- Skin care.
b- Nail Care.
c- Footwear.
2-Integumentary parameters:
A) Moderate scores in parameters 4
and 7: Indicative of callous formation
that
need to.
a-1- Footwear.
a-2- Range of Motion.
- Exercising the hip and knee
- Exercising the ankle
- Exercising the toes
B) High scores in parameters 1, 6
and 12: Indicative of infected ulcer
that need
to.
b-1- Skin care.
b-2- Temperature Hot.
b-3- Erythema.
C) High scores in parameters 2,6
and 12: Indicative of infected nails
that need
to.
c-1- Nail Care.
c-2- Temperature Hot.
c-3- Erythema.
3-Arterial Flow Parameters:
High scores in parameters 5, 10 and
11: Indicative of peripheral arterial
disease that need to.
a- Cold temperature.
b- Pedal Pulses.
c- Dependent Rubor.
4) Sensation Parameters:
High scores in parameters 8 and 9:
Indicative of loss of protective
sensation or neuropathy that need to.
a- Monofilament testing.
b- Sensation.
5) Boney Changes Parameters:
High scores in parameters 3, 8 and
9: Indicative of Charcot changes that
need to.
a- Deformity.
b- Monofilament.
Diabetic Foot Screening for Ulcer. [email protected]
c- Sensation.
Statistical analysis: The data was coded and
tabulated using a personal computer.
Statistical Package for Social Science
(SPSS) version 17 was used. Data was
presented using descriptive statistics in
the form of frequencies and
percentage. Inferential statistics as
correlations; compare of means &
regression tests were used. Statistical
significance was considered at p-value
≤ 0.05.
Results:
The results will be presented
into two main sections: Section I):
Illustrated the demographic & medical
data pertinent to the medical diagnosis.
The study findings revealed that; the
study subjects represented both female
and male with approximately the same
percentage (52%, 48%) respectively
with the mean of age (x+SD 53.2+8.4).
In relation to marital status 72% of
them were married and 48% were
house wife followed by retired, laborer
and not work represents (18%, 14%
and 10%) respectively. Regarding level
of education 54% of the study subjects
can not read and write while subjects
with diploma and can read and write
represents ( 22%, 20%) respectively
and only 4% of them had bachelor
degree.
Regarding body mass index
(BMI) only 10% of the studied
subjects had normal weight, while 30%
and 24% of them categorized as
overweight and obese respectively.
About the other categories extremely
obese and morbid obesity represents
(14%, 4%) respectively with
Mean+SD=24.87+12.81.
In relation to the duration of
diabetes the current study findings
illustrated that 32% of the study
subjects had diabetes between 5 and
less than 10 years ago while 24% of
them between 10 and less than 15
years ago. According to the other
percentage 14%, 8%, & 6%) had
diabetes between (15 to less than 20,
20 & 1 to 5 years ago) respectively
with Mean+SD= 9.60+6.96.
Also 62% of the studied sample
had polyuria and 56% had ploydepsia;
while who had polyphagia was 34%
and 32% experienced malaise while
who experienced loss of consciousness
was only 20% with mean+SD=
2.72+1.40. Moreover 82% of the
sample was undertaking insulin while
the rest was taking oral hypoglycemic
agent. 33% of the sample had chronic
diseases as (cardiac, asthmatic, deep
venous thrombosis, epilepsy,
rheumatoid, goiter and cancer); but
more than one third of the sample had
hypertension.
As regards foot injuries
problems Table 1 revealed that (31)
patients 62% of the subjects had no
experience of foot injury while the rest
of the sample (19) patients have been
experienced foot injury. However
42.1% (8 out of 19) patients who had
this experience were using traditional
medicine. 31.5% of foot injuries was
taking 1 up to 2 years for healing while
26.3% of the subjects was taking more
than 3 years for foot injury healing
with Mean+SD= 3.14+2.10.
Section II): Answered the
research questions; which related to the
periodical screening recommendations
for diabetic patient. Foot Screen and its
assistance in determining patient risk.
The correlation between patients' left
and right foot total score & body mass
index as well as duration of diabetes.
And finally the regression test which
illustrated the prediction of patients
who might get foot problems in the
future.
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It was noticed from Table 2
that between 60 to 70% of the subjects
needed screening yearly. However,
only 6% needed screening every 3
months. Table 3 illustrated that 72% of
the studied subjects were suffering
from (arterial flow and bony changes)
risk in the left foot, comparing to 66%
and 70% at the right foot respectively.
According to activity of daily
living it was observed from Table 4
that 68% of the study subjects were
independent while only 2% was
dependent.
In addition a clear moderate correlation
between total score of indicators of
discovering diabetes as (Polydepsia,
polyphagia…etc) & left and right foot
conditioning=0.390 and 0.376
respectively was shown in Table 5.
The same table displayed that there
was a weak correlation between
healing period of old foot injury & left
and right foot= 0.21 and 0.20
respectively.
As shown in Table 6 there was
a statistical significance mean of
difference for age as it equaled 9.44 &
10.47 for the left and the right foot
respectively. While regarding BMI it
was 13.41 & 10.71 for the left and the
right foot respectively.
Table 7 also revealed that the
patients who had more indicators of
discovering diabetes as polyurea,
polydepsia, and uncontrolled blood
glucose level….etc will have moderate
chance of getting foot problems in the
future with 0.40 & 0.38 for the left and
the right foot respectively.
Additionally this table illustrated that
patients who had in the past poor
healing of foot injury will develop
other foot problems in the future but
with weak degree with 0.22 & 0.21 for
the left and the right foot respectively.
Also almost the same finding was
reported regarding the predictor of age.
Table 1:
Percentage distribution of the study group regarding foot injuries
problems; patients' manipulation of foot injuries, duration of healing and foot
deformities (n=50).
Variables No. %
-Foot injuries:
-Yes
-No
19
31
38%
62%
Total 50 100%
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-Patients' manipulation of foot injuries:
-Ignore it
-Ask others
-Traditional medicine
-Consult a physician
-Consult a nurse specialist
2
2
8
6
1
10.5%
10.5%
42.1%
31.5%
5.2%
Total 19 100%
Duration of healing:
Mean+SD= 3.14+2.10
-1 –>2 years
-2 –>3 years
-3 – years
6
4
5
31.5%
21%
26.3%
Total 19 100%
Deformities after healing:
-No
Yes:
-Darkness
-Infection
-Abrasion
10
3
5
1
20%
15.7%
26.3%
2.2%
Total 19 100%
*Total number of patients had foot injury 19 out of 50.
Table 2:
Percentage distribution of the study group regarding left & right foot
regarding high risk diabetic foot by using (A 60-Second tool) (n=50).
Left Foot Right Foot
-Total Score: No. % -Total Score: No. %
Diabetic Foot Screening for Ulcer. [email protected]
Mean+SD=5.68+3.94 Mean+SD=5.72+3.91
-Recommended screening
yearly. Score of (0-6):
-Recommended screening/6
months. Score of (7-12):
-Recommended screening/3
months: Score of 13-19:
-Recommended screening/1-
3 months. (20-25):
30
17
3
0
60%
34%
6%
0%
-Recommended screening
yearly. Score of (0-6):
-Recommended screening/6
months. Score of (7-12):
-Recommended screening/3
months: Score of 13-19:
-Recommended
screening/1-3 months. (20-
25):
35
12
3
0
70%
24%
6%
0%
Total 50 100
%
Total 50 100
%
Table 3:
Percentage distribution of the study group regarding left & right foot
regarding high risk diabetic foot by using International working group on the
diabetic foot (IWGDF) – Risk classification system. (n=50).
International working group on the diabetic foot (IWGDF)
Left Foot Right Foot
-Total Score: No. % -Total Score: No. %
Normal=(0)/ no neuropathy:
-No changes
0
0%
Normal=(0)/ no neuropathy:
-No changes
0
0%
Diabetic Foot Screening for Ulcer. [email protected]
Integument Parameters=(1)/
Loss of protective sensation:
-Moderate scores in parameters
4, parameter 7
Integument Parameters=(2a)
/LOPS and deformity:
-High scores in parameters 1, 6
and 12
-High scores in parameters 2, 6
and 12
Arterial Flow Parameters:
(2b)/ Peripheral arterial
disease:
-High scores in parameters 5, 10
and 11
Sensation Parameters=(3a):
High scores in parameters 8 and
9
Boney Changes Parameters:
=(3b):
-High scores in parameters 3, 8
and 9
25
9
9
36
25
36
50%
18%
18%
72%
50%
72%
Integument Parameters=(1)/
Loss of protective sensation:
-Moderate scores in
parameters 4 and 7
Integument Parameters=(2a)
/LOPS and deformity:
-High scores in parameters 1, 6
and 12
-High scores in parameters 2, 6
and 12
Arterial Flow Parameters: =
(2b)/ Peripheral arterial
disease:
-High scores in parameters 5,
10 and 11
Sensation Parameters=(3a):
-High scores in parameters 8
and 9
Boney Changes Parameters:
=(3b):
-High scores in parameters 3, 8
and 9
25
9
9
33
24
35
50%
18%
18%
66%
48%
70%
Total 50 100% Total 50 100%
N.B. Total is not mutually exclusive.
Table 4:
Percentage distribution of the study group regarding activity of daily living
(ADL) (n=50).
Activity of Daily Living
-Total Score:
Mean+SD=11.42+3.20
No. %
-Independent
-With assistant
-Dependent
34
15
1
68%
30%
2%
Total 50 100%
Table 5:
Correlation between Left and right total score high risk diabetic &
indicators of diabetic problems. (n=50)
Indicators of diabetic problems
Total score of Inlow’s 60-Second
Diabetic Foot Screen
Correlation Result
Left foot Right foot
Duration of having diabetes 0.150 0.140
Total score of indicators of discovering diabetes 0.390** 0.376**
Total score of Activity of Daily Living 0.077 0.081
Diabetic Foot Screening for Ulcer. [email protected]
Healing period of old foot injury 0.217* 0.209*
*P Value ≤ 0.05
Table 6:
Compare of means Left and right total score high risk diabetic & (BMI
and age).
Chi-Square Left foot Right foot
Age 9.44* 10.47*
BMI 13.41* 10.71*
*P Value ≤ 0.05
Table 7:
Prediction probability test of predictors & total score of Inlow’s 60-
Second Diabetic Foot Screen which illustrated patients who might get foot
problems in the future:
Predictors
Total score of Inlow’s 60-
Second Diabetic Foot Screen
Regression Result
Left foot Right foot
Total score of indicators' discovering diabetes 0.40** 0.38**
Activity of Daily Living (ADL) 0.077 0.081
Body Mass Index (BMI) 0.089 0.094
Timing of the previous foot wound healing 0.22* 0.21*
Age 0.21* 0.20*
*P Value ≤ 0.05
Effect of Designed Nursing Care. [email protected]
Discussion: All over the world it was reported that 29.1 million people or 9.3% of the
population have diabetes. The diagnosed patients were 21.0 million people. While the
undiagnosed was 8.1 million people 27.8% of people (National Diabetes Statistics
Report 2014). Moreover; in 2010, about 73,000 non-traumatic lower-limb
amputations were performed in adults aged 20 years or older with diagnosed diabetes.
About 60% of non-traumatic lower-limb amputations among people aged 20 years or
older occur in people with diagnosed diabetes (American Diabetes Association,
2014).
Based on the current study it was observed that more than one third of the
sample their age ranged between fifty and less than sixty years old & more than half
of the sample was female. The majority of the sample was married. Merely half of
them was house wife and cannot read or write. This finding congruent with the
Centers for Disease Control and Prevention on (2013) which found that among
Americans aged 20 years or younger, about one-quarter of 1% (215,000 people) have
diabetes. Americans aged 20 years or older, 11.3% (25.6 million people) have
diabetes. But the prevalence of diabetes is greater among older people. And among
Americans aged 65 years or older, 26.9% (10.9 million people) have diabetes. While
in Egypt and based on the International Diabetes Federation (2013) 7.5 million
Egyptian have diabetes and proportion of deaths because of diabetes for people under
60 years old was 50%.
Almost two third of the sample had no experience of foot injury however one
third of the patients who had experience of foot injuries in the past; their foot injury
was taking 1 up to 2 years for healing; while almost one quarter of the sample was
Effect of Designed Nursing Care. [email protected]
taking more than 3 years for foot injury healing. This long time of healing probably as
a result of poor circulation because of obesity; which delay process of healing. Also
one third of the sample was overweight. A research study of consequence of diabetic
foot conducted by Jörneskog., (2012) revealed that Neuropathy, peripheral arterial
occlusive disease and microvascular disturbances are important factors contributing to
foot problems in diabetic patients. The alterations in skin microvascular function are
pronounced including severely reduced capillary circulation and abolished hyperemic
responses.
Moreover merely one third of the sample had diabetes between 5 and less than
10 years ago. While regarding the indicators of discovering diabetes as reported by
the participants in the current research; it was observed that around two third of the
studied sample suffered from polyuria, more than half of the sample had ploydepsia;
and who had polyphagia was almost one third of the sample. Also who experienced
malaise was one third of the sample; and patients who loss consciousness was only
twenty percent of the sample. The majority of the sample was undertaking insulin
while the rest was taking oral hypoglycemic agent. Most of the sample had chronic
disease (cardiac, asthmatic, deep venous thrombosis, epilepsy, rheumatoid, goiter and
cancer); but it was noticed that more than one third of the sample had hypertension.
The researchers reported that only two patients were divided their meals over
5 to 6 meals/day; while more than half of the sample were eating their meals over
three times/day while the rest was between once or twice meal/day. This gave an
indicator that none of the studied sample was follow the concept of (small frequent
meals) except two patients only; and that might put those patients with real risk of
imbalance blood sugar level which logically would affect their peripheral circulation
on the long term and might have negative drawback on their body system in general
and on their foot health condition in specific. A study by Miggiano & Gagliardi
(2006) supported the same finding as they mentioned that in the treatment of diabetes
the diet has an important role complementary to the pharmaceutical treatment. The
diet must provide the right amount of nutrients and calories in order for the individual
to reach and maintain the ideal weight, stabilize the blood glucose levels close to the
norm, and attain an optimal lipid profile. Also Zhang, Tang, Fang, Qian, Xu &, Ning
(2013) added that poor nutrition was closely correlated with infection with (r=0.64).
This finding was based on their research on 192 hospitalized diabetic patients
The current research revealed that around two third of the sample required foot
screening once per year while merely of one third of the sample needs this screening
every six months. A research of Assessment of ischaemia of ulcerated diabetic foot
and its treatment according to recent international guidelines by Vikatmaa, Ebeling &
Lepäntalo (2014) concluded that half of diabetic ulcers are ischaemic; almost all
neuropathic problems are often worsened by infection. Ischaemia can often be
repaired only if diagnosed and treated early enough. Unfortunately these days,
ischaemia is often diagnosed far too late. International recommendations emphasize
an immediate need for a paradigm change. Ischaemia should always be suspected as a
cause of diabetic ulcer unless proven. Also they emphasized on early diagnosis and
undelayed treatment with vascular consultation. On the other hand the researchers
found that most of the studied sample suffered from boney changed parameters such
as dropped metatarsal which put the patient on a real significant risk and prevent the
wearing of off-the-shelf footwear; while half of the sampled had previous foot
Effect of Designed Nursing Care. [email protected]
ulceration. The researchers had been view these problems as serious alarm for those
patients as at any time they can have foot problem; that is why it was crucial to direct
them for periodical foot screening plus using the giving (Customized Nursing
Guidelines) after explained it by the researchers to each participant in the current
study. DiPreta at (2013) performed a research about assessment and management of
diabetic foot and his findings congruent with the current research as he emphasized
that patients with diabetes and peripheral neuropathy are at risk for foot deformities
and mechanical imbalance of the lower extremity as peripheral neuropathy leads to an
insensate foot that puts the patient at risk for injury. And those patients really were in
need for health teaching but referral and periodical monitoring is crucial for
prevention of further foot complications.
Also the study revealed that more than two third of the sample was doing the
activity of daily living (ADL) as (eating, drinking, toileting,….etc) independently and
almost more than quarter of the sample was doing the activity of daily living but with
assistant. Inspite patients who were performing the activity of daily living (ADL)
with assistant were less than one third of the sample but indeed the researchers were
concerning more about them as the majority of the studied sample's age ranged
between (40 and less than 60) years old; this finding let the researchers be worry
about the diabetic patients who neither follow the periodical foot screening nor apply
any foot care guidelines as probably they will move back to the dependent category
soon; specially most of the studied sample has chronic diseases as mentioned before
which logically will increase their dependability. Sakurai at (2013) agreed with that
finding as he conducted a study of risks for impaired daily life function in the elderly
with type 2 diabetes in Japan and the study revealed that during 6 years of follow-up,
13.6% of subjects had developed a new ADL disability and 38.3% had developed a
new functional impairment. In the 65-74 years age group, basic ADL decreased only
in males, while females became functionally impaired. In 75-84 years age group,
ADL decreased in both men and women. Older age and metabolic syndrome
negatively affected ADL, while baseline ADL impairment, cognitive dysfunction,
physical inactivity, and insulin therapy were significant predictors of a future decline
in the ADL.
On the other hand the current study showed clear moderate correlation
between indicators total score of discovering diabetes (polyphagia, polydepsia,
polyuria, insomnia, malaise, drowsiness, loss of consciousness, periodical check-up
and accidently check-up) & left/right foot conditioning; which obviously mean as
much as diabetic indicators increase without early diagnosing or without follow the
medical regimen/Nursing Guidelines as much as foot condition for the diabetic
patients becomes worse. Thus all studied indicators of discovering diabetes played a
vital role in the future patient diabetic foot condition. Beand, (2009) agreed with this
finding as he documented in his article of Beginning Signs of Diabetes - Early
Detection of Diabetes that diabetes is known as one of the "silent killer" diseases.
Over 23 million people in the United States have diabetes; only about three quarters
of them know they have the disease. The other six million sufferers go undiagnosed
until symptoms of the disease become serious. When the disease is just beginning
signs of diabetes seem harmless; the sufferer does not seek medical advice, the
disease progresses and the symptoms continue untreated. From the current study
researchers view the documentation of Beand, (2009) and which was based on a large
Effect of Designed Nursing Care. [email protected]
survey could explain the correlation between the studied diabetic indicators and their
foot condition.
Also the current study revealed that there was a mean of difference between
left/right foot problems & body mass index (BMI) and patients' age which was
considered indicators of diabetic problems however the rest of diabetic indicators
(duration of having diabetes mellitus, indicators of discovering diabetes mellitus as
polydepsia, polyphagia…etc, ADL & healing period of old foot injury) had no
statistical significance mean of difference. From the researchers point of view this
was expected; as much as the diabetic patient’s weight increase as much as he/she will
be categorized in the obesity risks and this consequently will affect their foot
negatively as it will interfere with the circulation and the sensation of their foot
condition. Same analogy could apply on those patients' age as much as they became
elder as much as poor foot circulation hazards occur. So both BMI and age played a
negative role of both poor circulation and delay foot wound healing for the diabetic
patients. Dubský, Jirkovská, Bem , Fejfarová, Skibová, Schaper & Lipsky (2013)
congruent with the current study as they conducted a research of risk factors for
recurrence of diabetic foot ulcers on 93 of diabetic patient; they reported that obesity
was a risk factor which can give prediction of having foot problem for the diabetic
patients despite intensive foot care.
Moreover the researchers found that the patients who had high total score of
indicators factors of discovering diabetes (polyphagia, polydepsia, polyurea,
insomnia, malaise, drowsiness, loss of consciousness, periodical check-up and
accidently check-up) will have more probability with a moderate degree of getting
foot problem in the future for both the left and the right foot. Also patients' age and
patients who had in the past delaying foot injury healing; will have probability of
developing another foot problems in the future but with a weak degree for both the
left and the right foot. This gave a logic thinking that patients who spent more time to
discover that he/she was suffering from diabetes had a negative chance in destroying
the vascularity, the bony structure and the sensation of their foot that is why their
chance of developing foot problems in the future is higher than any other diabetic
patients. A study of determining prevalence of diabetes related foot disease done by
Shan, Caroline , Peter & Donald at (2009) revealed that based on self report of
symptoms and/or clinical history, and self report of foot ulceration and foot
deformity; the patients had between moderate and excellent expectation of getting
future foot injury.
Finally the researchers concluded that periodical screening of foot condition is
very vital for those patients with diabetes mellitus as it helps them of early detection
for any foot injury plus by using the tools of (Inlow’s 60 second diabetic foot screen
& the International working group on the diabetic foot) enable the researchers for
both Early Prediction of Foot Ulcer and implement the suggested Customized Nursing
Guideline. In general the primary health care (early detection) is the corner stone of
positive health prognosis especially with chronic diseases as diabetes which must be
under control and need frequent follow-up.
Conclusion of the study:
It was found that the more diabetic patients became aged the more foot care is
required. Almost quarter of the sample was categorized as obese which is a risky
Effect of Designed Nursing Care. [email protected]
indicator for insulin resistance which put the patients on the dangerous of poor foot
healing in case of injury. Near than half of the sample required more than two years
for foot healing in case of foot injury history. And in case of deformity after healing
was (darkness, infection or abrasion). All studied sample needs periodical follow up
depends on their foot screening results. There is a strong association between the
primary diabetic patients’ complains indicators as (polydepsia, polyphagia,
insomnia…etc) and their foot condition later and prediction of foot condition in the
future.
Recommendation of the study: ž 1-All diabetic patients with either type I or type II need to be scheduled on
ž foot assessment
ž 2-Replication of the study on larger sample.
ž 3-Continuation of the study in order to follow up patient’s foot condition after
ž taking the Customized Nursing Guideline foot care brochure.
Nursing implications: The nurse has a vital role in the early detection of diabetic foot problem. The
clinical nurse can utilize the (60 seconds tools) for the diabetic patients during the
follow up which enable the patient for early detection and prediction of foot problems.
Giving the diabetic foot care guideline will be more beneficent for those patients
specially it suits both patient who can and who cannot read or write as beside the
simple instructions there is the consequent image for foot care of diabetic patient.
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