Synopsis Proforma for Registration of Subject for Dissertation

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SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Miss.ANU T ABRAHAM

I YEAR M .Sc NURSING

MEDICAL SURGICAL NURSING

2009-2011

THE KARNATAKACOLLEGE OF NURSING

#12, KOGILU MAIN ROAD, YELAHANKA,

BANGALORE – 560064

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / Miss.ANU T. ABRAHAM
I YEAR M Sc NURSING
THE KARNATAKA COLLEGE OF NURSING
#12, KOGILU MAIN ROAD, YELAHANKA, BANGALORE-560064.
2. / NAME OF THE INSTITUTION / THE KARNATAKA COLLEGE OF NURSING
#12,KOGILU MAIN ROAD, YELAHANKA, BANGALORE-560064.
3. / COURSE OF THE STUDY AND SUBJECT / I YEAR M. Sc NURSING
MEDICAL SURGICAL NURSING
4. / DATE OF ADMISSION TO THE COURSE / 15/06/2009
5. / TITLE OF THE STUDY / .A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULEONKNOWLEDGE REGARDING PREVENTION OF DIABETIC FOOT ULCERS AMONG RECENTLY DIAGNOSED DIABETIC PATIENTS AT SELECTED HOSPITALS, BANGALORE.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“All human actions have one or more of these seven causes: chance, nature, compulsion, habit, reason, passion and desire.”

ARISTOTLE

“My feet is killing me”, is one of the most enduring phrases in the English language. Like all the clinches this is grounded in day to day experience. Diabetes mellitus is a group of metabolic disease characterised by increased levels of glucose in the body (hyperglycemia) resulting from defects in insulin secretion, insulin action or both14. In diabetes the cells may stop responding to insulin entirely. Long term effects of hyperglycemia contributes to (coronary artery disease, cerebrovascular accident, peripheral vascular obstructive disease), chronic micro vascular complications (kidney and eye disease) and neuropathic complications (diseases of the nerve)11.

The diabetic foot covers the spectrum of neurological, arterial and infectious foot problems that occur as a consequence of diabetes10. The wounds often due to minor injuries, may lead to amputations if not quickly treated. Between 50% to 75% of lower extremity amputations are performed on people with diabetes. More than 50% of amputations are thought to be preventable, provided patients are taught foot care measures and practice them on daily bases.14

The treatment consists of effectively alleviating mechanical pressure from the wound (i.e. prevention of repeated trauma by walking on the ulcer) on the one hand, and using adequate local care on the other hand4. In addition, patient’s vascular status needs to be assessed and corrected. If present, infections must be quickly and aggressively treated. The aim is to reduce the numbers of amputations. The best treatment however aims at prevention of foot ulcers1. It requires the knowledge of about the pathophysiological mechanisms of diabetic foot,the screening for feet at risk, and the education of the patient, family and the health care providers6.

Foot care prevention can reduce the occurrence of foot ulcerations and amputations. The most important factor related to the development of foot ulcers are peripheral neuropathy, associated with loss of pain5. Five cornerstones for prevention includes, regular examinations of the feet and foot wear, identification of the high risk client, education of the patient and the family, appropriate foot wear and treatment of nonulcerative pathology12.

Education plays an important role in prevention of foot ulcers49. The aim is to increase motivation and skills and enhance compliance with footwear advice. Despite being one of the most serious and costly complications of diabetes, foot complications are effectively prevented. By implementing a care strategy that combines prevention, the multidisciplinary treatment of foot ulcers, appropriate organizations, close monitoring and education of people with diabetes and health care professionals, it is possible to reduce amputation rates by upto 85%48.

6.2 NEED FOR THE STUDY

“Do not follow where the path may lead. Go instead where there is no path and leave a trail”.

Ralph Waldo Emerson

Diabetes is the fourth leading cause of death by diseases globally. The burden is particularly harsh in low or middle income countries, where many children with type -I diabetes die because they lack access to life saving insulin and where many do not receive the education required to delay and prevent complications48.

According to World Health Organization (2009) the total number of people with diabetes world wide is 171 million in 2000 and is projected to rise up to 366 million in 203050. International working group on the diabetic foot (2005) estimated that each year, around 3.8 million adults die from diabetes related causes, i.e. 6deaths every minute. It is estimated that 250 million people worldwide have diabetes representing roughly 6% of the adult population (20-79 age group). The number is expected to reach 380 million by 2025, representing 7.1% of the adult population48.

According to WHO(2009) the top 10 countries suffering from diabetes are India, China, USA, Indonesia, Japan, Pakistan, Russia, Brazil, Italy and Bangladesh. Recent studies in China, Canada, USA, and several European countries have shown that feasible lifestyle intervention can prevent the onset of diabetes in people at high risk50. Overall direct health care cost of diabetes ranges from 2.5% to 15% annual health care budget of a country. According to Centers for Disease Control and Prevention (CDC-2009) from 1980 to 2000, the number of Americans with diabetes is more than double. Currently, it is estimated that almost 21 million people in the US are affected by diabetes; by 2030 this figure is expected to exceed 30 million14.

National diabetes statistics (2007) in a survey on prevalence of diagnosed and undiagnoseddiabetes in US, in all age group in 2007, showed that total diagnosed patients are 23.6 million people, i.e. 7.1% of total population has diabetes. In this 17.9% people are diagnosed and 5.7% people are undiagnosed. There are approximately 798,000 new cases of diabetes which are diagnosed annually in the United States. The incidence rate is 1 in 340or 0.29%43. In MMWR Weekly (2008) a report summarized that during 2005-2007, average annual age adjusted incidence of diabetes ranged from 5-12.8 per 1,000 persons in US. The incidence increased 90% from 4.8 per 1,000 in 1995-1997 to 9.1 in 2005-200722.

Australian Health Magazine (2004) reported that half of the estimated 1 million diabetic patients were unaware that they had diabetes in Australia in 200141. Dr Michael Gravin (2007) stated that St. Lucia has the highest rate of diabetes in the world, with 28.1% of the population having abnormal glucose or high blood sugar and 8.1% of the population as diabetic, most commonly women being affected34.

Dr. Vijay Viswanathan (2006) conducted a study on diabetic foot in India and stated that diabetes is common in Indians of Asian subcontinent. India alone has 35 million diabetic patients and India will have the largest number of diabetic patients by the year 202548. According to International Diabetic Federation (2005) India alone counts over 35 million people with diabetes. Estimated figures for 2025 suggest that this will reach 73.5 million as a consequence of longer life expectancy, sedentary lifestyle and changing dietary patterns48.

Diabetic foot problems are among the most serious complications of diabetes. The rising prevalence of diabetes all over the world has brought with it an increase in lower limb amputations performed as a result of the disease22. Epidemiological reports indicate that over 1 million amputations are performed in each year. This amounts to a leg being lost to a diabetic patient somewhere in the world every 30 seconds50.

Approximately 7% of diabetic patients with foot ulcer will require an amputation. Diabetes is responsible for 75% of nontraumatic amputations performed yearly in Canada20. Andrew Boulton (2005) stated that in most developed countries the annual incidence of foot ulceration amongst people with diabetes suffer a lower limb amputation21.

In developing countries, foot ulcers and amputations are sadly very common. In some islands of Caribbean, the prevalence of diabetes is approaching 20%, foot lesions and gangrene are amongst the most frequent conditions seen in the surgical wards30. In India, the prevalence of diabetic foot ulcer in the rural population is 3.6%. Socio- cultural practices such as bare foot walking, religious practices like walking on fire, use of improper foot wear and lack of knowledge regarding foot care attributes towards increase in the prevalence of foot complications in India48.

Dr. Vijay Viswanathan (2005) stated that in India 40,000 legs are amputated per year, most of them as a result of an infection. 85% of these amputations could be prevented by simple and cost effective diabetic foot care; they are good foot hygiene, control of blood sugar, exercises, education on proper foot self care practices and regular checkups28.

Education of patients regarding the importance of prevention of foot ulcers is the need of the hour; primary prevention of diabetic foot ulcer is relatively simple and should be practical as established part of good medical care. Efforts to ensure primary prevention of diabetic foot ulcers should focus on the education of the patients on importance of measures to avoid occurrence of diabetic foot ulcers.

6.2 REVIEW OF LITERATURE

The review of literature is an integral component of any study of research project. It enhances the depth of knowledge and provides a clear understanding regarding a topic. It refers to an extensive, exhaustive and systematic examination of publications relevant to the research project2. This chapter presents a review of selected literature relevant to the study which is discussed under the following headings:

1. Literature related to incidence and risk factors of diabetic foot ulcers among diabetic patients.
2. Literature related to assessment of knowledge and practices on diabetic foot care among diabetes patients.
3. Literature related to prevention of diabetic foot ulcers among diabetic patients.
4. Literature related to effectiveness of self instructional module on prevention of diabetic foot ulcers among diabetic patients.

1. Literature related to incidence and risk factors of diabetic foot ulcers among diabetic patients

Fatma Al-Maskari (2007) studied on incidence and risk factors of diabetic foot complications among diabetic patients. A cross sectional survey was conducted with 513 randomly selected samples. The data was collected using interview, questionnaire and medical assessment. The findings revealed that 39% of patients had peripheral neuropathy and 12% had peripheral vascular disease41.

Lawrence A. Lavery etal (2006) conducted a study to assess the incidence and risk factors of diabetic foot ulcers in individuals with diabetes. A prospective study was conducted using 1,666 diabetic patients. The findings indicated that during the evaluation 151 patients had developed foot infections, most of the patients had soft tissue injury and 19.9% had osteomyelitis. This study concluded that foot ulcers occur frequently in individuals with diabetes, usually following trauma20.

Edward J. Boyko etal (2006) studied on prediction of diabetic foot ulcer occurrence using commonly available clinical information. A prospective study was done on 1,283 diabetic patients. The findings revealed that during the time 216 foot ulcers occurred at an incidence of 5/100 yearly. Significant predictors of foot ulcers were impaired vision, poor foot care practices, prior amputations, monofilament insensitivity and smoking18.

Caroline A. Abbott etal (2005) studied on foot ulcer risk in South-Asia and African-Caribbean compared with European diabetic patients in the United Kingdom. In this study 15,692 diabetic patients were included. The findings of the study suggested that the prevalence of diabetic foot ulcers among Europeans is 5.5% for South-Asians, it is 1.8% and in African Caribbeans the prevalence is 2.7%. The lower levels of peripheral artery diseaseand neuropathy, adequate insulin usage and foot care reduced the risk of foot ulcers in South-Asians and African-Caribbeans15.

S. Sriussadaporn etal (2004) conducted a study toassess the factors associated with diabetic foot ulceration in Thailand. A case control study was done on 55 patients with foot ulcers and 110 patients without foot ulcers. The findings of the study stated that the peripheral neuropathy, visual impairment, poor glycemic control were the major independent risk factors associated with foot ulceration46.

Ilona Statius Muller etal (2002) studied on foot ulceration and lower limb amputation in type 2 diabetic patients in Dutch primary health care. A cross sectional survey method was done between 1993-1998. The findings of the study was that the annual incidence of foot ulcers was 1.243% per year among which 25% had recurrent episodes42.

Victoria Cohen etal (2002) studied on the incidence and clinically relevant risk factors for new foot ulceration in a large cohort of diabetic patients in the community health care setting. The data was collected using questionnaire and clinical examination. The sample included 9,710 diabetic patients. According to the author foot ulcer occurred in 291/6613 patients who completed and returned their 2 year follow up questionnaire. The annual incidence was 2.2%.The findings of the study concluded that more than 2% of community based diabetic patients develop new foot ulcers each year47.

Jessie H .Ahroni etal (1999) studied on the risk factors for diabetic foot ulcers among adults with diabetes in North Carolina. A prospective study was done on 749 diabetic patients. The findings of the study was that certain foot deformities, reduced skin oxygenation and foot perfusion, poor vision, greater body mass, sensory and autonomic neuropathy independently influence foot ulcer risk, thereby providing support for a multifactorial etiology for diabetic foot ulceration16.

2. Literature related to assessment of knowledge and practices ondiabetic foot care among diabetic patient.

Hasnain S. etal (2009) conducted a study to assess the knowledge and practices among the diabetic patients visiting diabetic clinic in Jinnah hospital, regarding foot care. A cross sectional study was conducted using 150 samples and structured questionnaire was used to collect the data. The findings revealed that 29.3% of the patients had adequate knowledge, 40% had satisfactory and 30.7% had poor knowledge, whereas only 14% had good practices of foot care, 54% had satisfactory and 32% had poor practices36.

Smide B. etal (2009) conducted a study on the outcome of foot examinations in a group of Tanzanian patients and make comparisons with matched Swedish patients. A comparative study was done using 145 patients. The findings of the study revealed that Tanzanians had more foot problems and it was due to poor foot care practices. This study concluded that knowledge about foot problems will improve self foot care practices26.

Chone Gale etal (2008) conducted a study onpatient’s perspectives on foot complications in type II diabetes. A qualitative study using one to one interviews was done using semi -structured interviews. 348 samples were included in the study. The findings revealed that most of the participants were unaware of what a foot ulcer is?And prevention of accidental damage to the skin was not considered a priority; only 17% participants knew the self care practices to prevent foot ulcers33.

Ronny A. Bell etal (2008) conducted a study to assess the level of foot self care performed in a rural, multiethnic population of older adults and to identify factors associated with foot self care. A comparative study method using 701 samples were included. Participants completed in-home interviews and 5 foot self care practices.The findings of the study revealed that only 49% of the patients had adequate knowledge and practices31.

Martin C. Gulliford (2002) conducted a study to assess the diabetic foot disease and foot care in a Caribbean community. 2106 samples were included in the study and data was collected using structured questionnaire. The findings revealed that symptoms of neuropathy was reported by 1030 (49%), 71% subjects reported that they were practicing foot care and 63% patients reported they would treat blister or wound by themselves. The study concluded that implementation of strategy to improve care of the feet is needed35.

Dr. Bandar Mohammed Al-Juaid (2005) conducted a study on self foot care knowledge and practice among type 2 diabetes patients attending military family medicine clinic in Taif. A cross sectional study was done on 240 samples and structured questionnaire with face to face interviews was used to collect data. The findings revealed that 66% had adequate knowledge and practiced self foot care measures in home17.

3. Literature related to prevention of diabetic foot ulcers among diabetic patients.

Nalini Singh etal (2005) conducted a study to review the evidence on the efficacy of methods advocated for preventing diabetic foot ulcers in the primary care setting. The data was collected during 1999-2002 from 1,315 patients having type 2 diabetes mellitus. A prospective study was conducted. The prophylactic intervention including patient education, prescription of proper foot wear and intensive podiatric care was given to the patients. The findings of the study stated that the preventive strategies for diabetic foot ulcers help to lower the foot problems in diabetes45.

Wunderlich R. P. etal (2005) conducted a study to evaluate the effectiveness of a diabetic foot prevention programme to reduce amputations and hospitalizations. The duration of the study was 2 years. They implemented a lower extremity disease prevention programme which consisted of evaluation of neuropathy, peripheral vascular disease, deformities foot care and foot care education. The findings of the study revealed that after the implementation of the diabetic foot prevention programme, the incidence of amputation reduced to 4.74% from 12.89%29.

Alfonsa L. Calle etal (2002) studied on preventive foot care programme for people with diabetes. The sample size was 308. The preventive foot care programme included prescription of proper foot wear, foot hygiene, callus care, nail cutting, use of warming devices, foot self inspection with foot care education. The findings of the study revealed that after the implementation of the preventive foot care programme, the incidence of foot ulcer reduced to 6.34% from 19.2%19.

James M. Malone etal (2000) conducted a study on prevention of amputation by foot care and diabetic control education. A prospective randomized study was conducted on 203 samples. The participants underwent a session including podiatric examination and education on diabetic control. The findings of the study stated that these preventive strategies reduced the incidence of foot ulcers and limb amputations in diabetic patients21.

Litzelman D K etal (1999) studied on the role of foot wear in the prevention of foot lesions in patients with non insulin dependent diabetes mellitus. A randomised controlled trial was done on 352 samples which included detailed measurement of the shoes used by the patients, socks fibers, whether the patient had bought new shoes in the past 6 months. According to the author use of proper foot wear and recommendations for special shoes will reduce the occurrence of foot ulcers38.