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

  8

PN Peripheral Neuropathy

  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

  10

Chapter 1

Introduction

  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).

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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.

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Chapter 2

Background

  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.

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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.

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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)

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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?

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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

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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?"

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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 .

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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.

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:

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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)

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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)

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- 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.

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Chapter 7

Discussion

  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

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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.

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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

  47

Chapter8

Reference

  48

Reference List:

- Robert, J. Robert, A. Jason ,R. et al. 2010.Consensus recommendation on advancing

the standard of care for treating neuropathic foot ulcer in patient with diabetes.

Ostomy wound management.56,3-4.

- Pham,H. David,G. et al. 2000. Screening techniques to identify people at high Risk

for diabetic foot ulceration. Diabetes care.23, 606-607.

- Booth, J. 2000. Differences in the performance of commercially Available 10-g

monofilaments. Diabetes Care.23, 984-988.

Andrew, J. Boulton, M. et al. 2004. Neuropathic diabetic foot ulcers. Massachusetts

medical society.351, 50-53.

Hinchliffe, J. Jeffcoate, J. Bakker, K.et al . 2008. A systematic review of the

effectiveness of interventions to enhance the healing of chronic ulcers of the foot in

diabetes. Diabetes metabolism research and reviews. 24, 130-132.

Graneheim, H. Lundman, B.et al . 2004. Qualitative content analysis in nursing

research: concepts, procedures and measures to achieve trustworthiness .Nurse

education today.24, 106–110.

Münter, C. van der Werven, W. Sibbald,G. Price, P. 2007. Improved patient outcomes

for diabetic foot ulcers. Biatain 10-22.

Khanolkar, M . Bain, S. Stephens,J. 2008 The diabetic foot.

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Research

Group, Institute of Life Science, Swansea University, Swansea, UK. 101,685-688

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Jeffcoate, W. Harding, K. 2003. Diabetic foot ulcers.

Department of diabetes and endocrinology.361,1545-1548

Kimmel, H. Regler,J. 2011. An Evidence Based Approach to Treating Diabetic Foot

Ulcerations in a Veteran Population. The Journal of Diabetic Foot Complications. 3,

51-53

Thomas, B. 1990.Nursing research: an experiential approach. The C.V. Mosby

Luigi Uccioli, L. 2011. Advances in the Treatment of Peripheral Vascular Disease in

Diabetes and Reduction of Major Amputations. The International Journal of Lower

Extremity Wounds.10, 72–74

Jasper, M. Mantzoukas, S. 2008. Types of nursing knowledge used to guide care of

hospitalized patients. Journal of Advanced Nursing. 62, 318–326.

Malone, R. et al. 2004. What counts as evidence in evidence-based practice?. Journal

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Bonner, A. 2007. Understanding the role of knowledge in the practice of expert

nephrology nurses in Australia. Nursing & Health Sciences. 9, 161–167.

Gill, D. et al.1999. The use of hydrocolloids in the treatment of

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of Systematic Reviews. 8, 5-10

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Chapter 10

Appendix

  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

 

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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?