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6/01 cJCIRCIDateDuepSS-p. 15

 

 

FOOT CARE ASSESSMENT OF
DIABETIC PATIENTS
IN PRIMARY CARE

BY

Christine C. Cordray

. SCHOLARLY PROJECT

Submitted to
Michigan State University
In partial fulfillment of the
requirements for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1995

 

 

 

ABSTRACT
FOOT CARE ASSESSMENT OF

DIABETIC PATIENTS
IN PRIMARY CARE

By
Christine C. Cordray

Of the 2.1 million people over the age of 65 who have
diabetes in the United States, at least 63,000 have foot
disease. Undetected and untreated these problems can become
severe and lead to chronic hardships and quite often to
amputation. The patient most often rely on their primary
care provider for prevention, initial diagnosis, and
treatment of diabetes mellitus. The degree of morbidity and
mortality associated with diabetic foot disease could be
dramatically reduced by recognition and proper treatment.

The purpose of this scholarly project is to develop a
clinical assessment tool for diabetic foot evaluation in
primary care. It will provide an assessment tool for
primary care providers in the proper care of the diabetic
foot and provide guidelines for patient self-care
emphasizing prevention and early detection. Orem's (1985)
Theory of Self-Care is the theoretical framework utilized in
the development of this assessment tool. A.discussion of
the conceptual framework along with an adapted model to
illustrate the relationship between the tool variables and

theoretical concepts are presented.

DEDICATION
To Patrick for his never ending

support and understanding

iii

 

 

ACKNOWLEDGEMENTS

I would like to thank the chairperson of my scholarly
project committee, Patty Peek, for her guidance, support,
and encouragement not only throughout this project but
throughout this program. She has been a wonderful role
model and her expertise has been a priceless resource. I
could not have done it without her.

I would also like to thank the other members of my
committee, Sharon King and Lyn Behnke for their guidance,
support and the time they devoted in reviewing the drafts of

this scholarly project. Many thanks to all of you!

iv

TABLE OF CONTENTS

we;
List of Figures ...................................... vi
Introduction of the Project .......................... 1
Problem Statement .................................... 3
Conceptual Framework ................................. 5

Orem’s Theory of Self-Care & Definition of Concepts .. 6

Application to Project ............................... 12
Literature Review .................................... 16
Diabetic Foot ....... . .................. ... ........... 16
Self-Care in Diabetes ................................ 19
Foot-Care ............................................ 20
Summary .............................................. 26
Project Development and Evaluation Plan .............. 27
Assessment Tool Guidelines ........................... 27
Foot Assessment Tool Flowsheet .......... . ............ 32
Evaluation ........ . ............. ....... .............. 34
Implication for Advanced Nursing Practice ............ 35
Implications for Nursing Education ................... 37
Implication for Future Research ...................... 39
Reference List ............ . .......................... 42

LIST OF FIGURES

Pages
Orem’s Conceptual Framework for Nursing .............. 12
Diabetic Foot Health Promotion Self—Care Model ....... 13

vi

 

INTRODUCTION
Background of the Problem

Diabetes mellitus is a heterogeneous metabolic disorder
characterized by abnormally elevated blood glucose levels.
It is a public health problem of enormous scope.
Approximately 5.8 million people in the United States have
been diagnosed with diabetes with another 4-5 million
suspected of having the disease but, as of yet, are
undiagnosed (Mills, Beckett & Taylor, 1991). Those
afflicted with diabetes mellitus have high rates of
morbidity and mortality owing to the many complications of
the disease. The complications can manifest themselves as
ophthalmic, renal, vascular, neurologic, and pedal disease
(Plisken, Todd & Edelson, 1994).

Unfortunately, the most often overlooked and neglected
complications involve the feet. It is estimated that in the
United States foot disease is five times more prevalent in
diabetic patients than in those without diabetes (Caputo,
Cavanagh, & Ulbrecht, 1994). In fact, 20% of all diabetic
patients admitted to hospitals in the United States are
admitted for foot disease, with foot and ankle ulcers being
the most common presentation (Plisken, Todd & Edelson,
1994).

The human and financial costs of lower—extremity

amputation in patients with diabetes mellitus are well

 

 

 

 

  

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recognized (Bamberger & Stark, 1987). The amputation rate
in diabetic patients in the United States is reported to be
as high as 15 times that of nondiabetic patients, and of all
nontraumatic amputations performed, approximately 50% are in
patients with diabetes (Plisken, Todd & Edelson, 1994).

More than half of the diabetic patients who undergo limb
amputation will require contralateral limb amputation within
5 years, and 60% will die within the first 5 years after
amputation (Caputo, Cavanagh & Ulbrecht, 1994).

The increased risk for foot disease in diabetic
patients is primarily due to the combined effects of
peripheral vascular disease and peripheral and autonomic
neuropathies (Mills, Beckett & Taylor, 1991). These may
result in decreased sensation, dry, cracked skin, and loss
of the intrinsic muscle function of the foot (Collier &
Brodbeck, 1993). Patients may have a deformed foot with the
inability to sense repeated trauma. This may lead to
further deformity, tissue necrosis, and subsequent
ulceration. If not properly treated, soft-tissue infection,
osteomyelitis, and sepsis may result. This may necessitate
lower-limb amputation (Mills, Beckett & Taylor, 1991).

Often, with proper foot care this scenario can be
avoided, resulting in fewer lower—extremity amputations as
well as a decrease in the overall disease-related morbidity

and mortality (Christensen et al., 1991). The National

 

‘l'..

Institutes of Health Diabetes Advisory Board reported in
1992 that there are a number of patient care programs and
available preventive and therapeutic strategies that have
the potential for reducing the number of amputations, but
these strategies are not optimally used in public and
private health system settings.

For these reasons, it is important that primary care
givers thoroughly examine the feet and become familiar with
the various presentations of the diabetic foot. The
American Diabetes Association (1990) recommends that an
examination of diabetic feet be done at every regular visit.
Presently there is little evidence that this is being done
routinely in primary care. It is evident that an assessment
tool for foot care is needed in the primary health care
setting that will aid in the detection and early prevention
of diabetic foot complications.‘

Problem Statement

The purpose of this scholarly project is to develop a
clinical assessment tool for diabetic foot evaluation in a
primary care setting. It will provide an assessment tool
for primary care providers in the proper care of the
diabetic foot and provide guidelines for patient self-care
emphasizing prevention and early detection.

Pedal infection is a prevalent, debilitating, and grave

complication of diabetes mellitus (Leitcher et al., 1991).

One in five hospital admissions of people with diabetes a
for treatment of foot ulcers. Since its prevalence is more
likely to increase with longer duration of diabetes, pedal
infection is a complication seen often in older patients
(Leichter et al., 1991). Of the 2.1 million people over the
age of 65 who have diabetes in the United States, at least
63,000 have foot disease (Pelican et al., 1992). Undetected
and untreated these problems can become severe and lead to
chronic hardships and quite often to amputation.

Diabetic foot disease is associated with costly
hospitalization stays, incapacity, and mortality. The
financial impact of diabetic foot complications has been
estimated to be in excess of $200 million for hospital costs
alone, and several million more to cover unemployment
expenses (U.S. Department of Health and Human Services,
1991). Despite its gravity, pedal infection in diabetes has
not been subject to a detailed and objective scrutiny until
recently. There is now sufficient clinical and relevant
biochemical information to develop a more detailed picture
of pedal infections in the diabetic patient (Pelican et al.,
1992).

These data suggest that pedal infection and amputation
rate in diabetic patients is a more serious clinical
situation than in nondiabetic patients. Therefore,

modification in the usual clinical approaches must be made.

 

According to the U.S. Department of Health and Human
Services (1991), a national health goal for the year 2000 is
to reduce the rate of lower-extremity amputations in people
with diabetes from 8.2 per 1000 to 4.0 per 1000. With
appropriate care, the amputation rate could be decreased by
50% to 75% (Collier et al., 1993). It is estimated that 50-
75 percent of amputations caused by diabetes are preventable
by early detection and proper foot care. Early detection is
especially important since, once a problem occurs, chances
of complete healing are not good. Much of this care and
detection could be carried out by health care professionals
in primary health care settings or by patients themselves if
properly instructed.

Providing regular foot care for all diabetic clients,
both young and old, should be a vital part of primary health
care practice. When foot care is done on a regular basis,
client self-care education may be incorporated
simultaneously to prevent potential foot problems and ensure
early detection of abnormalities.

CONCEPTUAL FRAMEWORK

In this section, a discussion of the conceptual
framework with an accompanying explanation of theoretical
concepts as they related to the development of the proposed
protocol are presented. A discussion of Orem's (1985)

Theory of Self-Care, along with an adapted model to

 

 

illustrate the relationships between the protocol variables
and theoretical concepts are presented. Finally, the
relationship between this proposed diabetic foot assessment
tool and the practice of nursing as it relates to Orem's
(1985) Theory of Nursing Systems is explored.
Orem’s Theory of Self-Care and
Definition of Concepts

Orem's general theory of nursing is composed of three
related theories: a theory of self-care, a theory of self-
care deficit, and a theory of nursing systems. An
understanding of the major constructs are essential to the
clinical application of the model. Self-care is the set of
actions persons perform in the interest of life, health, and
well-being. Self-care theory includes self-care agency (the
ability to engage in self-care) and dependent-care agency
(the ability to provide care for a dependent, i.e., diabetic
client). Also included is therapeutic self—care demands,
the set of actions needed to meet requisites for the
maintenance and promotion of life, health, and well-being
(Orem, 1985).

Another significant concept within Orem's theory is
that of self-care deficit. Self-care deficit exists when
self-care agency is not sufficient to meet known therapeutic
self-care demands; it may be influenced by certain

conditioning factors (i.e., age, gender, maturity,

developmental state, health status, and health care system
factors). To assist the client towards the goal of improved
health, self-care deficit may require nursing agency
(capabilities) intervention. Nursing (helping) systems,
another major construct within the model, are those actions
by which the nurse and/or patient can act to meet the
patient’s self-care deficits and regulate the ability to
care for self. Methods of helping are chosen according to
the self-care needs and abilities of the patient (Orem,
1985).

Self-care theory operates on the assumption that all
individuals have a need to care for themselves, Self-care
agency. Self-care is the practice of activities that a
person initiates and performs on their behalf in the
interests of maintaining life, healthful functioning,
continuing personal development, and well-being (Orem,
1985). The Self-care agent is the provider of care (Denyes,
1988). Orem believes that self-care is learned, that one is
not born with the ability to determine and meet self-care
needs. Culturally derived, self-care practices are learned
first within the family, then from others, such as peers,
teachers, community leaders, and health care providers
(Denyes, 1988). The same concept can be applied to the

chronically ill patient.

Diabetes Mellitus is a chronic metabolic disorder
characterized by elevated blood glucose levels. Type I
diabetes mellitus, also called Insulin Dependent Diabetes
Mellitus (IDDM), commonly develops in persons under the age
of thirty. Exogenous insulin administration is required in
all persons with Type I diabetes, as the production of
insulin by the beta cell of the pancreas is lost (American
Diabetes Association, 1993a). Type II diabetes, Non-Insulin
Dependent Diabetes Mellitus (NIDDM), is the most common form
of diabetes. It is called NIDDM to indicate resistance to
the development of diabetic ketoacidosis. Persons may be
treated with no medication, oral hypoglycemic agents, or
insulin (American Diabetic Association, 1993a).

Management of diabetes mellitus requires modification
of dietary intake, lifestyle changes, family and patient
education, and on going support and follow-up. Routine
screening evaluations for microvascular, macrovascular, and
neurologic complications of diabetes are a necessity for the
well-being of the diabetic patient. Because diabetes
mellitus is a complex disease with a very involved
management plan, the diabetic patient becomes dependent on
the primary health care system to learn the skills essential
to successfully promote their self-care and well-being.

The lower extremity complications of diabetes can

involve the nerves, muscles, bones, and vasculature, making

 

 

 

 

 

 

management difficult and complex (Cooppan & Habershaw,
1995). Daily, lifelong preventive foot care is essential.
Foot care behavior are the self-care activities taught by a
primary health care provider (i.e., C.N.S.: clinical nurse
specialist) and undertaken by the patient with diabetes to
be performed on a regular basis in caring for the feet to
prevent potential foot problems and ensure early detection
of abnormalities.

A Dependent-care agent (i.e., parent, spouse,
significant other, sibling, or legal guardian) (Guido, 1988)
may also be involved in the self-care of the patient if the
patient is unable to independently learn and/or perform
appropriate self-care acts, Self-care deficit. The
dependent-care agent, by virtue of daily contact and
interaction, can influence the self-care agency of the
dependent diabetic patient. Dependent care agents may be
capable of teaching and assisting with proper self-care. On
the other hand, they may be unwilling, unable, uninterested,
or unknowledgeable of positive self-care practices (i.e.,
lack of dependent-care agenCY) (Orem,1985). Thus,
influences of the dependent-care agent can result in
positive as well as negative consequences with regards to
the health status of the diabetic patient who can be
particularly vulnerable at their particular stages of

cognitive development about their disease.

1‘)

[0

Quality of dependent-care agency must be considered
when directing the diabetic patient towards self-care goals.
However, diabetic patient at any stage of his/her disease
has the capability of some independent actions and possess
certain self-care strengths that enhance their self-care
agency (Denyes, 1988). Interventions from a health care
professional such as a Clinical Nurse Specialist can
facilitate the assessment and development of those strengths
of both the self-care agent and the dependent-care agent to
enhance self-care competence and promote health in the
diabetic patient. This intervention is what Orem (1985)
refers to in the third theoretical construct, nursing
systems.

Orem's (1985) states that “Nursing systems are formed
when nurses use their abilities to prescribe, design, and
provide nursing for legitimate patients (as individuals or
groups by performing discrete actions and systems of action
p. 38). .A nursing system is defined by Orem (1985) as “a
continuing series of actions produced when nurses link one
way or a number of ways of helping to their own actions or
the actions of persons under care that are directed to meet
these person’s therapeutic self-care demands or to regulate
their self-care agency” (p.31). Inherent in this statement
is the assumption that the patient is “under care” and has

entered the health care system.

 

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.
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11

Orem (1985) further defines Nurse agency as “the
complex capability for action that is activated by nurses in
their determination of needs for design of and production of
nursing for persons with a range of types of self-care
deficits” (p. 31). In general, nursing systems represent
all actions and interactions of nurse and patients in nurse
practice situations (Orem, 1985). Within the design of
nursing systems that Orem (1985) describes, the actions of
nurses, performed for the benefit of others, or “nursing”
has three orientations. These nursing actions are (a)
wholly compensatory, whereby the nurse compensates for the
individual’s inability to perform self-care by accomplishing
it for him or her; (b) partly compensatory, whereby the
nurse and the patient work together to meet the patient’s
self—care needs; or (c) based on the supportive-educative
framework, whereby the patient acts as the self-care agent
but requires assistance with decision making, behavior
modification, and acquisition of knowledge and skills (Orem,
1985).

Orem (1985) identifies the supportive-educative nursing
system based on the principle that both nurse and patient
together can act to meet the patient’s self-care demands.
The supportive-educative system is the focus of intervention
in the development of this protocol for diabetic foot care.

The nurse in the supportive-educative system acts primarily

 

12

as a consultant in regulating the exercise and development
of the self-care agency. The patient also regulates the
exercise and development of self-care and does accomplish
self-care. The patient requires help in decision-making,
behavior control, and in acquiring knowledge and skills in
the supportive-educative system.
Application to this project
The model for diabetic foot care promotion is based on

Orem's framework (Figure 1).

PATIENT

      
  

R THERAPEUTIC

 

 

(SELF-CARE SELF-CARE
AGENCY) DEMANDS
NURS E

 

R = RELATIONSHIP

< = DEFICIT
RELATIONSHIP
CURRENT 0R
PROJECTED

 

 

 

Figure l: Orem's conceptual framework for nursing

‘3 (Orem, 1985, p. 32).

o

r}

13

Practical application of the model in the diabetic health
care setting revealed a need to change the original model to
reflect the significance of the influence of the self-care
agent, dependent—care agent and the nurse agent in the
promotion of diabetic health and the self-care of their
feet. Orem’s model was amended (Figure 2) to provide a
guide for independent foot care actions, while acknowledging
the dependentscare agent’s role and the role of the CNS in

the health care of a diabetic patient.

 

 

DEPENDENT + DIABETIC

 

cmmamnxnm
DHEMENICME ~
.mmmn' l ///
I

F--_

SEW-CARE ACTION

l A

 

 

 

 

I DIABETIC

 

ISELF-CARE AGENCY , < F4 SELF-CARE DEMAND

h_—_

 

 

 

 

POSITIVE , DIRECT

 

 

 

 

 

 

 

RELATIONSHIP
I _ L_ - - - INDIRECT
RELATIONSHIP
CNS < DEFICIT OR
" PRACTITIONER POTENTIAL DEFICIT
‘ EDUCATOR RELATIONSHIP
‘ RESEARCHER
" CONSULTANT
0 1L KEY

 

 

 

 

 

NURSING AGENCY/ NURSING SYSTEM

Figure 2: Diabetic foot health promotion self-care model.

[4

The model demonstrates that, with proper direction and
appropriate nursing intervention by the CNS, the diabetic
patient, although possibly influenced by a dependent-care
agent, can enjoy the autonomy he or she is seeking while
achieving a positive health state.

The dependent-care agent functions as an assistant when
needed, an association depicted at the top of the model in
Figure 2 by a smaller rectangle (dependent-care actions)
positioned beside a larger rectangle (diabetic patient’s
self-care actions). Although the relationship between the
self-care agent (diabetic patient) and dependent-care agent
is more then likely, perfectly positive, the possibility of
a deficit or negative relationship exists, which may impact
the diabetic’s health and result in a self-care deficit that
requires nursing intervention. Diabetes has many complex
and involved self-care regimens (i.e., foot-care) that
initially must be taught by the nursing agent, however, the
importance of the dependent-care agent's influence cannot be
overlooked. A therapeutic self-care agent/ dependent-care
agent relationship is depicted on the left side of the model
in Figure 2 by an outer rectangle surrounding an inner
rectangle that is open, signifying the necessity of open,
honest communication between the diabetic patient and the
dependent-care agent in matters of self-care. Not

recognizing this interdependence may result in CNS and/or

93)

15

patient frustration when self—care goals cannot be realized
due to the patient/dependent-care agent relationship.

Orem's theory supports independent self-care actions
for health. But if the agency of the diabetic patient is
insufficient due to age, maturity, developmental state,
health state, and education, a self-care deficit may occur
and nursing agency (CNS) may be needed. As depicted in
Figure 2, the patient and CNS interact directly with each
other to alleviate the deficit. The connecting two-way
arrows between the CNS and diabetic self-care agency and the
CNS and therapeutic self-care demand illustrates the
importance of feedback and its influence on the demands for
CNS interaction according to the needs of the patient. The
dependent-care agent should be accessible to the CNS through
the patient in order to maintain appropriate self-care and
promote optimal well-being of the diabetic patient.

Nursing agency in Orem’s model utilizes methods of
helping within a nursing system to assist the diabetic
patient and the dependent-care agent toward the diabetic's
goal of positive health state. The method of helping within
the nursing system, inherent in the CNS roles, are shown in
the amended model (Figure 2). The significance of each of
the roles will necessarily vary according to degree of self-
care deficit, the quality of dependent agency, and the

dependency of the diabetic patient. With improved health

-‘1

16

state, the expert practitioner role may become less visible,
but the expertise of the practitioner will provide the basis
for education, consultation, and research.
LITERATURE REVIEW
Diabetic Peot

Foot problems in the person with diabetes result from
neuropathic changes and vascular insufficiency combining
with delayed healing which puts the foot at risk for
structural abnormalities and ulcers. The cause of diabetic
neuropathic changes is still unclear. Two theories are the
focus of research at this time. One theory postulates that
poor blood circulation to the peripheral nerves of the foot
may cause ischemia in the nerve cells thus delaying or
inhibiting nerve conduction (Gilden et al., 1990). The
second theory hypothesizes that a metabolic abnormality
occurs because nerves are exposed to a hyperglycemic
environment (Hanestad et al., 1992). This theory is
especially attractive since it has been found that
normalization of the blood glucose does result in improved
nerve conduction in the extremities. As a result of
neuropathy, the foot becomes insensitive to touch and
position. Decreased innervation to the muscles in the feet,
which support the tendons and bones, lead to muscle atrophy
and structural changes (Lima, 1988). These abnormalities in

turn create unusual areas of pressure which lead to lesions

{gr

[7

such as neurotrophic ulcers in the plantar region of the
foot (Lima, 1988).

Other problems of the diabetic foot include: dry skin
leading to open sores, circulatory deficiency leading to
lesions, and thickened toenails (Lima, 1988). .All of these
problems can lead to immobility and possible amputation.
The best treatment for all of them is PREVENTION.

Delbridge, Appleberg, & Reeve (1988) sought to
determine factors associated with the development of foot
lesions in patients with diabetes (> age 50 years). Eighty
subjects were divided into four groups based on the nature
and severity of foot problems (none, ischemic, ulcer, and
septic). By group, subjects were fairly matched on age,
duration of disease, and treatment modality for diabetes
control. Subjects were measured on the variables
glycosylated hemoglobin (i.e., HgAlc); frequency of hospital
admissions for diabetes control; degree of vascular
impairment; history of smoking; presence of neuropathy;
delay in treatment for foot lesions; and, patient
understanding and education of diabetes, diabetes
management, foot complications, and care of the feet.
Groups did not differ significantly with regard to HgAlc
levels, frequency of hospital admissions, or presence of
neuropathy. Subjects with foot lesions did exhibit,

however, significantly higher degree of vascular impairment,

To

18

history of smoking, increased delay in referral for foot

lesion treatment, and lower scores on the knowledge test.

The authors conclude that education of patients related
to foot care management can effect the development of foot
lesions. Without ascertaining if subjects had received any
diabetes education, the authors claim that subjects with
foot lesions may not have wanted to “know” about problems
with their feet. As such, these subjects may engage in
“willful self-neglect” as evidenced by indifference to
diabetes complications. This claim and speculation about
the lack of self-care motivation was made based on a
knowledge test without indices of reliability or validity.
It is possible that the instrument lacked construct validity
in that it failed to address or capture critical factors of
self-care foot knowledge. Furthermore, the knowledge
measure may not have been internally consistent (i.e.,

reliable).

Nevertheless, Delbridge, Appleberg, & Reeve (1988)
conclusively stress that education of diabetic patients
related to foot care management can be crucial in preventing
the development of foot lesions. The association between
diabetic foot complications and costly hospitalization

stays, incapacity, and mortality, reveals the critical need

19

for the implementation of frequent diabetic foot evaluation
and foot-care education by the primary health care provider.
Self-Care in Diabetes

Diabetes is largely considered a manageable chronic
disease. Its management status is primarily a function of
direct self-care interventions related to medication
therapy, diet, and exercise (Holzemer, 1992). Patient self-
care management of diabetes is aimed at not only affecting
normoglycemia, but at delaying the onset and/or minimizing
the severity of long term diabetes related complications
such as retinopathy, nephropathy, and peripheral and
autonomic neuropathy (Holzemer, 1992). Diabetes education
is the primary means of providing patients and/or their
families with the knowledge and information necessary for
self-care management of this disease.

In a study to assess the effects of a home based
diabetic education program, Rettig, Shrauger, Recker,
Gallagher, and Wiltse (1988) measured patient knowledge and
self-care skills in both randomly assigned treatment and
control groups of subjects. A.total of 373 subjects (193
control, 180 treatment) were measured on self-care knowledge
using a series of seventy multiple choice questions divided
into four content areas--diet, urine testing, medication
therapy, and foot care. Patient self-care skills were

measured by one-to—one demonstrations and focused on skill

20

in urine testing, medication use, foot care, and diet
prescription skill as noted by ability to draw up a 24 hour
meal plan. Foot care skills were noted by nurse examination
of the feet and included the presence of dirty foot soles,
presence and type of socks, and method of toenail clipping.
In addition, a 16 item checklist for abnormal conditions of
the feet was used to generate a total foot appearance score.

To analyze the effectiveness of the teaching program,
mean self-care knowledge and skill scores plus foot
appearance scores were used as some of the indices of
program efficacy. Results indicated that knowledge and
skill scores were significantly higher for the treatment
group in all subject areas and in total. With regards to
foot appearance scores, significant differences were noted
between the two groups. With a possible score of 100, the
treatment group obtained a mean score of 82.2 +/- 0.7 and
controls, 63.8 +/- 0.7 (higher scores indicated better
condition of the feet). The authors concluded that home-
based diabetes education interventions can positively effect
patient knowledge and skill outcomes. The author also
concludes that further studies need to be done to enhance
the validity and reliability testing of the self-care
knowledge and skills instruments.

Foot-care

The rates of major amputation among diabetics in the

21

United States remain high, in part because present knowledge
regarding the prevention and management of foot disease is
not widely applied in clinical practice (Caputo, Cavanagh &
Ulbrecht, 1994). Although it is well known that foot care
can prevent amputations, studies have shown that people who
have diabetes are not well versed in the care of the feet.
In one study of 372 patients with non-insulin-dependent
diabetes mellitus, 41% reported that they had not been told
to take especially good care of the feet (American Diabetes
Association, 1993b). In another study of 75 diabetic
patients, nearly three out of four, all of whom had been
taught other aspects of self-care, had not been taught
proper foot care (D'Eramo & Fain, 1988). .A simple program
teaching and reminding people with diabetes and their
caregivers about proper foot care pays off by preventing
problems that can lead to amputation (U.S. Department of
Health and Human Services Center for Disease Control and
Prevention, 1991).

A.program such as this was set up by the Indiana
University and Regenstrief Institute of Health Care in
Indianapolis and proved effective over a one-year period
(Litzelman, et al., 1993). A randomized trail involving 395
women with Type II (non—insulin-dependent) diabetes was
used. About half of the patients were enrolled in the

program and attended a teaching session conducted by a nurse

mi

22

clinician, during which they agreed to follow a “behavioral
contract” on foot care. They received reminder calls and
postcards up to three months later. Nurses and physicians,
meanwhile, were reminded to examine the participants’ feet,
through the use of colorful folders and instructional flow
sheets clipped to the patients' charts. The control
patients received standard care. Three hundred fifty-two
patients completed the study.

Patients and clinicians alike seemed to get the
program's message. On a test asking them about their foot
care behavior (such as remembering to trim.nails), research
subjects in the program scored better than the controls.
Program clinicians examined patients' feet during 68% of
visits, compared with 28% for the standard-care clinicians,
and did foot care teaching during 42% of visits, compared
with 18% for the control patients.

As a result, program patients were less than half (41%)
as likely to have serious foot lesions at the close of the
study. The number of amputations during the study were
small, but four were done in standard-care patients versus
just one among those in the program.

The investigators reported that the program.was
relatively inexpensive; study materials cost just $5,000.
Citing the high personal and economic toll exacted by

diabetic foot problems (including some 50,000 amputations

23

each year), the researchers note that programs like theirs
could easily be undertaken in primary care settings using
existing personnel.

Asserting that assessment of the effectiveness of
diabetes education has implications for health care policy,
Bloomgarten, et a1 (1987) undertook a randomized controlled
trial of diabetes education stating that education may be a
major factor related to metabolic outcomes. They
hypothesized that systematic education intervention would
result in improved metabolic outcomes. Glycosylated
hemoglobin levels were used as the primary index of glucose
control. Other outcomes measured post-education
intervention were fasting glucose levels, weight, lipid
levels, foot lesion development, hypertension control, and
utilization of medical care services. .A total of 127
subjects comprised the treatment group at completion of the
study with 139 subjects in the control group. Subjects were
predominately Black and Hispanic with almost 30% greater
than 70 years of age.

Treatment subjects were exposed to nine education
sessions, one of which focused on foot and skin care
emphasizing early detection of infection. A 15-item
instrument was used to measure both knowledge and self-care
behavior pre and post education program. One behavior

assessment item related to the frequency of checking feet

24

for sores. No index of the instrument’s validity or
reliability were reported.

At baseline, Bloomgarten, et al (1987) note that the
groups were comparable in knowledge and behavior scores.
Upon completion of the study however, the treatment group
exhibited a significant increase in knowledge scores
compared to the control group. Furthermore, behavior scores
increased significantly in the treatment group over time
when compared to the control group. As authors compared
scores of all subjects entering the study in each group with
those who completed the entire education program, they
attribute significant increases in knowledge and behavior to
“graduates” of the program. Since treatment group graduates
largely accounted for these significant increases,
Bloomgarten, et al (1987) hypothesized that these subjects
would also show an improvement in metabolic control
outcomes. Analysis of HgAlc levels however, revealed no
significant differences in glucose control between treatment
and control groups. With regards to the development of foot
care lesions, the two groups did not differ significantly
over time on this variable inquiry.

The authors assert that in light of the failure of
patient education programs to effect improvement in
metabolic control, patient education may be “functionally

meaningful” in that improvement in knowledge may result in

.‘ ad'

25

long term benefit for the patient. Bloomgarten, et al
(1987) emphasis the importance for further research in this
area and continue to stress the importance of diabetic
education and its implications for health care policy.

Patient education to help prevent diabetic foot
complications is ideally initiated before acute problems
develop. The opportunity, however, should not be lost to
educate the patient who already has such problems. Although
good control of glucose metabolism has not yet been proved
to prevent the long-term complications of diabetes, there is
some evidence that it can reduce diabetic neuropathy
(Bamberger & Stark, 1987). Patients who smoke cigarettes
should be encouraged to stop smoking, to avoid accelerating
atherosclerotic changes (Ary et al., 1989). Patients need
to wash and examine their feet daily, and to report any
calluses, corns, blisters, or ulcerations to the primary
care provider. Patients should never try to trim these
lesions at home (Ary et al., 1989). New shoes need to be
broken in slowly, and should not be worn more than one or
two hours a day. Diabetics with peripheral vascular disease
or neuropathy should never walk barefoot (Becker & Janz,
1990).

Foot care is not only an essential portion of the
physical examination of every person who has diabetes, it is

a skill that every such patient must learn as his best

26

defense against one of the most serious and costly
complications of diabetes — AMPUTATION.
Summary

The review of literature reveals the ongoing
complications of the diabetic foot and the crucial need to
gain control over the problem to maintain the health and
well-being of the diabetic patient. Much research has been
done in the areas associated with the pathological process
of foot lesion development and the positive impact of early
prevention education programs and the importance of patient
self-care knowledge. It has been proven that early
recognition, proper evaluation, and initial treatment will
significantly reduce foot complications in patients with
diabetes.

There is much literature identifying and supporting the
need for a standardized foot care screening tool in the
primary health care setting. Contrarily, very little
literature was found regarding why diabetic foot care
guidelines are not more readily used in primary health care.
It can be surmised that a major barrier to the use of a foot
care plan or assessment tools is the lack of concise and
specific guidelines that can be easily incorporated into the
limited time structure of the primary health care setting.

For a diabetic foot assessment tool to be useful to a

27

provider in primary care it must be comprehensive in a time
efficient manner.
PROJECT DEVELOPMENT AND EVALUATION PLAN

This author has attempted to condense and arrange the
literature to develop a tool for diabetic foot assessment
for practical clinical application in primary health care
within the framework of Orem’s (1985) Theory of Self-Care.
Emphasis is placed on primary care and the perspective of
the provider offering a structured systematic guideline that
can be easily utilized within the time limited constructs of
the primary health care setting. The goal is to increase
clinician and client awareness and facilitate a systematic
means of conducting functional assessment that is efficient
and user-friendly. Additionally, by routine screening early
recognition, proper evaluation, and initial treatment will
occur potentially reducing foot complications in patients
with diabetes and reduce cost by preventing premature
institutionalization and loss of limb function.

.Assesmment Tool Guidelines

Introduction of this foot assessment tool into a busy
primary health care setting can be easily done through an
inservice. The assessment tool flowsheet can be placed into
the diabetic patient's chart by the office clerk. A copy of
the assessment tool and guidelines should be placed in the

health care facilities policy and procedure book for quick

28

reference by staff and state officials (i.e., OSHA).
Discussion about staff satisfaction and concerns with the
assessment tool can be held during monthly staff meetings.

The assessment tool is designed as a flowsheet which
offers a user-friendly format that should only take 5
minutes to fill out. It is structured to provide a
comprehensive check list that is concise and facilitates the
providers ability to functionally assess the diabetic foot
in a time efficient manner. The documentation check list
for use in the diabetic patient's chart is an assessment
tool that can be utilized by either the CNS or physician.

A foot assessment utilizing this flowsheet should be
done every three months to evaluate the health of the
diabetic foot. An initial baseline assessment should be
done to establish each client's normal presentation.
Capillary filling time is a useful initial test to help
determine if the digits have a patent arterial blood supply
(Plisken et al., 1994). The tool is complaint oriented,
therefore, more frequent spot check can be done if patient
has a specific complaint. Further in depth evaluation of
deficit areas that are identified during examination of the
diabetic foot can be schedules according to urgency of
follow-up needs and according to individual primary care

practice time frames. If referrals need to be made for

29

specialist consultation notations can be made at the bottom
of this form to keep track of encounters.

Down the left hand side of the check list are the
specific areas of assessment. The flowsheet offers the
primary care provider a systematic step-by-step format for
addressing each area of the diabetic foot in a self
explanatory way. Three columns are provided to the right
for recording information at three individual visits. The
advantage to this is that the provider can easily follow a
patient's progress and quickly detect any changes in the
condition of their feet. This format provides a consistent
data base which assures proper foot assessment and the
detection and early prevention of diabetic foot
complications.

There are four priority areas on the assessment tool in
bold print that the primary care giver should evaluate
during each encounter with patient. These areas should be
assessed without patient complaint to note any deviation
from normal presentation. Note any disturbance in gait that
might affect how weight is being distributed to the
patient’s feet. Check the temperature of the client’s foot
with the back of hand. It is especially important to
determine the temperature of the skin and make a comparison
with the other limb in patients with a history of previous

skin breakdown (Bamberger & Stark, 1987). Dorsalis and

30

pedal pulses should be palpated bilaterally (use doppler if
necessary). Edema, whether pitting or nonpitting, should
also be investigated since it may be due to either local or
systemic disease (Ary et al., 1989). If any deviations from
normal are noted intervention is warranted. All of these
areas may reveal signs of circulatory and neurological
compromise leading to the onset of diabetic foot disease.

Physician consultation may be necessary if no
improvement in condition is seen within two weeks. Arterial
disease is much more of an immediate concern than either
venous or lymphatic disease and warrants prompt attention
(Ary et al., 1989). Immediate physician consultation is
suggested if any breakdown in skin, open areas or
discoloration that varies from normal are noted during
examination.

Patient foot care skills can be a vital asset in the
prevention, initial diagnosis, and early treatment of
diabetic foot disease. A diabetics first line of defense in
controlling and inhibiting further complications of their
disease is in their own self-care abilities. Client
education of proper foot self-care skills can be taught by
the primary care provider while the foot exam is being
performed. Patients with diabetes ought to be taught simple
common sense approaches to foot hygiene and daily feet

inspection techniques and should be advised about choosing

“‘9"

3|

proper shoe wear. Simple reminders, such as always wearing
protective footwear or looking for objects inside shoes
before putting the on, are essential in preventing
ulceration or infections.

There are a number of educational materials available
to the diabetic population that can help increase their
awareness of proper foot self-care. Many of these materials
can be obtain through the American Diabetic Association,
Novo Nordisk Pharmaceuticals Inc., American Podiactric
Medical Association, and insulin manufacturers (i.e.:
Squibb-Novo, Inc.). Diabetic support groups may also be a
useful source of information for the diabetic client and can
be contacted through their local public health department.

It is very important that the primary care provider and
the diabetic client address the feet during each visit. The
client must be taught the significance of removing his/her
shoes and socks during every encounter with a primary care
giver. By doing this the patient will prompt and promote
examination of their feet whether it be a quick spot check
or complete quarterly foot assessment. By working together
the primary care provider and the diabetic patient can
ensure a thorough foot examination and enhance the

livelihood and health of the diabetic patient.

Name:

32

Foot Assessment Tool

 

Date:

 

C/O:

(objective)

 

Gait: steady

unsteady

 

Shoes: fit well

 

type

 

Stockings: clean

 

type

 

constricting band

 

Moisture: normal

 

hyperhydrosis

 

dry

 

very dry/scaly

 

Temperature: R

 

(W—warm C-cool)

 

Varicose veins:

 

L
R
L

 

Pedal pulses:
palpable/doppler

 

(0+1,+2,+3,+4)

L"

 

Edema:

pitting/nonpitting

 

(0,+1,+2,+3,+4)

 

Red/blue foot

 

color

 

Brownish ankle

 

R
L
R
L
R
L

color

 

Cap. refill <3 sec

>3 sec

 

 

 

 

 

 

 

 

Date:
Sensation: " )
(light touch/pain)
m, I
diminished 9

 

Skin lesions:

IN - Ingrown nail
FI - Fissure

CO - Corn

CA - Callous

BL - Blister

BU - Bunion

   

CECE
CBC?

 

Nail condition:

normal

 

fungal growth

 

thick

 

brittle

 

other

 

Structural problems:

 

Referral:

 

Signature:

 

 

 

 

 

* Adapted from flowsheet used by Timothy Tetzlaff M.D., Riverside Medical Center,

Sault Ste Marie, Michigan.

34

Evaluation

Evaluation of this foot assessment tool is recommended
to be conducted after implementation to verify assumptions
and determine impact of patient outcomes. Theoretically, by
conducting diabetic foot care screening the primary care
provider can identify potential foot complication and
initiate early interventions to prevent the development of
foot lesions and avoid unnecessary foot disease, lower-
extremity amputation, as well as decrease the overall
disease-related morbidity and mortality.

One would expect patient outcome to be impacted greatly
by the implementation of this diabetic foot screening tool.
The following are specific outcome assumptions suggested for
evaluation of the effectiveness of this foot screening tool:

1. Increase primary care provider awareness of
potential diabetic foot complications and the importance of
early detection, prevention and treatment.

2. Increase diabetic patient awareness of their risk
for developing foot disease and the importance of proper
preventative foot self-care.

3. Increase in the number of patients that voluntarily
remove their shoes and socks during every clinic visit.

4. Increase in objective data regarding foot condition.

35

5. Increase in quality of care in the diabetic patient
population as evidenced by increased number of diabetics
with documentation of foot assessment in their charts.

IMPLICATIONS FOR ADVANCED NURSING PRACTICE

The nurse in advanced practice with his or her
eXpertise understand the multiple domains that impact the
well-being of the diabetic patient's health and the
importance of early detection and prevention in the
reduction of patient morbidity and mortality. The clinical
nurse specialist (CNS) in the primary care setting come in
contact with many diabetic patients. The CNS's ability to
draw from a broadened theoretical knowledge base allows
him/her to develop interventions to facilitate patient
learning of appropriate self foot care habits to promote
healthy feet. By using Orem's (1985) self-care deficit
theory as a strong theoretical base, the CNS can effectively
assess an individual's self—care ability and educating
accordingly. By incorporating the foot care assessment tool
into their practice and developing intervention to promote
self-care, the CNS can provide an added dimension to a
diabetic patient's care and fulfill many of the roles
inherent to their position. The CNS as: expert
practitioner, educator, researcher, and consultant can only

impact the health of the diabetic patient positively.

36

As expert practitioner, the CNS formulates medical and

 

nursing diagnosis and provides the necessary care, based on
sound theory and advanced clinical judgment, to promote
patient participation in positive self-care behavior. The
CNS may find himself or herself as a member of a
multidisciplinary team. Recognized for his or her nursing

expertise, the CNS can serve as consultant to other health

 

care professionals by providing information and advice,
obtained from the foot care assessment tool, on maintaining
the health and well-being of the diabetic patient.

As an assessor and researcher, the CNS can utilize the

 

foot care assessment tool to effectively identify diabetic
foot problems and areas of patient self-care deficit. .After
the assessment data is gathered a medical and nursing
diagnosis can be identified. Medical diagnosis should
include the etiology of the foot condition and the nursing
diagnosis on the model for this project: “self-care”.
Expanding the modifying factors of the conceptual framework
would allow the CNS to consider and/or rule out a greater
number of possible etiologies for any recognized self-care
deficit. After identifying the condition of the diabetic
foot and the self—care knowledge of the patient, the CNS can
implement interventions to promote the health of the foot

and self-care skills of the diabetic patient.

37

As educator, the CNS should assist the diabetic patient

 

in recognizing that successful self—care changes require
effort over an extended period to achieve the greatest
benefit. In short, self-care maintenance of diabetes is a
life-long commitment. It is important for the CNS as
educator to assist the patient with planning strategies that
are realistic for supporting or improving their self-care
within the context of their current lifestyle. Collaboration
is based on mutual exploration and implies joint
responsibility for the development and support of goals
related to self—care. The CNS can provide the patient with
examples of ways to improve self-care based on the data
collected form the foot care assessment tool and the
patient's individual obstacles and/or resources.
IMPLICATIONS FOR NURSING EDUCATION

Nurses, as the largest group of health professionals,
have more contact with the diabetic patient than any other
health care provider. As a result, the nurse has more
opportunity to address and/or intervene in the prevention,
initial diagnosis, treatment, and education of self-care
behaviors of the diabetic patient.

All nurses should be informed about the complexity of
managing the diabetic patient's health, especially in
regards to the health and well-being of their feet. The

ability of the nurses, at any level of education, to

38

accurately assess, plan, implement, and evaluate the health
status and self-care behaviors of a diabetic patient depends
upon the nurse's awareness of the multiplicity of factors
that contribute to the self—care agency.

Orem's (1985) self-care deficit theory of nursing links
nursing practice to the theory of self-care. The model's
conceptual framework provides a theoretical base for
nursing's role in assessing, facilitating and monitoring an
individual's self-care ability and educating accordingly.
Orem's (1985) model, therefore, must be introduced at all
levels of nursing education.

Due to the complexity of nursing roles and the case
management of the diabetic patient, nurses who are primary
care providers should be prepared at the graduate level.

The CNS in ambulatory, primary care settings should be
prepared to collect data that accurately assesses the health
of the diabetic foot, identifies the self-care needs of the
diabetic patient, and factors inhibiting or facilitating
self-care. The CNS will coordinate the care of the patient
by utilizing other health professionals as needed to develop
and execute intervention strategies. These behaviors
require advanced educational preparation in a research based
program.

Education in the appropriate collection, intervention

and evaluation of the diabetic foot and self—care data would

39

not only contribute to the body of nursing knowledge, it
would provide a mechanism to demonstrate effectiveness in
meeting measurable outcomes for self-care viability and
health promotion. Patient self—care deficits contribute to
health care costs by increasing the potential for illness
which in turn necessitates a costly move to institutional
care for the diabetic patient. Nurses who are educationally
prepared to promote early recognition, proper evaluation,
initial treatment, and patient self-care education can
contribute to the financial impact of hospitalization and to
the health of the diabetic population. If more value were
placed on illness prevention and health promotion, perhaps
more research dollars would be available to discover a cure
for Diabetes Mellitus.
IMPLICATIONS FOR FUTURE RESEARCH

As stated earlier, there is a lack of literature and
research addressing why standardized guidelines for diabetic
foot care are not routinely used in primary health care.
If studies could be conducted based on primary health care
needs and provider suggestions, a foot care assessment tool
could be developed according to the specific outcomes of
these studies producing a tool designed appropriately for
use in the primary health care setting.

Implications for research of this foot care assessment

tool should also be pursued. It is recommended that studies

40

be done incorporating the developed guidelines into
different primary health care settings to test the
functional and systematic structure of the tool. The
outcomes proposed in this project should also be tested and
the results used to influence the development of future foot
care assessment tools making them concise and easily
utilized within the constraints of primary health care.

Further inquiry should also focus on the assessment of
the reliability and validity of the instrument across
specified populations such as those defined by different age
groups and different ethnic/cultural populations. Of
particular need is to address research endeavors using
minority populations as these groups exhibit prevalence
and/or incidence of diabetes and its related complications.
Further research must be done concerning the foot assessment
tool developed in this project, specifically whether the
tool is being used, and user satisfaction (benefits and
barriers) of the tool, so that it may become a useful tool
for the primary health care provider.

In sum, the clinical nurse specialist, as a Master's
prepared professional in the primary care setting, can
contribute to the body of nursing and medical knowledge by
applying research findings and nursing theory while
functioning in the aforementioned role characteristics. The

clinical nurse specialist has the necessary skills, advanced

41

knowledge, and clinical judgment to effectively utilize the
proposed foot care assessment tool to promote the health and
well-being of the diabetic patient while enhancing their
self-care skills. Primary care is the diabetic patient's
first line of defense against the complication of their
illness. It is our duty and obligation as health care
professionals to provide them with the most proficient and
effective care in prevention of illness and promotion of

longevity.

References

List of References
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American Diabetes Association. (1993a). Implications
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American Diabetes Association. (1993b). National standards
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113—118.
Avy, D.V., Tobbert, D., Wilson, W. & Glasgow, R.E. (1989).
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