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DEVELOPMENT OF A BROCHURE ON FooF CARE FoA "
THEDIABETICCLIENT ‘

Scholaréy PFoiect for the Degree 0? M S N
MICHIGAN STATE UNIVERSITY
LEVONE McCULLouGH-
1993. ' "

 

 

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Development1

Development Of A Brochure 0n Foot Care For The Diabetic Client

Levone McCullough

Scholarly Project
Submitted to:
mchigan State University
In partial fulﬁllment of the requirements for the degree of
Master Of Science In Nursing
College of Nursing
1998

Development 2
Acknowledgements

Sincere thanks to the members of my committee for their support, guidance, and ongoing
efforts to help me achieve my ﬁnal product It is a pleasure for me to have the opportunity to
express my gratitude for all they have done for me. Thank you Brigid Warren, R. N., M.S.N.,
Georgia Padonu, R.N.,Ph.D., and Jackie Wright, R.N., M.S.N.

I especially want to thank my family and co-workers at Annapolis Hospital ( Emergency
Department), for their support, and unfailing encouragement throughout my graduate education.

DEDICATED TO MY BELOVED BROTHER
IVORY MCCULLOUGH

Development 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table Of Contents
AbstracL 6
Introduction 7
Background of the Problem 7
Purpose of the Problem 9
Literature Review 9
Diabetic FooL 9
Peripheral Neuropathy 9
Peripheral Vascular Disease 12
Susceptibility to Infection 13
Diabetic Self-Care Education 15
Summary 20
Conceptual Framework 21
Orem's Self-Care Deﬁcit Nursing Theory 21
Deﬁnition of Concepts 27
Application to ProjecL 27
Brochure DevelopmenL 30
Methodology 30
Target Group 31
Time 32
Cost 32
Distrubition 33
Evaluation 34

 

Implications for Nursing Practice
Implications for Nursing Education
Implications for Future Research

References
Appendix

Development 4

35
38
39

Development 5
List Of Figures
Orem's Self-Care Deﬁcit Nursing Theory Model

22

 

The supportive—educative system

A modiﬁed model: Client‘s self-care agency, focusing on diabetic foot-care

26
29

Development 6
Abstract
Development Of A Brochure 0n Foot Care For The Diabetic Client
By
Levone McCullough
Disabling foot problems are often associated with diabetes and it’s progression. Of the 16 million
diabetic persons in this country, about 25% will develop a severe foot or leg problem during their
lifetime. Diabetics are 15 times more likely than non-diabetics to develop gangrene of the
extremities. About 50% of all nontraumatic amputations occur in diabetics, accounting for about
120,000 amputation yearly. About 20% of hospitalizations for diabetes are due to foot infections,
which account for more in-hospital days than any other complications of the disease. Since
amputation is so devastating, preventive self-care is crucial. The Advanced Practice Nurses
(APN) are in a particulariy excellent position to give the diabetic client special consideration to
the care of the extremities. Education about proper foot care can help prevent serious diabetic foot
complications and assist in early detection of problems. Approximately 85% of diabetes care in the
United States we being provided in the primary care settings. Therefore, the APN's , because of
their practice within the healthcare system can play a key role in the educational process in the
care of the diabetic foot The purpose of this scholarly project is to develop an educational
brochure for the diabetic clients to enhance their self-care skills in the assessment and
management of foot-care in a primary care setting. This brochure will provide preventive
behaviors for client self-care stressing primary preventive and ealy detection. The theoretical
framework of Orem (1995) Self-Care Deﬁcit Nursing Theory (SCDNT) and literature review
guided the development of this educational tool. The expected outcome is that the client will have

an increased awareness of self-care in diabetic foot-care.

Development 7
Introduction
Backgmundﬂtﬂeﬂmblem
Diabetes is a serious chronic disease that aﬂects the body's ability to produce or respond to

insulin, a hormone that allows blood glucose to enter the cells of the body and generate the body's
energy. There are two major types of diabetes: insulin-dependent, also known as type I diabetes
and non-insulin dependent or type 2 diabetes. Type 2 is more prevalent in adults over 45,
accounting for 90 to 95 percent of all diagnosed cases of diabetes (Gavin, 199).

Approximately 16 million Americans have diabetes (Bash, Ledda, & deer, 199 ). People
with diabetes are at risk for chronic complications of the disease affecting the heart, kidneys, eyes,
nervous system, and lower extremities. Diabetes related foot complications can results in
amputation of the lower extremities and cause personal tragedy (Bodzin, 1997; Boyko, Reiber, 8.
Smith, 1995; National Institutes of Healﬂr [Nil-l], 1995). More than 25 percent will develop some
type of severe foot or leg problem during their lifetime. Nealy, 5 percent to 25 percent of people
with diabetes will lose a foot or leg. The seriousness of the situation can be shown by the fact that
two third of all amputation, not resulting from accident or trauma, happens to diabetics, resulting in
about 120,000 amputation yearly. In addition, the direct health care cost is beyond forty ﬁve
billion dollars annually (NIH,1995). With an additional cost of approximately forty seven billion
dollars credit to diabetes indirectly through disability, work loss, and premature mortality (NIH,
1995). About 20 percent of all hospitalizations for those suffering from diabetes are due to foot
infections, resulting in more hospital days than for any other complication of the disease (Basch,
Ledda, & Walker, 1997). Amputation statistics reveal diabetes mellitus to be one of the leading
causes of limb loss in the westem world (American Diabetes Association [ADA], 1996). These
darming statistics, encouraged the US Department of Hedih to set a goal for the year 2000 of a
40 percent reduction in amputation rates among diabetic clients (Department of Health & Human
Services, 1991).

Development 8

Primary care settings are responsible for providing mproximately 85 percent of diabetes care
in the United States. However, because of the changing health care system structure clients are
given 15 minutes or less per visit This frequent practice does not allow the health care provider
adequate time for routine assessment of their diabetic client's feet, unless it's their present health
deviation. Therefore, the urgency to educate the client and their caregivers on foot-cue, can
contribute to the reduction in diabetic foot problems (Hunt, 1995).

Studies have shown that proper foot care can reduce the vast number and severity of diabetic
foot problems. Proper foot care requires daily care and maintenance and can be effectively
implemented with the necessary knowledge, attitudes, and preventive care skills. Educating
clients with diabetes to care for their feet is recognized as a key to the prevention and early
detection of podiatric problems resulting in lower-extremity amputation as well as a decrease in the
overall disease related morbidity and mortality (ADA, 1993; Brown, 1991; Christensen et al.,
1991; Healthy People 2000, 1990; Litselman, Langefeld, 8. Slemenda, 1993). Preserving the
mobility of client with diabetes has always been a challenge. The APN is able to mate an
enormous difference in improving outcomes and reducing the cost of diabetes care, through early
assessment and appropriate educational interventions (Hunt, 1995 ).

Purpose Of The Project

The purpose of this scholariy project is to develop an educational brochure for the diabetic
client to enhance his/her self-care skills in the assessment and management of foot-care in a
primary care setting. Providing foot-care education for low/or high risk diabetic clients reduces the
incidence of foot ulcers (ADA , 1993; Edmonds et al., 1986). Therefore, the client and their
caregivers need to learn the importance of self-assessment. It is a skill that every such client must
learn as his/her best defense against one of the most serious and costly complications of diabetes,
which is amputation. The ultimate aim of this project is to provide guidelines for clients
self-assessment for the prevention of potential foot problems and early detection.

Development 9
Literature Review

The literature reviewed included the diabetic foot and diabetic self-care education, focusing

on early prevention, detection, and the need for self-care education.
Diabetic foot

The goal of this literature review is to critic research ﬁndings related to the triad of intrinsic
systemic disorders frequently cited as contributing to diabetic foot disease. These, include
peripheral neuropathy, peripheral vascular disease , and impaired resistance to infection (Ahroni,
1993 ; Frykberg, 1991; The Diabetic Control and Complications Trial Research Group (DCC'I),
1993 ).

EedpheraLNeumnarhv

Peripheral neuropathy is an extremely common complication of diabetes mellitus, affecting
approximately 50% of clients with long-standing (5-10 years for NlDDM, and 10-20 years for
IDDM) diabetes (Bridges, 1994; DCCT,1993;Frykberg,1991). The prevalence of neuropathy
has been directly related to the duration of diabetes and poor metabolic control ( DCCT, 1993;
Dridges, 8 Deitch, 1994 ). The exact pathogenesis of diabetes neuropathy is uncertain, but is
probably multifactorial. Accumulation of abnormal metabolic-byproducts within peripheral nerves
and microcirculatory failure with succeeding ischemic neuropathy are presumed to be important
factors ( Boulton, 1994; Flynn, & Tooke, 1992 ). Peripheral neuropathy is categorized into sensory,
motor, or autonomic components. Wrﬂr combinations of these types present in many diabetes
clients ( Frykberg, 1991).

Sensory neuropathy presents in the classic glove-and-stocking distribution symmetrically
affecting the toes ﬁrst and gradually moving proximally ( Frykberg, 1991 ). The most common
symptoms includes loss of deep tendon reflexes, proprioception, vibratory, pain, and light-touch
sensation ( Caputo, Joshi, 8 Weitekamp, 1997; Frykberg, 1991 ). As the symptoms progress in

the diabetic client the feet lose protective sensation. As a result, areas of redness or ear1y

Development 10
blistering on their feet aren't painful, because of sensory loss. These processes may then
progress to frank ulceration if left undetected and untreated (DCCT, 1993).

To successfully manage the foot problems of the majority of insensate diabetic client, the
primary care provider should understand how the psychology of sensory loss affects me behavior
of clients. The senses of touch and pain originates from hundreds of thousands of receptors
covering the entire surface of the body. These receptors form a protective bounda'y between the
person and the environment When we are touched or when a painful stimulus penetrates this
boundary, we are touched psychologically as well as physically. This effect was demonstrated in
several classic studies such as, Fisher, Heslin, and Rytling (1976) that suggests that even the
slightest touch alters the individual's perception of other people and their surroundings. Also a
study by Kleinke ( 1968 ), further indicated that touch not only affects perception but can be used
to manipulate behavior as well. For example, a small pet stratch on the ankle or foot of an
insensate diabetic client can go undetected for several days or weeks prior to seeking nredical
attention for a preventable infection. According to Fisher et al. (1976), and Kleinke (1968 ), this
behavior could be related to the concept of the body's disassociation from the insensitive areas.
Therefore injury to the insensitive pats become less important and less personalized to the
individual since there is a loss of painful sensation.

Motor neuropathy obviously results in muscle weakness, atrophy, and gait disturbance
(Conti, 8 Chaytor, 1995; Frykberg, 1991). In the diabetic foot. loss of motorﬁbers that lead to
intrinsic muscle atrophy causes imbalance between ﬁexor and extensor muscles. Clinical
presentations includes clawing of the toes, prominent metatasal heads, and anterior displacement
of an already atrophied plantar fat pad, which leads to pressure points and the fonnalion of
calluses. Subsequent continued pressure easily results in foot ulceration ( Boulton, 1988;
Cavanaugh et al., 1991; Yarbough, 8 Goodwin, 1992).

Development 11

Autonomic neuropathy has gained attention in recent years as an early manifestation of
peripheral neuropathy and signiﬁcant factor in foot ulceration (Frykberg, 1995). Autonomic
neuropathy is characterized as the dysfunction of thermoregulatory mechanisms in the foot
resulting in an altered vascular tone and skin blood flow as well as anhidrosis (lack of sweating).
The present of wide—spread arteriovenus shunting, divert blood flow from the nutrient capillary beds
and possibly impairing normal healing of dry, cracked skin, common precursors to infection and
ulceration in the diabetic foot (Birke et al., 1991; Conti, 8 Chaytor, 1995; Ryder et al., 1988).

Early detection of neuropathy influences on the diabetic foot can possibly prevent ulceration. A
study by Veves, Murray, Young, and Boulton (1992) investigated the association between foot
pressure changes and foot ulcerations (n=100). Two experimental groups, one comprising
diabetic subjects with neuropathy (n=28), plus one non-diabetic control group (n=14) were used.
All diabetic subjects were given the same education about foot care and were provided with
appropriate foot wear. Foot pressure measurements were made at the onset of the study and
again after a mean period of 30 months. The results of this study suggested that high plantar foot
pressures in diabetic persons are strongly predictive of foot ulcerations, especially in the presence
of neuropathy. This study also identiﬁed changes in high plantar foot pressures across time.
These results allows for ealy detection of elevated plantar foot pressure, which can be monitored ,
and measures to prevent the development of foot ulcers can be instituted and altered as indicated.

Peripheral neuropathy can be very devastating to a diabetic client , affecting every facet of
his/her life. Fortunately this affect, of this invading disease can be minimized with proper diabetic
management The DCCT (1993) study, clearly demonstrated the signiﬁcance of adequate glucose
control in delaying the onset or progression of peripherd neuropathy. This longitudinal study
included 1,441 clients with lDDM over approximately 6 1/2 years, clients with no neuropathy as
baseline who followed the intense control regimen showed a 69% risk reduction for the
appearance of clinical neuropathy at ﬁve years.

Development 12

Based on this DCCT study (1993), the ADA (1993) recommend, annud office testing for
neuropathy by checking knee and ankle reﬂexes as well as sensitivity of the feet to vibration, light
touch, and pinprick. At ﬁrst sign of sensory dysfunction in the extremities in client with IDDM or
NlDDM, consider revaluation of overall management program. Presently, this ADA
recommendation continue to be part of the ' Clinical Practice Recommendations of 1998' (ADA,
1998 ).

W

Peripherd vascular disease (PVD), has been identiﬁed as the primay etiology of diabetic foot
ulcerations. However PVD plays a dominant role in only one third of diabetic ulcers and co-exists
with neuropathy (Frykberg, 1995; Garrison, 8Campbell, 1993). In diabetics, PVD develops at an
earlier age and is 20 times more prevalent in diabetic persons than in non-diabetics (Gerding,
Piziak, 8 Rowbothman, 1991; Gibbons, 8 Freeman, 1987). In addition, when PVD develops in a
person with diabetes, it's progression is more rapid than that in nondiabetics and occurs equally in
women and men (Bessman, 8 Sapico, 1991).

PVD in diabetes mellitus affects both the large (macrovascular) and smdl (microvascular)
blood vessels respectively (Conti, 8 Chaytor, 1995; Faris, 1986). Luge vessel atherosclerotic
lesions affecting the tibioperoneal trunk of the lower leg are the hallmark of diabetic macrovascular
disease. Literature reviewed has cited PVD development in diabetes, as a result of increased
low-density lipoprotein cholesterol and decreased high lipoprotein cholesterol and uncontrolled
glycemic levels causing rapid arterid plaque fonnalion ( Foster, 1994; Frykberg, 1991; Gerding,
Piziak, 8 Rowbothman, 1991;Joslin, 1992 ).

Diabetic microvascular disease refer to abnonnalilies of the capillaries, the hallmak being a
thickening of the capillary basement membrane. Which leads to impaired diffusion; increased
arteriovenous shunting with impaired hyperemic response to heat and inflammation; a blockage of
oxygen utilization; loss of postural vasoconstriction; and increased capillary permeability; leading

Development 13
to edema and impaired client defenses against bacterial infection (Flynn, 8 Tooke, 1992; Jap, 8
Tooke, 1994)

In addition, the person with diabetes frequently has bilateral involvement, with multiple
occlusions and decreased capacity for developing collateral circulation (Bennett, 1979; Cooppan,
8 Habershaw, 1995). This is different from the person without diabetes in whom the lesions are
thought to be localized and unilateral (Foster, 1994; Donovon, 8 Rowbothman, 1986). Once
arteriosclerotic disease is present in the small vessels in the diabetic foot there is minimal effective
means of curing the problem. Presently, advances in vascula surgery have enabled successful
‘ reconstruction to the dorsalis pedis or posterior tibia arteries the limb-salvaging procedures of
choice in most cases (Conti, 8 Chaytor, 1995; Frykberg, 1991).

The primary signs of PVD include hair loss; shiny or atrophic skin changes; cold feet feet and
ankles that are darker in color than the leg; and dependent rubor. Symptoms that consistently
result from PVD are intermittent claudication (pedal pulses usually absent); in men, organic
impotence on a vascular basis; rest pain relieved by standing or walking; failure of a wound to
respond to appropriate treatment and grangrene resulting in amputation. Also, in diabetics with
PVD coronary artery disease and stroke are common (Coleman, 1992).

A typical scenario of a diabetic client with PVD, may report intractable toe pain unrelated to
activity. Pain at night is often attributable to ischemia, which is often chaacterized by skin around
the toes that is red, shiny, and lacking hair (Coleman, 1992).

5 fl 'lil I l f l'

Infections of the feet are a major source of morbidity among diabetic clients and often lead to
death. The pathogenesis of foot infection in clients with diabetes is multi-factorial. The triad of
neuropathy, ischemia and altered client defenses is believed to contribute to most serious
infections and places the diabetic client at high risk for amputation (Kaufman, 8 Bowsher, 1994;
Frykberg, 1991).

Development 14

When diabetes is uncontrolled, the client may become susceptible to infection and have an
altered client defense to ﬁght infections, which has been cited as signiﬁcant factors in the etiology
of diabetic foot infecﬁons, ulceration and gangrene (Frykberg, 1991; Gerding, et al., 1991).

This immunodeﬁciency is due to a deﬁciency in the phagocytic activity of leukocytes, impaired
intercellular bacterial killing, and a defect in normal chemotalic mechanisms. In this environment
even common pathogens can result in lethal infections especially in the presence of peripheral
neuropathy and PVD (Frykberg, 1991; Paduano, 1992).

It's not that diabetic clients are invaded by bacteria more frequently than non-diabetics, but
because they handle the invaders less well than do non-diabetic individuas (Bravennan, 1971;
Felig, 8 Bergman, 1995). For example, a minor injury from the friction of new shoes, can set the
stage for catastrophe events. Once the skin is broken on an insenate diabeﬂc foot, bacteria may
enter, causing infection mat spreads rapidly because client's resistances is low and hyperglycemia
impedes neutr0philic phagocytosis. The blood supply previously adequate for nonnd activity, is
stressed by the demands of the infection; resulting in possible grangrene,and generalized
septicemia (Felig, 8 Bergman, 1995).

Clinical presentations of diabetic foot infections varies in degrees, however the process stat
as red or warm spots which may go undetected (Foster, 1994; Levin, 8 O'Neal, 1988). Ulcers can
therefore form, and become infected, producing erythema and or purulent dranage. Pain may be
absent in clients with neuropathy. Subtle ﬁnding such as erythema, increased drainage, ankle or
leg pain and crepitance may be the ﬁrst signs of a limb-threatening infection. Fever, chills and
Ieukocytosis are absent in two thirds of clients with limb-threatening infection (Gibbons, 1992).
Fever, although frequently absent, may signify septicemia, deep tissue infection and or metastatic
seeding (Grayson, et al., 1994). Also, unexplained hyperglycemia is an important clue to
uncontrolled infection (Caputo, Joshi, 8 Weitekamp, 1997).

Development 15
Diabetic Self-Care Education

Most foot ulcers and other infected lesions that lead to gangrene of the feet are preventable,
nonetheless they continue to exact a tremendous toll in the diabetic population. Therefore, the
primary care provider (i.e. APN) must emphasize to the client the importance of foot self-care
(Graber, Wooldridge, 8 Brown, 1986; Hunt 1995). Chronic illnesses, such as diabetes are
incurable conditions that often require a tremendous amount of effort on the pat of the client and
family members to manage and control symptoms. These conditions have exacerbations and
remission, but in the case of diabetes there are no holiday or vacation for the diabetic client, the
management plan needs to be carried out daily, often severd times each day. The management is
essentially accomplished through self-care practices on the part of the clientffamily.

Self-care is deﬁned by Orem (1995) as ' the practice of activities that individuds initiate and
perform on their own behalf in maintaining life, health, and well-being' (p. 104). For the diabetic
client these activities include following them formulas, foot-care, exercise, and medication
therapy (Rankin, 8 Stalling, 1990).

Diabetes education must provide understanding at a number of levels to be truly effective in
supporting a client's self-care practices. Besides acquiring self-care skills and knowledge clients
must be educated to comprehend, analyze, and integrate the infonnalion they gather into
day-to-day living. This integration process and the decisions made as a result of this process can
be taught and reinforced through on-going educational mediums, such as one-on-one teaching,
group teaching, media, and written materials (Johnson, 1982; Rankin 8 Stdling, 1990).

A study by Kruger, and Guthrie (1992), investigated the effectiveness of a 'hand—on' foot-cae
teaching/learning approach for adults with diabetes. By random assignment, the control group
received a lecture presentation on foot-care, while the experimental group palicipated in a
hands-on session on foot care in addition to the lecture presentation . Data concerning the
subjects foot-care knowledge and skills, the condition of their feet. and their level of HbA-1c were
gather prior to and six months after the foot-care educationd session.

Development 16
The authors results indicates no signiﬁcant increases in knowledge about foot-care were

observed in the experimental group. The experimenta group reported improvements in inspecting
and washing their feet on a daily basis, and in care of the toenails. No signiﬁcant differences were
observed in the status of the subject's feet The HbA-1c readings were signiﬁcantly improved for
both the experimental (t=4.10, df=10, p=0.002) and control (t=2.25, df=9, p=0.051) groups.
Authors concluded that a hands-on educational session may improve foot-care practices
temporarily. However, long term effects need to be studied to discover overdl improvement of
foot-care practices and physical status of the feet

Another study by, Ledda, Walker, and Basch (1997), to develop, formatively evduate, and pilot
test a self-care, take-home program for the prevention of foot problems in Aﬁican Americans with
diabetes. The program included twenty-seven African American subjects with NlDDM from a foot
clinic in New York City. Twenty-one were women and six were men. The age range was 45 to 83
years (mean=63). The following inclusion criteria were established: self-described as African
American; diagnosis of NlDDM; > 40 years of age; completed at least 6 years of education;
nonactive foot lesions; ulcers, or lower extremity amputation of any kind; and a home telephone.

The orientation session was a brief (15-minute), one-on-one meeting, and a reviewed and
demonstrated short (16-item) foot-care behavior survey. The take-home program components
included a two-sided folder containing the newly developed client instruction booklet with a reading
level at or below sixth grade, a large hand mirror, a lotion sample, and an emery board. Through
telephone follow-up 2 to 3 weeks after orientation, subjects reported the following: good to
excellent overdl rating of the program, favorable reactions to the client instruction booklet, and to
the large hand mirror, and most importantly a positive effect on their daily foot-care practices.

In an earlier study to assess the affects of a home based diabetic education program, Rettig,
Strauger, Recker, Gallagher, and Wrttse (1988) measured client knowledge and self-care skills in
both randomly assigned treatment and control groups of sumects. A totd of 373 subjects (193
control, 180 treatment) were measured on self-care knowledge using a series of seventy multiple

Development 17
choice questions divided into four content areas; diet, urine testing, medication therapy, and
foot-care. Client self-care skills were measured by one-to-one demonstrations and focused on skill
in urine testing, medication use, foot-care, and diet recommendation skills as noted by ability to
draw up a 24 hour meal plan. Foot-care skills were noted by nurse exarninalion of the feet and
included the presence of dirty foot soles, presence and type of socks, and methods of toenail
clipping. In addition, a 16 item checklist for normal 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. Wrth regards to foot appearance scores, signiﬁcant differences
were noted between the two groups. Wrth a possible score of 100, the treatment group obtained a
mean score of 82.2 +I- 0.7 and controls, 63.8 H— 0.7 (higher scores indicated better condition of
the feet). The authors concluded that home-based diabetes education interventions can positively
effect client knowledge and skill outcomes. The authors also concludes that further studies need
to be done to enhance the validity and reliability testing of the self-care knowledge and skills
instruments.

Diabetic foot ulcers and amputations rank high among the disabling complication of diabetes
mellitus. Although it has been estimated that one half of the amputations in clients with diabetes
are preventable with proper foot care education (ADA, 1996; Edmond, et al., 1986; Levin, 1989 ).
Unfortunately, because of the limited time allotted for diabetic foot screening and foot care
education, many clients are not taught the skills necessary to protect their feet from injury
subsequent chronic ulceration and possible limb loss (Ahronid, 1993; Griﬂiths, 1981).

Several classic studies have shown that people who have diabetes are not well versed in the
care of the foot In one study of 372 clients with NlDDM, 41 percent reported that they had not
been told to take especially good care of their feet ( Michigan Diabetes Research and Training

Development 18
Center, 1986 ). In another study of 75 diabetic clients,nearly three out of four, all whom had been
taught other aspects of self-care, had not been taught proper foot-care ( D'Eramo, 8 Fain, 1988 ).
Although simple preventive strategies on the part of the health care provider or client can reduce
the likelihood of amputation, many of these procedures are not being systematically applied
(Wylie-Rosett, et al., 1995 ).

There is increasing evidence to suggest that education on foot-care is essential for clients
with diabetes (Ahroni, 1993; Kruger, 1992). This concept was realized by ﬁre Rehabilitation
Service of ﬁre San Diego Veterans Administration Medical Center (SDVAMC), and prompted , ﬁre
development of a nurse-run diabetic foot clinic to provide diabetic clients with comprehensive
foot-care education. A retrospective analysis of ﬁre nurse-run clinic was made to determine
whether it was effective in its services. One hundred male diabetic foot clients, ranging in age
from 50 to 80 years, were referred to ﬁre outclient nurse-run diabetic foot clinic over a one year
time frame. All of ﬁre clients had experienced sonre type of foot lesion ﬁrat had healed prior to
referrd to ﬁre nurse-run clinic. Of ﬁre 100 clients referred to the nurse-run diabetic foot clinic, 86%
achieved his goal, 12% were able to beconre independent of ﬁre clinic, remaining vigilant in ﬁreir
foot-care and free of lesions. The results of ﬁris retrospective analysis indicated ﬁrat the concept of
a nurse-run diabetic foot clinic can effectively teach clients how to care for their diabetic feet and
avoid debilitating foot problems (Joseph, 1989).

A majority of educational programs feature foot-care as a small component (Barnett, 8
Odugbesan, 1987). One study ﬁrat was devoted to foot-care demonstrated ﬁrat diabetic client's
knowledge increased following instruction (Fletcher, 1990) Anoﬁrer study, by Lilzelman et al.
(1993), clients were questioned about ﬁreir regular foot-care routine and were asked to show how
ﬁiey examined their feet During ﬁreir self-examination, nurse clinicians observed wheﬁrer clients
scnrtinized ﬁre toenails, ﬁre sole of ﬁre feet, and ﬁre area between ﬁre toes. Musculoskeletal and
dermatology abnormalities were assessed, pulses palpated, and lesions noted.

Development 19
In a clinical setting clients received education at each visit Results indicated a decrease in serious
foot lesions, and sonre appropriate foot-care behaviors increased.

Anoﬁrer study using a pre-test and 6 nronﬁr post-test control group design. Krugh and Guﬁrrie
(1992), examined ﬁre effectiveness of a one-week client education program on foot-care. Inclusion
criteria required subjects (n=50) to have a 5-year history of diabetes nrellitus, but no frank
paﬁrology of ﬁre feet A paticipaﬁve, hands-on teaching / learning treatment was used. Through
ﬁndings indicated that in sonre areas of evaluation ﬁrere were small differences between ﬁre
experimental (n=23) and control (n=27) groups. The auﬁrors found no statistically signiﬁcant
differences. The failure to detect signiﬁcant differences between experinrental and control groups
may be due to inadequate sample size. The auﬁrors cited high subject atlriﬁon in ﬁre experimental
group from pre- to post-test as one reason for no signiﬁcant ﬁndings.

An earlier study by, Delbridge, Appleberg, 8 Reeve (1988) sought to determine factors
associated wiﬁr ﬁre developnrent of foot lesions in clients with diabetes (> age 50 years). Eighty
subjects were divided into four groups based on ﬁre 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 ﬁre variables
glycosylated hemoglobin (i.e. HgAl c); frequency of hospital admissions for diabetes control;
degree of vascular impainnent; history of smoking; presence of neuropaﬁry; delay in treatment for
foot lesions; and client understanding and education of diabetes, diabetes management;
foot corrrplicaﬁons and care of ﬁre feet Groups did not differ signiﬁcanﬁy with regad to HgAlc
levels, frequency of hospital admissions, or presence of neuropaﬁry. Subjects wiﬁr foot lesions did
exhibit, however, signiﬁcanﬁy higher degree of vascular impairment, history of smoking, increased
delay in referral for foot lesion treatment, and lower scores on ﬁre knowledge test

The auﬁrors conclude ﬁrat education of clients related to foot care management can effect ﬁre
development of foot lesions. Wrﬁrout ascertaining if subjects had received any diabetes educaﬁon,
ﬁre auﬁrors claim ﬁrat subjects wiﬁr foot lesions may not have wanted to 'know' about problems

Development 20
wiﬁr ﬁreir feet As such, ﬁrese subjects may engage in “willful self-neglect“ as evidenced by
indifference to diabetes complications. This claim and speculation about ﬁre lack of self-care
motivation was based on a knowledge test wiﬁrout indices of reliability or validity. It is possible ﬁrat
ﬁre instrument lacked construct validity in ﬁrat it failed to address or capture critical factors of foot
self-care knowledge. Furﬁrennore, ﬁre knowledge measure may not have been internally
consistent (i.e. reliable). Noneﬁreless, ﬁre auﬁrors conclusively stress that educaﬁon of diabetic
clients related to foot-care management can be crucial in preventing ﬁre development of foot
lesions. Education on ﬁre diabetic foot has been proven imperative. Clients wiﬁr diabetes and
ﬁreir signiﬁcant others must be taught and repetitively reinforced on ﬁre diligent care of ﬁre diabetic
foot, to prevent or delay lower-extremity complications ﬁrat can result in arnputaﬁon.
Summary
In summary, ﬁrere is an abundant amount of literature on ﬁre paﬁrogenesis of diabetic foot
complications. Also, the wide variety of literature reviewed has demonstrated ﬁrat with proper
foot-care, educaﬁon, and glycemic control, peripheral neuropaﬁry, PVD, and foot infecﬁons can be
prevented or delayed in persons wiﬁr diabetes nrellitus.

There is generous amount of research to date, indicaﬁng ﬁrat education is essential for ﬁre
diabetic client to enhance self-care for early detection, and prevention of foot complications. Such
as, research done by DCCT (1993); Delbridge, Appleberg, 8 Reeve (1988); Graber, et al. (1986);
Kruger, and Guﬁrrie (1992); Retlig, et al. (1988); and Veses et al. (1992), identiﬁed an
improvement in foot-care after sessions of educational presentations. However, ﬁre majority of
research indicated a temporary improvement in self-care-foot-care, which has been identiﬁed as a
weakness in ﬁndings. Also, ﬁre literature reviewed failed to idenﬁfy ﬁre effective mode of
education. Therefore, ﬁre need for research on ﬁre Iong-tenn effect of education and ﬁre effecﬁve
nrode of education for clients wiﬁr diabetes is forthcoming.

Development 21
Because of ﬁre limited time allotted per client by primary care providers, foot care educaﬁon
and screening are frequenﬁy omitted until complications develops. Therefore, ﬁre ability of ﬁre
client or healﬁr care provider to perform self-care-foot—care is vital for healﬁry feet 1.
Conceptual Framework

This section will discuss the conceptual framework of Orem's (1995) Self-Care Deﬁcit Nursing
Theory (SCDNT). Also, an explanation of related ﬁreoretical constructs as ﬁrey are linked to ﬁre
development of ﬁre proposed education brochure. Concluding wiﬁr an adapted model to illustrate
ﬁre relationship between ﬁre proposed diabetic foot care brochure, Advanced Practice Nurse
(APN), and ﬁre ﬁreoretical constructs of Orem's (1995) SCDNT.

Orem labels her SCDNT as a general theory composed of ﬁrree related ﬁreories : (1) ﬁre
ﬁreory of self-care (describes why and how people care for ﬁremselves); (2) ﬁre ﬁreory of self-cae
deﬁcit (describes and explains why people can be helped through nursing); and (3) ﬁre ﬁreory of
nursing systems (describes and explains relationships ﬁrat must be brought about and maintained
for nursing to be produced) (ﬁgure 1). An examination of ﬁre major constructs of ﬁrese theories
were necessary in ﬁre development of ﬁris educational brochure. The major constructs of ﬁrese
theories begins wiﬁr self-care. Self-care, 'is ﬁre practice of acﬁrn'ties ﬁrat maturing and mature
persons initiate and perform, wiﬁrin time frames, on their own behalf in ﬁre interests of maintaining
life, healﬁrful funcﬁoning, conﬁnuing personal developnrent and well-being" (Orem, 1995 p. 461).

Subdivision of ﬁre self-care ﬁreory includes self-care agency, (which is ﬁre complex acquired
ability of mature and maturing persons to know and meet ﬁreir ongoing requirerrrents for deliberate,
intentional action to regulate ﬁreir own human functioning and development ); dependent care

agency ( person oﬁrer ﬁran ﬁre individual who provides care, such as a spouse caring for hisﬂrer
mate wiﬁr a chronic illness); self-care needs (ﬁre reasons for which self-care is undertaken ); and
ﬁrerapeutic self-care demands (refers to ﬁrose self-care activities required to meet ﬁre self-care
needs) (Orem, 1995; Wesley, 1994).

Development 22

 
    
  
 

Self-care

   
   

  
  

 

.r___ _,

a:

.5 ” Self~care Self-care 9
o h agency demands *3
'= g 0 a.
‘6'0 3 5':
cu- o
o 3 2.

 

 

er I

Conditionin
factors

 

Nursing
agency

Eightej; Orem's connceptual framework for nursing (Orem, 1995, p. 35). R, relationship; < deﬁcit

 

 

relationship, current or projected.

Development 23
According to Orem (1995), self-care is ﬁre voluntary, deliberate action performed by

individuals for themselves or for others to maintain life, healﬁr, and well-being. Deliberate action by
ﬁre adult to maintain a state of health for ﬁremselves (self-care agency) and ﬁreir dependents
involves (dependent-care agency) self-care. Self-care action requires a base of education in ﬁre
home, at school, and from practical experiences in self-care. These self-care acﬁons are learned
acﬁvilies, learned ﬁrrough interpersonal relaﬁons and communication. Acquiring good health
habits are necessary in preserving health, butﬁre ability to alter old habits to meet new
requirements may be essential. That's why education in self-care, not just training in self-care
pracﬁces is essential for ﬁre development of knowledge, skills, and favorable attitude toward
self-care and healﬁr. Knowing what actions to perform and having ﬁre skills to perform ﬁre actions
are combined wiﬁr learned knowledge of events and expected result of ﬁrose performances. For
example, a diabetic client or dependent-care agency deliberate assessnrent of his/her feet daily, is
a series of purposefully actions resulﬁng in ea'ly detecﬁon or prevention of foot ulcers. However,
a lack of ﬁris self-care knowledge, is a self-care need unmet creaﬁng a self-care deﬁcit ﬁrat may
require nursing agency intervention.

The self-care deﬁcit theory,“ is a relaﬁon between ﬁre human properties, ﬁrerapeutic
self-care demand and self-care agency in which constituent developed self-care agency are not
operable or not adequate for knowing and meeting sonre or all elements of ﬁre existent or
projected ﬁrerapeutic self-care demand, and explains when nursing is needed and how people
wiﬁr chronic illnesses can be helped ﬁrrough nursing“ (Orem 1995, page 461 ). Self-care deﬁcit
may be influenced by certain conditioning factors, such as age, gender, developnrental state,

healﬁr state, sociocultural orientation, healﬁr care system factors, and farrrily system factors,
pattern of living, environmental factors, resource availability and adequacy (Orem, 1995).

Self-care deﬁcit ﬁreory is ﬁre essential element of ﬁre SCDNT. The ﬁreory expresses why
individuals require and can be helped ﬁrrough nursing (Orem, 1995 ; Parker, 1990). According to
Orem (1995), deﬁcit, stands for ﬁre relaﬁonship between ﬁre acﬁon ﬁrat individuals should take

Development 24
and the action capabilities of individuals for self-care or dependent-care. This ﬁreory includes two
client variables, self-care agency and ﬁrerapeutic self-care demand, and ﬁre nurse variable ,
nursing agency. In ﬁre conceptualizaﬁon of ﬁre ﬁleory self-care deﬁcits, the client variables are
considered as related, and ﬁre ﬁreory of nursing system, nursing agency is considered as related
to boﬁr client's variables. Therefore, SCDNT demonstrates and explains ﬁre relationship between
what actions individuals are capable of and ﬁreir demands for self-cae.

This relaﬁonship is vital to ﬁre examination of self-care. Self-care agency , is one who cares
for his/her own care, or ﬁre ability of individuals to parﬁcipate in ﬁreir own self-care (Orem, 1995 ;
Cavanagh, 1991). The capability to engage in self-ca‘e is a learned behavior, ﬁrat is inﬂuenced by
internal and extema factors. Such as, culture, conrmunity, and healﬁr care providers (Denyes,
1988). The human capability named self-care agency, ﬁre power to engage in self-care develops
in ﬁre course of day-to-day living ﬁrrough ﬁre automatic process of learning. This sarrre concepts
was uﬁlized in ﬁre conceptualization of ﬁris proposed project

Some types of health problems lend ﬁrenrselves nrore easily to self-care ﬁran oﬁrers.

Diabetes is one of ﬁrese, ﬁrerefore ﬁre need for educaﬁonal intervention is essenﬁal for proper and
effective self-care. Management of diabetes mellitus requires lifestyle changes, modiﬁcation of
dietary intake, and life time family and client education, alone wiﬁr ongoing follow up and support
Because of ﬁre complexity of ﬁris chronic disease, ﬁre primary healﬁr care system can and should
be ﬁre client'slfamily's source for acquiring ﬁre skill necessary for promoting their self-care abilities,
to maintain optimal healﬁr-status.

Self-care agency requires acquiring skills to care for oneself. This includes the client's
understandings of ﬁre diagnosis, management and conrplicaﬁons. A client's primary care provider,
such as an APN, is essential in ﬁre teaching of day-to-day preventive foot-care in diabetes. Since
foot infections are ﬁre most common problems for diabetes and can frequently lead to anputation.
Therefore client teaching should be directed toward prevention and early detection of any foot
abnorrnaliﬁes (Donahue-Porter, 1985; Miller, 1982).

Development 25
There comes a ﬁnre in ones life when internal and external factors hinder self-care through
self-care agency. These factors such as, maturity, age, healﬁr status, and etc... can prevent one
from caring for ﬁremselves, a dependent-care agency may becorrre necessary for well-being. A
dependent -care agency, is a maturing adolescent or adult who accept and fulﬁll ﬁre responsibility
to know and meet ﬁre self-care needs of relevant others, who is unable to independenﬁy perform
appropriate self-care skills .

The development of dependent care-agency by individuals is usually a response to needs
(self-care deﬁcit) and acceptance of family members or signiﬁcant oﬁrers for assistance wiﬁr ﬁreir
conﬁnuing self-care (Orem, 1995). Dependent-care agency, like self-care agency must be able to
perform ﬁre day-to-day acﬁons to meet ﬁrerapeuﬁc self-care demand, knowing ﬁre capabilities and
limited actions of ﬁre self-care agency. For example, a diabetic client who is unwilling and
disinterested in learning and perfonrring preventive foot-care, ﬁrerefore his spouse willingly takes
on ﬁre role of dependent-care agency to accomplish ﬁre goal of self-care. This scenaio illustrate
ﬁre conceptualizaﬁon of dependent -care agency wiﬁrin ﬁre development of ﬁlis project

Dependent -care agency can be enhanced ﬁrrough a primary cae provider, such as an APN,
to improve ﬁre skills of the dependent-care agency for the prevenﬁon of abnonndities and promote
health. Orem (1995) refer to this intervenﬁon as ﬁre nursing system ﬁre ﬁrird construct of SCDNT.

The ﬁnal construct of ﬁle SCDNT is ﬁre nursing system theory (ﬁgure 2) which includes a
series and sequences of deliberate practical acﬁons of nurses performed at ﬁnres in coordinaﬁon
with acﬁons of ﬁreir client to know and meet conrponents of ﬁreir client's ﬁrerqreulic self-care
demands and to promct and regulate ﬁre exercise or development of client's self-care abilities.
This system is composed of ﬁrree sub-systems: (1) wholly compensatory, is used when a client's
self-care agency is so limited ﬁrat ﬁre client is totally dependent on ﬁre nurse for well—being; (2)
party compensatory, is used when a client can meet sonre of his/her needs creaﬁng a nurse/client
partnership but needs ﬁre nurse to meet oﬁrers; (3) supportive-educative, is used when the

Development 26

 

Accomplishes patienf’s
therapeutic self-care

 

Compensates for patient's
inability to engage
in self-care

Nurse
action

 

Supports and'protects
P0500!

 

 

 

Whollycompeneaiorysystem

 

Performs some self-care
measures for patient

Compensates for self-care
limrtaIronsof patient

 

 

Assists patient as required
Nurse
action

 

 

Performs some self-care
measures

 

 

Patient

Regulates self-care agency action

 

from nurse

 

'Acceptscareandassistance

 

 

I Accomplishes self-care

 

Patient
action

 

Nu“. J Regulates the exercise and
action 7' development of

self-care agency

Supportive-educative system

 

ﬁgural; The Basic Nursing Systenrs. This project focused on ﬁre supportive-educative system;
part of ﬁre basic nursing systems wiﬁrin Orem's conceptual framework for nursing. The practice of
nursing: The individual as ﬁre unit of service (Orem, 1995, p. 307).

 

Development 27
client can meet self-care demands but needs assistance with decision making, behavior
control, and acquiring knowledge and skills (ﬁgure 2); (Orem, 1991, and 1995).

Deﬁnition Of Concepts

The following deﬁnitions of concepts will be utilized for ﬁre purpose of ﬁris scholaly project

Selfacarze: ls ﬁre practice of acﬁvities ﬁratﬁre diabetic client initiate and perform on his/her
own behalf in assessment and management of foot-care.

Selfacareagency: The diabetic client who performs ﬁre foot self-cae actvites.

Selfzcatedeﬁcit: The self-care agency is unable to perform his/her foot self-care activities
because of limitaﬁons Ge. visually impaired, obese, lack of knowledge and skills).

Nursingagency: a registered nurse with a master's degree and has advanced education
and clinical traininng in family healﬁr cae. Therefore, ﬁris advanced practice nurse (APN) is able
to work wiﬁr diabetic clients of all ages and ﬁreir families, providing ﬁre infonnaﬁon necessary to
enhance ﬁreir self-care skills in ﬁre assessrrrent and management of foot-care.

Appicaﬁon To Project

Orem's SCDNT (1995) is frequently used in clinicd practice, educaﬁon and research wiﬁrin
ﬁre nursing profession. Orem's SCDNT (1995) provides directions to practicing nurses in ﬁreir
clients assessment in idenﬁfying deﬁcit and ﬁre depﬁr of nursing intervention (3). An analysis of
ﬁre relationship among ﬁre variables in ﬁris scholarly project is grounded on ﬁre construct of
self-care.

The focus of this project is primarily on ﬁle supportive-educative system as ﬁre nursing
intervention to enhance ﬁre diabet'c client's self-care abilities. The supporﬁve-educaﬁve system is
furﬁrer deﬁned as a system where ﬁre individual is able, or can and should learn to perform ﬁle
required self-care nreasure, but cannot do so wiﬁrout assistance. Valid helping techniques in
ﬁrese situations include combinaﬁons of support, guidance, provision of a developmenta
environment and teaching (Orem, 1995). Therefore, ﬁre APN would mainly function as a
practitioner, assessor or educator for ﬁre diabetic client on foot-care.

Development 28
The action of ﬁre diabetic client would be to accept and perform regula routine foot-care, to

prevent potential foot problem ﬁrrough early detecﬁon of podiatry problems.

In conceptudization of this project and Orem's ﬁreory of SCDNT, ﬁre client variabm are
viewed as related, and wiﬁrin ﬁre ﬁreory of nursing system, nursing agency is viewed as related to
boﬁr client variables. A modiﬁed Orem's model (ﬁgure 3) illustrates ﬁre relationship among ﬁre
client and nursing variables ﬁrat pilot the development of ﬁlis educational brochure indicating ﬁre
signiﬁcant of self-care agency, dependent-care agency, ﬁrerapeutic self-care demands and
nursing agency. This model represents ﬁre outcorrre of all diabetic clients, which is to obtain
self-cae, wheﬁrer it's ﬁrrough ﬁre assistance of a dependent-care agency or nursing agency to
enhance his/her self-care in assessment and management of foot-care.

A self-care agency as shown in ﬁre model (ﬁgure 3) can be affected from tinre to time by
limitations ﬁrat do not allow him/her to meet ﬁreir ﬁrerapeutic self-care demands. These limitations
may occur because of factors ﬁlat are internal or external to ﬁre individua, such as lack of
resources or an accident However ﬁris model focused on resource availability of ﬁre diabeﬁc
self-care agency. This event may hinder ﬁre self-sac agency in nreeﬁng ﬁrerareuﬁc self-care
demands creaﬁng a deﬁcit (ﬁgure 3). Because of ﬁre direct effect ﬁris deﬁcit has on acquiring
diabetic self-care, ﬁre assistance of a nursing agency or dependent care-agency may be required
for stable diabetic self-care (ﬁgure 3).

The italic R indicate a continuous feedback of communication and interacﬁon between ﬁre
clients and nurse's variables, to obtain independent diabeﬁc self-care. Orem refers to ﬁris
nurse/client relaﬁonship as a 'whole system of action“ (page 71) to achieve ﬁrerapeutic self-care
demands (Orem, 1995). The developrrrent of ﬁlis nurse/client relationship is client's choice,
however ﬁre continuaﬁon is a joint agreement based on self-care capabilities. Anoﬁrer integral
elenrent is ﬁre nurse/clientldependent care agency relationship, ﬁre nursing agency must
recognize ﬁris essentially for uncomplicated ongoing self-care in ﬁre diabetic client (ﬁgure 3).

Development 29

   
  

Client'sSelf-Care

Ase-Icy: .
Dlebetlc foot
Self-Caro ‘

Stable Diabetic Diabetic Client’s
Self-cam . w:
. Molds
-_-\ M M

\ as.“
”mm gr \ gr

 

Mummers):
development ofbroclm'e.
APNrolas: educator

Kev
R, direct relaﬁonship and
feedback communication

 

ﬁgure}: A modiﬁed model: Client's self-care agency, focusing on diabetic foot-care.

Development 30

Dependent-care agency is explained indirecﬁy in Orem's ﬁreory, and illustrated synonyrrrously
as self-care agency wiﬁrin ﬁre SCDNT model (ﬁgure 1). However, for ﬁris project (ﬁgure 3)
dependent-care agency is referred to as a separate concept, but direcﬁy inﬂuence ﬁre balance of
self-care for ﬁre diabeﬁc self-care agency. Alﬁrough, ﬁris feedback communication and
relaﬁonship has ﬁre potenﬁal of being nonﬁrerapeutic (ﬁgure 3), which may require nursing
intervention. Recognizing ﬁre importance of ﬁris relaﬁonship eiﬁrer ﬁrerapeulic or non-ﬁlerapeutic,
togeﬁrer wiﬁr ﬁre dependent-care agency can balance ﬁre diabeﬁc day-to-day self-care acﬁviﬁes
(ﬁgure 3).

The nursing agency (APN) (ﬁgure 3), is understood as ﬁre developed and developing abilities
of a nurse to provide nursing for an individual diabetic client or groups. Meﬁrods of delivering
nursing to a diabeﬁc wiﬁr legiﬁmate deﬁcit (s) wiﬁrin ﬁre nursing systems varies, however ﬁre
primary focus of ﬁlis project is ﬁre supporﬁve-educaﬁve system (ﬁgure 2). The essential
techniques used by ﬁris system include a combinaﬁon of support, guidance, provision of
developmental environment, and teaching (Orem, 1995). Therefore, ﬁle APN's (nursing agency)
action would mainly be as a practitioner, assessor or educator in ﬁre self-care agency or
dependent -care agency development of self-care abilities to accomplish self-sac (ﬁgure 3).
However, all previous mentioned APN's roles are utilized at onset of relationship (ﬁgure 3) and
less visible as self-care capabilities ae improved (ﬁgure 3).

Brochure Development
Methodology
The development of ﬁris conceptual model was grounded on ﬁre literature review and Orem
(1995) SCDNT. This brochure was developed for use in a primay care facility to reinforce oﬁrer
teaching meﬁrods. The key component “self-care" was obtained from Orem's (1995) SCDNT for
practical applicaﬁon in primary healﬁr care. The brochure consists of two main parts; self-care;
inspecting your feet (ﬁrerapeutic self-care demands), and self-care; keeping your feet healﬁry

(self-care skills).

Development 31
Bart]; Daily visual inspection is ﬁre diabetic client's ﬁrst line of defense (Sage, 1991). The
brochure contains visual early warning sign for ﬁre diabetic client Such warning signs as below:
1. Color changes
2. Swelling
3. Temperature changes
4. Sensation changes
5. Hot spots
6. Cracks, sores, and ulcers
7. Ingrown toenails
8. Drainage and odor
To aid in visual inspection a hand mirror is encouraged. lf self-inspecﬁon is impaired (e.g. has
visual inrpairnrent or is obese) requesting support from a relative or friend is also encouraged. The
brochure stresses ﬁre immediate notiﬁcation of client's primay care provider if a foot problem is
detected.
Built: The brochure will also emphasize self-care; keeping your feet healﬁry by encouraging
ﬁre diabetic client to practice ﬁre following approaches in foot-care:
1. Check shoes and socks
2. Exercise your feet
3. Take special care
4. Control your diabetes
Diabetes does not have to lead to serious foot problems. The primary care provider and client
can work as a team to keep ﬁre diabetic feet hedﬁry and treat any problems ﬁlat occur. But,
keeping ﬁre diabetic feet ﬁt takes effort and conrrrrilrrrent from ﬁre nrost important team
member—— 'THE Client'.

Development 32
Iametﬁmun

The target client group for ﬁris brochure includes type I or type II diabetic clients. It can be
reviewed wiﬁr and given to a newly diagnosed client, established diabeﬁc client, or ﬁrose diabetic
clients who are new to ﬁre clinic. Oﬁrer intended characterisﬁcs of ﬁle client who can beneﬁt from
ﬁre contents of ﬁris brochure includes: age range 10 and greater, intact visud abiliﬁes; can read
English; reading ability of at least sixﬁr-grade level.

This brochure was speciﬁcally designed to be used as an adjunct diabetes educationa tool by
primary care providers (i.e. APN) in primary care settings (i.e. private clinics, or managed care
groups). However, ﬁre brochure contents is general enough to enhance any diabeﬁc educational
program, wiﬁr medical follow-up available.

lime

The primary care provider or auxiliary personnel would on ﬁre average spend ﬁve minutes
reviewing ﬁre brochure wiﬁr ﬁre diabeﬁc client or signiﬁcant oﬁrer, prior to taking it home. Since
nrore ﬁran half of all nontraumatic amputations in ﬁre United States are direcﬁy related to
preventable diabetic foot complications (Christensen, et al. 1991). Therefore, taking ﬁlls
ﬁve-minutes to review ﬁre foot-cae brochure could be ﬁre ﬁrst step toward prevention and early
detecﬁon of diabetic foot complications. Treatment of foot ulcers starts wiﬁr prevention and
prevention starts wiﬁr awaeness. ln ﬁre case of foot-cae, awareness means knowing how to
prevent problems before ﬁrey develop and how to cope wiﬁr ﬁlose ﬁrat do.

(East
The implenrentation of any educational tool is highly inﬂuenced by start-up cost and long-teml
cost Fortunately brochures are a cost-effecﬁve mean of providing healﬁr care educaﬁon to a large
population such as diabetic clients. This cost also includes ﬁre cost of personnel ﬁnre in preparing
and delivering material. The projected cost per brochure range from $0.02 to $0.05 each, because

it can be reproduced wiﬁrin ﬁre clinic.

Development 33
The nonrinal cost per brochure can easily be justiﬁed if only one diabetic client identiﬁed or
prevented a foot ulcer, because of acquired self-care skills from ﬁris educaﬁonal brochure.
D' l 'I l'

Educaﬁonal material, wheﬁrer written or verbal, can be distributed and conrrnunicate in four
ways, such as personal, mass, direct and interactive. Of ﬁrese four, two have been shown
effective in ﬁre distribution of ﬁre brochure. Mass distibuﬁon includes advertising, direct mail and
public relations and can be very inrpersonal in nature. Direct distribution is personalized neutral
communication which is directed to named receiver(s) (Gronrros,1990). This project will focus on
ﬁre directrlisflibulionmethm.

lnrproving client foot care skills can be a vital asset in ﬁre prevention, initial diagnosis, and
early treatment of diabeﬁc foot disease. A diabetic's ﬁrst line of defense in conﬁolling and delaying
furﬁrer corrrplications of ﬁleir disease ,is in ﬁreir own self-care capabilities. Clients wiﬁr diabetes
ought to be taught simple common sense approaches to daily foot inspection techniques and foot
hygiene and advised about choosing proper shoe wear. Simple reminders, such as never go
barefoot or looking for objects inside shoes before pufﬁng ﬁrem on, are essential in preventing
ulceration or infecﬁon. This brochure will provide ﬁre diabetic client and/or family wiﬁr ﬁre basic
guidelines for ﬁrese self-care actvites at home atﬁreir own pace ﬁrus exercising nrore control over
ﬁre learning experience. That is why, it is important ﬁrat ﬁris brochure be distributed in ﬁre form of
directrlisllibufian in ﬁre clinic before, during, or after ﬁre exam, each timing has advantages.
Distibuﬁon before and after contact wiﬁr primary care provider allows ﬁre client to read ﬁre
infonnaﬁon over and to formula questions. During ﬁre foot-exam, ﬁre client can be taught proper
foot self-care skills, and enhanced by ﬁre brochure after departure from ﬁre clinic/primary care
provider. Erﬁrer nreﬁrod of distibuﬁon can be effecﬁve, so long as awareness of self-cue in ﬁre
assessment and management of foot-care is emphasized for ﬁre prevention and early detecﬁon of
ulceration and infecﬁons.

Development 34

A chronic disease such as diabetes has many disabling side-effects, one in palicular can be
deteriorating vision. For ﬁrese clients ﬁris brochure's print can effectively be enlarged before
distribution.

Evaluation

Wlﬁr direct distribution of ﬁlls brochure , increased foot self-care knowledge would hopefully
be ﬁre outcome. The inﬂuence of proper foot self-care assessrrrent can be measure by ﬁre
increased in compliance to preventive measures and early detecﬁon of conrplications. This can be
evaluated wiﬁr chart review, it could show ﬁre progress or lack of, ﬁrat diabetic clients may make in
regards to foot-care as documented subjective and objective observaﬁons of abnormalities and
physical status of ﬁre feet Anoﬁrer way of measuring ﬁre brochure's effectiveness, is by increased
awareness of ﬁre feet The simple act of removing shoes and socks prior to contact wiﬁl ﬁreir
primary care provider, can encourage partial or full foot inspection. Also, a follow-up phone call or
a survey mailed to ﬁre recipients can help in evaluating and detenrrining ﬁre outcome of ﬁre
teaching/learning effectiveness of ﬁre brochure.

The use of written material such as a brochure requires assessment of it's readability. There
are various means of assessing ﬁre readability of materials. In genera, such meﬁrods amlnpt to
“grade“ a teaching tool based upon sentence lengﬁr, number of syllables or word lengﬁr, number
of words per page, and number of illustrations per number of words (Fry, 1997; Hafner, 1996;
Klare, 1974; McLaughlin, 1969). This brochure readability was measured using SMOG formula,
which is one of ﬁre nrost common nreﬁrod of measuring readability. The variables used in ﬁre
SMOG formula includes; average number of words of 3 syllables or rrrore per 30 sentences
(McLaughlin, 1969). Also, a selection of 5 diabetic clients was used to assess ﬁre readiability for
ﬁle layperson. They were able to evaluate ﬁre level of understanding and signiﬁcance of contents
for ﬁre intended traget group Ge. diabeic clients).

Development 35

This brochure contents and organizaﬁon can also be fully evaluated by answering “yes“ to ﬁre
following questions:

1. Are sentences and item lengﬁr as short as possible?

2. Is unfamiliar jagon avoided?

3. Are instrucﬁons limited to “must Know“ facts?

4. Is infonnaﬁon organized in a logica way?

5. Is a shopping list provided for equipment/medicaﬁons?

6. Does client/family know how to idenﬁfy problems, what to look for?

7. Does clientlfamily know what to do if problems arise?

8. Who is to be called ifproblem occur?

The convenience of a peer group (2 APNs) or two diabetic educators in ﬁre state of Michigan
could be used to review ﬁre brochure's contents and effectiveness, and provide information on:
How do providers perceive ﬁre beneﬁts of using ﬁris brochure in encouraging diabeﬁc foot
self-care? What are providers currenﬁy using as diabetic educational tools to inﬂuence foot
self-care? What oﬁrer factors and or variables are important to include to self-care activiﬁes?
Answers to ﬁrese questions can be used to provide education to all providers caring for diabetes to
at least maximize ﬁre effectiveness of foot self-care as a means of maintaining long-tenn viability of
ﬁre diabetic feet

lmplcations For Advanced Nursing Practice

The irrrplicaﬁon for nursing practice will be discussed wiﬁrin ﬁle concept of 'self-care' adapted
from Orem (1995). According to Orem ﬁre nurse's goal is to increase ﬁle client's ability to perform
self-care. Self-care is deﬁned as “ﬁre practice of activrlies that maturing and mature persons
iniﬁate and perform, wiﬁrin time frames, on ﬁreir own behalf in ﬁre interests of mainta'ning life,
healﬁrful funcﬁoning, continuing personal development. and well-being“ (Orem, 1995, p. 461).

When working wiﬁr ﬁre diabetic client, ﬁre goal of ﬁle nurse in advanced pracﬁce is to

increase ﬁre diabeﬁc's self-care capabilities.

Development 36
Therefore, ﬁre diabetic client is able to achieve his/her maximum healﬁr potential and is able to
adequately care for his/her feet The nursing challenge is to idenﬁfy ways to increase awareness
of proper foot self-care among ﬁle diabetic populaﬁon. By developing an educaﬁonal brochure on
foot self-care ﬁre diabeﬁc client and or Ifamily can learn assessment behaviors ﬁlat contribute to
healﬁry feet The nurses in advanced practice, because of ﬁreir practice wiﬁlin ﬁre healﬁrcare
system, play key roles in ﬁre assessnrent education, and referra of problem in ﬁre care of ﬁre
diabetic foot The nurse in primary care can provide accessible, continuous, coordinated care to
ﬁre diabetic client and for family.

The APN (as an assessor) may already have access to a data base useful in identifying newly
diagnosed; clients at high-risk; and recovering diabeﬁcs clients, because of previous contact wiﬁr
ﬁle clinic. Because ﬁre APN develops a conﬁnuous relationship over ﬁnre ﬁre APN has ﬁre
potential to impact ﬁre diabetic client's foot self-care abilities. Self-care abilities previously
assessed may be updated and applied to ﬁre development of strategies ﬁrat enhance ﬁle diabetic
foot self-care abilities. In addition, ﬁre APN in primary care is in an idea position to assess foot
self-care skills of al diabetic clients served.

In utilizing Orem's (1995) concept, supporﬁveleducaﬁve nursing intervenﬁon, ﬁle APN can
regulate ﬁre delivery and development of foot self-care abilities, while ﬁre client himself/herself
accomplishes foot self-care. By developing an intervention to promote foot self-care ,such as ﬁre
development of ﬁris brochure, ﬁre APN can aid ﬁre diabetic client to hisﬂrer goal of foot self-ca’e.

Wrﬁrin ﬁre clinicd setting an APN has multiple funcﬁons, however in developing, distributing,
and evaluating a diabeﬁc educational brochure his/her roles are narrowed. Generally , ﬁre APN's
roles will mainly be to help in making decisions and conrrnunicaﬁng knowledge and skills. Uﬁlizing
Orem's (1995) concept, supporﬁve/educative nursing intervention, ﬁre APN will function initially as
an assessor which was previous discussed. For ﬁre purpose of ﬁris project ﬁre APN's main
functions are, educator and pracﬁtioner to promote foot self-cae.

Development 37

As educator, ﬁre APN can provide education to ﬁre diabeﬁc clients on short and long term
beneﬁts of proper foot self-care. These long term beneﬁts are decreased morbidity, nrortality and
amputations ﬁrrough prevention. Short term beneﬁts are ﬁrat ﬁrey may be able to identify and
report early changes in ﬁreir feet during daily inspection.

As pracﬁﬁoner, ﬁle APN has expert knowledge in disease processes and presents alternative
for working ﬁrrough a problem for ﬁre diabetic client and Ior family. Improving foot self-care can be
complicated if client's self-care needs we not met, ﬁre client and Ior family may need guidance.
The APN is brought in as a resource to prevent ﬁre client and Ior family from having to use Ind and
error nreﬁrod to manage care. The APN should provide needed information and periodic updating
as required. Also ﬁre APN as practitioner, can reduce individual health care cost, and treatment of
early foot abnonnaliﬁes, ﬁrrough knowledge of and uﬁlizaﬁon of dl available resources to provide
ﬁreir clients wiﬁr ﬁre best possible foot-care.

In ﬁre wake of managed care organizations controlling ﬁre healﬁr care system of ﬁris nation,
ﬁre APN's effectiveness in providing cost-effective and high-quality care need documented positve
enrollees outcomes. The implenrentaﬁon of ﬁris educational brochure by APN's ﬁrrough-out a
managed care organization (e.g., Healﬁr Alliance Plan , [HAP] ), to it's diabetic population could be
beneﬁcial to ﬁre organizaﬁonal matrix. That is, ﬁre client is provided wiﬁr preventive heaﬁr care
educaﬁon and care, ﬁre APN as an elfecﬁve primay care provider is evident and ﬁre potential
cost-saving outcomes realized by ﬁre organizaﬁon's leaders.

Realistically, ﬁris auﬁlor found it cumbersome utilizing Orem's SCDNT in ﬁre development of
ﬁre educaﬁon brochure for use in a primary care setting. Because, Orem's SCDNT is complex and
at ﬁnres ﬁre compound use of temrs leads to sonre awkwardness for ﬁre practicing nurse user of
ﬁre model. However once ﬁre various uses of tenninology (e.g., self-care actions, self-care
demand, self-care agency shared wiﬁr oﬁrers) are mastered, ﬁren ﬁre directions for nursing
pracﬁce application become clear.

Development 38

lmplicaﬁons For Nursing Education

Healﬁl care education has been emphasized in ﬁre literature as a major means to assure an
effecﬁve ﬁrerapeuﬁc management program for ﬁre diabeﬁc client and Ior family. The key to ﬁre
care of diabetes for ﬁre individual is self-care and ﬁlls is best achieved ﬁlrough ﬁre educaﬁonal
process.

The importance of foot self-care capabilities should be integrated into ﬁre curriculum on
management of ﬁre diabeﬁc client for al levels of nursing education. Speciﬁc foot care educaﬁon,
may reduced boﬁr ﬁre incidence of disease and ﬁre expense associated wiﬁr adnrission to hospital.
Also, nurses are frequenﬁy ﬁre educator to diabetic clients on various healﬁr care skills. As a
result, ﬁre nurse has nrore opportunities to address and Ior intervene in ﬁre prevention, initid
diagnosis, treatment, and education of self-care capabilities of ﬁre diabetic client

Nursing educaﬁon programs must also include ﬁre concept of self-care, especially in ﬁre
changing arena of healﬁr cae today, wiﬁr its increased focus on promotion and maintenance of
healﬁr. Diabetes and it's complicaﬁons Ge. foot ulceration, and infections) can be mininrized, and
Orem's self-care approach may be helpful in encouraging self-cae wiﬁr ﬁris client population to
increase foot self-care capabiliﬁes. Therefore, Orem's SCDNT, should be introduced at al levels
of nursing education.

The advanced nurse should be a graduate level prepared nurse. The APN should have
knowledge of healﬁr promotion and self-care, wheﬁrer it be for persons who have no disease or for
ﬁre person who have chronic healﬁr problems, is criﬁcal in our current hedﬁr care system.
Implementation of care ﬁrat focuses on healﬁl promotion and self-owe has been shown to be
cost-effective (Saﬁiet, 1992). Nursing has a tradition of placing emphasis on client education and
counseling. Clients must be prepared to beconre acﬁve parﬁcipants in ﬁreir healﬁr care. To
assure that APN can be effective in teaching and counseling, inclusion in curricula of content on

educational strategies ﬁrat we effective is necessary.

Development 39

The teaching of foot self-care in ﬁre diabeﬁc populaﬁon, can contribute to decreasing healﬁr
cae cost by decreasing ﬁre potential for complications which in turn requires hospitalizaﬁon, for
ﬁre diabetic client The APN who is Master prepared to promote early detecﬁon and self-care
educaﬁon can impact positively to ﬁre healﬁr care cost, and ﬁre overall well-being of ﬁre diabeﬁc
population and ﬁreir feet

All nurses should be informed about ﬁre perplexity of managing a chronic illness like diabetes,
especially in regards to ﬁre healﬁr and well-being of ﬁreir feet The nursing professional has an
obligation to empower clients and ﬁrus equip ﬁrem wiﬁr ﬁre knowledge to control ﬁreir diabetes
raﬁrer ﬁran to allow ﬁreir diabetes to control ﬁrem.

Implications For Future Research

The topic of ﬁle diabetic foot has been studied over a number of years and ﬁre climate of ﬁre
public seems to indicate, ﬁrat current attention given ﬁris topic will continue. Self-care in ﬁre
diabeﬁc client is also a topic ﬁrat has been frequenﬁy studied and proven eﬂfecﬁve in preventing or
delaying foot complications. However, ﬁre long-tenn effectiveness of foot self-care education will
need longitudina studies. Thus, it is reconrrrrended ﬁrat ﬁre educational tool developed in ﬁris
project be utilized at sonre point in ﬁme to address ﬁle following research questions.

1. Will ﬁre recipients of ﬁre review and take home brochure have improve retention of

foot-care knowledge?

2. Will ﬁre recipients of ﬁre review and fate home brochure have improve foot-care practices?

3. If ﬁlere's improvement in foot self-cue, is ﬁris a long or short term effect?

4. Are ﬁrere speciﬁc sociodemographic variables ﬁrat affect foot self-care education

compliances?

APN's because ﬁrey are cost-effective are being utilized for longitudind studies such as ﬁre before
mentioned reconrmendaﬁon, to collect and analyze data to see if positive outcomes are achieved.
Finding from ﬁrese studies , uﬁlizing ﬁlis brochure would be valuable in reﬁning and improving ﬁre
brochure to furﬁler enhance diabetic foot self-care education.

Development 40
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D'EIEIQIQQLJLU), 20 - 23.

Development 47
Zwemer, F. L. (1990). Arnputaﬁons in diabeﬁc Native Americans. IheELQvideLJﬂB), 117-
1120.

Development 48

Appendix
An educational brochure “Diabetic Self-Care Foot care“ for ﬁre diabeﬁc clients to enhance ﬁreir

self-care skills in ﬁre assessment and management of foot—care in a primay care seﬁing.

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