Approximately 40%-60% of all lower-limb amputations are conducted in patients suffering from diabetes mellitus (Apelquist & Larson, 2002). Unfortunately, more than 85% of these cases are the result of a diabetic foot complication that has been caused by deep infection and gangrene (Apelquist & Larson, 2002). The risk of undergoing a lower limb amputation is twenty times higher in people with diabetes mellitus than in the general population (Apelquist & Larson, 2002). The major causes of morbidity, disability and emotional and physical losses in persons with diabetes mellitus are amputations of lower limbs and diabetic foot (Apelquist & Larson, 2002). It is therefore important to implement a prevention strategy to reduce the incidence of the diabetic foot and its related complications in at-risk populations. This paper provides an anticipatory care plan for the diabetic foot in the North Batinah region in Oman. The care plan entails: opening diabetic foot clinics and training nurses to work in the clinics; screening of feet at risk and professional foot care; education of patients, caregivers and healthcare providers; and provision of adapted footwear for diabetics.
Profile of the Area of Practice
The number of patients diagnosed with diabetes mellitus in the North Batinah region in Oman is high. For instance, the number is 3521 in Sohar, 6900 in AL Suwaiq, 2505 in Al Khabura, 1758 in Shinas and 1003 in Liwa. The high incidence rate of diabetes mellitus in the region has increased the chance of the development of diabetic foot problems in most patients in the region. Therefore, prevention strategies that would result in a fall in the incidence of the diabetic foot need to be given great importance (Trautner et al., 1998).
The Need for Anticipatory Care
The early diagnosis and management of risk factors such as ischemia and infection may hinder or delay the development of diabetic foot (Boyko et al., 1999). The risk of ulcers and amputations is higher among persons who have had diabetes for more than 10 years (Rangnarson & Apelquist, 2001). The risk is also higher in men and in those with poor control of glycemia and/or cardiovascular, retinal or renal problems (Rangnarson & Apelquist, 2001). An increased risk of amputation is related to a number of conditions which include: “peripheral neuropathy with loss of protective sensation, altered biomechanics (in the presence of neuropathy); evidence of increased pressure; bone deformity; peripheral vascular disease; a history of ulcers or amputation; and severe nail pathology” (Rangnarson & Apelquist, 2001, p. 2079). Strategies that can be used to reduce the risk of diabetic foot or subsequent lower limb amputations have been examined by Boyko et al. (1999) who report more than 50% effectiveness of preventive programs, execution of clinical guidelines in primary health care, patient education, foot care and wearing of suitable footwear, education of healthcare professionals as well as a multidisciplinary approach to the minimization of the incidence rate of amputations in diabetic patients. Thus, in order to reduce the development of diabetic foot and lower limb amputations, and anticipatory care approach is needed.
The Anticipatory Care Plan
The anticipatory care plan for the reduction of diabetic foot incidence is based on the anticipatory care model and consists of the following strategies: opening diabetic foot clinics and training nurses to work in the clinics; screening of feet at risk and professional foot care; education of patients; and provision of adapted footwear for diabetics.
Opening diabetic foot clinics and training nurses to work in the clinics
The first strategy will involve opening a diabetic foot clinic in the 6 polyclinics in the region and train six registered nurses to work on these clinics. The clinics will exclusively focus on diabetic foot care. The nurses will receive extensive training on the care of diabetic foot thereby enhancing the professionalism of the healthcare professionals as far as the diabetic foot is concerned.
Screening of feet at risk and professional foot care
Screening of feet at risk will be conducted in each of the patients who come to the clinics. Specifically, the screening will be done on patients who are diabetic or who are at risk of developing diabetes. The patients who visit the diabetic foot clinics will be referred to the clinics by their physicians from the polyclinics. The screening will entail “the history on the potential prior ulcers and/or amputations, an inspection of the patients’ feet (for deformities, bone prominence, callus, skin integrity, joint motility, and discoloration) as well as their footwear, assessment of pulse at dorsal arteries of the foot and posterior tibial artery, and neuropathy testing (using neuropathy disability score, monofilament, tuning fork or cotton wool)” (Armstrong et al. 1998, p. 290). These are the most up-to-date screening techniques. The screening will enable the clinics to implement the appropriate education and management strategies so as to minimize the risk of complications arising and/or developing.
Foot care in diabetics is particularly important, but it necessitates special knowledge and skills. This is because errors in treatment can have adverse results (Van Houtum et al., 1996). According to Van Houtum et al., “between 13% and 30% of all foot lesions are related to foot injuries (either self-inflicted by the patient or by professional chiropodists)” (p. 329). Insufficient foot care or lack of high hygienic standards also contributes highly to foot complications. Foot complications are also caused by using instruments that eliminate horny skin, inaccurate or incorrectly used foot care tools such as tweezers, scissors, and razor blades, and extremely long or hot foot baths. Suitable foot care treatment will include: “care of callus; removal of corns; care of inter-digital spaces; treatment of fissures, macerations and fungal diseases; nail care; and the careful correction of nail deformities” (Van Houtum et al., 1996, p. 330).
The recognition of pathological foot changes and the evaluation of patients’ footwear and stockings will be done by extensively trained chiropodists. The treatment of an ingrown toenail, which was traditionally done through surgery will be effectively treated conservatively by the trained nurses through packing, pressure relief and, where needed, antibiotics. This is because surgery done on the diabetic feet is linked to a higher risk of gangrene later on (Van Houtum et al., 1996). Self-administered foot care, which involves caring for the feet by the patients themselves, is particularly important for elderly patients because it will significantly reduce foot injuries.
Education of patients and caregivers
Besides professional foot care, education of patients is another important strategy. The education program will involve all patients who have been identified through screening as having a high risk of developing diabetic foot. The main objective of the education program is to improve the motivation of the patients and their skills in diabetic foot care. Patients will be informed, through education sessions and educational materials such as books and magazines, on how to identify possible foot complications and to take appropriate actions in the event that they actually occur (Boyko et al. 1999). The education sessions will be conducted on different occasions such as during the patients’ first visit, during screening and during subsequent visits. The education sessions will be conducted using different techniques such as chart demonstrations, practical demonstrations and through normal dialogues between the patients and the healthcare professionals. After every education session, the healthcare professionals will assess the patients’ understanding, motivation and level of competence in foot care through questions-and-answers discussions.
The education sessions will be conducted in stages according to the content that will be provided. The content of the sessions will include: daily foot inspection, including areas between the toes; if the patient cannot inspect the feet, someone else should do it; regular washing of the feet with careful drying, especially between the toes; the temperature of the water should always be less than 37 °C; avoidance of walking barefoot in- or outdoors, and of wearing shoes without socks, avoidance of using chemical agents or plasters to remove corns and calluses; daily inspection and palpation of the inside of the shoes; in case of impaired vision, the patients should not try to treat the feet by themselves; the use of lubricating oils or creams for dry skin but not between the toes; daily change of stockings; wearing stockings with seams inside-out or preferably without any seams at all; cutting nails straight across; avoidance of cutting corns and calluses by patients but by a health care professional; ensuring that the feet are examined habitually by a health care professional; and the patient should notify the health care provider immediately if a blister, cut, scratch or sore develops (Ortegon et al., 2004). In addition to foot care, all patients will be adequately educated about the significance of stopping smoking and attaining good control of glycemia as a component of the prevention of the development of diabetic foot and subsequent amputation of lower limbs. The sessions will be conducted every Saturday and the entire education program will take two months. Therefore, every year will have six education programs.
In order to reap maximum benefits from the education program, the education will be conducted in a simple, appropriate and consistent manner. This means that the same verbal and written statements will be made and the key message will be repeated over and over again. The appropriate use of language within the education materials and sessions is of particular importance because the majority of the patients with a high risk of developing diabetic foot are non-medical persons. Therefore, the use of medical jargon and vocabulary will be avoided to enable the patients to understand the message and the education materials (Klonoff & Schwartz, 2000). The education program will use a problem-oriented approach which will help the patients to understand the importance of gaining the necessary knowledge rather than having the feeling that they are being coerced into learning. The goal and technique of education will be tailor-made to every patient depending on their socio-economic background and their needs. The reason for this is that patients can only benefit from education if the education succeeds in modifying the habits and behavior patterns of the patients (Apelquist & Larson, 2002).
The inclusion of patients’ relatives and carers in the education program will be done especially for vulnerable populations such as children and the elderly. This is because such patients are not in a position to adequately care for themselves and therefore require other people to take care of them (Muller et al., 2002). The type of education the relatives and carers will receive is no different from the one the patients will receive. This will ensure that both patients and their relatives/caregivers are at par as far as information on care is concerned. In addition to educating patients on foot care, the education will also extend to the actions they should take if and when they develop foot complications and what to do if their physicians recommend the amputation of their limbs (Foster, 1997). On a final note, it is important to note that identifying patients who are at risk of developing diabetic foot recognizing early signs of changes in the diabetic feet are the most crucial duties of diabetic foot clinics. This is because they significantly reduce the chances of the development of diabetic foot and further complications that lead to limb amputations (Edmonds & Foster, 2005).
Provision of appropriate footwear for diabetics
Frykberg (1997) argues that “between 28% and 55% of all foot lesions in diabetics are related to footwear” (p. 307). One of the strategies of this anticipatory care plan is to provide appropriate footwear for diabetic patients in the region. The clinics will sign a contract with a local footwear manufacturer to produce and deliver diabetes-appropriate footwear. The clinics will then provide the footwear to the at-risk patients. The fundamental features of appropriate footwear for diabetics include low heels to protect the forefoot from enhanced pressure, a wide forefoot that is not stiff in the toe region and adequate space to be able to take an elastic insole (Holstein et al., 2000). Additionally, the shoes should be made of high-quality soft leather especially on the upperparts and internal stitches should not be used. In addition, “a sole stiffening plate with a rocker sole is among the design features of suitable protective shoes for diabetics used to minimize plantar pressure” (Apelquist, 1998, p. 26). Such shoes reduce pressure in the sole region by approximately 40–50% (and 60% compared to barefoot walking) because the shoes have suitable multi-layered insoles in comparison with the normal shoes. Stockings that have been specially padded will also be provided to the at-risk patients to further reduce pressure load and the impact of shear forces. To take into consideration those patients who will refuse the special shoes (this is a possibility), such patients will be provided with sufficiently deep-running shoes (Lavery et al., 2004).
Evaluation of the Strategies Employed in Assessing the Impact Gains
The major objective of this anticipatory care plan is to reduce the chances of the development of diabetic foot among diabetic patients in the North Batinah region in Oman. If this is achieved, then the incidence of the diabetic foot, as well as the number of lower-limb amputations in the region, will be significantly reduced. The incidence rate of the diabetic foot and the number of lower limb amputations will be used as the measure of the effectiveness of the anticipatory care plan. This plan will have several other benefits. First and foremost, the costs incurred by patients (as well as clinics) in managing and treating diabetic foot complications will be significantly reduced. This is because the focus of the plan is on prevention (before the condition occurs) rather than on treatment. As a result, clinics will see fewer cases of the diabetic foot and its related complications (Edmonds & Foster, 2005).
The second benefit is increased knowledge about diabetic foot among the population in the region. The education program of the plan will ensure that the population is well informed about how to take care of the feet of the diabetic patients, what to avoid and what to do in case a foot problem develops. Such crucial knowledge will be gained not only by patients but also by their relatives and other carers thus ensuring the continuity of care at home (Edmonds & Foster, 2005). Most importantly, healthcare professionals will also gain advanced knowledge and skills required for ineffective management, treatment and prevention of diabetic foot.
This anticipatory care plan aims at addressing the diabetic foot problem in the North Batinah region in Oman through prevention rather than treatment. The impact of the plan will be evaluated by: the incidence of the diabetic foot and related complications (a lower incidence rate will translate into the success of the plan), the number of visits made to the clinics (fewer visits will mean that patients have the knowledge and skills to take care of their feet) and the costs incurred in the management of diabetic foot and its related complications (lower costs will translate into the success of the plan).
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Appendix A: The Anticipatory Care Plan
|Opening diabetic foot clinics and training nurses to work in the clinics||2 months|
|Screening of feet at risk and professional foot care||Ongoing|
|Education of patients and caregivers||2-month program: 6 sessions every year|
|Provision of adapted footwear for diabetics||Ongoing|