RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DISSERTATION

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|1 |Name Of the candidate and address |Mrs.Renu Rajendran, |

| | |M.Sc. Nursing 1st Year, |

| | |Noor College Of Nursing, |

| | |Bhoopasandra, Bangalore. |

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|2 |Name Of the Institution |Noor College of Nursing, |

| | |Bhoopasandra, Bangalore. |

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|3 |Course of the Study and Subject |M.Sc Nursing 1st Year, |

| | |Medical Surgical Nursing. |

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|4 |Date of Admission to the Course |29 – 06 - 2008 |

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| | |“Effectiveness of structured teaching programme on the |

|5 |Title of the Topic |knowledge and practice on prevention of diadetic foot ulcer |

| | |among patients in selected hospitals at Bangalore”. |

6. Brief resume of the intended study

Introduction

Diabetes Mellitus is a group of metabolic disorders characterized by elevated levels of

glucose in the blood (hyperglycemia), resulting from defects in insulin secretion, insulin action or both.American Nurses Association expert committee and classification of diabetes mellitus (2003).

Diabetic foot ulcers are the most common foot injuries leading to lower extremity amputation.The long term effects of hyperglycemia contribute to macro-vascular complications such as coronary-artery disease , ceribro-vascular disease , micro-vascular and neuropathic.The foot is particularly vulnerable to circulatory and neurological disorders , so that even minor foot injuries can lead to ulcerations and infections.Foot ulcers , amputations are a major cause of morbidity,disability and costs for people with diabetes.American Diabetic Association (1998).

More than 120 million people in the world have diabetes mellitus and too many of these

subjects suffer from diabetic foot ulcers which may eventually lead to an amputation. In 1995, India had

19.4 million diabetes compared to 16 million in China which comes second. According to WHO, by 2025 India will have 57.2 million diabetics while China will have 37.6 million diabetic patients.

According to Boulton (2004), the “ Triad of neuropathy, deformity and trauma is present in almost two thirds of patients with foot ulcers”. It is widely known that diabetic foot ulceration is a significant end stage complication of diabetic mellitus.

The relationship between a patient with diabetes and the health care team is unique. Unlike Patients with most diseases who simply carryout their physician’s instructions, people with diabetes must make important daily decisions on their own regarding their medical care. These decisions determine in large part how well the patient’s diabetes is controlled and thus how susceptible they are to complications. All of this demands a rather sophisticated knowledge base by the patient, one that can be formed only through ongoing education with the support of a multidisciplinary team approach.

Need for the study

Chronic complications of diabetes mellitus isimportant implications for planning nursing care irrespective of where the patient is at home or in hospital. The nurse should carefully assess his nursing needs giving special consideration to risk associated with impaired circulation and sensation, increased risk of infection and delayed healing. Recognition of these risk factors will enable care to

accommodate the patient’s particular vulnerabilities and will help to ensure that suitable educational

support is provided to prevent complications

American Diabetes Association (1998) states that risk identification is fundamental for effective management of the foot in people with diabetes. The early recognition and management of the risk factors for ulcers and amputation can prevent , delay the onset of these adverse outcomes. Patients with diabetes and high risk foot conditions should be educated regarding their risk factors and appropriate management. Most foot lesions can be prevented by a health teaching for the patients.

Peter B (1997) conducted a study to assess the influence of patient’s knowledge on prevention of diabetic foot ulcers among diabetic patients in selected hospitals.A total of 150 samples and descriptive research design was choosen for the study.A structured questionnaire were used to collect data and descriptive influencial statistics is used for the data analysid.Study results showed that the patients who had higher knowledge on prevention of diabetic foot ulcers had a less incidence of diabetic ulcer than the patients those who had lesser knowledge.

A Whittemore (2000) reported that nurses play a major role in the early detection, ongoing assessment and prevention of diabetic foot ulcers among diabetic patients.Nurses need to have a periodic assessment and health education on the prevention of diabetic foot ulcers.

Since nurses play a vital role in the care and management of diabetic patients should have adequate knowledge on prevention of diabetic foot ulcers.Nurses should educate the patients on various complications of diabetis and its preventive measures.Patients also expected to have knowledge on self-care management on the prevention of diabetic complications.These factors made the investigatore to conduct a study on “ A structured teaching programme on the knowledge and practice of prevention of diabetic foot ulcersamong patients in selected hospitals”.

6.2 Review of literature

The review of literature refers to an extensive, exhaustive and systematic examination of publications relevant to the research project. Qualitative research is typically conducted with in the context of previous knowledge. A through literature review provides a foundation on which to base new knowledge and usually conducted well before any data is collected in qualitative studies. A familiarization with previous studies can also be useful in suggesting research topics or in identifying aspects of a problem about which more research is needed .

Literature review was done for the present study and presented under the following headings.

1. Studies related to diabetes mellitus.

2. Studies related to diabetic foot ulcers.

3. Studies related to structured teaching programme.

1.Studies related to diabetes mellitus.

Nursing research studies in the areas of metabolic and endocrine function continue to

focus on issues associated with diabetes and factors affecting its management.

Mc Daniel G (1993) studied the effect of post teaching telephone follow up on patients self care behaviors and knowledge.31 elderly patients with diabetes mellitus were randomly assigned to experimental and control groups. Subjects in the experimental group were contacted by telephone within 28-48 hour after discharge from the hospital. The calls were repeated at weekly intervals for 3 weeks. Each phone call consisted of assessing the subject’s self care knowledge and practice in self care activities or behaviors.Supplimental instructions were provided when indicated. Subjects in the control group did not receive a phone call after discharge from the hospital. Diabeticself care knowledge and self care behavior were assessed in both groups and the result indicated that the experimental group had higher scores in knowledge and self care behavior than control group.

Strojek K (2000) in his study on “Features of macro vascular complications in type II diabetic patients”, recommended that a careful assessment of clinical symptoms followed by preventive diagnosis of high risk patients as well as proper patient education allow for significant reduction of the consequences of macro vascular complications in diabetic patients.

Goldfracht (2000) conducted a nation wide program in Beersheva; Israel, for improving the effectiveness of primary care providers to monitor and control glycemic level of diabetic patients. A retrospective cohort study approach was used for the study. Totally 876 physicians participated in the study. Samples were selected randomly from the clinics and patients were selected from register entries. The data analysis was carried out by descriptive statistics.The study found that the glycemic control improved especially with in the group with highly uncontrolled diabetes .The implication of this study was that effective care by primary health care providers resulted in improvement of glycemic level in patients with diabetes.

2. Studies related to diabetic foot

Mc Dermott J E (1993) observed that diabetes remains the world leading cause of amputation. Prevention is the key to successful management. Patient education efforts coupled with a team approach of aggressive early management represent the optimum current strategy.

Christoph (1996) conducted a study to find out the incidence of amputations and their relative risks in diabetes patients.The study reports were compared to the non-diabetic population. The samples ware selected from hospitals of approximately 160, 000 inhabitants. A survey approach was used. The result indicated that the incidence of amputations was 33.8% in diabetic population and 9.4% in non-diabetic population. The relative and population attributable risk indicates that improving foot care in diabetic individuals appears to be the main reason for the reduction of amputation rate from 90% to 46%.

Journal of American Medical Association (2004) emphasize that diabetic foot ulcer is a major health problem, which require multidisciplinary approach with permanent patient education as its essential part and a specific co-operation of all levels and different health care specialties.

Sheelian (2003) conducted a study to assess the effect of health teaching on prevention of diabetic foot ulcers among patients in selected diabetic health centers.A Quasi experimental research design and a sample of 100 was utilized for the study.Health teaching on prevention of diabetic foot ulcer was given as intervention for the samples.The results showed that increased level of knowledge on prevention slowed down the progression of diabetic foot ulcer among diabetic patients.

3. Studies related to structured teaching program.

New milestones in diabetes management is the role of laymans in developing the concept

of diabetes management parallelly with the evolution from a patient to a consumer. Education may

result in improved self-care practices, and demonstrably improves the parameters of emotional well

being. In addition to addressing self-care practices education had been shown to improve diabetic

foot care.

Kahn and Weir (2006) reported that the education of people with diabetes influences their understanding, attitudes and practices related to living well with diabetes. Educational program empowers those with diabetes to achieve optimal self-management of their education. The authors

are in the opinion that the goal of any educational program is to help patients with diabetes gain knowledge and skills that enable them to care for themselves and to develop the attitude that will

enable them to make behavioral changes.

American Diabetes Association (2000) reported that Diabetic self-management education is usually best when provided in outpatient or home setting. They are of the opinion that the involvement of health professionals in assessment of patients for the planning of care and for self management can improve their knowledge level in preventive aspects.

Ecker. J (2004) did a project to demonstrat the feasibility of structured treatment and teaching program for Type 2 diabetic patients in order to improve the overall quality of care.A total of 100 samples were selected for the study.A structured questionnaire were used to collect the data and descriptive influencial statistics is used for the data analysis.The result of the study indicate that establishing a structured treatement and teaching programme can improve the quality of diabetes therapy in preventing diabetic foot ulcer.

6.3 Statement of the problem

A study to assess the effectiveness of structured teaching programme on the knowledge and practice on prevention of diabetic foot ulcer among patients in selected hospital at Bangalore.

3. Objectives of the study

1. To asses the knowledge on prevention of diabetic foot ulcers among diabetic patients.

2. To assess the level of practice on the prevention of diabetic foot ulcer among diabetic patients.

3. To determine the effect of structured teaching programme on the knowledge and practice of prevention of diabetic foot ulcers among diabetic patients.

4. To associate the selected demographic variables with level of knowledge and practice of prevention of diabetic foot ulcers.

6.4 Hypothesis

There will be a significant difference in the level of knowledge and practice regarding prevention of diabetic foot ulcers among patients who had a structured teaching programme than who did not.

6.6 Operational definitions

1. Effectiveness:

It refers to the act of estimation.

2. Structured teaching program:

It refers to a systematically organized teaching strategy for one hour duration on care of diabetic foot ulcers. It includes the information regarding diabetes mellitus, its complications, the prevention and care of diabetic foot ulcers

3. Diabetic foot ulcer:

Soft tissue injury of the foot, formation of fissure between the toes or in an area of the dry skin or formation of callus due to diabetes.

4. Knowledge:

It refers to the information on diabetic foot ulcers and its preventive measures.

6.7 Assumptions

1. Lesser knowledge will lead to higher incidence of diabetic foot ulcer.

2. Knowledge enhances practice.

3. Practice results in less incidence.

6.8 Delimitations

1. The study is delimited to selected hospitals in Bangalore.

2. The study delimited to patients with diabetis mellitus.

Materials and methods

7.1 Sources of data

It includes 30 patients with diabetic foot ulcer undergoing treatment in selected hospitals at Bangalore.

7.2 Methods of data collection

Research method : Evaluative approach

Research design : Quasi experimental method,

Single group-pre and post test design.

Sampling technique : Non probability convienience sampling technique

Sample size : 30 diabetic patients with foot ulcer

Setting of the study : The study will be conducted in selected hospitals at Bangalore.

7.2.1 Sampling criteria

. Inclusion criteria

1. Age group between 21-70 years.

2. Both male and female.

3. Patients with diabetis mellitus.

4. Patients who are willing to participate.

5. Patients who can understand,read,write or speak English or Kannada.

Exclusion criteria

1.Patients who have already developed a diabetic foot ulcer.

2.Patients who are not co-operative.

.

7.2.2 Data collection tool

A structured questionnaire and structured scale will be utilized to collect the data on knowledge and practice on prevention of foot ulcers amongdiabetic patients.

3. Data analysis method

The data obtained will be analysed in terms of objectives of the study using descriptive and inferential statistics.Frequencies and percentage will be used for analysis of demographic data. Mean pretest and post test will be done.A ‘t’ test will be done to determine the significant difference between mean pretest and post test knowledge scores of the group.‘Chi-square’ will be done to determine the association between mean pretest knowledge score and demographic variables of the subjects.

7.3 Does the study require any investigation or interventions to be conducted on patients/humans/animals?

YES

Structured teaching on knowledge and prevention of diabetic foot ulcer is given as intervention.No other experimentation is carried out.

7.4 Has ethical clearance been obtained?

YES

Permission was taken from the concerned authority in the hospital to conduct the study. Oral consent was received from the subjects after explaining the purpose of the study.

8.List of references:

1. Asian Williams (2006); The Diabetic Foot: The role of the Podiatrist;

“Journal of Community Nursing”; 20(11); 39-41.

2. Basavanthappa B T (2003); “Medical Surgical Nursing”; Jaypee; New Delhi; 711.

3. Corce F (1999); Diabetic Foot; “Diabetes Care”; 23(6).

4. David Moreau (2004); “Straight A’s in medical surgical nursing”; Lippincott Williams and

Wilkins; Philadelphia; 292–295.

5. Harshmohan (2005); “Textbook of pathology”; 5th Ed; Jaypee; New Delhi; 1243–1288.

6. Humprey, Thomas, Dowse, Zimmet (1996); A survey to Measure the 12 Year Incidence of

Nontraumatic Lower Extremity Amputations in Nauracians. (Abstract from Medline).

7. Larson K (1995); Decreasing Incidence of Major Amputation in Diabetic Opatients; A

Consequence of a Multidisciplinary Foot Care Team Approach (Unpublished thesis).

8. Legette and Francier N (1994) A study to assess the diabetic knowledge of nurses in long team

care facilities ( Unpublished thesis).

9. Mary Y Sleggreen (2006); step-up care of Diabetic Foot Ulcers; Nursing Management;

“The journal of Excellence in Nursing Leadership”; 25-31.

10. Mohan V (1999); Diabetic Control and Complication Trail; “International Journal of

Diabetes”; 24(2).

11. Polit, Beck and Hungler (2001); “Essentials of Nursing Research, Methods, Appraisal and

Utilization”; 5th Ed. Lippincott Williams & Wilkins; U.S.

12. Potter A P & Perry G A (2005); “Fundamentals of Nursing”; 6th Ed. Mosby; St Louis.

13. Smith J (2006); A Study to Assess the Evidedence for the Effectiveness of Debridement as a

Treatment for Diabetic Foot Ulcer; “British Journal of Medicine”; 4.

14. Spencer (2004); Effectiveness of Various Offloading Modalities to Treat of Diabetic Foot

Ulcer; “Diabetes care”; 27; 635-636.

15. Sr Nancy (2002); “Stephanie’s Principles and Practice of Nursing”;

3rd Ed. N R Indore; 2; 1-44.

16. Suzanne C, Smeltzer, Brenda G Bare (2004); Brunner and Suddarth’s “Text Book of

Medical Surgical Nursing”; 10th Ed. Lippincott Williams and Wilkins; Philadelphia;

1150-1200.

Electronic source:







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|9 |SIGNATURE OF THE CANDIDATE | |

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|10 |REMARKS OF THE GUIDE | |

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|11 |NAME AND DESIGNATION | |

| |11.1 GUIDE | |

| |11.2 SIGNATURE | |

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| |11.3 CO – GUIDE | |

| |11.4 SIGNATURE | |

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| |11.5 HEAD OF THE DEPARTMENT | |

| |11.6 SIGNATURE | |

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|12 |12.1 REMARKS OF THE | |

| |CHAIRMAN AND PRINCIPAL | |

| |12.2 SIGNATUTE | |

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