Rajiv Gandhi University of Health Sciences Karnataka



“A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON KNOWLEDGE REGARDING DIABETIC WOUND DRESSING AND WOUND CARE PRACTICES AMONG STAFF NURSE AT SELECTED HOSPITALS AT TUMKUR”

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

Miss NISHI RANA

MEDICAL AND SURGICAL NURSING

Akshaya College of Nursing,

Tumkur, Karnataka.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. Name of the Candidate : Miss Nishi Rana

And address M.Sc Nursing, 1st Year

Akshaya College of Nursing,

Tumkur, Karnataka.

2. Name of the Institution : Akshaya College of Nursing

3. Course of Study : M.Sc. Nursing 1st year,

And Subject MEDICAL AND SURGICAL NURSING

4. Date of Admission to : 30-10-2011

Course

5. Title of the Topic : “A study to assess the effectiveness of planned teaching programme on knowledge regarding diabetic wound dressing and wound care practices among staff nurse at selected hospitals at Tumkur.

6. BRIEF RESUME OF THE INTENDED WORK

6.1INTRODUCTION

“The most important practical lesson that can be given to nurses is to teach them what to observe”

Florence Nightingale

Diabetes mellitus is a group of metabolic disease characterized by increased levels of glucose in the body (hyperglycemia) resulting from defects in insulin secretion, insulin action or both2. In diabetes the cells may stop responding to insulin entirely. Long term effects of hyperglycemia contributes to (coronary artery disease, cerebrovascular accident, peripheral vascular obstructive disease), chronic micro vascular complications (kidney and eye disease) and neuropathic complications (diseases of the nerve) 1.

In United state an estimated 20.8 million people or 7% of the population has diabetes mellitus. And 41 million more people have prediabetes. The long term complications of diabetes are what make it such a devastating disease. Diabetes is the leading cause of adult blindness, end stage renal disease, and diabetic foot ulcerations, leading to lower limb amputations.1 Between 50 % to 75 % of lower extremity amputations are performed on people with diabetes. More than 50% of amputations are thought to be preventable, provided patients are taught foot care measures and practice them on daily bases.2

Foot complications are the most common cause of hospitalization in the person with diabetes 3. The development of foot ulcers complications is a multifactorial process 4. The diabetic foot covers the spectrum of neurological, arterial and infectious foot problems that occur as a consequence of diabetes5. From 50% to 75% of lower extremity amputations are performed on people with diabetes. More than 50% of these amputations are thought to be preventable, provided patients are taught foot care measures and practice them on a daily basis (ADA, Preventive Foot Care in People With Diabetes, 2003).6 Foot assessment and foot care instructions are most important when caring for patients who are at high risk for developing foot infections.6The treatment consists of effectively alleviating mechanical pressure from the wound (i.e. prevention of repeated trauma by walking on the ulcer) on the one hand, and using adequate local care on the other hand7. The best treatment however aims at prevention of foot ulcers6. It requires the knowledge of about the path physiological mechanisms of diabetic foot, the screening for feet at risk, and the education of the patient, family and the health care providers8.

Education plays a vital role in prevention of foot ulcers from sepsis. The aim is to increase motivation and skills and knowledge that enhance the nurse in wound caring. Despite being one of the most serious and costly complications of diabetes, foot complications are effectively prevented. The multidisciplinary treatment of foot ulcers, appropriate organizations, close monitoring and education of people with diabetes and health care professionals, it is possible to reduce amputation rates by up to 85% 9. Education regarding proper wound dressing in aseptic method, control of diet, proper wound care in home, regular health check up, and use of proper insulin in time, those reduces the risk wound sepsis and reduces chance of lower extremity amputation.

6.2 NEED FOR THE STUDY

Diabetes is the fourth leading and a serious health problem that lead to cause of death globally and its prevalence is increasing rapidly. The burden is particularly harsh in low or middle income countries, where many children with type -I diabetes die because they lack access to life saving insulin and where many do not receive the education required to delay and prevent complications1.

According to World Health Organization (2009) the total number of people with diabetes worldwide is 171 million in 2000 and is projected to rise up to 366 million in 203011. International working group on the diabetic foot (2005) estimated that each year, around 3.8 million adults die from diabetes related causes, i.e. 6 deaths every minute. It is estimated that 250 million people worldwide have diabetes representing roughly 6% of the adult population (20-79 age group). The number is expected to reach 380 million by 2025, representing 7.1% of the adult population10.

According to WHO (2009) The top 10 countries suffering from diabetes are India, China, USA, Indonesia, Japan, Pakistan, Russia, Brazil, Italy and Bangladesh . Recent studies in China, Canada, USA, and several European countries have shown that feasible lifestyle intervention can prevent the onset of diabetes in people at high risk. Overall direct health care cost of diabetes ranges from 2.5% to 15% annual health care budget of a country. According to Centers for Disease Control and Prevention (CDC - 2009) from 1980 to 2000, the number of Americans with diabetes is more than double. Currently, it is estimated that almost 21 million people in the US are affected by diabetes; by 2030 this figure is expected to exceed 30 million. 2

According to International Diabetic Federation in 2006, "the disease now affects a staggering 246 million people worldwide, with 46% of all those affected in the 40-59 age group. This survey shows nearly 60% of the patients are suffering from diabetic complications. The new data predict that the total number of people living with diabetes will skyrocket to 380 million within twenty years if nothing is done."12

American Podiatric Medical Association 2006 new survey commissioned by the American Podiatric Medical Association (APMA) discovers that problems are particularly challenging among Hispanic-American patients, finding that One-third of Hispanic Americans without diabetes report foot and leg problems, according the APMA survey. These lower-extremity problems include numbness, tingling or burning, as well as cramping calves, which are all precursors of diabetes, according to the survey of 600 patients. The APMA says the survey results are in line with statistics from the Centers for Disease Control and Prevention, which estimates that almost half of the 2.5 million Hispanic Americans with diabetes do not know they have the disease. 13

National diabetes statistics (2007) in a survey on prevalence of diagnosed and undiagnosed diabetes in US, in all age group in 2007, showed that total diagnosed patients are 23.6 million people, i.e. 7.1% of total population has diabetes. In this 17.9% people are diagnosed and 5.7% people are undiagnosed. There are approximately 798,000 new cases of diabetes which are diagnosed annually in the United States. The incidence rate is 1 in 340or 0.29%43. In MMWR Weekly (2008) a report summarized that annual age incidence of diabetes is 5-12.8 per person in US. The incidence increased 90% from 4.8 per 1,000 in 1995-1997 to 9.1 in 2005-2007. 14

The International Diabetes Federation (IDF) has proclaimed 2005 to be the "Year of the Diabetic Foot." Together with the International Working Group on the Diabetic Foot and related wounds, the IDF has launched a year-long campaign to raise awareness of the diabetic foot worldwide. In this organizations are briefly described, an overview of the aims of the global awareness campaign is given, and the activities to promote World Diabetes Day in 2005 are outlined. Attention is also paid to present and future developments to improve the standards of diabetic wound care worldwide12.

Dr.Kshitij shankhdhar 2008 conducted a study about diabetes and diabetic wounds in India and stated that diabetic foot is the most complication and that cause increase mortality and morbidity in diabetic patients. Diabetic wound care is one of the ignored aspects of diabetic care in India. Due to social religious and economic compulsions many people walk bare foot. This lead to inappropriate usage of foot wear and late presentation of foot lesion. India has 42 million people with diabetes and related complications; put it first on the list of the 10 nations most affected by this disease. The study on 18,000 people in India reveals that 70% of undiagnosed diabetes mellitus, which is higher than expected. In this 25% of those with diabetes may develop diabetes ulcer. 15

Infectious Diseases Society of America (IDSA) In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific for these infections. The following year, the Infectious Diseases Society of America (IDSA) published their Diabetic Foot Infection Guidelines. In this review some of the critical points from the Executive Summary of the IDSA document Diabetic foot infections are a common and often serious problem, accounting for a greater number of hospital bed days than any other complication of diabetes. The patients who admitted in hospital with diabetes need more care from infections, use of antibiotics, OHA’s, and proper wound dressing and foot care. 16,

6.2REVIEW OF LITERATURE

The review of literature is an integral component of any study of research project. It enhances the depth of knowledge and provides a clear understanding regarding a topic. It refers to an extensive, exhaustive and systematic examination of publications relevant to the research project11. This chapter presents a review of selected literature relevant to the study which is discussed under the following headings:

1. Literature related to importance of diabetic wound dressing and care practices among nurses.

2. Literature related to assessment of knowledge of aseptic dressing practices and care of diabetic wound in diabetic patients among staff nurse.

3. Literature related to effectiveness of self instructional module on dressing practices and care of diabetic wound in diabetic patients among staff nurse.

1. Literature related to importance of diabetic wound dressing and care practices among staff nurses

A study was conducted to investigate the use of dressings on patients with diabetic foot ulceration. This paper reports the results of a non-comparative, two-centre study investigating the performance characteristics of SeaSorb dressing in patients with this condition. The study was conducted on 41 patients. The relative ulcer area showed a significant decrease from 100% to 33%. A total of 12 adverse events were reported: seven mild to moderate and five severe. None were directly attributed to the study dressing. 21

A study was conducted to compare the efficacy and tolerance of an alginate wound dressing with Vaseline gauze dressing in the treatment of diabetic foot lesions. Seventy-seven patients were enrolled. The study concluded that As compared with Vaseline gauze, calcium alginate appears to be more appropriate for topical treatment of diabetic foot lesions in terms of both healing and tolerance. 22

A study was conducted to determine the importance and effectiveness of aseptic silver-releasing dressing in the management of infected chronic diabetic wounds. The review included randomised or non-randomised control trials. Of the over 1957 potentially releasing studies examined. This review strengthens the case for the use of silver dressings when managing infected chronic wounds. 23

A study was conducted to compare the importance of the sustained silver-releasing foam dressing with local best practice (LBP) on delayed healing diabetic ulcers using a real-life setting. A total of 619 patients with ulcers of varying etiologies were treated for four weeks with either the silver foam dressing or LBP. This study shows that the silver foam dressing supports faster healing of delayed healing wounds. 24

A study was conducted to assess the clinical use of advanced biological therapies in treating diabetic foot ulcers in practice and the effect of these therapies on time to healing. This was a retrospective cohort study. 2517 patients with diabetic neuropathic foot ulcers. The study reveals that there were much more improvement Advanced biological therapies within 1 month, and improved healing of refractory diabetic foot ulcers. Differences on outcomes among advanced biological therapies were noted. 25

2. Literature related to assessment of knowledge on dressing practices and care of diabetic wound in diabetic patients among staff nurse.

A comparative study examining diabetic patients in Tanzania and Sweden with a quantitative approach. The aim of the current study was to present the outcome of clinical nurse performed foot examinations in comparsion with Tanzanians and Swedish patients. 145 diabetic patients in each country were examined, matched in gender and age. This study concluded that Nurse performed foot examinations showed that the Tanzanian diabetic patients in this study had poorer foot status than the Swedish study sample. 26

A prospective cohort study of newly hospitalized, adult diabetes patients with foot ulcers was conducted. 627 diabetes patients evaluated during the study period, 92 (15%) had diabetic foot ulcers. Of these 92 patients, 30 (33%) were selected for surgery (minor and major amputations). This study reveals that Diabetic foot ulcers are associated with significant morbidity and mortality in Tanzania. Education of patients should underscore the importance of foot care and consulting a doctor during the early stages of foot ulcer disease. 27

A study was conducted to determine the effects of ulcer size, site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. 194 (77% males) with a mean age of 50-60 were included in the study. The majority of ulcers were neuropathic (67.0%) and present on the forefoot. This study concluded that Ulcer area, a measure of ulcer size, predicts the outcome of foot ulcers. Its inclusion into a diabetic wound classification system will make that system a better predictor of outcome. 28

A study was conducted to compare the effectiveness of diabetic ulcers in directing appropriate therapy and possibly predicting outcomes. A total of 383 patients with foot ulcer were seen. Out of the 200 subjects, 65% were males and 35% were females Forty five percent of the subjects had neuropathic ulcers. the study has revealed that grading and staging of diabetic foot ulcer affects and predicts the outcome. Amputation rates increase with increase in grade. This helps further on assessing the severity of wound at the time of presentation and shows better association with the outcome. 29

A study was conducted to compare different outcome measures in the audit of management of diabetic wounds. Data collected in 449 patients, 352 (78.4%) ulcers were superficial and 134 of these (38.1% of 352) were neither ischemic nor infected. This study means ulcer-related outcomes may underestimate the true morbidity and mortality associated with diabetic foot disease. It suggested that when attempts are made to compare the effectiveness of management in different centers, greater emphasis should be placed on patient-related outcome measures. 30

3.Literature related to effectiveness of self instructional module on dressing practices and care of wound in diabetic patients among staff nurse.

An observational and sectional study was conducted to analyze the quality of the wound dressing procedure performed on hospitalized patients at a medical surgical unit of a University Hospital, based on their classification according to the degree of care dependency and activity performance phases. Using a check list, 168 wound dressings were observed between October and December 2005. Procedure quality was analyzed based on the Positivity Index (IP). Rigorous execution of procedures allows for risk decrease and assures beneficial results for patients, conferring quality to nursing actions. 31

A study was conducted to establish if nurses' actions when carrying out 'aseptic technique' using the 'gloves technique' are simple and based on up-to-date knowledge and do not incur unnecessary wastage. A sample of convenience was used involving 21 trained nurses. Observation and formal interviews were used to collect quantitative and qualitative data. Results showed that not all nurses in the sample applied a 'simple aseptic technique'. The rationale for the practice of aseptic technique was not always research based, though other aspects of wound management were derived from research findings. The study highlighted other areas of aseptic technique which require investigations. 32

A prospective, descriptive study surveyed staff nurses regarding glove use in diabetic wound dressing. The application of sterile and clean procedure to the practice of wound care nursing was examined. A self-report wound care survey instrument was developed by Nursing Consortium for Research and Practice members. The questionnaire comprised 31 questions and required approximately 10 minutes to complete. Differences were found between acute care and home health nurses. These included health care setting, degree of professional education, and nurses' experiential background. Instead, it may be necessary for nurses to "unlearn" lessons from basic nursing education before they can adapt to new practices and clinical policies. 33

A self instructional study was conducted on nurses University of Ege Faculty of Medicine Application and Investigation Hospital at Internal Medicine Clinics. This study aims to identify nurses' practices and opinions of hand washing during diabetic wound care. A questionnaire survey was used for this study. A total of 129 clinical nurses was examined. The study revealed that nurses have a poor level of knowledge concerning quality of hand washing. These conclude that to improve hand hygiene and quality of hand washing compliance, additional factors must be considered. These factors include improving healthcare workers--especially nurses'--skin conditions, hand hygiene techniques and disinfections substantially. 34

A retrospective case series from India that collected data from 1998 into 2009.  A self instructional study about wound dressing was done. They looked at the application of a 3% citric acid gel preparation onto 115 diabetic ulcerations. Culturing was collected from wound site.  They found that in moderate ulcerations they had 94%+ healing. They concluded that citric acid was safe and maybe even promoted granulation tissue while killing the bacteria found on the wounds. 35 

A survey was conducted to assess the prevalence of various therapeutic approaches for chronic diabetic wounds in 14 primary care and rehabilitation units and long-term care units. 96 of the 1 163 patients hospitalized at the time of our survey met the inclusion criteria. Wounds were generally cleansed using soap and physiological saline, No topical antibiotics were prescribed. anecdotal use of antiseptic solutions and nutrition management plans was done. This survey showed that doctors and nursing staff are extremely keen on the idea of specific training and practical advice concerning chronic diabetic wound management.36

A study to assess the effectiveness of wound dressings for the treatment of diabetes wounds and venous leg ulcers. 42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression.37

6.3 PROBLEM STATEMENT

“A study to assess the effectiveness of planned teaching programme on knowledge regarding diabetic wound dressing and wound care practices among staff nurse at selected hospitals at Tumkur.

6.3 OBJECTIVES

1. To assess the knowledge regarding diabetic wound dressing and wound care among staff nurse.

2. To determine the effectiveness of self instructional module regarding diabetic wound dressing and wound care among staff nurse.

3. To compare the pre and post test score regarding knowledge diabetic wound dressing and wound care among staff nurse.

4. To find out the association between selected staff nurses from the wards with knowledge regarding diabetic wound dressing and care of diabetic wound among staff nurse

6.3 OPERATIONAL DEFINITION

1) Assess

It refers to the evaluation of desired or intended results of the study.

2) Effectiveness

It refers to the successfulness in producing desired or intended result that is brought by administration of self instructional module.

3) Structured teaching programme

It refers to the learning material prepared in Kannada and English language, by the researcher to provide information regarding diabetic dressing and wound care by the staff nurse.

4) Knowledge

It refers to the level of understanding and awareness of staff nurse on diabetic wound dressing practices assessed by self administered questionnaire.

5) Diabetic wound or diabetic ulcer.

It refers to an ulcer in the upper or lower extremities due to any injury or infection, secondary to diabetes mellitus, or due to peripheral neuropathy.

6.3 HYPOTHESES

H1.There is a significant difference between pre-test and post- test level of knowledge of the staff nurses after administration of structured teaching programme on effectiveness of aseptic dressing in diabetic foot ulcers and woun

6.4. ASSUMPTION

The staff nurses may have some knowledge regarding diabetic wound dressing and wound care.

7.MATERIALS AND METHODS

7.1SOURCES OF DATA

Research Design : quasi experimental,One group pre test and Post test

design

Setting of the study : Middle age population in selected rural areas at Tumkur.

Sample size : 60 subjects

Sampling technique : simple random sampling

Sampling criteria

Inclusive criteria

• Middle age (30 to 50 years) population in a selected rural area of Tumkur.

• Both males and females

• People who are willing to participate in the study

• Participants of the study those who are available during the study.

1) EXCLUSION CRITERIA:-

• People who are not available at the time of data collection period.

• People who are not willing to participate in the study.

• The persons who had undergone a similar teaching program before.

7.2METHODS OF DATA COLLECTION

Method of data collection: self administration of questionnaire

TOOL-1

Part A : Proforma for collecting demographic data

Part B : structured questionnaires to assess knowledge regarding

diabetic wound dressing and wound care practices among staff nurses.

TOOL-2 : Structured teaching programme regarding diabetic wound dressing and wound care practices

Methods of Data analysis and interpretation

Pre and post test scores of knowledge will be analyzed through the following technique.

Descriptive statistics: Mean, standard deviation, range and mean score percentage will be used to quantify the level of knowledge before and after self instructional module.

Inferential statistics: Paired t-test will be use to examine the effectiveness of self instructional module by comparing the pre- test and post- test score.

Chi-square test will be worked out to determine the association of socio-demographic factors of people with pre-test knowledge and practice.

Duration of the study : 6 weeks

3. :Does the study the require any investigation or intervention to be conducted

on the patient or human beings or animal? so please describe briefly

NO

7.4 : Has ethical clearance been obtained from your institution in case of the above

Yes,Ethical clearance been obtained from the institutions ethical committee

LIST OF REFERENCES

BOOK REFERENCES

1. Lewis L. Sharon, Heitkemper Milian Margaret etal(2007) “MEDICAL SURGICAL NURSING”, 7 th edition, Mosby publishers :Missouri ;Pg no. 1253 – 1288

2. Smeltzer C. Suzanne, Bare G. Brenda etal(2008), “TEXTBOOK OF MEDICAL SURGICAL NURSING”, 11 thedition, Lippincott publishers: Philadelphia Pg no: 1375-1435.

3. Siegreen MY: 2005 STEPPING UP CARE FOR DIABETES FOOT ULCERS. Nursing 35 -36 page.

4. Boulton AJM, Kirsner RS, Vileikyte etal 2004: NEUROPATHIC DIABETIC FOOT ULCERS, N Engl J Med 351:48

5. Ignatavicuis D.Donna, Bayne Varner Marillyn(2004) “MEDDICAL SURGICAL NURSING” 4 th edition ,W.B. Saunder’s company :Philadelphia; Pg no. 1584-1621

6. Basavanthappa B.T. (2003), “MEDICAL SURGICAL NURSING”, 1st edition, Jaypee brother’s medical publishers: New Delhi: Pg no.687-711.

7. Black M. Joyce, Hawks Hokanson Jane (2005), “MEDICAL SURGICAL NURSING”, 7 th edition, Saunder’s publishers: Missouri; Pg no.1243-1288.

8. Dirksen Ruff Shannon, Lewis Manlik etal (1996), “ CLINICAL COMPANION TO MEDICAL NURSING” 1 st edition, Mosby Publications: Missouri; Pp no. 174-184.

9. Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA Cochrane Database Syst Rev. 2006 Jul 19;3:CD001103. Dressings for healing diabetic foot and venous leg ulcers. ,

10. Viswanathan Vijay, Sharad Pendrey etal (2005), “Diabetic foot in India”

11. Onuchin SG, Elsukova OS, Onuchina EL. Klin Med (Mosk). 2008 The risk factors and clinical forms of diabetic foot infections in dependence on the type of diabetes mellitus]

12. Karel Bakker, William H. van Houtum 2007 Volume 5, Number 6, 436-440, 2005: “The International Diabetes Federation focuses on the diabetic foot”.

13. Brian McCurdy, Senior Editor VOLUME: 19 PUBLICATION DATE: Dec 01 2006 Survey: One-Third Of Hispanic Patients Exhibit Warning Signs Of Diabetes Sidebars_in_article: Issue Number: 12

14. Nather A. (2008) “State specific incidence of diabetes among adults participating status 1995-1997 and 2005-2007”. MMWR Weekly October 31.

15. Dr.Kshitij Shankhdhar Volume 8, Number 6 2008, 452-457p “Diabetic foot problems in India: An overview and potential simple approaches in a developing country”

16. Sanders LJ, Dunlap G. Transmetatarsal amputation: a successful approach to limb salvage. J Am Podiatr Med Assoc 82(3):129-135, 1992.

17. Center for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2005. Atlanta, Ga:U.S. Department of Health and Human Services, Centeres for Disease Control and Prevention, 2005.

18. Funk C, Young G. Subtotal Pedal Amputations: Biomechanical and Intraoperative Considerations. J Am Podiatr Med Assoc 91(1):6-12, 2001.

19. Ohsawa S, Inamori Y, Fukuda K, Hirotuji M. Lower Limb Amputation for Diabetic Foot. Arch Orthop Trauma Surg 121, 2001.

20. WHO (2009) “The global impact”, .

21. Bale S, Baker N, Crook H, Rayman A, Rayman G, Harding KG, Ince P, Game FL. J Wound Care. 2001 Mar;10(3):81-4.Exploring the use of an alginate dressing for diabetic foot ulcers. Wound Healing Research Unit, University of Wales College of Medicine, UK. ,

22. Lalau JD, Bresson R, Charpentier P, Coliche V, Erlher S, Ha Van G, Magalon G, Martini J, Moreau Y, Pradines S, Rigal F, Wemeau JL, Richard JL Diabetes Metab. 2002 Jun;28(3):223-9.Efficacy and tolerance of calcium alginate versus vaseline gauze dressings in the treatment of diabetic foot lesions. Service d'Endocrinogie-Nutrition, Hôpital Sud, Amiens.

23. Hayter M, Chang CJ, Lo SF, Hu WY, Lee LL J Clint Nurse. 2008 Aug;17(15):1973-85. A systematic review of silver-releasing dressings in the management of infected chronic wounds. Department of Nursing, Tzu Chi College of Technology,

24. Russell L, Crespi A, Münter KC, Beele H, Gröchenig E, Basse P, Alikadic N, Fraulin F, Dahl C, Jemma AP. J Wound Care. 2006 May;15(5):199-206. Effect of a sustained silver-releasing dressing on ulcers with delayed healing: the CONTOP study

25. Kirsner RS, Warriner R, Michela M, Stasik L, Freeman K Arch Dermatol. 2010 Aug;146(8):857-62. Advanced biological therapies for diabetic foot ulcers.. ,

26. Smide B. 2009 Feb;18(3):391-8. Outcome of foot examinations in Tanzanian and Swedish diabetic patients, a comparative study.

27. Gulam-Abba,s Z Lutale JK, Morbach S, Archibald LK Diabet Med. 2002 Jul;19(7):575-9. Clinical outcome of diabetes patients hospitalized with foot ulcers, Dar es Salaam, Tanzania..

28. Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Armstrong DG, Harkless LB, Boulton AJ. Diabet Med. 2001 Feb;18(2):133-8. The effects of ulcer size and site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. Department of Medicine and Diabetes, Manchester Royal Infirmary, Manchester, UK. samson@dc.cmht.nwest.nhs.uk

29. Gul A, Basit A, Ali SM, Ahmadani MY, Miyan Z. J Pak Med Assoc. 2006 Oct;56(10):444-7. Role of wound classification in predicting the outcome of diabetic foot ulcer.

30. Jeffcoate WJ, Chipchase SY, Diabetes Care. 2006 Aug; 29(8):1784-7.Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures.

31. Nonino EA, Anselmi ML, Dalmas JC Rev Lat Am Enfermagem. 2008 Jan-Feb;16(1):57-63. Quality assessment of the wound dressing procedure in patients at a university hospital..

32. Bree-Williams FJ, Waterman H. J Adv Nurs. 1996 Jan;23(1):48-54. An examination of nurses' practices when performing aseptic technique for wound dressings.

33. Wise LC, Hoffman J, Grant L, Bostrom J J Wound Ostomy Continence Nurs. 1997 May;24(3):144-50.Nursing wound care survey: sterile and nonsterile glove choice.

34. Akyol AD. J Clin Nurs. 2007 Mar;16(3):431-7. Hand hygiene among nurses in Turkey: opinions and practices.

35. Nagoba BS et al. April 23, 2010 A Simple and effective approach for the treatment of diabetic foot ulcers with different Wagner grades.  International Wound Journal,

36. Caron-Mazet J, Roth B, Guillaume JC. Ann Dermatol Venereol. 2007 Aug-Sep;134(8-9):645-51. Prevalence and management of chronic wounds in 14 geriatric institutions of the Haut-Rhin [Article in French] Service de Dermatologie, Hôpital Pasteur, 39, 17925687

37. Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA, Cochrane Database Syst Rev. 2006 Jul 19;3:CD001103. Dressings for healing of diabetic foot and venous leg ulcers.

38. Brem H, Tomic-Canic M, Tarnovskaya A, Ehrlich HP, Baskin-Bey E, Gill K, Carasa M, Weinberger S, Entero H, Vladeck B. Surg Technol Int. 2003;11:161-7. Healing of elderly patients with diabetic foot ulcers, venous stasis ulcers, and pressure ulcers.

9. Signature of the candidate :

10. Remarks of the guide :

11. Name and designation of

11.1 Guide :

11.2 Signature :

11.3 Co-guide :

11.4 Signature :

11.5 Head of the department :

11.6 Signature :

12. Remarks of the Principal :

12.1 Signature :

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