RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 / NAME OF THE CANDIDATE
AND ADDRESS / Ms.MANJU JOSE
Ist YEAR M.Sc NURSING
SRILAKSHMI COLLEGE OF NURSING
SUNKADAKATTE
BANGALORE-91.
2 / NAME OF THE INSTITUTION / SRILAKSHMI COLLEGE OF NURSING.
3 / COURSE OF THE STUDY
AND SUBJECT / M.SC NURSING 2008-10
MEDICAL –SURGICAL NURSING.
4 / DATE OF ADMISSION TO THE COURSE / 17.6.08.
5 / TITLE OF THE STUDY / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING IMPORTANCE OF FOOT CARE AMONG DIABETIC CLIENTS ADMITTED IN SELECTED HOSPITAL BANGALORE, KARNATAKA.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

Diabetes is rapidly emerging as a major health problem in India, especial in urban area. Diabetes currently affects more than 194 million people world wide and the figure is exceptionally to be increased by 2025 with the maximum burden falling upon developing countries. At present, India is considered as the “Diabetic Capital Of The World”. There are approximately 3.5 crore diabetics in India, and this figure is expected to increase up to 5.2 crore by 2025. Every fifth patient consulting physician is a diabetic and every seventh patient visiting a family physician is a diabetic keeping in view the alarming increase in the incidence and prevalence of diabetics in India, the WHO has declared India as the “Diabetic capital” of the world.8,10,

Moreover, there is an equally large pool of persons with impaired glucose tolerance , many of whom will develop type II diabetes in future. There is evidence to suggest that prevalence of type 2 diabetes is increasing even in rural areas. The rapid increase in population, increase longevity and high ethinic susceptibility to diabetes, coupled with rapid urbanisation and changes from traditional lifestyles will more likely trigger a diabetic epidemic.3,10

Diabetes is a chronic disorder and affects large segment of the population of which the problem are synchronous. As many as 25% of diabetic individuals are experiencing problems some point in their life time, which often leads to amputation. Diabetic infections are severe and more difficult to treat than infections in non-diabetics.Good health is a pre-requisite to successful human endeavour and therefore core to economic growth and activity. Economic loss due to chronic ill health is associated not merely with the cost of care but takes a heavy toll in terms of loss in productivity.10,8

The prevailing poverty, ignorance, illiteracy and poor health consciousness further adds to the problem. Patients can access any level of care based on proximity, knowledge and resources. Thus many sociological factors determine long term outcome of illness.In diabetes, the incidence and prevalence of infections are on its increase. More than half of the non-traumatic lower limbs amputations are associated with diabetic changes such as sensory and autonomic neuropathy, peripheral vascular disease an increased risk and rate of infections and poor healing.10,8,15

Clients with diabetes are susceptible to infection of many types. Once infection occur they are difficult to treat. Diabetic foot infections are very common. Nearly 60% of the diabetic client experience neuropathy. Upto 40% of diabetic clients with foot infections may require amputation, and 5% to 10% will die despite amputation of affected area. With proper education and early intervention, foot infections are usually eliminated in a timely manner.12,8

6.2 NEED FOR THE STUDY

The prevalence of diabetis mellitus is rising to epidemic proportions .Diabetis mellitus is feared most for morbidity and mortality associated with its chronic complications. Since the introduction of new oral agents insulin devices and better patient care fortunately both type I & II diabetes now enjoy significant longivity but unfortunately with that we are witnessing rising pool of micro and macro vascular complications. This is going to put enormous financial and man power burden on the total health care system and medical faternity since the cost of treating complications happens to be ever more than five times than treating diabetis mellitus itself.9,12

Although all diabetic patients are prone to micro vascular complications namely Diabetic- Neuropathy, Nephropathy, retinopathy which can impede there quality of life, but it is macro-vascular complications which most increase morbidity and mortality. Diabetic neuropathy deserves special attention as it is the most common type and can lead to serious complications in those with diabetis.9,

Vascular complications are one of the most serious consequences of diabetics and are responsible for most of the excess mortality observed in diabetic patients. It is likely that all the blood vessels both small and large are abnormal in diabetic patients with long standing disease. Although there is generalized micro angiopathy but micro vascular blood vessel in retina, renal glomeruli and micro-vessels of large nerves seem to have significant pathology.Similarly of the large vessels, the arteries of the lower limbs are particularly affected, although the carotid and coronary vessels are also involved. Statistics of vascular disease in patients with type-2 diabetics are alarming. The risk of coronary artery disease or stroke is increased 2–4 folds compared with general population and the risk of peripheral vascular disease is increased four times.9,12,8,1

Diabetic micro vascular complications can occur in patients with either type 1 or type 2 diabetes despite improvements in management of glucose, B.P and lipid vessels.As many as 37% patients with DM suffer at last one micro vascular complication and at least one micro vascular complication and at least 13% have more than one.In the study of 3010 diabetics by Ramachandran.A, the prevalence of microvascular complication was Neuropathy-27.5% Retinopathy-23.7% Nephropathy-5.5% Prevalence of CHD-11.4% PVD-4%.9,1

A study concluded by Dr. Rajeev Chawla Sr. Consultant Physician Diabetologist. Maharaja Hospital Delhi comprising 720 type 2 Diabetic patients, Retinopathy was seen in 21.2% Micro albuminuria in 41%, Peripheral neuropathy 15.3% CAD – 7%, PVD – 7.4% of patients.There is no perfect way to predict which patients with diabetes will develop micro vascular complications nor the severity and at what stage will micro vascular complications shall manifest.In fact many studies have established beyond doubt that about 20% patients do have atleast one or more micro vascular or macro vascular complications at the time of diagnosis of type-2 DM (UKPDS).9,1

In the study conducted by Dr. Rajeer Chawla, Physican Diabetologist, Delhi, the prevalence of various micro and macro vascular complications of onset was NPDR 10% peripheral neuropathy-20% micro albuminuria-16% .According to study conducted by Michell Crulabani, Mary John, Rajeesh brac, Department of community Medicine CMC, Ludiana, India. In this their only 57% of the patient however knew that the feet are affected in diabetes.9,7

A study conducted by Viswanathan et al, on the knowledge of diabetic subjects regarding foot problems and care of feet they demonstrated that a low knowledge score was more common among women than in men. In a study conducted in Chandigarh it was again shown that knowledge concerning the prevention of diabetes complications was partial amongst diabetes with only 63.3% of the diabetes taking care of their feet through regular washing.14

6.3 REVIEW OF LITERATURE

  1. Murugans, Mani K.R, Uma Devi.P. study on the prevalence of methicillin resistant staphylococcus aureus among diabetes patient with foot ulcers and their anti microbial susceptibility pattern in the year 2002 August. It was carried out at Department of microbiology science college, coimbatore, Tamilnadu. Out of 2314 strains of Staphylococcus aureus isolated from diabetic foot ulcers 99% are to be methicillin resistant.more presicly ,MRSA strains [100%]wre resistant to pencillin 82.76% to clotrimoxazole ,64.11% to gentamycin ,60.08% to erythromycin .but all strains were resistant to vancomycin.5

2. Deepa Mohan, Deepa raj, CS shandhirani. study on the awareness and knowledge of Diabetes among the Chennai people.In the year 2005. It was carried out in Chennai population. Results was that the study stated that there is a lack of awareness of diabetes among the Chennai residents.of the total 26001 individuals only 75.5% of the whole population reported that they new about a condition called diabetis or coversely nearly 25% of the Chennai population was unaware of a condition called diabetis .only 22.2%of the whole population and 41.0% of the known diabetic subjects were aware that diabetic could be prevented.only 19% of whole population knew that diabetis could cause complication. they concluded that awareness and knowledge regarding diabetis is still grossly inadequate in India massive diabetis education programmes are urgently needed both in urban and rural India.1

3. Michell gulabani, Mary John, Rageesh Issac done a study to asses the knowledge of diabetes, its treatment and complications amongst diabetic patient in a tertiary care hospital in the year 2005 July and August. It was carried out in Diabetic patients attending the integrated diabetic clinic in CMC, Ludhiana La University affiliated teaching hospital. And the result was knowledge regarding the treatment and complication of diabetes showed serious deficiencies, more so among women even though most had been diabetic for years. Low knowledge score more among women than men.the fact that 51% thought that diabetis is curable and that only 64 patients out of 101 ,correctly said that treatment continues through out the life .only 47 correctly said that diabetis is preventable and only 29 were aware of cause of diabetis.in our study 51.5% actually knew the symptoms of hypo glycemia.this shows that knowledge of diabetis in patients is partial and most patients may not be able to take appropriate corrective measures sufficiently early and may seek medical aid very late.7

4. Suparno ganguly, Koustubh Chakroborthy, Pankaj Kumar mandal etaldone a comparative study between total contact casting conventional dressing in the Non-surgical management of Diabetic planter foot ulcer in the year was hold from January 2004 to May 2005, in Diabetic centre. And the result was 21 out of 26 patients complete healing seen the selected patients randomly to group A [given contact casting ] ,and category B simple dressing ,29 each . in category A 33 ulcers were present in all ,out of which 36 was healed and only 25 ulcers was healed in category B .11

5. Dr.Rajeev Chawla done a study on the clinical evaluation and screening on vascular complications in diabetes among diabetes Mellitus clients in the year 2007 at North Delhi diabetic centre. The result was that, the prevalence of diabetic neuropathy was in the highest 20% , NPDR 10% ,microalbuminuria 16%.as many as 50% of patients newly diagnosed type 2 diabetis already have evidence of some macro vascular disease ,hence, inspite of great strides in the management of diabetis death rate continues to rise largely from vascular disease .hence,message is very clear that having type 2 diabetis is like having had an MI in the past.9

6. kumukale, Dr Rawat (2006)conducted comparative study on insulin levels and glycosilated haemoglobin Levels in type II obese diabetic patients. This study was undertaken to determine the role and other related bio-chemical parameters, Insulin and glucose along with the lipid study in the different stages in type I and type II diabetes particularly, they were divided into controlled (50) and uncontrolled (50) obese patients the FBS and PPBS is normal fasting insulin level and post prandial insulin level is found to be the same as normal individual and there is no change in their glycosylated Hb. In type II obese uncontrolled diabetic patients the FBS Level & PPBS are 2 times of the normal individuals and their fasting as well as Post Prandial insulin level are 2 times the normal individuals,whereas their glycosylated Haemoglobin level increased 4 times in comparison to normal individual.13

7. Ferrer- Garcia JC, Merino- Torres JF, Perez Bermejo. conducted study about “Insulin-inducednormoglycemia reduces islet number needed to achieve normoglycemia after allogeneic islet transplantation in diabetic mice”

(Laboratory of Experimental Diabetes, Endocrinology Department, UniversityHospital La Fe, Av. Campanar 21, Valencia 46009, Spain. (2006))

The Edmonton protocol established that insulin independence could be reached with the transplantation of an appropriate number of islet cells. However, to effect a cure, islets from two or three pancreases are needed. The aim of this study was to examine whether normoglycemia, with insulin treatment before and after transplantation, reduces the islet number needed to achieve normoglycemia in allogeneic islet transplantation. Swiss mice were used as donors and recipients. Diabetes was induced by i.p. administration of streptozotocin (180 mg/kg BW). Diabetic mice were transplanted with 300 (n = 16), 400 (n = 16), or 500 (n = 16) islets under the left kidney capsule. For every group, half the animals were kept normoglycemic with insulin treatment from day 4 before transplantation to day 10 after transplantation. At the end of the study, all normoglycemic mice were given an i.p. glucose tolerance test (IPGTT). For statistical analysis, paired or unpaired Student's t-test or ANOVA was used. Only insulin-treated mice achieved normoglycemia by the end of the study (37.5% of animals transplanted with 400 islets and 50% transplanted with 300 or 500 islets). At the end of the study, normoglycemic mice transplanted with 300 allogeneic islets showed better glycosylated hemoglobin (HbA1C) than did normoglycemic mice transplanted with 500 islets (300 islets: 2.7 +/- 0.2%; 500 islets: 3.6 +/- 0.2%; p < 0.05). After the IPGTT, insulin-treated mice transplanted with 500 islets showed abnormal glucose tolerance; however, insulin-treated mice transplanted with 300 or 400 islets showed normal glucose tolerance. Insulin treatment reduced the islet number needed to achieve normoglycemia in allogeneic islet transplantation. The HbA1C and IPGTT results suggest that transplanting smaller numbers of allogeneic islets improves beta-cell function; some studies suggest that this may be due to lower immunogenicity, hypoxia, and inflammation.16

STATEMNT OF PROBLEM :-

A study to assess the effectiveness of structured teaching programme on knowledge regarding importance of foot care among diabetic clients admitted in selected Hospital , Bangalore , Karnataka .

6.4 OBJECTIVE OF STUDY:-

  1. To assess the knowledge on importance of foot care among clients suffering with Diabetis Mellitus.
  1. To prepare and introduce Structured Teaching Programme (STP) on importance of foot care among clients suffering with Diabetis Mellitus.
  1. To assess the effectiveness of structured teaching programme (STP) on importance of foot care through knowledge score.
  1. To determine the association between pre-test knowledge score and selected demo graphic variables.

6.5 OPERATIONAL DEFINITION

  1. Assess : It is the organized systematic continuous process of collecting data from diabetic clients regarding foot care.
  1. Effectiveness : It refers to significant gain in knowledge regarding foot care among diabetic clients by structured teaching programme which may result differences between pre-test and post test scores.
  1. Structured Teaching Programme : It refers to the correct response of the diabetic clients to structured knowledge questionnaire on foot care achieved by knowledge score.
  1. Knowledge : It refers to the correct response of the diabetic clients to structured knowledge questionnaire on foot care achieved by knowledge score.
  1. Foot care : It refers to the care of the terminal part of the lower limb among diabetic client.
  1. Diabetic Mellitus : It is a chronic systematic disorder characterized by either a deficiency of insulin or a decreased ability of body to use insulin.

7. Client : Refers to a person diagnosed with diabetis mellitus.

6.6 HYPOTHESIS :

H1: There is a significant relation between knowledge level and foot

care practice among diabetic clients.

H2 : There is a significant association between experimental group

and control group.

H3 : The mean post test scores of subjected exposed to STP will be

greater than this mean pre-test scores as measured by structured

knowledge questionnaire at 0.05 level at significance.

6.7ASSUMPTIONS

1. Diabetic patients are more common to acquire neuropathic

complications.

2. Structured teaching programme will enhance the knowledge of

diabetic patients regarding foot care.

3. Knowledge may prone a way for prevention of complications.

6.8DELIMITATION

1.The study was limited to those clients who are attending the teaching

programme.

2.The study sample is limited to those who are able to understand

English and kannada.

3.The sample size is limited to 60 .

4.The study is limited to those who are illiterate.

6.9PILOT STUDY

The study population is around 8-10. The purpose of pilot study is to

find out the feasibility of study and the design on plan out statistical

analysis.

VARIABLES

These are concepts of various levels of obstruction that are entered,

manipulated and collected in the study. In this study-

Independent variable -Structured teaching programme

Dependent variable - Foot care.4

7. MATERIALS AND METHODS.

The study is designed to determine the effectives of structured

teaching programme on importance of foot care among diabetic

clients of selected hospitals ,Bangalore Karnataka.

7.1SOURCE OF DATA

Data will be collected from diabetic clients of selected hospitals

in Bangalore, Karnataka.

7.1.1RESEARCH DESIGN

Pre-test- Post-test Design.

7.1.2RESEARCH APPROACH

An evaluative research approach.

7.1.3SETTING OF STUDY

Selected Hospitals , Bangalore, Karnataka .

7.2METHOD OF DATA COLLECTION (INCLUDING SAMPLING PROCESS)

Structured knowledge Interview Schedule and Structured Teaching

Programme on importance of foot care.

7.2.1SAMPLING TECHNIQUE

Random Sampling Technique.

7.2.2SAMPLE SIZE

The sample of study consists of 60 diabetic patients.

SAMPLING CRITERIA

INCLUSION CRITERIA

  • Patients who are suffering diabetis mellitus.
  • Patients who are willing to participate in the study.
  • Patients can understand, read &write Kannada.
  • Patients who are present during the time of data collection.

EXCLUSION CRITERIA

  • Patients who are not willing to participate in the study.
  • Who are unable to response to questions.
  • Patient who aren’t present during the time of data collection.

7.2.5 TOOL FOR DATA COLLECTION

Structured Questionnaire, Checklist will be used for data collection.

PROCEDURE FOR DATA COLLECTION

The investigator will collect the data from diabetic patients using

Structured questionnaire, checklist schedule to assess the knowledge