Foot Assessment Education Program for Nurses in Saudi Arabia - Literature review Example

FOOT ASSESSMENT EDUCATION PROGRAM FOR NURSES IN SAUDI ARABIA: LITERATURE REVIEW Code + Course Name Professor’s Name College, University Name City, State Date Table of Contents Background 3 Methodology 4 Literature Review Results 5 Discussion 9 Education Program 11 Conclusion 12 References 13 Background Preventing the occurrence of foot problems in people with type 2 diabetes requires vigilance in the assessment and care of the foot. People with diabetes and individuals at an advanced age are at risk of developing foot related problems such as foot lesions and ulcers (Seid & Tsige 2015; Soliman & Brogan 2014, p. 13). Lesions commonly result from trauma on the various areas of the foot whose healing can, however, be exacerbated by infections, neuropathic changes as in diabetes and physiological changes associated with ageing such as insufficiency in blood circulation and tissue oxygenation (Holt 2013). Poorly fitting footwear is among the common causes of trauma. This may result from new boots or shoes that can lead to blister development on the foot. Walking barefoot can also traumatise the foot. Neuropathy, a complication of diabetes has the potential to delay the management of such blisters or foot ulcers due to impaired or lowered sensation that masks pain and lower’s an individual urge to seek treatment measures (Holt 2013). Besides, it is also argued that calluses occurring at plantar foot area increase ulceration at that site 77 times if there is an underlying peripheral insensitivity (Holt 2013). Therefore, prevention of traumatic injury to the feet, wearing shoes or boots that fit appropriately and early identification and management of developing foot problems is paramount in the reduction of foot related problems. Identification of individuals at risk of developing foot problems is integral in minimising foot problems. Nurses, even in Saudi Arabia, are salient health care providers that participate in the assessment of the feet of patients at risk and using the assessment findings, ascertain whether a patient is at risk of developing foot problems and disorders (Aalaa et al. 2012). In Saudi Arabia, foot problems are significant especially in people with diabetes. Studies done in Saudi Arabia regarding foot care and foot problems suggest a significant prevalence of foot problems especially diabetic foot ulcer at 4.3% with about a third of the cases leading to amputation (Alkhier, Elsharief & Alsharief 2011, p. 58). This is attributable to the high prevalence of diabetes in this country ranking third in the world according to the International Diabetes Federation’s (IDF) 2005 findings. It is also estimated that 85% of diabetes-related amputation occur as a result of foot ulcers (Alkhier, Elsharief & Alsharief 2011, p. 56). The costs associated with the management of foot problems is substantial to any given nation. Though there are no studies to indicate the cost associated with the management of foot problems in Saudi Arabia, cost-related studies done in other countries suggest significant expenses to respond to the problem. For instance, in United States (US), its approximated that 38.2 billion US dollars were incurred in the form of direct expenses in foot ulcer treatment (Driver et al. 2010, p. 338). Considering the high prevalence of the problem in Saudi Arabia, the health care cost associated with it shall also be substantial. Al-Shehri (2014) also demonstrated a detrimental impact on diabetic foot problems in Saudi Arabia on the quality of life with a lower “quality of life” exhibited by individuals with retinopathy and diabetic foot. Therefore, foot assessment is meant to enhance the maintenance of feet in a healthy condition, identify any problem that might occur regarding the feet, promote self-care practices, and enable early identification and referral of individuals at high risk of foot problems for specialised care. Patients at risk of foot problems need to be knowledgeable regarding the assessment and care of their feet. However, Qadi and Al Zahrani (2011), through their study done in Jeddah city, demonstrated that diabetics had lower levels of knowledge regarding foot care especially in early ulcer detection and appropriate foot-wear selection. Health care workers such as nurses, and patients who are aware of the care and prevention of foot problems lower the occurrence of foot problems complications such as amputation (Al-Wahbi 2010). Hence, a foot assessment education program targeting nurses in Saudi Arabia shall enhance their knowledge and skill regarding the assessment. The acquired skill and knowledge can then be passed on to the patients at risk. Therefore, this literature review’s goal is to identify relevant assessment techniques that can be applied by nurses in Saudi Arabia to their practice and in patient education to lower the occurrence of foot problems in Saudi Arabia. Methodology This review entailed a search of literature related to foot assessment and care from Google Scholar and Ovid databases. Ovid database search included multiple database search such as Medline, EMBASE, AMED, PreMEDLINE, CINAHL, and MEDLINE. Key words used in the search included ‘foot assessment’ and ‘foot care’ in people with type 2 diabtes. The articles reviewed are dated between 2008 and 2015 that are written in English and related to foot assessment in humans. From the search, one article was identified from Google Scholar and three from the Ovid database appropriate for this review. Literature Review Results It has been identified by that various components are critical to foot assessment. Boulton et al. (2008) assert that history taking is salient in identifying the risk factors that might predispose a patient to the development of foot problems. Elements of the history include previous foot problems such as amputation, foot ulceration, or foot deformity (Boulton et al. 2008, p. 1679). Harrison-Blount et al. (2015) sought to assess the acceptability and applicability of the various foot assessment methods and come up with an appropriate evidence-based tool befitting foot assessment. Items that comprised the tool were selected from reviewed literature with the application of a modified Delphi method whose panel comprised expert health professionals. Various test assessment methods for foot assessment that have been advocated for by other researchers were tabled for recommendation against known risk factors for foot problems (Harrison-Blount et al. 2015). Patient history elements identified as significant in foot assessment include history of smoking, footwear, vascular surgery and previous ulceration that all received an approval rating of 4-5 on the Likert scale (Harrison-Blount et al. 2015, p. 8). Other recommended areas in history taking include history of peripheral vascular or neuropathic symptoms, renal problems, or vision problems. After the history, general inspection is recommended by Boulton et al. (2008) and Harrison-Blount et al. (2015). General inspection against infection as a risk factor including visual assessment of swelling, odour, pus, warmth and redness was accepted by the eight-member panel team with a Likert rating of 4-5 (Harrison-Blount et al. 2015). This should be carried out in a well-lit room when the patient is bare feet to identify any developing problems. Also the foot wear used should also be inspected for appropriateness for the feet. Dermatological assessment is also integral to foot assessment as recommended by Harrison-Blount et al. (2015) and Boulton et al (2008). Boulton et al. (2008) recommend a global inspection of the skin to identify areas of structural changes, abnormal erythema or ulceration. Interdigital examination should be considered in dermatological assessment. Harrison-Blount et al. (2015) identified assessment areas in dermatological assessment that included assessment corns and callus, maceration, extravasation of tissue, blisters, fungal infection, crackedness and skin dryness all which received an approval rating of 4-5 on the Likert scale by 86%, 86%, 86%, 100%, 86%, 100% and 86% of the panel team members respectively. Findings such as callus that is accompanied by haemorrhage, paronychia or nail dystrophy should prompt referral for specialised care. Findings such as differences in skin temperatures between one foot and the other be it global or focal are said to be predictors of ulceration or vascular disease (Boulton et al. 2008). Musculoskeletal assessment is also part of foot assessment (Boulton et al. 2008). It includes identifying the presence of any foot deformities. The latter include rigid deformities that commonly occur in the digits presenting as contractures that cannot be manually reduced with ease. Distal phalangeal extension and interphalangeal flexion accompanying hyperextension of the metatarsal phalangeal joint are musculoskeletal foot deformities that are linked to skin breakdown due to their associated increase in plantar pressures. Such deformities include hammer toe, claw toe, overlapping toes, bunion and rocker bottom deformity (Boulton et al. 2008). Charcot arthropathy is also a possible finding under musculoskeletal assessment that manifests as hot, red unilateral swelling of the foot in addition to the foot been flat. The musculoskeletal assessment was also recommended in Harrison-Blount et al.’s (2015) study although it was classified under deformity assessment. Elements of deformity assessment that were evaluated included assessment for Charcot's foot, hammer or claw toes, prom met heads and hallux abducto valgus. However, only Charcot foot was accepted by the panel members with a rating of 4-5 by 100% of the members with the other receiving a rating of below three (Harrison-Blount et al. 2015). Roberts and Newton (2011) also recommend assessment of foot deformity. The deformities are said to have the potential of exposing the foot to excessively high pressures with an increased risk for development of ulcers (Roberts and Newton 2011, p. 486). Neurological assessment targets identification of losses of sensations that would protect the foot. It is, especially, important in diabetic patients who are at risk of developing neuropathy that impair pain sensations of the feet (Roberts & Newton 2011). They recommend the test to be done once a patient is a confirmed diabetic. A 10g monofilament is critical in neurological assessment in addition to either of tests that include “pinprick sensation” test, ankle reflexes, “vibration perception threshold” (VPT), tuning fork vibration test (Boulton et al. 2008, p. 1680; Roberts and Newton 2011). These assessment elements were also considered and assessed for inclusion in Harrison-Blount et al. (2015) study. However, only the tuning fork and monofilament tests were rated 4-5 on the Likert scale by 100% of the panel members with other tests been strongly rated 1-2, thereby excluded from inclusion in the final tool (Harrison-Blount et al. 2015, p. 7). In Boulton et al.’s (2008) review, it is suggested that the buckling 10-g monofilament can assess losses in pressure sensation and that its positive findings are strong indicators of possible subsequent ulceration. It is recommended by Boulton et al. (2008) that the test is done on the fifth, third and the first metatarsal heads of each foot besides the distal hallux’s plantar surfaces. However, Roberts and Newton (2011) it to be done across the foot on several sites while avoiding wounded areas as it may lead to cross contamination. The tests should be done while the patient’s eyes are closed. The type of monofilament is significant since the authors suggest that many commercially available ones exhibit inaccuracies. The authors recommend the use of single-use disposable monofilaments. The steps for using the monofilament includes a prior demonstration of pressure sensation to the patient on sites such as the upper arm or any other proximal site. After that, the monofilament is applied on the various prescribed sites and the patient is required to respond by a ‘no' or ‘yes' when asked where the filament is being applied (Boulton et al. 2008, p. 1680). Pressure sensations and site identification should be recognisable to the patient normally. The 128-Hz tuning folk is also applicable in neurological assessment of the foot’s vibration sense. The folk is applied bilaterally tested over the tip of hallux. Presence of an abnormality is suspected when the patient fails to perceive the vibration sensation despite the examiner’s perception of the same while holding the tuning fork. Pinprick sensation test entails utilization of a disposable pin that is applied on the hallux proximal to the toenail with sufficient pressure that can deform the skin. If the patient does not perceive the sensation of either halluces then the test is said to be abnormal. Ankle reflex test utilizes a tendon hammer that is struck at the Achilles' tendon when the ankle is either at rest or under reinforced stretch. Total absence of the reflex is deemed abnormal (Boulton et al. 2008, p. 1681). VPT testing is done using a biothesiometer that has its stylus held over the dorsal aspect of the big toe. The device's amplitude is then increased until the vibration can be detected by the patient. The amplitude at which the vibration is detected is termed as VPT, and it is deemed abnormal if it is over 25V (Boulton et al. 2008, p. 1682). Roberts and Newton (2011) suggest that certain shoes should be avoided in patients at risk of foot problems including foot ulcers. Therefore, assessment of the suitability of foot wear for a given patient should be done, and the authors recommend the avoidance of shoes worn excessively, those with overt sole weaknesses, or those exhibiting prominent seams or internal stitches in the vicinity of the toe area Vascular assessment is informed by the association between peripheral artery diseases (PAD) and foot problems such as foot ulcers (Boulton et al. 2008). This assessment determines the risk status of the lower extremity. Under vascular assessment, “the dorsalis pedis and posterior tibial pulses” should be palpated and classified as ‘absent’ or ‘present’ (Roberts & Newton 2011, p.486; Boulton et al. 2008, p. 1682). Patients with absent tibial and pedis pulses should have their ankle brachial pressure index (ABI) tested (Boulton et al. 2008, p. 1682). In Harrison-Blount et al. (2015) vascular assessment against the risk factor of ischaemia included various tests such as pulse assessment in the dorsalis pedis and posterior tibial artery, temperature on touching, Doppler, TBI and ABI. Ankle pressure is assessed using a Doppler ultrasonic probe. ABI value of more than 0.9 is considered normal while that of lower than 0.4 and 0.8 is linked to tissue necrosis and claudication respectively (Boulton et al. 2008). Pulse assessment and temperature touch were accepted by 100% and 86% of the panel team in Harrison-Blount et al. (2015) with a Likert rating of 4-5 while the others were poorly rated and, therefore, excluded in the final assessment tool. Tehan, Bray and Chuter (2015) compared the specificity and sensitivity of three vascular assessment methods in detecting PAD. The latter is a foot problems’ risk factor among elderly individuals and even in diabetic patients. These methods included ABI, toe-brachial index (TBI), continuous wave Doppler ultrasound (CWD). The study demonstrated that CWD had the highest negative and positive predictive values, highest specificity and sensitivity in recognizing PAD in both diabetic and non-diabetic patients. ABI had the least sensitivity when it was used in both groups, but it exhibited high and similar specificity in both groups of patients. TBI was more sensitive than ABI in PAD detection. TBI’s sensitivity was, however, lower in diabetic individuals than in non-diabetic individuals while its specificity in PAD detection was greater in the diabetic group in comparison to that without diabetes (Tehan, Bray and Chuter 2015). The diagnostic utility of “both TBI and ABI” was equal in the group with no diabetes although the former exhibited superiority in the diabetic group. Discussion The literature review has identified that foot assessment should be comprehensive to identify the factors predisposing to foot problems and to enable early, timely management of such problems. Foot assessment components include tests such as history taking, general inspection, dermatological, musculoskeletal, neurological and vascular assessment (Holt 2013; Boulton et al. 2008; Rao et al. 2012; DiPreta 2014; Chang et al. 2013). Dermatological assessment areas supported in the reviewed literature including Harrison-Blount et al. (2015) assessment of acceptability and applicability, include examining areas of callus, ulceration, erythema and maceration. Skin temperature differences have been demonstrated paramount due to their predictive value for ulceration or vascular disease (Boulton et al. 2008; Harrison-Blount et al. 2015; Mendes et al. 2015). This was also strongly approved in Harrison-Blount et al.’s (2015) study. These are elements that can be applied in the Saudi Arabia setting. Musculoskeletal assessment also encompasses examination of the foot for foot deformities as recommended in Boulton et al. (2008), Roberts and Newton (2011), and Harrison-Blount et al.’s (2015) studies. Among the foot deformities, Boulton et al. (2008) recommended assessment for deformities such as claw toe, hammer toe and Charcot's foot. The deformities may expose foot areas to high pressures predisposing them to ulceration. Highly pressurised feet as a result of deformities may require specialist pressure offloading (Roberts & Newton 2011). Harrison-Blount et al. (2015) suggested that Charcot foot assessment is more paramount than assessment of the other foot deformities. This may be due to association of Charcot foot syndrome with diabetes complications and the poor prognosis of the syndrome in such patients (Rogers et al. 2011). Hence, Boulton et al. (2008) recommend immediate referral of patients found to have Charcot's foot. Neurological assessment was recommended in all the articles reviewed. It is meant to elucidate any losses in protective sensation (LOPS) that might signify neuropathy, a possible complication associated with the development of foot ulcers among diabetics (Clayton & Elasy, 2009; Burdette-Taylor 2015). LOPS is associated with aggravating foot problems not identified early enough because of the masked pain and touch sensation. The 10g monofilament is the basic recommended test for neurological assessment of the foot (Boulton et al. 2008; Harrison-Blount et al. 2015; Feng, Schlosser & Sumpio 2009). Also, the tuning fork was also recommended by Roberts and Newton (2011), Boulton et al. (2008) and Harrison-Blount et al. (2015). LOPS, when assessed by the 10g monofilament, is suggested to be highly predictive of recurrent or future ulceration. Lack of detection of pressure at anatomic sites of the examined foot areas has been linked with large fibre nerve dysfunction. It is recommended that pressure testing should avoid callused areas of the foot to enhance the applicability of the findings (Boulton et al. 2008). The tuning fork tests the sense of vibration whose loss is also associated with neuropathic disorders that predispose to foot problems (Feng, Schlosser & Sumpio 2009; Roberts & Newton 2011). Other neurological assessment identified that have been suggested suitable in assessing risk for ulceration include ankle reflexes testing and the pinprick sensation test. However, ankle reflex and pinprick sensation testing were not established to be of significance to the assessment tool postulated by Harrison-Blount et al. (2015). These assessments methods have been in use among health care workers in Saudi Arabia but there emphasis and well structured presentation shall improve on their utilization and applicability in Saudi Arabia. Vascular assessment includes palpation of the “posterior tibial and dorsalis pedis arteries” and assessment using ABI, TBI and CWD (Tehan, Bray & Chuter 2015; Harrison-Blount et al. 2015). Vascular assessment is underpinned by PAD as a risk factor for foot problems. Tehan et al. (2015) suggest that ABI is not as sensitive and specific as TBI and CWD. This is supported by studies such as Ikem et al.’s (2010) that demonstrated ABI to be subjective recommending the use of Doppler-aided assessment methods such as CWD. Boulton et al. (2008) also mention that ABI measurements may be hampered by incompressibility of arteries due to medial calcinosis giving a false picture of raised supra-systolic ankle pressure. Nevertheless, in the assessment of ischaemia, palpation of the arteries was recommended by Harrison-Blount et al. (2015) and Boulton et al. (2008). Foot wear assessment entails assessing the appropriateness of footwear used. It is recommended that footwear should not be tightly fitting, should not have prominent seams or internal stitches, and should not have been excessively worn in addition to not having overt weaknesses in the sole area (Roberts & Newton 2011; Harrison-Blount et al. 2015). These would be useful elements in Saudi Arabia where shoes worn are quite variable and individuals with diabetes will need education on the best footwear to use. Education Program The findings of the above review suggest that foot assessment should encompass an initial history, general inspection, dermatological, neurological, musculoskeletal, vascular and footwear assessment. The education program shall, therefore, consist of components of foot assessment. The education program is adopted from a similar program developed by a Diabetes Nursing Interest Group in Canada but employing assessment elements identified from this literature review (Registered Nurses Association of Ontario [RNAO 2015). The nurses in Saudi Arabia setup shall be provided with a participant’s package that shall consist of pre-test questions to give information regarding individual learning needs of the participants (Barge 2007). After introducing them to the workshop, the assessment components shall be introduced to them, and a volunteer shall be used to demonstrate the various assessment areas and techniques including history taking, general inspection, neurological, dermatological, musculoskeletal and footwear assessment. The participants shall then be invited to work in small groups with return demonstrations on the assessment components been done on a volunteer from each group. Patient history shall consist of assessment for previous ulceration, amputation, vascular surgery and cigarette smoking. General inspection of the dermatological elements that shall include skin status assessment comprising of dryness, thickness, colour, and cracking, sweating, fungal infection, blistering, calluses or presence of internal bleeding into a callus, and presence of ulceration. Musculoskeletal inspection shall consist of assessment for deformity including Charcot joint, and hammer and claw toes capable of raising planter pressure. Neurological assessment shall entail the use of a 10g monofilament to assess LOPS by detecting sensations at least five sites of the foot. A 128-Hz tuning fork shall also be used to assess vibration sense. Vascular assessment based on identification of PAD shall consist of pulse assessment at the dorsalis pedis and posterior tibial arteries. ABI, TBI and CWD may be used additionally. Foot wear assessment shall entail an examination of footwear, that is, how fitting they are, identification of excessively worn footwear, too short or too narrow footwear. The assessment components shall then be summarised before concluding the education workshop by subjecting the participants to a post-test before evaluating the workshop and the impact to participants. Conclusion Essential components in foot assessment include history, general inspection of the musculoskeletal and dermatological parameters, neurological, vascular and footwear assessment. These should be incorporated in the guidelines for foot assessment due to their determined efficacy and significance. The effectiveness and appropriateness of some parameters in the assessment such as the ankle reflex and biothesiometry in neurological assessment, and TBI, ABI and CWD in vascular assessment is still in doubt (Harrison-Blount et al. 2015; Tehan, Bray & Chuter 2015). Such components may require further research to augment the justification for their inclusion in foot assessment. 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Tehan, PE Bray, A & Chuter, VH 2015, Non-invasive vascular assessment in the foot with diabetes: Sensitivity and specificity of the ankle-brachial index, toe brachial index and continuous wave Doppler for detecting peripheral arterial disease. Journal of Diabetes and its Complications, vol. 2015, no. (July), pp. 1-6. Read More