Faculty of medicine and health sciences

Department of nursing

Research about:
Experience of Diabetic
Patient After Amputation
 Prepared by  
Amer Saleli & Baher Ebedat,
Hosam Al-Esaa & Ameen abu
Hania

 Supervised by  
Mrs. Mahdia Al-Koni
2015

ACKNOWLEDGEMENTS

I
 Our deepest appreciation is to Mrs. Mahdia ALKoni for her tireless efforts, there are no
words to express the appreciation we hold for you. You were for us a leader, advisor,
teacher, and seminar supervisor, and our role model. Thank you.
Without the help of diabetic patients at Nablus district this scientific study would not
have been possible. Thank you for participation
Although it would be impossible to name individually all of the people and the events
that contributed to the success of this project and the accomplishment of a remarkable
educational and experiential milestone, we know and value and appreciate each and every
one.
To our families who made many sacrifices to help us accomplish my goals. You were to
us supported, and encouraged, we are grateful, thank you.
For all teachers in the Collage of nursing at Al-Najah National University , you provide
us intellectually challenge and helped us grow professionally.
we have learned a lot from each of you and consider our self extremely fortunate to have
worked with you
Faculty student roles thank you.
Last but not least, our deepest gratitude for everyone who contributed to this works &
appreciates their efforts.

Abstract
Diabetes mellitus is a metabolic disease characterized by elevated levels of glucose in the
Blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.

II
Amputation is the surgical removal of all or part of a limb or extremity such as an arm,
leg, foot, hand, toe, or finger.

According to the World Health Organization(WHO ,2013), 347 million people

Worldwide have diabetes , in Palestinian Ministry of Health( 2014) published that the
number of diabetes reviewers in primary health care clinics were 134,336 revisers.

Diabetes increases the risk of long-term complications which is believed to develop after
many years of the disease onset. The major long-term complications are related to
damage to blood vessels which is doubled by diabetes is the risk of cardiovascular
disease.

The damage of blood vessels result in lower limb ischemia, that lead to develop necrotic
tissue and result to decision of amputation.

Research question

• What is the first feeling you have experience

• How amputation affect your life
• Who are your supporter
• What changed in your life experienced after amputation
• What about your journey of rehabilitation
• How nurses and other health professionals treat you at hospital
• What you need to make its easer for you to adapt

Aims & objectives

To investigate the lived experience (psychosocial and emotional status) of diabetic

patient after an amputation, and their coping mechanisms they used.

To explore about their initially emotion after amputation.

To investigate about their care in hospitals and their needs.

Methodology:

III
Study design: Qualitative narrative design was used in this study, Semi-structured
interview and open-ended questions was used to get required information

Study population: The study population consisted of diabetic patient who have
amputation in Nablus district, within age of 50-80 years old

The study sample purposeful sample , 7 interview performed

Data collection: We make an interviews with each patient in theirs homes and we ask him a
related question to purpose of study, And the interview was 20-45 minute and we recording
it.

Timing: 2 weeks from 1/11/2015 -15/11/2015

Analysis: Phenomenological psychologists analyze their data by using a systematic and rigorous
process. Data analysis consists of four consecutive steps.

The result

Show that Participants had varying psychological reactions after the lower limp
amputation . Some were battling with issues of body image, pain, disability and poor
functional independence. Others were reported to be coping well. Both negative and
positive coping strategies were demonstrated by the participants.

The participants had supportive families and friends. They also had complain poor
rehabilitation services resources and this had a negative impact of their ability to recover.
Some participants had given their lives to God, so they would be responsible for the well-
being.

The health professional team varies in deal with patient having amputation, some of them
are supportive and other are not.

Table of content

N Subject Page

IV
o
1 Acknowledgment II
2 Abstract III
3 Table of content V
4 Introduction 1
5 Literature review 6
6 Methodology 18
7 Result 26
8 Discussion 38
9 Conclusion 42
10 Recommendations 43
11 Limitation of the study 44
12 References 68
13 Appendix A 72
14 Appendix A 73

V
 Chapter One
Introduction

Introduction
Diabetes mellitus is a metabolic disease characterized by elevated levels of glucose in the
Blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.

1
Insulin is a hormone produced by the pancreas, controls the level of glucose in the blood
by Regulating the production and storage of glucose. In the diabetic state, the cells may
stop Responding to insulin or the pancreas may stop producing insulin entirely, this leads
to hyperglycemia.

According to the World Health Organization Palestine as many other developing

countries is going through an epidemiological transition with its associated rise in chronic
diseases which increased by 31.1% in 2004-2006. At the same time the health system is
facing the challenges of controlling the incidence of some communicable diseases. In
2007, the health system was able to reduce the mortality rates of infectious disease to
27.8 per 100 000 population (who, 2008).

According to the World Health Organization(WHO ,2013), 347 million people

Worldwide have diabetes , in Palestinian Ministry of Health( 2014) published that the
number of diabetes reviewers in primary health care clinics were 134,336 revisers, and
the percentage of male revisers to diabetes clinics (45.9%),while the percentage of
females revisers to diabetes clinics were (54.1%). The number of new diabetes patients
who are enrolled in the primary health care diabetic clinics were 4,816 patients of whom
2,679 females (54.1%) and 2,137 males (45.9%). (92.3%) of new diabetes patients age 35
years and older. The highest number of new diabetic patient in Hebron 2,216 new patient
(46.1%), followed by Nablus 591 new patient (12.5%), then Jenin 480 new patients
(10%) of the registered cases. (4.3%) of diabetic patient with type 1 insulin-dependent
and (64.8%) of diabetic with type 2 treated by oral tablet, (20.6%) using insulin, (9.9%)
take oral tablet and insulin together, and (0.4%) only exercising and diet(MOH, 2014).

Diabetes increases the risk of long-term complications which is believed to develop after
many years of the disease onset. The major long-term complications are related to
damage to blood vessels which is doubled by diabetes is the risk of cardiovascular
disease. The main "macrovascular" diseases are ischemic heart disease , stroke and
peripheral vascular disease. Diabetic retinopathy, which affects blood vessel in the retina
of the eye, can lead to visual symptoms, reduced vision, and potentially blindness.

2
Diabetic neuropathy is the impact of diabetes on the nervous system, most commonly
causing numbness, tingling and pain in the feet and also increasing the risk of skin
damage due to altered sensation. Together with vascular disease in the legs, neuropathy
contributes to the risk of diabetes-related foot problems (such as diabetic foot ulcers) that
can be difficult to treat and occasionally require amputation.
The quality of life of a person with type 2 diabetes is influenced by several factors, this
include awareness of the complication and risk-factors of diabetes, and age of the patient,
duration of the disease, and BMI of the patient.(Kalda, Ratsep et al. 2008) .

Older age, lower education, being unmarried, obesity, hypertension and

hyperlipidemia were also associated with impaired Quality of life ( QOL) .Effective type
2 diabetes management and improved quality of life of individuals and prevent diabetes
complication as amputation are interrelated. The measurement of quality of life is an
important component in continuous improvement of chronic disease management in
primary care settings.

Patient education, understanding, and participation is vital, since the complications of

diabetes are far less common and less severe in people who have well-managed blood
sugar levels (Stahl F, Johansson R. 2008). Attention is also paid to other health problems
that may accelerate the deleterious effects of diabetes. These include smoking, elevated
cholesterol levels, obesity, high blood pressure, and lack of regular exercise
(Hosseinpanah, F et al. 2007).

Amputation is the surgical removal of all or part of a limb or extremity such as an arm,
leg, foot, hand, toe, or finger. About 1.8 million Americans are living with amputations.
Amputation of the leg -- either above or below the knee -- is the most common
amputation surgery.

Reasons for Amputation:

There are many reasons for amputation; the most common is poor circulation because of
damage or narrowing of the arteries, called peripheral arterial disease that lead to

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 inadequate blood flow which deprive body's cells from oxygen and nutrients, as a result,
the affected tissue begins to die and infection is the absolute result.
Other causes for amputation may include:
Severe injury (from a vehicle accident or serious burn, for example)
Cancerous tumor in the bone or muscle of the limb
Serious infection that does not get better with antibiotics or other treatment
Thickening of nerve tissue, called a neuroma Frostbite
Recovery from Amputation
Recovery from amputation depends on the type of procedure and anesthesia used.
Phantom pain (a sense of pain in the amputated limb) or grief over the lost limb, is the
most common post amputation pain, when it's occur the doctor will prescribe medication
and/or counseling, as necessary. Ideally, the wound should fully heal in about four to
eight weeks. But the physical and emotional adjustment to losing a limb can be a long
process. Practice with the artificial limb may begin as soon as 10 to 14 days after surgery.
Physiotherapy, beginning with gentle, stretching exercises, often begins soon after
surgery.

Long-term recovery and rehabilitation will include:

 Exercises to improve muscle strength and control
 Activities to help restore the ability to carry out daily activities and promote
independence
 Use of artificial limbs and assistive devices
 Emotional support, including counseling, to help with grief over the loss of the limb and
adjustment to the new body image .

Significance of study:
During our clinical training it is observed that there is a significant proportion of diabetic
patients with amputation with different reactions to the experiences of patients who have
amputation that varies from the psychological and psychosocial and emotional responses
(stress, depression, withdrawal, isolation and a sense of stigma). In spite of the great
impact of amputation on the diabetic patient psychosocial status and the effects on their

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quality of life, there is lack of studies about the lived experience for patient with Diabetes
after amputation in Palestine, especially in North of West Bank. For that it is believed
that it is believed that it is of great importance to conduct this study to determine the lived
experience of diabetic patients after amputation, and to know some of the burden that can
worsen the quality of life for those patients.
Problem statement:
It is believed that it is of great importance to investigate the lived experience of diabetic
patients after amputation in the north of west bank, also to highlight the view of patients
and their families about amputation.
Aims of the Study:
To investigate the lived experience (psychosocial and emotional status) of diabetic
patient after an amputation, and their coping mechanisms they used.
The diabetes-related amputation occurs every 30 seconds, and 85% of these amputations
are precipitated by a minor foot injury such as a blister or a callus. But unfortunately
these injuries are often ignored because diabetes causes peripheral neuropathy (nerve
damage to the feet). But nowadays foot health and diabetes education campaign is
successful, (Rogers, 2005).

Patients with DM have statistically significant impairment of all aspects of QOL, not
simply physical functioning. DM put a substantial burden on affected individuals by
influencing physical, psychological and social aspects of QOL. (Porojan, Poanta et al.
2012)

A lower limb amputation is a surgical procedure that results from a serious medical
condition such as diabetes, trauma or neoplasm affecting the individual’s well-being,
quality of life, and autonomy. Anxiety, depression, body-image anxiety and social
discomfort have been pointed out as frequent consequences of a lower limb amputation
(Hugo, et al. 2005).

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 Chapter two
Literature
review

Literature review

A study was conducted in Irish, (2015), about Management of diabetic foot disease and
amputation in the Irish health system: a qualitative study of patients’ attitudes and
experiences with health service, the sample was 10 men participated in the study who had

6
either active foot disease or a lower limb amputation as a result of diabetes, were
recruited from the Prosthetic, Orthotic and Limb Absence Rehabilitation (POLAR) Unit
of an Irish hospital. One-to-one interviews were conducted in the POLAR unit using a
semi-structured topic guide. Thematic analysis was used to identify, analyze and describe
patterns within the data. The result was most participants expressed a need for emotional
support alongside the medical management of their condition. There were substantial
differences between participants with regard to the level of education and information
they appeared to have received regarding their illness. There were also variations in
levels of service received. Transport and medication costs were considered barriers.
Having a medical card, which entitles the holder to free medical care, eased the burden of
the patient’s illness. A number of participants attributed some of the problems they faced
with services to the health care system as whole rather than health care professionals.
( Andrew Hanrahan,. et al. 2015).

A study was conducted in USA,( 2012), about How long to treat with antibiotics
following amputation in patients with diabetic foot infections? Are the 2012 IDSA DFI
guidelines reasonable, aimed To the best of our knowledge, there has been no published
study designed to identify the most appropriate duration of antibiotic therapy in lower
extremity skin and skin structure infections in diabetic patients [aka “diabetic foot
infections” (DFI)] post-amputation. However, recent guidelines published by the
Infectious Diseases Society of America (IDSA) provide recommendations for treatment
duration in these patients. Therefore, our objective is to review the literature evaluating
antibiotic treatment in DFI to determine if the IDSA guidelines are reasonable, Evidence
for the use of antibiotics after amputation comes largely from preoperative surgical
prophylaxis studies evaluating the rate of infection after amputation. Three such studies
were identified; 2 found a 5-day course of antibiotics post amputation resulted in a
reduction of infection rate, while 1 Found no additional benefit. Comparative antibiotic
studies in DFI also offers evidence for treatment duration, of which, 10 studies were
identified. Five included patients who received amputations; however, only 1 reported
treatment outcomes in a subset of diabetics requiring amputation. In this study, the
authors concluded that antibiotic treatment is likely necessary after amputation. The

7
result was we recommend that post-operative treatment duration be individualized, and,
until further studies are done, it seems reasonable to adhere to the recommendation
provided by the 2012 IDSA DFI guidelines for a 2–5 day course of antibiotic therapy
postoperatively when no residual infected tissue remains. (D. B. May, et al,. 2012).

A study was conducted in Singapore,(2013) , about Distal amputations for the diabetic
foot , aimed to Minor amputations in diabetic patients with foot complications have been
well studied in the literature but controversy still remains as to what constitutes
successful or non-successful limb salvage. In addition, there is a lack of consensus on the
definition of a minor or distal amputation and a major or proximal amputation for the
diabetic population. In this article, the authors review the existing literature to evaluate
the efficacy of minor amputations in this selected group of patients in terms of diabetic
limb salvage and also propose several definitions regarding diabetic foot amputations, the
results was Minor amputations in patients with diabetic foot problems have been shown
to be effective in limb salvage and reducing morbidity and mortality in patients. The
authors have proposed several definitions regarding diabetic foot amputations while
further studies are needed for a consensus on the definition on a successful versus non
successful diabetic limb salvage surgery.( Aziz Nather, 2013).

A study was conducted in Philadelphia , (2005) . about Risk of amputation in patients

with diabetic foot ulcers: a claims-based study, The objective of this study was to
undertake a retrospective analysis of claims data of diabetic foot ulcer (DFU) patients to
determine the rates of amputation and identify the risk and protective factors. The eligible
cohort consisted of all patients with two or more ICD-9 diagnostic claims16 for a DFU
and evidence of diabetes based on a relevant diagnostic code or prescription data
indicating use of insulin or oral hypoglycemic therapy. The index date was the day of the
first DFU diagnosis and patients were also required to have 3 months of data prior to this
date without any medical claims indicating a primary or secondary DFU diagnosis or any
LEA. In addition, patients were required to have continuous eligibility for in- and
outpatient coverage during the pre- and post diagnosis periods. The results was In the
5911 patients with DFU, 116 individuals who had LEAs were identified as cases yielding
a crude amputation rate of 1.96%. The incidence density rate was 0.02298 per person-

8
year (or 2.30 per 100 person-years), based on a total person-time of 5046.9 years in the
eligible subjects. Assuming a Poisson distribution, a 95% CI around this estimate would
be 0.0191–0.0277 per person-year (or 1.91 to 2.77 per 100 person-years). (David J.
Margolis,. 2005).

A study was conducted in China , ( 2013) , about patients with chronic diabetic foot
ulcers, hyperbaric oxygen reduces major amputations, aimed to Included studies
compared usual care (e.g., control of glycemia, revascularization, debridement, off-
loading, and metabolic and infection controls) plus HBO with usual care alone in patients
with type 1 or type 2 diabetes and chronic lower-extremity ulcers attributable to diabetes.
Outcomes included ulcer healing (complete epithelialization of the wound), major (above
the ankle joint) or minor (below the ankle joint) amputation, and adverse events. Using
MEDLINE and EMBASE/Excerpta Medica (both to Apr 2012); Cochrane Library
(2012); reference lists; abstracts of major diabetes, endocrinology, and plastic surgery
meetings (2003 to Apr 2012); and trial Web sites, were searched for randomized
controlled trials (RCTs) and nonrandomized controlled trials. 13 trials (n = 624),
including 7 RCTs (n = 359, mean age range 53 to 72 y; follow-up range 2 to 92 wk), met
selection criteria. No RCT reported allocation concealment, 2 had blinding, 3 used a
random-number generator, and all reported loss to follow up. Only the results of RCTs
are presented here.the results was In patients with chronic diabetic foot ulcers, adding
hyperbaric oxygen to usual care reduces major amputations. (Boden G, et al, 2013)

A study was conducted in Sourasky Medical Center, Tel Aviv, Israel,( 2012) , about
Rehabilitation outcome of post-acute lower limb geriatric amputees,the purposed was To
characterize the lower-limb elderly amputee patients admitted to a post-acute
rehabilitation program, assess their 1-year survival rate, estimate rate of prosthetic fit and
report rate and factors associated with 1-year post-discharge prosthetic use, Most elderly
amputees in our country are referred to a post-acute care facility for rehabilitation and
assessment for potential prosthetic fit. The current study was performed in a university
affiliated 300-bed major post-acute geriatric rehabilitation centre, admitting older patients
from major acute hospitals in nearby cities. Half of the patients are admitted for
rehabilitation after orthopedic surgery, stroke or deconditioning due to prolonged

9
hospitalization. The other half are admitted for medical care, encompassing treatment for
severe pressure ulcers, management of advanced heart failure, terminal cancer, chronic
ventilation, etc. All admitted patients carry full medical coverage provided by four health
maintenance organizations (HMOs) conforming to the following admission criteria: >60
years old, functionally dependent, lack of social support system, or living in an unfitted
home environment (i.e. no elevator or narrow doorways leading to the bathroom). Since
post-acute amputees have a low rehabilitation potential (low survival rate and low rate of
prosthesis fit) we suggest that: (a) – rehabilitation efforts should best be targeted
depending on need, and (b) – rehabilitation professionals should make educated estimates
of outcomes at the beginning of rehabilitation based on the characteristics of the patients
(level of amputation and functional level on admission).( Avital Hershkovitz, Israel
Dudkiewicz, Shai Brill, 2013).

A study was conducted in New York, (2009) , about Mechanism of Sustained Release of
Vascular
Endothelial Growth Factor in Accelerating
Experimental Diabetic Healing , aimed to we hypothesize that local sustained release of
vascular endothelial growth factor (VEGF), using adenovirus vector (ADV)-mediated
gene transfer, accelerates experimental wound healing. This hypothesis was tested by
determining the specific effects of VEGF165 application on multiple aspects of the
wound healing process, that is, time to complete wound closure and skin biomechanical
properties. After showing accelerated wound healing in vivo, we studied the mechanism
to explain the findings on multiple aspects of the wound healing cascade, including
epithelialization, collagen deposition, and cell migrate Intradermal treatment of wounds
in non-obese diabetic and db/db mice with ADV/VEGF165 improves healing by
enhancing tensile stiffness and/or increasing epithelialization and collagen deposition, as
well as by decreasing time to wound closure, using Construction of an ADV expressing
bioactive human VEGF for murine study Human umbilical vein endothelial cells
(HUVECs) were homogenized and total RNA was extracted. The full-length human
VEGF165 cDNA was amplified by PCR with appropriate primers containing restriction
sites (HindIII and XbaI) for subcloning into pBluescript (Stratagene, La Jolla, CA). After
sequence confirmation, the human VEGF-165 cassette was cloned into the multiple

10
cloning site of an adenovirus shuttle vector (pXC1) containing adenovirus type 5
sequences (bp 22–5,790) and a Rous sarcoma virus promoter. This same vector was used
as the positive control Dl-312 in the experiments. For the rescue of the recombinant
adenovirus, we successfully used the two-plasmid co-transfection system (Microbix
Biosystems, Inc., Toronto, Ontario, Canada). Virus particle titer was determined by
optical absorbance at 260 nm, and plaque-forming unit titer (pfu ml1 ) was quantified by
standard agarose overlay plaque assay on 293 cells. Plaque-forming unit (pfu)
determination can vary up to one order of magnitude when the same batch of virus is
used in different assays, causing a significant variation in particle measurement. To
prevent this problem and to keep the viral loads constant, the same batch of virus was
used for all in vitro and in vivo experiments. The results was ADV/VEGF165 accelerates
time to closure in db/db mice To determine whether ADV/VEGF165 accelerates wound
healing, time to wound closure was determined using four different doses of
ADV/VEGF165. Wounds treated with ADV/VEGF165 healed 6.6 days sooner than
controls (Figure 1). Treated wounds healed in 27.2±1.4 days. Saline-treated wounds
healed in 34.2±7.0 days, whereas wounds that were treated with the virus vector alone
healed in 33.5±6.5 days. Statistical significance (Po0.05) was noted after comparison of
the 5 1011 vp per wound VEGF165-treated group and control groups (Table 2).
However, such high doses of VEGF165 may have a toxic effect in the mice used in the
study, as the incidence of mortality in the high-dosage VEGF165-treated group was
greater than in other groups. A minimum 10% increase in mortality relative to controls
was found at ADV/VEGF doses of 5 109 vp per wound and higher.( Alan D.Weinberg,
et al, . 2012).

A study was conducted in USA ,( 2001) , about Fluorescein dermofluorometry for the
assessment of diabetic microvascular disease, the aim was Fluorescein dermofluorometry
can be used to relate the uptake of fluorescein in the skin to blood flow. We have
characterized the uptake of fhe dye by a wash-in time constant that is inversely
proportional to the local blood flow. The purpose of this study was to explore the use of
dermofluorometry in the assessment of patients wifh diabetic microvascular disease,
using Ruorescein dermofluorometry was performed in four groups of patients: non-
diabefic control patients, diabetic control patients, diabetic patients with chronic foot

11
ulcers, and diabetic patients with acute foot ulcers. The outcomes of the patients with foot
ulcers were documented 4-14 months after participation. Following an intravenous
injection of sodium fluorescein, the change in the fluorescein signal with time was
continuously measured at the plantar surface of the foot. Both the initial slope of the
signal and the wash-in time constant were calculated in each subject. The results was The
fluorescein wash-in time constant demonstrated better correlation with the presence of
diabetic microvascular disease than did the initial slope of the signal. Differences in the
wash-in time constants of non-diabetic and diabetic subjects support the hemodynamic
hypothesis for the development of microvascular disease. The indication of early wash-
out of the fluorescein signal may also be useful in the prediction of ulcer healing.
( Deborah K. Oh, et al, .2001).

A study was conducted in Brazil , ( 2015 ) , about Development of the Tardivo Algorithm
to Predict Amputation Risk of Diabetic Foot, aimed to Diabetes is a chronic disease that
affects almost 19% of the elderly population in Brazil and similar percentages around the
world. Amputation of lower limbs in diabetic patients who foot complications is a
common occurrence with a significant reduction of life quality, and heavy costs on the
health system. Unfortunately, there is no easy protocol to define the conditions that
should be considered to proceed to amputation. The main objective of the present study is
to create a simple prognostic score to evaluate the diabetic foot, which is called Tardivo
Algorithm. Calculation of the score is based on three main factors: Wagner classification,
signs of peripheral arterial disease (PAD), which is evaluated by using Peripheral Arterial
Disease Classification, and the location of ulcers. The final score is obtained by
multiplying the value of the individual factors. Patients with good peripheral
vascularization received a value of 1, while clinical signs of ischemia received a value of
2 (PAD 2). Ulcer location was defined as forefoot, midfoot and hind foot. The
conservative treatment used in patients with scores below 12 was based on a recently
developed Photodynamic Therapy (PDT) protocol. 85.5% of these patients presented a
good outcome and avoided amputation. The results showed that scores 12 or higher
represented a significantly higher probability of amputation (Odds ratio and logistic
regression-IC 95%, 12.2–1886.5). The Tardivo algorithm is a simple prognostic score for

12
the diabetic foot, easily accessible by physicians. It helps to determine the amputation
risk and the best treatment, whether it is conservative or surgical management. Using 62
patients with diabetic foot, from March 2011 to March 2013 were used to develop the
scoring method. The patients were treated at the Center for Diabetic Foot at Hospital
Anchieta (CeDiFo), served by the Faculdade de Medicina do ABC (FMABC), which is
coordinated by Dr. Tardivo. The study was approved by the research ethics committee at
FMABC and participants signed a consent form. The clinical investigation was conducted
according to the principles expressed in the Declaration of Helsinki. The results was
Patients with diabetic foot need to be treated using a multidisciplinary approach. Diabetes
does not have cure and the risks to patients may persist throughout life. The Tardivo
algorithm is a fundamental tool for predicting whether the diabetic foot has a higher
chance of healing or a higher chance of requiring amputation and may be a useful for
guiding treatment. The proposed score classification system for the diabetic foot may
enable better quality of life for diabetic patients and promote better low-cost care for
millions of individuals worldwide. The adoption of this score associated with
antimicrobial photodynamic therapy could reduce amputations in diabetics in over 80%
of cases, resulting in lower costs, fewer hospitalizations and no side effects. (Fernando
Adami, et al, . 2015).

A study was conducted in Canada , ( 2015) , about Tool for Rapid & Easy Identification
of High Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second
Diabetic Foot Screening Tool, aimed to Most diabetic foot amputations are caused by
ulcers on the skin of the foot i.e. diabetic foot ulcers. Early identification of patients at
high risk for diabetic foot ulcers is crucial. The ‘Simplified 60-Second Diabetic Foot
Screening Tool’ has been designed to rapidly detect high risk diabetic feet, allowing for
timely identification and referral of patients needing treatment. This study aimed to
determine the clinical performance and inter-rater reliability of ‘Simplified 60 Second
Diabetic Foot Screening Tool’ in order to evaluate its applicability for routine screening.
Using The tool was independently tested by n=12 assessors with n=18 Guyanese patients
with diabetes. Inter-rater reliability was assessed by calculating Cronbach’s alpha for
each of the assessment items. A minimum value of 0.60 was considered acceptable.

13
Reliability scores of the screening tool assessment items were: ‘monofilament test’ 0.98;
‘active ulcer’ 0.97; ‘previous amputation’ 0.97; ‘previous ulcer’ 0.97; ‘fixed ankle’ 0.91;
‘deformity’ 0.87; ‘callus’ 0.87; ‘absent pulses’ 0.87; ‘fixed toe’ 0.80; ‘blisters’ 0.77;
‘ingrown nail’ 0.72; and ‘fissures’ 0.55. The item ‘stiffness in the toe or ankle’ was
removed as it was observed in only 1.3% of patients. The item ‘fissures’ was also
removed due to low inter-rater reliability. Clinical performance was assessed via a pilot
study utilizing the screening tool on n=1,266 patients in an acute care setting in
Georgetown, Guyana. In total, 48% of patients either had existing diabetic foot ulcers or
were found to be at high risk for developing ulcers, the results was Clinicians in low and
middle income countries such as Guyana can use the Simplified 60- Second Diabetic
Screening Tool to facilitate early detection and appropriate treatment of diabetic foot
ulcers. Implementation of this screening tool has the potential to decrease diabetes related
disability and mortality.( Brian Ostrow, et al, . 2015).

A study was conducted in Singapore, 2014, about The modified Pirogoff’s amputation in
treating diabetic foot infections: surgical technique and case series, aimed to This paper
describes the surgical technique of a modified Pirogoff’s amputation performed by the
senior author and reports the results of this operation in a single surgeon case series for
patients with diabetic foot infections, using Six patients with diabetic foot infections were
operated on by the National University Hospital (NUH) diabetic foot team in Singapore
between November 2011 and January 2012. All patients underwent a modified Pirogoff’s
amputation for diabetic foot infections. Inclusion criteria included the presence of a
palpable posterior tibial pulse, ankle brachial index (ABI) of more than 0.7, and distal
infections not extending proximally beyond the midfoot level. Clinical parameters such
as presence of pulses and ABI were recorded. Preoperative blood tests performed
included a glycated hemoglobin level, hemoglobin, total white blood cell count, C-
reactive protein, erythrocyte sedimentation rate, albumin, and creatinine levels. All
patients were subjected to 14 sessions of hyperbaric oxygen therapy postoperatively and
were followed up for a minimum of 10 months. The results was The modified Pirogoff’s
amputation has been found to show good results in carefully selected patients with

14
diabetic foot infections. The selection criteria included a palpable posterior tibial pulse,
distal infections not extending proximally beyond the midfoot level, ABI of more than
0.7, hemoglobin level of more than 10 g/dL, and serum albumin level of more than 30
g/L. (Amaris Shumin Lim, et al, . 2014).

A study was conducted in UK , (2010) , about Matching the numerator with an

appropriate denominator to demonstrate low amputation incidence associated with a
London hospital multidisciplinary diabetic foot clinic, the purposed was To establish a
method to assess amputation incidence that addresses the problems matching a numerator
with an appropriate denominator in London and to demonstrate low amputation incidence
associated with the activity of our multidisciplinary diabetic foot clinic, using Hospital-
coded inpatient data was examined to derive the numerator: the number of non-traumatic
amputations performed on subjects with diabetes each financial year where the Primary
Care Trust commissioner code was our main local Primary Care Trust. Denominators
were derived from the main local Primary Care Trust’s Quality and Outcomes
Framework data sets. Not all Primary Care Trust subjects with diabetes receive inpatient
care at our hospital, so that the denominators were corrected for the hospital’s percentage
market share for the provision of inpatient diabetes care for the Primary Care Trust each
financial year, derived from the Dr Foster database. The results was We report for the
first time amputation incidence in a London population. Acknowledging the limitations
of accurately defining incidence in London, we demonstrate low amputation incidence
associated with our multidisciplinary diabetic foot clinic. (C. D. Bicknell, et al, . 2010).

A study was conducted in Netherlands , (2010) , about Differences in minor amputation

rate in diabetic foot disease throughout Europe are in part explained by differences in
disease severity at presentation, aimed to . We evaluated minor amputation rate, the
determinants of minor amputation and differences in amputation rate between European
centres. Using In the Eurodiale study, a prospective cohort study of 1232 patients (1088
followed until end-point) with a new diabetic foot ulcer were followed on a monthly basis
until healing, death, major amputation or up to a maximum of 1 year. Ulcers were treated

15
according to international guidelines. Baseline characteristics independently associated
with minor amputation were examined using multiple logistic regression modelling.
Based on the results of the multivariable analysis, a
disease severity score was calculated for each patient. The results was Minor
amputationis performed frequentlyin diabetic foot centres throughout Europe andis
determined by depth of the ulcer, peripheral arterial disease, infection and male sex.
There are important differences inamputation rate between the European centres, which
can be explained in part by severity of disease at presentation. This may suggest that
early referral to foot clinics can prevent minor amputations.( A. Jirkovska, et al,. 2010).

A study was conducted in Denmark , ( 2013) , about Reduced incidence of lower-

extremity amputations in a Danish diabetes population from 2000 to 2011, the aim was to
estimate time trends in the incidence of lower-extremity amputations in Danish people
with Diabetes, using We studied major and minor lower-extremity amputations from
2000 to 2011 among 11 332 people with diabetes from the Steno Diabetes Center.
Amputations were identified by linkage of the electronic medical system with the
National Patient Registry. Sex-specific incidence rates of amputations by age, diabetes
duration, calendar time and diabetes type were modelled by Poisson regression. The
results was . The incidence of major lower-extremity amputations reduced significantly
from 2000 to 2011 in Danish people with diabetes followed at a diabetes specialist centre.
(K. Færch, et al,. 2013).

A study was conducted in Pennsylvania, ( 2010) , about The differential effect of

angiotensin-converting enzyme inhibitors and angiotensin receptor blockers with respect
to foot ulcer and limb amputation in those with diabetes, aimed to This was a
retrospective cohort study using the general medical practices of The Health Information
Network (THIN). By agreement, patient data are recorded and stored in THIN as if it
were an electronic medical record including all past and current medical diagnoses (acute
and chronic) using Read codes and information on prescribed medications, using British
National Formulary (BNF) codes. All laboratory values, aspects of the physical exam,
hospitalizations, consultations, and prescription medications are electronically entered

16
into THIN datasets. Subjects in THIN have been shown previously to be demographically
comparable to the general UK population.12 The THIN database includes records for
more than 4.7 million patients, with approximately 2.26 million active patients from 300
practices in England and Wales. The annual estimated number of subjects lost to
followup is small (3%). Our study was reviewed and accepted by the Institutional Review
Board of the University of Pennsylvania. Using To be included in our inception cohort, a
subject had to have at least two separate medical records for diabetes noted between
January 1995 and August 2006. We used this algorithm to assure that the subject truly
had diabetes. In addition, the subject had to be at least age 35 at the time of diagnosis,
could not have had a pervious history of venous leg ulcer, DFU or LEA, and must have
used an ARB and/or ACEi, which was first prescribed between 1995 and 2006. the
results was Based on our selection criteria, we identified 78,178 individuals with
diabetes. ACEi or ARB were used by 40,342 individuals (51%). From this group, 35,153
individuals were treated with ACEi, 12,437 individuals with ARB, and 7,248 were
exposed to both drugs. The total number of evaluable exposures was 47,590. One
hundred and seven individuals were excluded from our analysis because they were
treated with both agents at the same time. The mean age of our subjects was 64.4 (95%
CI: 64.2, 64.5) years with a median of 64.4 years. Females represented 45% (18,281) of
the cohort. The mean total duration of diabetes was 6.3 years (median 5.98) and total
person-time of 216,070 years. There were some statistical differences in covariates based
on whether they received ACEi or ARB. (Arturo R. Maldonado, et al,. 2010).

17
 Chapter three
Methodology

Methodology

3.1. Study Design:

18
Qualitative phenomenological design was used in this study. We mean by narrative
analysis uses field texts, such as stories, autobiography, journals, field notes, letters,
conversations, interviews, family stories, photos (and other artifacts), and life experience.

Semi-structured interview and open-ended questions was used to get required

information. Pen and notebook, and recorder were used while making an interview, and
then make documentation for analysis the interviews that helped us to cover the lived
experience after amputation. The guideline includes questions about (demographic data
about the participant and questions about lived experience after amputation.

3.2. Sampling:

The setting for this study was Palestinian diabetes patient who have amputation in
Nablus. Purposeful sampling was used to collect data. The sample size included 7
participants 40 to 80 years old who experienced an amputation as a result of diabetes.
Participant should be able to speak and understand Arabic, be willing to provide written
informed consent, agree to participate in a 20-45 minute interview, and agree to have the
interview digitally recorded. Before signing a consent form, the purpose of the study was
explained to the participants. Participants were informed of their right to withdraw from
the study at any time without reprisal and the right to have any recorded data on the
digital tape or transcript excluded from the data analysis process.

3.3 Inclusive criteria:

Both gender (male and female) are equally included, and ages between (40-80) years,
who had amputation as a result of diabetes mellitus, will be included for the purpose of
the current study.

3.4Exclusion:

* Any patients less than 40 years and more than 80years.

* And who have an amputation as a result of other reasons.

3.5 Selection of the Study Instruments

19
The interview process was done using a semi-structured interview guide with different
themes and underlying issues designed from the study purpose and research questions.
The interview guide acted as a support to ensure that the important issues were not
forgotten during the interview. It also served to organize the discussion by designating
the order in which different themes were addressed. The interview guide was used as a
checklist to ensure that all the themes were addressed instead of letting the interview
questions guide the conversation. This allowed the interviewees to generally feel relaxed
and natural, rather than formal.

3.6. Data collection process:

After taking permission from the patients to do interview in their homes in Nablus, the
sample will be convenient and it’s definition (Convenience sampling is a non-probability
sampling technique where subjects are selected because of their convenient accessibility
and proximity to the researcher The subjects are selected just because they are easiest to
recruit for the study and the researcher did not consider selecting subjects that are
representative of the entire population )

Firstly , consent form is read to the participants then they signed after he /she accepted to
participate in the study, one face-to-face interviews lasting between 20 and 45 minutes
were performed with each patient in private room. Demographical and clinical data were
collected using a self-developed questionnaire with simple closed questions. And then we
asked them question about their lived experience . and data was collected be same group
one to ask question ,two to take note about patient and other to redirector the interview if
need . the data was analyzed according to Gorgi.

3.7 Ethical consideration:

We will take the IRB to our research from An-Najah National University ,and then we
will take permission from ministry of health, to make our research in Palestinian center of
diabetes in Nablus. The participants will sign and accept the consent form that we give to
them. Participants will be informed that all these data will be secret, and kept in private
office at the university. Subject name will be written in form of symbols to make sure

20
that the aim is to gather information about our study not for sharing the information with
others.

3.8 Data Analysis

Phenomenological psychologists analyze their data by using a systematic and rigorous

process. Data analysis consists of four consecutive steps that must be undertaken in their
order (Robinson, 2007). Prior to the analysis, each interview was transcribed verbatim.
All steps in the analysis were performed within the phenomenological reduction (Giorgi,
1997).

In order to present the study in writing, the method, purpose, and research questions were
considered as coherent and not as separate parts. The analysis of the material began from
the time of the beginning of the data collection. The understanding of how to analyze the
collected material has been evident to the researcher since making the choice to utilize a
qualitative method. The interview guide has been designed as a breakdown of the various
themes in addition to background information.

All steps in the analysis were performed within the phenomenological reduction
(Robinson & Englander 2007; Giorgi, 1985, 1997).

"Step 1: Getting the sense of the whole statement by reading the entire description.

Step 2: Discriminating meaning units within a psychological perspective.

Step 3: Transforming the subject’s every day expressions into psychological language.

Step 4: Synthesizing transformed meaning units into a consistent statement of the

structure of the phenomenon”.

Step 1: Getting the sense of the whole statement by reading the entire description

The entire interview protocol was read several times in order to get a sense of the whole
experience. The idea was to obtain a description, not to explain or construct (Giorgi,
1989). Wertz (1985) suggest that readers should see raw data as well as processed data

21
The first reading be done in the natural attitude (i.e., the everyday attitude) told the
researcher to more actively identify and critically examine their own interests, creditors
learned, theories, hypotheses and existential assumptions about the phenomenon and then
set them in brackets (Giorgi, 2005).

If certain passages of the collected material unclear, it is important that the author does
not padding with their own interpretation, but instead goes back to the interviewee and
ask for clarification descriptions. If the author is unable to collect further information
about them will be later forced to describe the uncertainties that exist in the data.
Ambiguities and contradictions in the data may not reduce or declared the basis of
possible interpretations, but must always be described as such. (Robinson & Englander
2007), (Giorgi, 1985, 1997

Step 2: discriminating meaning units within a psychological perspective

After going through the first step, Giorgi (1986) suggests that the whole description
should be broken into several parts to determine the meaning of the experience and these
are expressed by the slashes in the texts (Giorgi, 1985) or by numbering of lines
(Wertz,1985 ). Parts that were relevant to the phenomenon that is being studied were then
identified. The process of delineating parts is referred to as meaning units, they express
the participant’s own meaning of the experience, and they only become meaningful when
they relate to the structure of all units (Ratner, 2001). A word, a sentence or several
sentences may constitute a meaning unit.

Each meaning unit is constituent and therefore focuses on the context of the text (Giorgi,
1985). The meaning units are correlated with the researcher’s perspective and therefore
two researchers may not have identical meaning units (Giorgi & Giorgi, 2003a). This

22
process takes place within what is called reduction. It is important in phenomenological
psychology to withhold the existential judgment about the experience of the participant.

Step 3: Transforming the subject’s every day expressions into psychological

language

The researcher returns to all of the meaning units and interrogates them for what they
reveal about the phenomenon of interest. Once the researcher grasps the relevance of the
subject's own words for the phenomenon, Researcher expresses this relevance in as direct
manner as possible. This is called the transformation of the subject's lived experience into
direct psychological expression. This step that makes it clears through the description of
the intrinsic meaning in the material. Furthermore, the researcher must make clear the
implicit meaning of meanings which the text points to, i.e., make explicit what is
implicitly given. For that transformation must be kept at a descriptive level, it is essential,
however, does not go beyond what is directly given in the data

Step 4: Synthesising transformed meaning units into a consistent statement of the

structure of the phenomenon.

- Making the meanings units coherent and syntheses by relating them to each other
to have meaning statements.

Specific statements are written for individual participants and a process of analysis is
used whereby common themes across these statements are elicited and Then form a
general structural description which becomes the outcome of the research. , the actual
sentence structure on the investigated phenomenon described (Robinson & Englander
2007), (Giorgi 1985, 1997).

Sentence structure consists of the elements identified in the previous step and understood
through their relationships and the way in which they are related to each other. Sentence
structure is achieved by the researcher as in step three make use of imaginary variations
to arrive at the final sentence structure that cannot vary. All data must be considered and

23
the researcher must also have been sticking to a purely descriptive language. If there are
contradictions or ambiguities in the material shall be described but not explained or
understood in terms of interpretations, theories, hypotheses or other existential
assumptions. If the context and other contextual factors are relevant to the phenomenon
must also be described. There are three levels at which the structure can be described.
The first level is the individual structure that is based on a description from an informant.
The second level is the general structure that can be achieved by having multiple
descriptions (usually three). At the third level we find the universal structure, which is
located on a philosophical level. To find the general structure is always desirable when it
can be generalized to other people experiencing the same type of phenomenon

Once the description of the psychological structure of each individual had been
identified, the researcher looked at statements that can be taken as true in most cases.

8.9 Trustworthiness

Matters relating to the implementation of interviews and analysis can say something
about the survey's reliability. Before the interviews, the authors write down what they
expected to find in the survey and be conscious of how their backgrounds might be to
color the survey. The authors could thus greater curb their expectations, bracketing
(Robson, 2002).
The authors may, by making themselves aware of their own attitudes, become a better
listener who trying to put themselves aside and take the dialogue partner seriously.

All interviews will be recorded on a tape and transcribed verbatim. This makes survey
more credible than if the authors had only taken notes during the interview (Robson,
2002).
Credibility of the data may be related to whether respondents tell the authors truth
(Malterud, 2003). In this study authors are looking for experiences to diabetic patient
have amputations. An experience is subjective and thus true for the one who tells it.
The mothers will be asked if the authors really got something out of this when she had
told its history. It is important that the analysis and presentation of findings will be made
in a credible manner.

24
The authors will follow analysis model to Giorgi (1985) as described and will try to be
true to the stories of mothers and teachers. The authors selected in this study using
phenomenological approached to the theme, this will give the authors more aspects of the
findings. Using a developed analytical model, will give opportunity to test the analysis
that will be done (Robson, 2002).

8.10 Evaluating the quality of phenomenological research

When presenting phenomenological research, its value is established by honoring

concrete individual instances and demonstrating some fidelity to the phenomenon (Wertz,
2005). Research reports may, for example, contain raw data such as participants’
quotations providing an opportunity for readers to judge the soundness of the researcher’s
analysis.

The quality of any phenomenological study can be judged in its relative power to draw
the reader into the researcher’s discoveries allowing the reader to see the worlds of others
in new and deeper ways. Polkinghorne (1983) offers four qualities to help the reader
evaluate the power and trustworthiness of phenomenological accounts: vividness,
accuracy, richness and elegance. Is the research vivid in the sense that it generates a
sense of reality and draws the reader in? Are readers able to recognize the phenomenon
from their own experience or from imagining the situation vicariously? In terms of
richness, can readers enter the account emotionally? Finally, has the phenomenon been
described in a graceful, clear, poignant way

25
Chapter four
The Result

26
 The result

Introduction

This chapter serves to outline the outcomes of the in-depth interviews with key
informants. Following analysis of the in-depth interview, five main themes emerged after
the categorization of the various concepts expressed by the key informants. These were: a
psychological aspect, Changes in lifestyle, Adaptation and adjustment, Rehabilitation and
nursing and professionals care.

Demographic data :

The number of interview was seven

Mean of age was 57± 5 years old

gender Frequency Percent

Male 5 71%
Female 2 29%

Period from discovery of Diabetic

Frequency Percent

Less than 10 years 2 29%

10-20 years 4 58%

More than 20 years 1 13%

Level of education

27
degree Frequency Percent

Illiterate 2 29%

Primary 3 42%

High school 2 29%

Themes and subthemes

Theme Sub themes

28
 3.1 Psychological aspect Emotional disturbances after amputation
Positive psychological impact
Negative psychological impact
Body image
feeling of Pain
3.2 Changes in lifestyle Be dependent
Social identity
The life become hard
3.3 Adaptation and adjustment Ability to adapt
Adjustment to new situation
3.4 social support social support
3.4 Rehabilitation Rehabilitation
needed facilities
3.5 nursing and professionals care nursing and professionals care

4.1 Psychological aspect

Psychologically the participants dealt with a lot of hardships following a lower limb
amputation. The new life experience, having to face the world without a limb brought
different psychological reactions. Participants went into a state of shock and disbelief.

29
The reality of not knowing what to expect following an amputation was a concern. Not
knowing what the difference will be now that they had to live with an amputation and
how the amputation was going to impact on their lives was a concern. In these situations,
they did not know what adjustments they needed to make and what adaptation they had to
make in order to factor the amputation smoothly into their lives. They did not know what
difficulties they had to face and there were perceived uncertainties about life in the
future.

4..1.1 Emotional disturbances after amputation

“Initially it was a big shock. I was feeling crushed, I really cried so much.”1

“This is unbelievable that one tell you that you will continue your life without your leg,
but the worst thing become really.”2

“I didn’t realize I would have an amputation’ I didn’t realize the restrictions … It is sad
that it happened because of the diabetes, I blame my self for not adapt with regulation of
diabetes.”3

“In the beginning I think in my life how will be like, I feel depressed, nervous, I hoped
that I am died before this moment.” 4

“I didn’t realize that my leg wasn’t there, this was the biggest shock in my life.”5

“Initially I found it very hard to understand to terms amputation, this term mean that the
cure is become amputee person, I feel my life will end.”6

“In the first I can’t understand the thought that I will be without leg, its like magic.”7

4.1.2 Positive psychological impact

Some of the participants were able to draw positive inspirations from the amputation.
They tried to live a positive life, keeping a positive attitude. They were able to see that

30
there is still a life after the amputation. There is still a lot to live for. Some even modified
their lifestyles.

Every human mind is different, not everyone thinks alike. Some people get disheartened .
..There were some who gave up and passed away within a fortnight, for me my life
continue as in the past. 2

In the first I ask myself, why me? What I did in my life? but I do things like I did before,
the difference is that it is time consuming, it now takes long to do an activity but not
much has changed5 ‫ الحمد هلل على كل حال‬.. ‫قدر هللا وما شاء فعل‬

I want to make sure that it looks good, especially if I’m wearing a dress. 7

4.1.3 Negative psychological impact

I feel that the time for the strong man ended.1

“I have been cheated out of a lot of things. I feel that I miss out of a lot of Things, it’s the
worst thought, there is a lot of things that go through my mind, everything is
disorganized.”3

For me it was hard, one leg gone, I will never get it again, I will be disable person. It
made me feel inferior, because I could no longer be my family’s breadwinner 4

“When I was still in the hospital, I usually think, what will the people say? How they will
look to me? 6

4.1.4 Body image

Almost of Participants connecting lower limb amputation with disability but all of them
are conscious about their image . A lower limb amputation changes ones’ physical
appearance so much that they feel that the general public will perceive them differently.

The first thought in my brain that I will be disable person. 1

I feel that me less of a person now that I have this disability.6

You need to show for all that you are still strong, unfortunately this is hard with
amputation leg.7

31
4.1.5 Feeling of Pain

All limitations were generally of mobility with stability and balance challenges rather
than pain inhibiting their function. In this study, some participants experienced a great
deal of pain and discomfort following lower limb amputations. This may include rest pain
in the stump or even pain from ischemic changes of the contralateral leg. This is also the
case in participants with peripheral vascular disease where the other leg is starting to
show signs of vascular disease while the participant is recovering from the leg that was
amputated. The pain is unbearable and so uncomfortable that it can have an impact on
sleep and result in sleep disturbances. According to Resnick at al, (2004), participants are
likely to experience pain following a lower limb amputation.

The pain wakes me up in the middle of the night. I sit up, I was scream like a baby.1

“Actually, since my leg amputation. Initially, I don’t sleep well, and now I have lots of
pain and numbness at night.”3

I experienced many type of discomfort, pain, numbness.4

No pains, I don’t feel anything else. 5

Pain was after surgery while I am in the hospital, after that no pain or any discomfort
sensations.7

4.2 Changes in lifestyle

People with a lower limb amputation faced challenges and limitations including social
interaction during their time of reintegration to the society of origin. At times they were
unable to join fellow family members in social outings and events. In other instances they
loved doing certain activities together before they had an amputation and after the
amputation they were unable to continue with shared activities.

4.2.1 Be dependent

One of the changes in life style after amputation as participant said that they have to
depend on other in their daily activates, this are some examples.

32
It’s very difficult! You have to depend on many people. I hate it when I can’t do
something myself 1

I could no longer be my family’s breadwinner 2

I depend on my son in all thing.4

I can’t do all of my activates in home without assistance.5

All want to help me but I don’t like this, this give you feeling of disable.

This is the life, after I care for them (her sons and daughters), they care for me now.6

4.2.2 Social identity

All Participants were seen to have strong relationships with their sons, daughters and
relatives following a lower limb amputation, this result in strong support from family and
friends.

Certain things like walking, shopping and standing. .. The worst thing of them all is not
being able to visit neighbor, friends. 2

I think just in terms of moving around, having to get up for pray in early morning I have
to find out crutches first. And make sure that the light on I need to walk in the dark
without knocking into anything. 5

I’m a women. I like to socialize but since I have amputation I’m out of it. 3

4.2.3 The life become hard

Really after amputation, I can’t do normal things that I was doing it and I have to use a
wheelchair all the time. 1

Sitting in a wheelchair, go to the toilet, it’s not be easy thing this now a long story,
ooooooooooh.4

In any place the first thing that you think to be sure you will not fall because its will be an
embarrassment more than any thing else.6

4.3 Adaptation and adjustment

33
Participants may have accepted the new condition gradually. Participants may be withdrawn,
feeling that coping in their new chapter of life will be overwhelming.

4.3.1 Ability to adapt

There is always a solution to most things 1

This situation annoying me because I don’t want it to win … I don’t want my left leg or
lack of leg to rule me.2

2.‫ بس انا ما رح خلي فقداني لقدمي اليسرى او اني اعيش بدون قدم يقيدني‬.. ‫هاد الوضع بالنسبة لي مزعج‬

Now I am in realty, I start think how to facilitate my life and how to depend on my self, I
would wear clothes that easy to put on e.g. trouser with elastic rather than the belt.5

Losing a leg is not a problem. I help myself with whatever. Life will goes on. I feel good,
leg amputation had no effect on my life. It hadn’t made difference for me.7

“I am coping well, I move around, I do bath myself and do some cooking, ,‫الحمد هلل‬
4 ‫ربنا يديم علينا الصحة والعافية‬

4.3.2 Adjustment to new situation

some participants had accepted the amputation and stating that there are have varying
ways of adjusting, coping and adapting to a lower limb amputation.

Other ways of coping, staying positive and avoiding destructive situations involved
managing and handling stress well. Some participants made every effort to depend on
themselves.

Some of the Participants also felt that they did not have a choice but to accept the current
status and not accepting it will result in more struggle.

If I could get back to my previous function everything would be normal. 1

Now my inseparable friend is my pair of crutches.2

34
Until now I still in denial about my leg amputation or this just thing difficult thing to
believe in my mind, now or later I must to accept, realizing that there are some of the
difficulties that I should deal with it in my future.6

“It [the experience of an amputation] brought me closer to God. It made me realize God
was by my side all along. 3

In the first I had must to learn to live with this and that’s all, the God give us the power to
adapt. 4

4.4 social support

My family have been giving me a lot of support, helped me to trust myself again and to
cope with this situation. 1

In this age what we need rather than go to pray, there is multi cars, ‫هللا يرضى عليهم اوالدي مش‬
1 ‫منقصين علي شي‬

My sons, daughters, friends give me support from the beginning until now, without them
I don’t know how to do. 2

My friends and neighbors still coming to me, my sons and Grandsons always near me.3

My daughter despite her responsibilities in her home, she would make sure that she
makes food at home and send them to me, to make sure that I have enough to eat. 3

All family members are supportive, I don’t feel alone in any time.4

My family are supportive and very helpful. They also hire someone to help me. 5

My daughter and wife help with all needs and they get me feeling shy and cooking
Washing my clothes and making bed.6

4.4 Rehabilitation

4.4.1 Rehabilitation

35
Rehabilitation is important because it is helping me to return to do my daily life. 1

What means of rehabilitation, I never have it.3

I don’t go to special center.4

Rehabilitation has helped me, but it’s very hard for me, and I don’t know if I’ll be able to
walk alone!. . . I can’t accept this situation because it’s revolting being like this . . .
without driving, walking, working . . . it’s very sad depending on others . . . I was a very
dynamic man before this happened. 5

No one tell me about this. 6

After my leg amputation what will help, I am still alive.7

7.‫ هينا عايشين والحمد هلل‬.. ‫شو رح ينفع شي‬...‫بعد ما راحت رجلي‬

4.4.2 needed facilities

We don’t need thing rather than Satisfaction of God. 1

If they offer to me Electric wheelchair, to able go around. 2

The government not offer prosthesis, I hope to have one.3

I need financial support.4

4.5 nursing and professionals care

“While in hospital I don’t found any emotional support from health professionals at all.
They don’t give me any information on the procedure, or how this will affect your life
and how to adapt or cope . 1

“I cannot complain about anything. When I was in hospital, I had good support because I
had doctors, nurses. .. They were all supportive. They were always there to help change
my dressings [following the amputation] and provided for my needs. 2

Nurses and doctors do what they can do, thanks for them. 3

3 .‫ والباقي على هللا وهاد الي مكتوب علينا‬... ‫االطباء والممرضين عملو الي عليهم يخلف عليهم ما قصرو معي‬
36
Some of them are supportive, and some are careless.4

Thanks to all. 5

They don’t understand how its hard to person to loss part of his body, how he complain,
some of them are easily become nervous.6

Chapter five
37
 Discussion

Discussion

Introduction

This study has provided insight into these participants’ experiences of living with an
amputation and has revealed factors that may influence whether people experience post
amputation, how they adapt, what they need, and their hopes.

Psychological aspect

38
In the initial stages participants went through feeling of loss, grief, crying and miserable
moments of trying to live with the amputation. They had to cope with the idea of not
having a leg, trying to come to terms with it.

Some Participants found it stressful to deal with the amputation. They found the
amputation limiting in terms of involvement and participation in normal activities.

Participants found it hard to go through, especially because it’s a new experience in their
lives. In some instances there was uncertainty about their health status.

Some participant felt that the amputation will potentially put them at a disadvantage
while exploring their ambitions during the process of reintegration into society.

Pain

In this study, participants did not seem to establish any relationship between pain and
functional limitation. All them Experience pain directly after amputation in hospital or
after discharge but this last for short time after amputation.

The second discomfort the patient face is numbness, some of them still complaining of it
until now.

Body image

Almost of Participants with a lower limb amputation are conscious about their image. A
lower limb amputation changes ones’ physical appearance so much that they feel that the
general public will perceive them differently. Some, therefore, tried to preserve their
normal physical appearance to the best of their ability. They insisted on ensuring that
they wore long pants with the prostheses to make sure that when they go out, people who
do not know would not notice.

About their life after amputation some participant said that they can adapt and having no
problem but the most of them their life become harder they had a fear of falling and tried
to avoid being embarrassed by falling in public. They imagined themselves falling in and
people feeling sorry for them. Apart from the emotional impact, falls can also result in
injuries, especially to the stump. During these periods, participants developed various
coping mechanism. These included learning to fall safer, e.g. on their back rather than the

39
stump, having two pairs of crutches if they live in a double storey house, where one pair
is kept on each floor and they move on their bottom on the staircase to the next floor to
eliminate the risk of falling (Zidarov et al, 2009).

Positive adaptation

Some people felt that nothing much had changed in their lives except not having two
legs. They at times saw that the operation had to be done for their own survival and the
betterment of their lives. This form of acknowledgement and acceptance was also a
finding in the study by Mac Neill et al, (2008) showed that, participants coped well
following a lower limb amputation.

Participants also felt that they did not have a choice but to accept the current status and
not accepting it will result in more struggle.

Social support

In this study, the families and relatives were very supportive. They tried their utmost best
to be there for the participants. This included the sons, daughters , the and friends. These
close people intervened very early and then gave continued and valuable support to the
participants. The nature of this support ranged from psycho-emotional to physical
demands. Participants lost skills like driving, particularly a car. This is just one of the few
examples where a spouse or a friend had to pick up and drop them to various places to
engage in their usual activities. Participants appreciated this but they also expressed that
they did not like being dependent and it was very inconvenient at times.

In this study, some participants tended to put their faith in God. They felt that God had
decided that they had to get the amputation and therefore God will take care of them.
They did not see the need to question anything and they said that God had all the
answers. They felt that through praying, they will overcome. This coping skill was
expressed in a way that suggested that they did not have much to worry about as far as
the amputation was concerned as God will lead the way.

This study has revealed the benefits of social support from family and friends, as long as
it was considered appropriate and focussed on the needs of the person. It is known that

40
this has a protective benefit and that it is beneficial in terms of general adjustment to
amputation with greater life satisfaction, mobility and more engagement in meaningful
activity. Social support is clearly crucial to the process of adjustment in the social
context, but in the persons work environment, there may have to be additional
adjustments

Conclusion

Participants had varying psychological reactions after the lower limp amputation . Some
were battling with issues of body image, pain, disability and poor functional
independence. Others were reported to be coping well. Both negative and positive coping
strategies were demonstrated by the participants

The participants had supportive families and friends. They also had complain poor
rehabilitation services resources and this had a negative impact of their ability to recover.
Some participants had given their lives to God, so they would be responsible for the well-
being.

The health professional team varies in deal with patient having amputation, some of them
are supportive and other are not.

41
Recommendations

 We recommend that people with chronic disease who require a planned

amputation have counselling which includes family and close friends from an
early stage. This has the potential to aid adjustment after the amputation through
ensuring that family and social support is appropriate, allows for the development
of independence and maintains identity as much as possible.

42
  support of family members and friends have for these participants is crucial in
their longer term recovery and adjustment over time. It is also important that
longer term counselling should be available also by health care professionals
according to the persons changing needs over time and in relation to both their
amputation and their chronic disease.
 Most of participant has deficit knowledge about rehabilitation, so the health
professionals should increase their awareness about rehabilitation and the
government should offer specialized center for them.
 Future studies should attempt to gather enough and useful data on the items
related to the impact of financial resource, compliance with medical treatment,
rehabilitation and prosthetics issuing to see if that could explain the outcome of
these participants

Limitation of the study

This study aimed to explore the experience of undergoing amputation due to

diabetes/peripheral vascular disease.

 The planed site for research not be accessible due to not have permission from the
administrative of the clinic, so we switch to individualized interview at homes.

43
  Ideally, the participants would have been same period post amputation, but time
restrictions for the research made this impossible.
 A perceived limitation could be seen to be the sample size. However, it was not
the intention to survey a large and diverse population in order to be generalisable
with the results but to gain indepth insight into the participants experiences
 The research limited to diabetic, Further research is required to look at other
distinct groups.

Year Author Study title Purpose Subject Result

2015 Sarah Management Diabetes is an A purposive sample of Results suggest that
Aug Delea1*, of diabetic increasingly individuals who had rehabilitation services
Claire foot disease prevalent either active foot should place a strong focus
Buckley1, and chronic illness disease or a lower on psychological as well as
2, Andrew amputation that places a limb amputation as a physical adjustment to

44
Hanrahan in the Irish huge burden on result of diabetes were active foot disease or lower
3 , Gerald health the individual, recruited from the limb amputations. The
McGreal3 system: a the Prosthetic, Orthotic delivery of services needs
, Deirdre qualitative health system and Limb Absence to be
Desmond study of and society. Rehabilitation standardised to ensure
4 and patients’ Patients with (POLAR) Unit of an equal access to medical
Sheena attitudes and active foot Irish hospital. One-to- care and supplies among
McHugh experiences disease and one interviews were people with or at risk of
with health lower limb conducted in the lower extremity
services amputations POLAR unit using a amputations. The wider
due to diabetes semi-structured topic social circumstances of
have a guide. patients should be taken
significant Thematic analysis was into consideration by
amount of used to identify, health care
interaction analyse and describe professionals to provide
with the health patterns within the effective support while
care services. data patients adjust to this
The purpose of potentially life changing
this study was complication. The
to explore the patient’s perspective
attitudes and should also be used to
experiences of inform health service
foot care managers and health
services in professionals on ways to
Ireland among improve services.
people with
diabetes and
active foot
disease or
lower limb
amputations.

45
13 S. W. How long to To the best of Evidence for the use Given the general lack of
Septe Johnson*† treat with our knowledge, of antibiotics after data, we
mber PharmD, antibiotics there has been amputation recommend that post-
2012, R. H. following no published comes largely from operative treatment
Accep Drew*‡ amputation study designed perioperative surgical duration be individualized,
ted 13 PharmD in patients to identify the prophylaxis studies and, until further studies
Nove MS and with diabetic most evaluating the rate of are done, it seems
mber D. B. foot appropriate infection after reasonable to
2012 May*‡ infections? duration of amputation. Three adhere to the
PharmD Are the 2012 antibiotic such studies recommendation provided
*Campbel IDSA DFI therapy in were identified; 2 by the 2012 IDSA DFI
l guidelines lower found a 5-day course guidelines for a 2–5 day
University reasonable extremity of antibiotics course of antibiotic therapy
College of skin and skin postamputation postoperatively
Pharmacy structure resulted in a reduction when no residual infected
and infections in of infection rate, while tissue remains.
Health diabetic 1
Sciences, patients [aka found no additional
Buies “diabetic foot benefit. Comparative
Creek, infections” antibiotic studies in
†Forsyth (DFI)] post- DFI also offers
Medical amputation. evidence for treatment
Center, However, duration, of which, 10
Winston- recent studies were
Salem, guidelines identified. Five
and ‡ published by included patients who
Duke the Infectious received
University Diseases amputations; however,
Medical Society only 1 reported
Center, of America treatment outcomes in
Durham, (IDSA) a

46
 NC, US provide subset of diabetics
recommendatio requiring amputation.
ns for In this study, the
treatment authors concluded that
duration in antibiotic treatment is
these patients. likely necessary
Therefore, after amputation.
are reasonable.
 May Aziz Distal Minor Minor amputations in
2013; Nather, amputations amputations in patients with diabetic foot
Revis FRCS* for the diabetic problems
ed: 3 and Keng diabetic foot patients with have been shown to be
June Lin foot effective in limb salvage
2013; Wong, complications and
Accep MRCS have been well reducing morbidity and
ted: studied in the mortality in patients. The
24 literature but authors
June controversy have proposed several
2013; still remains as definitions regarding
Publis to what diabetic foot
hed: constitutes amputations while further
16 successful or studies are needed for a
July non-successful consensus on the definition
2013 limb salvage. on a successful versus
In addition, nonsuccessful
there is diabetic limb salvage
a lack of surgery.
consensus on
the definition
amputations
Septe Jeffrey S. Risk of The eligible cohort In the 5911 patients with
mber Markowit amputation consisted of all DFU, 116 individuals who

47
21, z, DrPH1 in patients patients with two or had
2004 ; Elane M. with diabetic more ICD-9 diagnostic LEAs were identified as
Accep Gutterman foot ulcers: claims16 for a DFU cases yielding a crude
ted in , PhD1 a claims- and evidence amputation
final ; Glenn based study of diabetes based on a rate of 1.96%. The
form Magee, relevant diagnostic incidence density rate was
Augus MBA2 code or prescription 0.02298 per
t 12, ; David J. data indicating use of person-year (or 2.30 per
2005 Margolis, insulin or oral 100 person-years), based
MD, hypoglycemic on a total
PhD3 therapy. The index person-time of 5046.9
date was the day of the years in the eligible
first subjects. Assuming
DFU diagnosis and a Poisson distribution, a
patients were also 95% CI around this
required to have 3 estimate would be 0.0191–
months of data prior to 0.0277 per person-year (or
this date without any 1.91
medical to 2.77 per 100 person-
claims indicating a years).
primary or secondary
DFU diagnosis
or any LEA. In
addition, patients were
required to have
continuous eligibility
for in- and outpatient
coverage during
the pre- and
postdiagnosis periods.
20 Liu R, Li In patients Included MEDLINE and In patients with chronic

48
Augus L, Yang with chronic studies EMBASE/Excerpta diabetic foot ulcers, adding
t 2013 M, Boden diabetic compared Medica (both to Apr hyperbaric
G, Yang foot ulcers, usual care 2012); oxygen to usual care
G. hyperbaric (e.g., control of Cochrane Library reduces major amputations.
oxygen glycemia, (2012); reference lists;
reduces revascularizati abstracts of major
major on, diabetes,
amputations debridement, endocrinology, and
off-loading, plastic surgery
and metabolic meetings (2003 to Apr
and 2012);
infection and trial Web sites
controls) plus (www.clinicaltrials.go
HBO with v,
usual care www.novonordisktrial
alone in s.com,
patients and
with type 1 or www.clinicalstudyresu
type 2 diabetes lts.org) were searched
and chronic for
lower- randomized controlled
extremity trials (RCTs) and
ulcers nonrandomized
attributable to controlled
diabetes. trials. 13 trials (n =
Outcomes 624), including 7
included ulcer RCTs (n = 359, mean
healing age range 53 to 72 y;
(complete follow-up range 2 to
epithelializatio 92 wk), met selection
n of the criteria. No RCT

49
 wound), major reported allocation
(above the concealment, 2 had
ankle joint) or blinding,
minor (below 3 used a random-
the ankle joint) number generator, and
amputation, all reported loss to
and adverse followup.
events. Only the results of
RCTs are presented
here

May Avital Rehabilitatio To characterize Most elderly amputees Since post-acute amputees
2012 Hershkovi n outcome of the lower-limb in our country are have a low rehabilitation
tz1,2, post-acute elderly referred to a potential
Israel lower limb amputee post-acute care facility (low survival rate and low
Dudkiewi geriatric patients for rehabilitation and rate of prosthesis fit) we
cz2,3 & amputees admitted to a assessment for suggest
Shai post-acute potential prosthetic fit. that: (a) – rehabilitation
Brill1,2 rehabilitation The current study was efforts should best be
program, performed in a targeted
assess university affiliated depending on need, and (b)
their 1-year 300-bed major post- – rehabilitation
survival rate, acute geriatric professionals
estimate rate of rehabilitation should make educated
prosthetic fit centre, admitting older estimates of outcomes at
and patients from major the beginning
report rate and acute of rehabilitation based on
factors hospitals in nearby the characteristics of the
associated with cities. Half of the patients
1-year post- patients are admitted (level of amputation and
discharge for rehabilitation after functional level on
prosthetic use orthopedic surgery, admission).

50
stroke or
deconditioning
due to prolonged
hospitalization. The
other half are
admitted for medical
care, encompassing
treatment for severe
pressure ulcers,
management of
advanced heart failure,
terminal
cancer, chronic
ventilation, etc. All
admitted patients
carry full medical
coverage provided by
four health
maintenance
organizations (HMOs)
conforming to the
following
admission criteria:
>60 years old,
functionally
dependent,
lack of social support
system, or living in an
unfitted home
environment (i.e. no
elevator or narrow

51
 doorways leading to
the bathroom)..
12 Harold Mechanism In this study, Construction of an ADV/VEGF165
March Brem1 of Sustained we hypothesize ADV expressing accelerates time to closure
2009 , Arber Release of that local bioactive human in db/db mice
Kodra1 Vascular sustained VEGF for To determine whether
, Michael Endothelial release of murine study ADV/VEGF165
S. Growth vascular Human umbilical vein accelerates wound
Golinko1 Factor in endothelial endothelial cells healing, time to wound
, Hyacinth Accelerating growth factor (HUVECs) were closure was determined
Entero1 Experimental (VEGF), using homogenized using four
, Olivera Diabetic adenovirus and total RNA was different doses of
Stojadino Healing vector (ADV)- extracted. The full- ADV/VEGF165. Wounds
vic2 mediated gene length human treated with ADV/
, Vincent transfer, VEGF165 cDNA was VEGF165 healed 6.6 days
M. Wang3 accelerates amplified by PCR sooner than controls
, experimental with appropriate (Figure 1).
Claudia wound healing. primers Treated wounds healed in
M. This containing restriction 27.2±1.4 days. Saline-
Sheahan4 hypothesis was sites (HindIII and treated
, Alan D. tested by XbaI) for subcloning wounds healed in 34.2±7.0
Weinberg determining into days, whereas wounds that
5 the specific pBluescript were
, Savio effects of (Stratagene, La Jolla, treated with the virus
L.C. VEGF165 CA). After sequence vector alone healed in
Woo6 application on confirmation, 33.5±6.5 days.
, H. Paul multiple the human VEGF-165 Statistical significance
Ehrlich7 aspects of the cassette was cloned (Po0.05) was noted after
and wound healing into the multiple comparison
Marjana process, that is, cloning of the 5 1011 vp per
Tomic- time to site of an adenovirus wound VEGF165-treated

52
Canic2 complete shuttle vector (pXC1) group and
wound closure containing adenovirus control groups (Table 2).
and skin type 5 sequences (bp However, such high doses
biomechanical 22–5,790) and a Rous of
properties. sarcoma virus VEGF165 may have a
After showing promoter. toxic effect in the mice
accelerated This same vector was used in the
wound healing used as the positive study, as the incidence of
in vivo, we control Dl-312 in the mortality in the high-
studied the experiments. For the dosage
mechanism to rescue of the VEGF165-treated group
explain the recombinant was greater than in other
findings on adenovirus, we groups. A
multiple successfully used the minimum 10% increase in
aspects of the two-plasmid co- mortality relative to
wound transfection system controls was
healing (Microbix found at ADV/VEGF
cascade, Biosystems, Inc., doses of 5 109 vp per
including Toronto, Ontario, wound and higher.
epithelializatio Canada). Virus
n, collagen particle titer was
deposition, and determined by optical
cell migration. absorbance at 260 nm,
Intradermal and plaque-forming
treatment of unit titer (pfu ml1
wounds in ) was quantified by
non-obese standard agarose
diabetic and overlay
db/db mice plaque assay on 293
with cells. Plaque-forming
ADV/VEGF16 unit (pfu)

53
 5 improves determination
healing by can vary up to one
enhancing order of magnitude
tensile when the same batch
stiffness and/or of virus
increasing is used in different
epithelializatio assays, causing a
n and collagen significant variation in
deposition, as particle
well as by measurement. To
decreasing prevent this problem
time to wound and to keep the viral
closure loads
constant, the same
batch of virus was
used for all in vitro
and in vivo
experiments.
22 , Deborah Fluorescein Fluorescein Ruorescein The fluorescein wash-in
Augus K. Oh\ dermofluoro dermofluorome dermofluorometry was time constant demonstrated
t 2000 Richard metry for the try can be used performed in four better correlation with the
N. Jones^ assessment to relate the groups of patients: presence of diabetic
William of diabetic uptake of non-diabefic control microvascular
Marshall^ microvascula fluorescein in patients, diabetic disease than did the initial
and r disease the skin to control slope of the signal.
Richard L. blood flow. patients, diabetic Differences
Magin^ We patients with chronic in the wash-in time
have foot ulcers, and constants of non-diabetic
characterized diabetic and diabetic subjects
the uptake of patients with acute support the hemodynamic
fhe dye by a foot ulcers. The hypothesis for the

54
 wash-in time outcomes of the development
constant patients with of microvascular disease.
that is foot ulcers were The indication of early
inversely documented 4-14 wash-out of the
proportional to months after fluorescein signal may also
the local blood participation. be useful in the prediction
flow. The Following an of ulcer
purpose of this intravenous injection healing.
study was to of sodium fluorescein,
explore the use the
of change in the
dermofluorome fluorescein signal with
try time was continuously
in the measured at the
assessment of plantar surface of the
patients wifh foot. Both the initial
diabetic slope
microvascular of the signal and the
disease wash-in time constant
were calculated in
each subject.
Recei João Development Diabetes is a 62 patients with Patients with diabetic foot
ved: Paulo of the chronic disease diabetic foot, from need to be treated using a
May Tardivo1, Tardivo that affects March 2011 to March multidisciplinary approach.
24, 2, Algorithm to almost 19% of 2013 were used to Diabetes does
2015 Maurício Predict the elderly develop the scoring not have cure and the risks
Accep S. Amputation population in method. The patients to patients may persist
ted: Baptista3 Risk of Brazil and were treated at the throughout life. The
July *, João Diabetic Center for Diabetic Tardivo algorithm is a
26, Antonio Foot Foot at Hospital fundamental tool for
2015 Correa1 Anchieta predicting whether the

55
Publis , Fernando (CeDiFo), served by diabetic foot has a higher
hed: Adami1 the Faculdade de chance of healing or a
Augus , Medicina do ABC higher chance of requiring
t 17, Maria (FMABC), which is amputation and may be a
2015 Aparecida coordinated by useful for guiding
Silva Dr. Tardivo. The study treatment.
Pinhal1 was approved by the The proposed score
research ethics classification system for
committee at FMABC the diabetic foot may
and participants enable better quality of
signed a consent form. life for diabetic patients
The clinical and promote better low-
investigation was cost care for millions of
conducted according individuals worldwide.
to the principles The adoption of this score
expressed in the associated with
Declaration of antimicrobial
Helsinki. photodynamic therapy
could
reduce amputations in
diabetics in over 80% of
cases, resulting in lower
costs, fewer
hospitalizations
and no side effects.
June M. Gail Tool for Most diabetic The tool was Clinicians in low and
29, Woodbury Rapid & foot independently tested middle income countries
2015 1 Easy amputations by n=12 assessors such as Guyana can use the
, R. Gary Identification are caused by with n=18 Guyanese Simplified 60-
Sibbald2 of High ulcers on the patients with Second Diabetic Screening
*, Brian Risk skin of the foot diabetes. Inter-rater Tool to facilitate early

56
Ostrow2 Diabetic i.e. diabetic reliability was detection and appropriate
, Reneeka Foot: foot assessed by treatment of diabetic foot
Persaud3 Validation & ulcers. Early calculating ulcers. Implementation of
, Julia M. Clinical Pilot identification Cronbach’s alpha for this screening tool has the
Lowe2 of the of patients at each of the potential to decrease
Simplified high risk for assessment items. A diabetes related disability
60 Second diabetic foot minimum value of and mortality.
Diabetic ulcers is 0.60 was considered
Foot crucial. The acceptable. Reliability
Screening ‘Simplified scores
Too 60-Second of the screening tool
Diabetic Foot assessment items
Screening were: ‘monofilament
Tool’ has been test’ 0.98; ‘active
designed to ulcer’ 0.97;
rapidly detect ‘previous amputation’
high 0.97; ‘previous ulcer’
risk diabetic 0.97; ‘fixed ankle’
feet, allowing 0.91; ‘deformity’ 0.87;
for timely ‘callus’
identification 0.87; ‘absent pulses’
and referral of 0.87; ‘fixed toe’ 0.80;
patients ‘blisters’ 0.77;
needing ‘ingrown nail’ 0.72;
treatment. and ‘fissures’
This study 0.55. The item
aimed to ‘stiffness in the toe or
determine the ankle’ was removed as
clinical it was observed in
performance only 1.3% of
and inter-rater patients. The item

57
 reliability of ‘fissures’ was also
‘Simplified removed due to low
60 Second inter-rater reliability.
Diabetic Foot Clinical performance
Screening was assessed via a
Tool’ in order pilot study utilizing
to evaluate its the screening tool on
applicability n=1,266 patients in
for routine an acute care setting in
screening. Georgetown, Guyana.
In total, 48% of
patients either had
existing
diabetic foot ulcers or
were found to be at
high risk for
developing ulcers
Recei Aziz The modified This paper Six patients with The modified Pirogoff’s
ved: Nather, Pirogoff’s describes the diabetic foot infections amputation has been found
14 FRCS amputation surgical were operated on by to show good results in
Nove (Ed)*, in treating technique of a the National carefully selected
mber Keng Lin diabetic modified University Hospital patients with diabetic foot
2013; Wong, foot Pirogoff’s (NUH) diabetic foot infections. The selection
Revis MRCS infections: amputation team in Singapore criteria included a palpable
ed: 8 (Ed), surgical performed by between November posterior tibial pulse, distal
March Amaris technique the senior 2011 and January infections not extending
2014; Shumin and case author and 2012. All patients proximally beyond the
Accep Lim, Med. series reports the underwent midfoot level, ABI of more
ted: Student, results of this a modified Pirogoff’s than 0.7, hemoglobin level
10 Dennis operation in a amputation for of
March Zhaowen single surgeon diabetic foot more than 10 g/dL, and

58
2014; Ng, case series for infections. Inclusion serum albumin level of
Publis MMed patients with criteria included the more than 30 g/L
hed: 3 (Ortho) diabetic foot presence of
April and infections a palpable posterior
2014 Hwee tibial pulse, ankle
Weng brachial index (ABI)
Hey, of more than 0.7, and
MMed distal infections not
(Ortho) extending proximally
beyond the midfoot
level. Clinical
parameters such as
presence of pulses and
ABI were
recorded. Preoperative
blood tests performed
included a glycated
hemoglobin level,
hemoglobin, total
white
blood cell count, C-
reactive protein,
erythrocyte
sedimentation rate,
albumin, and
creatinine levels. All
patients were
subjected to 14
sessions of hyperbaric
oxygen therapy
postoperatively and

59
 were followed up for
a minimum of 10
months.
2 July J. Matching the To establish a Hospital-coded We report for the first time
2010 Valabhji, numerator method to inpatient data was amputation incidence in a
R. G. J. with an assess examined to derive the London population.
Gibbs*, L. appropriate amputation numerator: the number Acknowledging the
Bloomfiel denominator incidence that of non-traumatic limitations of
d†, S. to addresses the amputations accurately defining
Lyons†, demonstrate problems performed on subjects incidence in London, we
D. low matching a with diabetes each demonstrate low
Samarasin amputation numerator with financial year where amputation incidence
ghe‡, P. incidence an the Primary Care Trust associated with our
Rosenfeld associated appropriate commissioner code multidisciplinary
§, with a denominator in was our main local diabetic foot clinic.
C. M. London London and to Primary Care Trust.
Gabriel–, hospital demonstrate Denominators were
D. multidiscipli low derived from the main
Hogg** nary diabetic amputation local Primary Care
and C. D. foot clinic incidence Trust’s Quality and
Bicknell* associated with Outcomes Framework
the activity of data sets. Not all
our Primary Care Trust
multidisciplina subjects with diabetes
ry diabetic foot receive inpatient care
clinic at our hospital, so that
the denominators were
corrected for the
hospital’s percentage
market share for the
provision of inpatient

60
 diabetes care for the
Primary Care Trust
each
financial year, derived
from the Dr Foster
database.
4 P. van Complicatio The incidence In the Eurodiale study, Minor amputationis
Nove Battum*, ns of minor a prospective cohort performed frequentlyin
mber N. Differences amputation study of 1232 patients diabetic foot centres
2010 Schaper*, in minor may vary (1088 followed until throughout Europe andis
L. amputation significantly, end-point) with a new determined by depth
Prompers rate in and diabetic foot ulcer of the ulcer, peripheral
*, J. diabetic foot determinants were followed on a arterial disease, infection
Apelqvist disease of minor monthly basis until and male sex. There are
†, E. throughout amputation healing, death, major important differences in
Jude‡, A. Europe are in have not been amputation or up to a amputation rate between
and M. part studied maximum of 1 year. the
Huijberts* explained by systematically. Ulcers were treated European centres, which
differences We evaluated according to can be explained in part by
in disease minor international severity of disease at
severity at amputation guidelines. Baseline presentation. This may
presentation rate, the characteristics suggest that early referral
determinants independently to
of minor associated with minor foot clinics can prevent
amputation and amputation were minor amputations.
differences in examined using
amputation multiple logistic
rate between regression modelling.
European Based on the results of
centres. the multivariable
analysis, a

61
 disease severity score
was calculated for
each patient.
Accep M. E. Complicatio Diabetic foot We studied major and . The incidence of major
ted 18 Jørgensen, ns disease and minor lower-extremity lower-extremity
Septe T. P. Reduced amputations amputations from amputations reduced
mber Almdal incidence of severely 2000 to 2011 among significantly from 2000 to
2013 and K. lower- reduce quality 11 332 people with 2011 in Danish
Færch extremity of life and diabetes from the people with diabetes
amputations have major Steno Diabetes Center. followed at a diabetes
in a economic Amputations were specialist centre.
Danish consequences. identified by linkage
diabetes The of the electronic
population aim of this medical system with
from 2000 to study was to the National Patient
2011 estimate time Registry. Sex-specific
trends in the incidence rates of
incidence of amputations by age,
lower- diabetes duration,
extremity calendar time and
amputations in diabetes type were
Danish people modelled by Poisson
with regression.
diabetes
Manu David J. The This was a To be included in our Based on our selection
script Margolis, differential retrospective inception cohort, a criteria, we identified
receiv MD, effect of cohort study subject had to 78,178 individuals
ed: PhD1 angiotensin- using the have at least two with diabetes. ACEi or
March ; Ole converting general separate medical ARB were used by 40,342
29, Hoffstad, enzyme medical records for diabetes individuals (51%). From
2010 MA2 practices of noted between this group, 35,153
inhibitors
Accep ; Stephen The Health January 1995 and individuals

62
ted in Thom, Information August 2006. We were treated with ACEi,
and
final MD, Network used 12,437 individuals with
angiotensin
form: PhD3 (THIN). By this algorithm to ARB, and
receptor
June ; Warren agreement, assure that the 7,248 were exposed to
blockers with
14, Bilker, patient data are subject truly had both drugs. The total
respect to
2010 PhD2 recorded and diabetes. number of
; stored in THIN In addition, the evaluable exposures was
foot ulcer
Arturo R. as if it were an subject had to be at 47,590. One hundred and
and limb
Maldonad electronic least age 35 at the seven
amputation
o, MD4 medical record time individuals were
in those with
; Robert including all of diagnosis, could excluded from our
diabetes
M. Cohen, past and not have had a analysis because they
MD5 current pervious history of were treated with both
; Bruce J. medical venous agents at the same time.
Aronow, diagnoses leg ulcer, DFU or The mean
PhD6 (acute LEA, and must have age of our subjects was
; Timothy and chronic) used an ARB 64.4 (95% CI: 64.2, 64.5)
Crombleh using Read and/or ACEi, which years
olme, codes and was first prescribed with a median of 64.4
MD4 information on between 1995 and years. Females
prescribed 2006. represented 45%
medications, (18,281) of the cohort.
using British The mean total duration
National of diabetes
Formulary was 6.3 years (median
(BNF) codes. 5.98) and total person-
All laboratory time of
values, aspects 216,070 years. There
of the physical were some statistical
exam, differences in
hospitalization covariates based on

63
 s, whether they received
consultations, ACEi or ARB
and
prescriptionis
small (3%).
Our study was
reviewed and
accepted

2008 Ruth Predictors of This study 200 patients with type

The mean age of the
Kalda,1 quality of examines the 2 diabetes were
respondents was 64.7
Anneli life of factors that studied in Estonia in
(±11.1) years and the mean
Rätsep,1 patients with most strongly 2004–2005. A patient
duration of the diabetes
and type 2 influence the blood sample, taken
was 7.5 (±1.8) years.
Margus diabetes quality of life during a visit to the
Logistic regression
Lember2 of patients with family doctor, was
analysis showed that
type 2 collected. The family
quality of life was most
diabetes. doctor also provided
significantly affected by
data on each patient’s
awareness of the
body mass index
complications and risk-
(BMI), blood pressure,
factors of diabetes, and by
and medications for
the age, duration of the
treatment of type 2
disease, and BMI of the
diabetes. Patients
patient. Patients who were
completed a SF-36
less aware had a
during a doctor visit,
significantly higher quality
and also a special
of life score (p < 0.001 in
questionnaire which
all cases). The age and
we provided to study
BMI of the patients as well
their awareness about
as the duration of the
diabetes type 2.
diabetes all lowered the

64
 score of the quality of life.

2005 Singh N1, Preventing To The EBSCO,

Prevention of diabetic foot
Armstron foot ulcers in systematically MEDLINE, and the
ulcers begins with
g DG, patients with review the National Guideline
screening for loss of
Lipsky diabetes. evidence on Clearinghouse
protective sensation, which
BA. the efficacy of databases were
is best accomplished in the
methods searched for articles
primary care setting with a
advocated for published between
brief history and the
preventing January 1980 and
Semmes-Weinstein
diabetic foot April 2004 using
monofilament. Specialist
ulcers in the database-specific
clinics may quantify
primary care keywords.
neuropathy with
setting. Bibliographies of
biothesiometry, measure
retrieved articles were
plantar foot pressure, and
also searched, along
assess lower extremity
with the Cochrane
vascular status with
Library and relevant
Doppler ultrasound and
Web sites. We
ankle-brachial blood
reviewed the retrieved
pressure indices. These
literature for pertinent
measurements, in
information, paying
conjunction with other
particular attention to
findings from the history
prospective cohort
and physical examination,
studies and
enable clinicians to stratify
randomized clinical
patients based on risk and
trials.
to determine the type of
intervention. Educating
patients about proper foot
care and periodic foot

65
 examinations are effective
interventions to prevent
ulceration. Other possibly
effective clinical
interventions include
optimizing glycemic
control, smoking cessation,
intensive podiatric care,
debridement of calluses,
and certain types of
prophylactic foot surgery.
The value of various types
of prescription footwear
for ulcer prevention is not
clear.
2012 Porojan Assessing The purpose of The study group
Patients with DM have
M1, health related the study was consisted of 50
statistically significant
Poantă L, quality of to analyze the patients, males and
impairment of all aspects
Dumitraşc life in quality of life females, aged 60 (+/-
of QOL, not simply
u DL. diabetic in a group of 6), diagnosed with
physical functioning. DM
patients diabetic type 2 DM and
put a substantial burden on
patients followed up at an
affected individuals by
without major outpatient clinic. The
influencing physical,
complications. Romanian version of
psychological and social
the SF-36
aspects of QOL. The
questionnaire was
progressive nature of type
used as a health survey
2 DM and the real risk for
tool to measure the
developing chronic
quality of life (QOL)
complications certifies that
of patients in the
insulin use will be a reality
study.

66
 for most diabetic patients,
but its use did not seem to
have a negative impact
upon QOL. Glycemic
control becomes an
important measurement for
preventing long-terms
complications and provides
a better QOL to diabetic
patient. This end-point

References
67
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Ferreira, J. Apelqvist, J. van Baal , K. Bakker, K. van Acker ,L. Prompers, L.
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Alan D. Weinberg , Arber Kodra , Claudia M. Sheahan , Harold Brem , Hyacinth
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Amaris Shumin Lim, Aziz Nather, Dennis Zhaowen Ng, Hwee Weng Hey, Keng Lin
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Armstrong D.G., Hugo, Lipsky B.A. , Singh N., (2005). Preventing foot ulcers in patients
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Arturo R. Malddonado, Bruce J. Aronow , David J. Margolis, Ole Hoffstad ,Robert M .

Cohen , Stephen Thom, Timothy crombleholme ,Warren Bilker.(2010). The
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boden G, Liu li l, yang G, yang M. (2013) systemic review of the effectiveness of

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Bukley. Andrew, Delea. Claire, Desmond. Sheena, Hanrahan. Gerald, Mcgeal. Deirdre,
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Appendix A

Interview Questions

71
 ‫‪What‬‬
‫‪How nurses‬‬ ‫‪What‬‬
‫‪youother‬‬
‫‪and‬‬ ‫‪is‬‬
‫‪need‬‬
‫‪thehealth‬‬
‫‪How‬‬ ‫‪to‬‬
‫‪first‬‬
‫‪make‬‬
‫‪feeling‬‬
‫‪amputation‬‬‫‪its easer‬‬
‫‪you‬‬ ‫‪have‬‬
‫‪professionals‬‬‫‪for‬‬
‫‪affect‬‬ ‫‪you‬‬
‫‪your‬‬‫‪experience‬‬
‫‪treat‬‬ ‫‪to adapt‬‬
‫‪life‬‬
‫‪you‬‬ ‫‪at hospital‬‬
‫‪What‬‬ ‫‪about‬‬ ‫‪Who‬‬
‫‪your‬‬ ‫‪are‬‬
‫‪journey‬‬
‫‪your‬‬ ‫‪supporter‬‬
‫‪of‬‬ ‫‪rehabilitation‬‬
‫‪What changed in your life experienced after amputation‬‬

‫‪Appendix A‬‬

‫جامعة النجاح الوطنية‬

‫استمارة الموافقة على المشاركة بالبحث‬
‫اقر أنا ‪ ......................‬بأني اطلعت على بيان مفصل عن البحث المقدم من الطلبة (عامر سليلة ‪ ,‬باهر‬
‫عبيدات ‪ ,‬حسام العيسى ‪ ,‬امين ابو هنية )‬
‫‪.‬بكلية التمريض في جامعه النجاح الوطنية‬
‫وأوافق طواعية على المشاركة في هذا البحث الذي يهدف إلي الكشف عن السلوك الحياتي للمرضى بعد إجراء‬
‫جراحة بتر أحد األطراف أو كالهما وأثر ذلك على تطور حالتهم المرضية ‪,‬وكيفيه التعديل‪ 9‬على هذه السلوكيات‬
‫‪.‬ألخذ أفضل نتيجة صحية ممكنة للمريض‬
‫وانه تم إبالغي بخطوات البحث والفوائد المرتبة عليه‪ ,‬وانه ال يترتب على عدم موافقتي على االستمرار فيه أي‬
‫‪ .‬أضرار من قبل الباحثين‬
‫‪ .‬مع العلم بأن المعلومات المأخوذة من المريض ال تستخدم لغرض أخر غير البحث العلمي‬
‫‪.‬وانأ أوافق على تسجيل المقابلة للغرض العلمي‬
‫لقد قرأت المعلومات السابقة أو تليت علي وكانت لي الفرصة للسؤال عما أريد وأجيبت أسئلتي كلها بما أرضاني‬

‫‪72‬‬
73