Extended Review: Nursing Care and Diabetic Patient Leg Amputation

This report presents an extended literature review on the nursing care of diabetic patients who have undergone leg amputation due to complications from diabetic foot ulcers. The study explores the patients' perceptions and identifies critical aspects of care. The introduction highlights the global prevalence of diabetes and its complications, including diabetic foot ulcers, which often lead to amputation. The background section discusses the WHO's definition of diabetic foot, the high rate of amputations in diabetic patients, and the factors contributing to ulcer development. The methodology outlines the research question, objectives, and PEO framework used to guide the literature search. The search strategy details the databases, keywords, and Boolean operators employed to select relevant peer-reviewed articles published between 2011 and 2020. The findings section covers the quality of life post-amputation, the perception of amputees, nutritional requirements, and the nursing role in patient examination, education, and discharge planning. The discussion section analyzes the strengths and limitations of the review, and the conclusion summarizes the key findings and implications for nursing practice. The report emphasizes the importance of patient perception in developing effective nursing care plans and the need for early education and preventive measures to reduce the risk of amputation. The report also highlights the need for more research to address the dietary needs of diabetic patients with foot ulcers.

Running head: NURSING CARE
Nursing Care Post Leg-Amputation in Diabetic Patients
Name of the Student
Name of the University
Author Note

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Acknowledgement

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Abstract
Aim: The following study aims to conduct an extended review of the literature to
explore the perception of diabetic patients who have recently undergone leg
amputation due to severe complication of diabetic foot ulcer and to determine the
critical aspects of care that the nursing individuals have to ensure for such patients.
Background: Diabetic foot is characterized by WHO as a foot in people with
diabetes with neurologic disarranges, some level of vascular inclusion with or without
metabolic complexities of diabetes in lower limit and inclined to disease, scarring,
with or without profound tissue harm. Existing examination on the experience of
individuals with diabetes and foot infection or potentially amputations is centred
transcendently on understanding the mental parts of life post-amputation.
Methods: Review of literature conducted using a search protocol with inclusion and
exclusion criteria to select peer-reviewed articles published between 2011 to 2020
with the highest relevancy to the research question.
Findings: Diabetes is the primary source of non-traumatic amputation. There is a
need for leading more research to address dietary issues of diabetic foot ulcer
subjects. Early training in nursing individuals is essential in advising individuals with
diabetes about the foot dangers they face without cautious preventive measures and
self-administration.
Conclusion: Patient perception knowledge is required to develop the nursing care
plans for diabetic patients who have suffered from a leg amputation.

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Table of Contents
Acknowledgement.............................................................................................1
Abstract..............................................................................................................2
Introduction........................................................................................................4
Background........................................................................................................4
Methodology......................................................................................................7
Research Question........................................................................................7
Research Objectives......................................................................................7
PEO Questions..............................................................................................7
Search Strategy.............................................................................................7
Inclusion Criteria.........................................................................................9
Exclusion Criteria........................................................................................9
Screening of Studies....................................................................................10
Selection of Research Studies.....................................................................10
Summary of the Selected Articles................................................................12
Findings...........................................................................................................14
Quality of Life Post Amputation....................................................................14
Perception of the Amputees.........................................................................16
Nutritional Requirement...............................................................................17
Nursing Role in Examination and Screening of Patients.............................17
Nursing Role in Patient Education...............................................................18
Role of Nurses in Discharge Planning and Rehabilitation...........................20
Discussions......................................................................................................21
Strengths and Limitations................................................................................25
Conclusion.......................................................................................................25
References.......................................................................................................27

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Introduction
Diabetes is one of the most severe non-communicable diseases that is
currently affecting the health of the global population. It has become an epidemic
disorder in most of the countries all across the globe (Unnikrishnan et al. 2017).
Several pieces of evidence suggest that its negative consequences are affecting the
health care service providers, along with the community the most (Nanditha et al.
2016). One of the several complications of diabetes includes diabetic foot ulcers and
infections. A foot ulcer is defined as a foot with a neurological disorder and vascular
involvement. It is prone to grave tissue damage and infection (Boulton 2020).
Treatment options for foot ulcers change contingent upon the seriousness of the
injury. In general, the treatment utilises techniques to evacuate dead tissue or trash,
keep the injury clean, and advance recuperating. Wounds should be checked much
of the time, no less than each one to about a month. At the point when the condition
brings about a severe loss of tissue or dangerous disease, an amputation might be
the main alternative (Heald et al. 2019).
The following sections of the paper will conduct an extended review of the
literature to analyse the perception of diabetic patients who have undergone leg-
amputation surgery and the different aspects of nursing care for such patients. The
paper will follow a comprehensive search protocol for the search of literature relevant
to the literature and select few papers to be reviewed using Caldwell critiquing tool
and then analyse the content of the selected articles to develop a comprehensive
discussion on the nursing care for diabetic patients who have recently undergone leg
amputation.

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Background
As indicated by the report of the World Health Organization (WHO), the
number of diabetic patients in 2000 came to 171 million. It was anticipated to
increment 380 million by 2025 (Roglic 2016). Tackling the issue worried about the
worldwide increment in the number of diabetes frequencies and its inconveniences
requires a close joint effort among wellbeing framework and individuals; create
national and global systems and communication with other wellbeing colleagues. By
this methodology, giving adequate and viable wellbeing, administrations are
essential for patients and their families (Ogurtsova et al. 2017). Also, improving the
nature of medical attendants' clinical presentation can prompt changes in customer
and patient social orders.
Among diabetes' confusions, various sorts of foot issues, for example, ulcers
and diseases are standard, and it has indicated an expanding pattern in the previous
decade (Santema et al. 2018). Diabetic foot is characterised by WHO as a foot in
people with diabetes with neurologic disarranges, some level of vascular inclusion
with or without metabolic complexities of diabetes in lower limit and inclined to
disease, scarring, with or without profound tissue harm. A few examinations have
demonstrated that 15 per cent of diabetic patients will be experiencing diabetic foot
ulcer during their lifetime (Paisey et al. 2019). A diabetic foot ulcer is the broadest
reason for hospitalisation in diabetic patients. Then again, these ulcers can prompt
contamination, gangrene, amputation and even demise if the fundamental
consideration is not given.
Moreover, lower limb amputation is related to delayed hospitalisation and
recovery. Furthermore, it is required for home consideration and social help. In
general, the pace of lower appendage amputation in diabetic patients is 10–30 times
higher than non-diabetics (Paisey et al. 2019). In the initial two years after
amputation, there is a 50 per cent danger of re-amputation, and three years after
lower appendage amputation, half of the patients might be dead.
Over 60% of diabetic foot ulcers are the consequence of hidden neuropathy
(Azzopardi et al. 2018). The more usually depicted systems of activity are the polyol
pathway. The hyperglycaemic state prompts an expansion in real life of the
chemicals aldose reductase and sorbitol dehydrogenase—these outcomes in the
change of intracellular glucose to sorbitol and fructose. The gathering of these sugar

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items brings about an abatement in the combination of nerve cell myoinositol,
required for normal neuron conduction (Ibrahim 2018).
Furthermore, the concoction transformation of glucose brings about the
exhaustion of nicotinamide adenine dinucleotide phosphate (NADP) stores, which
are fundamental for the detoxification of sensitive oxygen species (ROS) and the
combination of the vasodilator nitric oxide (NO) (Walton, Minton and Cook 2019).
There is a resultant increment in oxidative weight on the nerve cell and an expansion
in vasoconstriction prompting ischemia, which will advance nerve cell injury and
passing. Hyperglycemia and oxidative pressure likewise add to the anomalous
glycation of nerve cell proteins and actuation of protein kinase C, (PK-C) bringing
about further nerve brokenness and ischemia (Chen et al. 2019).
The improvement of diabetic foot ulcers results from a few components.
These components can expand the danger of foot ulcer and cause separation in the
skin or hindrance in the injury mending. Fringe neuropathy can cause excessive
weight on certain purposes of the feet. Therefore, ischemia can build the
helplessness to ulceration by impedance in fringe vascular. What is more important,
different factors, for example, poor vision, constrained joint development, lacking foot
inclusion, and shoes can be susceptive to ulceration in diabetics (Mathioudakis et al.
2017). The most significant point is that 85% of diabetic foot amputations are
preventable with due consideration and instruction (Mathioudakis et al. 2017).
Perfect administration for avoidance and treatment of diabetic foot is: the standard
impression of the foot, decide in danger foot, training to patient and wellbeing staff,
proper foot inclusion, and early treatment of foot issues. As per the convention
suggested by the American Diabetes Association (ADA), one of preventive strategy
in diabetes care is multidisciplinary group approach that its favourable circumstances
have appeared in a few investigations (Boyko 2018).
The individuals from group for diabetic foot care, as a rule, comprise of
general professional, nurture, teacher, orthotic, and podiatrists and a few advisors;
vascular specialist, contamination sickness pro, dermatologist, endocrinologist,
dietician, orthopaedic and it is fundamental the entrance to focuses and home
consideration administrations (Loke et al. 2018). Although all members have an
impact on a decrease, the occurrence of foot ulcer and amputation, the job of nurse
caretaker and podiatrists are basic and important.

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Existing examination on the experience of individuals with diabetes and foot
infection or potentially amputations is centred transcendently on understanding the
mental aspects of life post-amputation. Different examinations centre around
anticipation and care forms for diabetic foot ulceration and patients' observations and
information by self-care (Ribu et al. 2008). Significant elements examined in the
investigations remember the estimation of training for advising and planning people
for dangers related with diabetes, and life after amputation including the restoration
procedure; the significance of wellbeing experts in showing sympathy and
comprehension of patients' needs; and the centrality of thinking about individual
patient conditions in the arrangement of viable consideration and treatment (Briggs
2006). There is an absence of research on diabetic patients with active foot infection
as well as lower appendage amputations and their involvement in wellbeing
administrations explicitly. There is likewise an absence of information relating to
diabetes and foot care benefits in the global wellbeing framework, which is described
by the variety in the arrangement of diabetes administrations and qualification to free
medicinal services.
Methodology
Research Question
 What is the perception of diabetic patients who have undergone leg
amputation recently?
 What are the major nursing care aspects requirement for management
of a diabetic patient who has undergone leg amputation surgery
recently?
Research Objectives
 To explore the perception of patients with diabetes who had diabetic
foot ulcer and have undergone leg amputation surgery.
 To study the different aspects of nursing care and management of
diabetic patients who have undergone leg amputation surgery in the
recent past.
PEO Questions
The research question was framed according to the Population, Exposure &
Outcome structure. The key population for the study is the patients who are suffering
from diabetes and are at risk of developing a diabetic foot ulcer. The exposure for

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the chosen population was that all patients had undergone leg amputation surgery
due to the inevitable complication of the diabetic foot ulcer, which forced the surgery
(Matsushita et al. 2017). The outcome for this study would be the perception of the
amputees and the different aspects of care regulated by the nursing individuals
following the condition of the patient.
This particular PEO question has been chosen as it covers all aspects to fulfil
the objective of the current study.
Population Diabetic Patients
Exposure Leg Amputation
Outcome Perception of the patients and Nursing Care aspects
Search Strategy
To lead the extended review of literature for selection of articles with high
pertinence to PEO question, clinical databases, including, PubMed Central, BioMed
Central, and CINAHL, will be looked (Rabinstein 2018). The essential goal of the
search technique is to discover a peer-reviewed published article that concentrates
with high importance to the selected theme or the research question. The inquiry in
the referenced clinical databases will be performed with the utilization of keywords.
The keywords for the search include diabetes, diabetic patients, diabetic foot ulcer,
diabetic complications, leg amputation, nursing care and patient perception (Font-
Jimenez et al. 2020). The contribution of these keywords in the propelled search
choice of the databases with the assistance of Boolean operators will be guaranteed
to expand the indexed lists and channel them as per for the more straightforward
determination of articles and studies with high significance (McGowan et al. 2016).
The utilization of Boolean operator 'AND' between the keywords will introduce a
higher include in the list items with results that may be applicable or not significant to
the picked PEO research question. The utilization of this Boolean administrator
assists with social affair an outline of the accessible literature and decide the
incorporation or evacuation of catchphrases to build the importance of the indexed
lists. The utilization of Boolean operator will be guaranteed to limit the check of
indexed lists and to channel the outcome with lesser number of articles with the most
noteworthy importance and giving vital snippets of data on the examination question
(McGowan et al. 2016).

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Database Results Primary
research
Publication
DATE to
last nine
years
Free full
text
Relevant
to subject
Duplicate
s
BMI 550 362 147 8 4 2
CHINAL 248 124 80 7 2 1
PubMed 436 203 116 15 6 2
Total of articles related to the topic found in all databases search:
Duplicates: 6
Remaining articles: 8 Chosen articles: 5
Keywords Keyword Keyword
Keyword 1 Leg
amputation
OR Amputation
surgery
Boolean AND
Keyword 2 Nursing
care
OR Patient
perception
Boolean AND
Keyword 3 Diabetic
Patient
OR Diabetic
foot ulcer
The determination of the articles for additional assessment and union of data was
finished with the assistance of incorporation and avoidance convention, referenced
beneath.
Inclusion Criteria
The essential inclusion criteria for the articles found by leading the search is
the incorporation of just friend surveyed articles. The date of distributing is a viable
method for guaranteeing recency in the bits of proof gave by the chose examine
contemplates. The articles and studies distributed between the years 2011 to 2020

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will be chosen for additional assessment and combination of data. The language of
distribution was constrained to English only in the advanced search option
accessible in the database. No geographical restriction was set for the determination
of pertinent articles. This was guaranteed to build the generalisability of the
examination discoveries and to get a more extensive worldwide review of the proof
supporting the perception of diabetic patients who have undergone leg amputation
and the role of nurses in providing care to such patients (Dickson et al. 2017).
The methodological convention followed by the exploration reads were
likewise considered for the further channel of list items. Just the articles that followed
the first two degrees of the level of evidence, that is, strategies that followed
randomized control trials, and prospective cohort studies were considered for
incorporation in the examination and further assessment.
Exclusion Criteria
To guarantee higher relevancy of the selected articles with the picked
research question and to ensure more excellent reliability and validity of the data to
be reviewed, several exclusion criteria were followed. This incorporated the
prohibition of unpublished articles, opinion papers, and publication letters that were
not chosen for further assessment (Gartlehner et al. 2017). In addition, inquire about
examinations or articles which were distributed in any language other than English or
published before the year 2011, were rejected from further evaluation.
The research articles that were arranged under lower levels in the level of
evidence were prohibited from the further determination in the investigation.
Factors Inclusion Criteria Exclusion Criteria
Years 2011 to 2020 Articles published before 2011
Type of Articles Peer-reviewed Non-peer reviewed
Language English Language other than English
Types of articles Primary Grey literature and websites
Screening of Studies
To screen the articles that appeared in the search results, abstract and title
screening methods were employed. Abstract screening is one significant part of
leading a high‐quality and exhaustive orderly survey and meta‐analysis. Theoretical
screening permits the audit group to direct the monotonous however crucial initial

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step to blend the surviving writing: examining the incorporation of references found
through research databases to the references that ought to be "full‐text" screened
and in the long run remembered for the survey (Gates, A., Johnson, C. and Hartling
2018).
Critiquing Tool
To critically analyse the selected articles, this study has undertaken the use of
Caldwell’s Critique tool. A typical strategy for evaluating understanding both of
nursing and the examination strategies used inside nursing is the introduction of a
definitive study of a distributed critiquing tool. As indicated by Caldwell, Henshaw
and Taylor (2011), given the power of the utilization of proof in nursing, it is
significant that understudies are empowered to investigate distributed research to
decide the convenience of that exploration in their picked field of work. By 'study' the
scientists mean the capacity to fundamentally assess distributed research by
recognizing the qualities and shortcomings of the examination and shaping decisions
concerning its overall quality and appropriateness. Coughlan et al. (2007) and Ryan
et al. (2007) have featured that the capacity to fundamentally evaluate inquire about
and apply this to the recognizable proof of best practice is a crucial part of nursing
practice. The requirement for medical caretakers to be skilled in conveying proof-
based consideration is unequivocal in current Nursing, and Midwifery Council
benchmarks for pre-enlistment nursing (NMC, 2004) and remains so in the proposed
norms for training right now being counselled on (NMC, 2010). The system is
intended to be utilized both as a showing instrument and as a guide to evaluation.
One of the inspiring components for delivering the system was to give clearness and
to guarantee reasonableness for those understudies undertaking a primary survey of
an exploration paper for evaluation purposes.
Selection of Research Studies
Following the search strategy mentioned above, the research articles that
showed the highest relevancy to the PEO research question and objective were
selected for further reading and were critically analysed with the help of the Caldwell
critiquing tool. The final set of articles were then passed on for full-text evaluation
and synthesis of information was performed for the selected articles.