Nursing Interventions for Prevention of Foot Ulcers in Patients with Diabetes : an Integrative Review

Conclusion: The current evidence demonstrates the importance of health education as a tool in diabetic foot and lower extremities amputation prevention. This type of education increases patient’s awareness of their own disease and help them to develop skills for self-care and better lifestyle. Nursing Interventions for Prevention of Foot Ulcers in Patients with Diabetes: an Integrative Review REVIEW


Introduction
Diabetes mellitus (DM) has been considered one of this century's most serious diseases.It requires several interventions for its prevention, treatment and rehabilitation [1].According to the International Federation of Diabetes, the number of people with DM may reach 642 million people by 2040 [2].These alarming indexes are justified by the chronic complications caused by this disease, including micro-vascular (retinopathy and diabetic nephropathy), macrovascular (coronary artery disease, stroke and peripheral vascular disease) and neurological complications [3].
Diabetic neuropathy is characterized by demyelination of axon segments due to chronic hyperglycemia.It causes functional and structural impairment of peripheral nerves, leading to lack of peripheral sensitivity, deformities and ulceration [4][5].In addition, the pathological process of infection, ulceration or destruction of the deep foot tissues associated to neurological abnormalities and various degrees of peripheral vascular disease in the lower extremities of DM patients is known as diabetic foot [6].Due to foot ulcerations, DM patients are usually susceptible to lower extremities amputation.According to several data, its prevalence and incidence have increased worldwide.It is also considered an irreversible, costly and incapacitating complication with severe physical, mental and social consequences [7].
Additionally, poor therapeutic education is one of the main risk factors for these complications.The American Diabetes Association (ADA) mentions the relevance of educational approach in preventing those complications and reinforce the importance of daily and proper care of the lower limbs in preventing ulcers occurrence [8].The regular feet evaluation of patients with DM should be performed by family physicians or nurses at the recommended frequency [9].In this setting, nurses have an essential role in the implementation of interventions aimed to prevent foot ulcers in DM patients.
Therefore, this research aims to investigate the current evidence on nurses' interventions in the prevention of foot ulcers in DM patients.

Methods
Researchers decided to carry out an integrative review of literature based on the following stages: elaboration of the guiding question; search in lite-rature; data production; critical analysis of the included articles; comparison of the evidence and review presentation [10].
The elaboration of the guiding question was based on the PICO anagram, being P = for population; I = intervention (or exposure); C = comparison; and O = outcome.In order to formulate the question, it is recommended to define at least the P and the I parameters [11][12].Thus, the following question was elaborated: what evidence is available about interventions developed by the nurses to prevent foot ulcers in people with DM?In this sense, P = person with diabetic foot, aged > 18 years; I = type of intervention used.
The following databases were used to select the articles: Base de dados em Enfermagem -BDENF, Literatura Latino-Americana e do Caribe em Ciências de Saúde -LILACS, Indice Bibliográfico Español de Ciencias de la Salud -IBECS (via Virtual Health Library -VHL), Cumulative Index to Nursing and Allied Health Literature -CINHAL, National Library of Medicine and National Institutes of Health -PUBMED (via Portal CAPES) and in the electronic library Scientific Electronic Library Online -Scielo-Br.The choice of the databases was motivated by the fact that they have national and international high-impact publications, by the breadth of the search spectrum and by the diversity of indexed journals.
The inclusion criteria were: manuscripts available in full, without temporal cut, in the Portuguese, English or Spanish languages that addressed interventions for the prevention of foot ulcers in people with DM.Abstracts, annals, editorials, letters to the editor, revisions, reflections, duplicities, articles with incomplete details, dissertations, theses and articles without a nurse as author were excluded.
The data were collected in July 2016 by using the controlled descriptors in the following search equation: nursing AND diabetic foot AND prevention and control, According to DeCS (Descriptors in Health Science) e Mesh (Medical Subject Headings).
The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) checklist [13] was used for the selection of studies.Initially, 410 publications were identified.Subsequently, three Relevance Tests (RT) were applied.The preliminary selection of the references was performed through the RT I, considering the inclusion and exclusion criteria, and 233 publications were included in the first moment.Subsequently, the RT II was applied, which consisted in reading the title and the abstract of the article.Following to the selected articles, the RT III was carried out, which consisted on reading the entire articles and identifying their pertinence (Figure 1).The selected studies were categorized based on an adapted instrument [14] using a code for identification of the studies, objectives, interventions and outcomes.
For classifying the level of evidence (LE), the authors adopted the scheme proposed by Melnyk and Fineout-Overholt [15]: level 1 -evidence from a

Results
Among the selected articles, only three were published in Brazilian databases, the other (n = 12) were published in international journals.Regarding the databases, one article was published in LILACS, two in BDENF, three in CINAHL and nine in PUB-MED.It is worth noting that among the 15 articles that compose this study, eight were published in nursing journals, six in multidisciplinary journals and only one in a medical journal.Among those from nursing journals, two were from specialized publications (nephrology and vascular), while among multidisciplinary journals, four had scopes focused on DM care.
Regarding LE of the studies, the great majority of them were LE 3 (n = 5), followed by LE 4 (n = 4), LE 2 and LE 6, as presented in table 1. Regarding study designs, there was a predominance of crosssectional and descriptive studies.When analyzing the target audience of the intervention, 14 studies had people with DM as target group, and only one study was directed to health practitioners (physicians, medical assistants and nurses) (Table 1, 2

Discussion
Nursing interventions for the prevention of diabetic foot were performed both individually [16,21,23,25,[28][29] and in a collective basis [19,20,22,24,26,30], or both [17][18]27].The vast majority of interventions were from institutional health promotion programs [16, 18, 20-21, 24, 26, 27, 29, 30].These foot care promotion programs aim to empower patients for self-care, reducing the occurrence of diabetic foot ulcers, both at community and/or hospital level.It is emphasized that programs with nurses in the management process have better results [16,21].Educational programs are necessary to a proper self-care performance, especially in patients at higher risk [28].The practice of self-care and/or taking care of the feet of people with DM requires the establishment of a close and collaborative relationship between patients and practitioners.
Health education emerges as a strategy that facilitates this process of interaction, allowing awareness to motivate and promote changes in people's attitudes [18][19][20].
Early intervention is the best way to reduce the incidence of foot injuries in diabetic patients and consequently decrease lower extremity amputations [21].One study emphasizes that health education cannot be part of a treatment, since the treatment must occur through the demands that arise during education sessions, considering the determinants and conditioning factors [23].
The foot care guidelines included: daily evaluation, nail cutting in straight line, non-cuticle removal, proper footwear, no bare feet, use of cotton socks without elastics, foot hydration and files [17-18, 20, 25].
Different approaches can be used to guide the education process.A study [28] based on Roy's model of adaptation in a church with African and American people pointed out excellent results, considering the influence of religious factors for the adoption and modification of care behaviors with the feet.A Brazilian study [19] that evaluated the discussion method to carry out educational activities highlighted significant changes in the process of managing foot care.The educational intervention based on this method allowed identifying and modifying habits and attitudes based on the dialogue, an emancipator educational practice.The intensity of the educational intervention is another corroborating factor for the reduction of foot ulcers incidence in diabetic patients [22].Thus, patients who participate actively and regularly in educational programs had better performance and engaged more in the practice of self-care, reducing the number of complications [28].
For the promotion of behavioral changes, several resources and strategies have been used in the interventions, such as educational sessions [16-17, 20, 23, 25, 30], printed materials (letters, pamphlets, fliers) [18,[20][21], reinforcement phone calls [21,25], educational videos [26], plays [30], professional update seminars [16][17], home and/or outpatient visits [20,23,28].It is recommended that health services have, use, and promote resources and strategies to facilitate interventions for the prevention of foot injuries in diabetic patients, such as audio tapes, video tapes, pamphlets, fliers, magazines and books; reinforcement of social interventions (patient and family association); and further research on the evaluation of the impact of health education on diabetic patients [24].
The use of multimedia (video) resource about proper foot care is important for maintenance of healthy feet for people with diabetes.It promotes improvement in behavior over time, especially when the content of the video approaches positive aspects of adequate care.Thus, this resource emerges as a new education strategy to help health promoting behaviors [26].
It is important to have trained professionals capable to provide care and guidance on self-care.A study [18] showed that after the implementation of disease management program, the incidence of amputations decreased from 12.8/1,000 people with diabetes/year to 6.2 (p <0.05); the number of hospital admissions due to foot injury decreased from 22.8/1,000 limbs /year to 14.2 (p <0.05); the mean time of hospitalization was reduced from 4.7 days to 3.7 days (p <0.05).In addition, there was a reduction in the number of specialist nurses to provide care.
Considering that behavioral changes are achieved, another strategy that can be adopted is the simulation of techniques on foot care.This allows reflection about the practices, not only by people with the disease, but also by their caregivers and by the health team, who intends to offer better quality care and with resoluteness [30].
In the development of this research, the authors sought to review studies with evidence about nursing interventions in several strategies to promote behavioral changes in preventive care of foot injuries of diabetic patients.As observed, the participation of these professionals was essential and there was shared responsibility and satisfaction within the process of behavior change through interaction with patients in the search for care.

Conclusion
The evidence analyzed should consider the characteristics of the target population, socioeconomic and environmental conditions, as well as the use of media resources, which potentiate changes in positive behaviors.
Health education has proved to be an adequate tool in the prevention of diabetic foot and consequent amputations of lower extremities.It led to awareness of people on the development and the adoption of skills for self-care and improvement of the lifestyle.
The aim of this study is to encourage health professionals, especially nurses working with DM patients, to carry out intervention research with theoretical support, as well as methodological designs with a higher level of evidence, contributing to im-provement of the evidence-based clinical practice.
Among the limitations of this study, we highlight the discrepancy in the levels of scientific evidence of the analyzed articles.Despite of this, we cannot make generalizations and state that nurses are not performing high-level intervention studies.However, this reveals a thin line regarding methodological designs on the use strategies to increase prevention of diabetic foot.

Figure 1 :
Figure 1: Flowchart for the publications selection for the integrative review, based on the PRISMA model -Fortaleza-Ceará-Brazil, 2016.

Table 1 .
). Characterization of studies based on level of evidence, type of study and target audience, Fortaleza-Ceará-Brazil. 2016.
Source: Data obtained from the selected databases, 2016.

Table 2 .
Distribution and characterization of studies included in the Integrative Review based on code, intervention and outcome, Fortaleza-Ceará-Brazil, 2016.
24cidence of amputations decreased 47.4%.Reduction in hospital admissions due to diabetic foot decreased by 37.8%.The mean time of hospitalization was reduced from 4.75 to 3.72 days.All with p <0.05.19Questionnaire and educational activity based on the method of discussion and the prevention of foot injuries in diabetic patients.Significant difference in foot care: nail trimming, proper footwear, use of cotton socks with no elastics and hydration of the feet.The average knowledge of the patient, before and after implementation of the health education program: Problems in the feet was 1.18 and 1.57 (Student's t = 7.38 and p = 0.000).The warning signs of foot problems were 1.3 8 and 2.69 (Student's t = 4.90 and p = 0.000).Foot care was 1.03 and 2.37 (Student's t = 8.08 and p = 0.000)24Individual sessions (face-to-face) through interactive teaching, hands-on training, and telephone sessions to reinforce foot care There was a reduction in the occurrence of skin, foot and toe problems (all p = <0.05)