الفهرس 
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Abstract
Diabetes Mellitus (DM) is the most common metabolic disorder seen in primary care and it is considered the leading cause of cardiovascular disease, renal failure and blindness. The long term sequel of DM is the microvascular and macrovascular complications to target end organs: the eyes, kidneys, heart, blood vessels and nerves. Among the complications of DM are foot problems, the most common cause of non-traumatic lower limb amputation. As the longevity of the population increases, the incidence of DM related complications also increase.
A lower limb amputation is defined as the complete loss in the transverse anatomical plane of any part of the lower limb. All amputations are classified as either major or minor. Lower extremity amputations in people with diabetes are a major cause of morbidity and mortality and place a significant economic burden on society. Amputation may be the end,
the loss of a part, but it may also be the end of pain and a new beginning.
The main concern of the multidisciplinary health team as well as the patient is to achieve successful wound healing. Stump healing is a complex and dynamic process. The
knowledge of the physiology of the normal stump healing trajectory through the phases of hemostasis, inflammation, granulation (proliferation) and maturation (remodeling)
provides a framework for an understanding of the basic principles of stump healing. Health care continues to change towards more patient focused care. One of the main methods to
reorganize a care process is the development and implementation of a clinical pathway. Through this understanding, the clinical pathway team can develop the skills required to
care for a stump and the body can be assisted in the complex task of tissue repair.
Clinical pathways are defined as complex interventions consisting of a number of
components based on the best available evidence and guidelines for specific conditions. A clinical pathway defines the sequencing and timing of health interventions and should be developed through the collaborative effort of physicians, nurses, and other associated
health professionals. They aim to link evidence to practice and optimize clinical outcomes while maximizing clinical efficiency. Clinical pathways connect the world of practice with
the world of knowledge.
Clinical pathways have four main components: a timeline, the categories of care or activities and their interventions, patients’ outcomes, and the variance record. The use of clinical pathways can lead to improvement in patient’s care through proper utilization of resources, ensuring that consistency and quality of care are maintained in addition to the
benefit of short hospital stay and the decrease of hospital cost. Although many studies have been carried out in Egypt on the clinical pathways, no study has been done on diabetic patients undergoing lower limb amputation. Therefore, this study aimed to determine the effect of clinical pathway implementation on healing of post lower limb amputation for diabetic patients.
Materials and Method
•A quasi experimental design was used to conduct this study
•The study was conducted in two settings at Alexandria. The first setting was
Alexandria Main University Hospital, the vascular unit at the surgical department.
The second setting was the private Alexandria Vascular Center (AVC) at Smouha
district.
•The study subjects comprised of a convenience sample of 40 adult diabetic patients
undergoing lower limb amputation and admitted to the previously mentioned
settings. They were sequentially recruited equally into 2 groups; study and control
groups (20 patients each). An equal ten patients were taken from each hospital for
control and study groups. Twenty patients were assigned to receive care according
to the clinical pathway (study group) and the rest received conventional (routine)
care (control group). Data were collected from control group followed by the study
group to avoid contamination.
•Four tools were used to collect the necessary data in order to fulfill the study’s aim.
All participants were assessed using Tool one (Perioperative Diabetic Lower Limb
Amputation Assessment ”PDLLAA”), part I is used to evaluate the comprehensive
patients’ condition. Patients were assessed preoperatively on the first hospital
admission day. Then assessment was continued on operative day Tool one part II.
Each patient was assessed using Tool one part I postoperatively and a weekly
follow up visits (up to 6 weeks) at the outpatient clinic.
•Implementation of Tool two (Clinical Pathway Protocol): each patient in the study
group was subjected to clinical pathway protocol.
•Tool three (Clinical Pathway Variances Observation Checklist Assessment ”CPVA”)
was used to elicit the variances in patients don’t follow the plan outlined in the
clinical pathway.
•Assessment of patient satisfaction was done for each patient in both groups on
discharge using tool four (Patients’ Satisfaction Scale about Caring Process).
•Evaluating the clinical pathway: it consisted of comparing the outcomes of both
groups using Tool one and Tool four.