Help Notes for Nurses No. 4 Diabetes-Related Foot Problems. Why this is a High-Priority Education Is

▼ ❑ What is the key diabetes-related foot care issue?

• ❑ In a 2014 article entitled "Diabetes Foot Education ...", and published in the Annals of Long Term Care, the authors (Sweta Tewary, PhD, MSW, Naushira Pandya, MD, CMD, FACP, and Nicole Cook PHD, MPA) point to evidence of rising prevalence of Type 2 Diabetes, noting that complications involving foot problems are a major source of concern linked to this increased prevalence. They state that "the most common cause of hospitalizations among persons with diabetes is diabetic foot problems, including ulcerations, infections, and gangrene." They report that $245,000,000,000 (245 billion dollars) were spent in managing diabetes-related foot problems in 2012 in the USA. This means that leaders in jurisdictions who are worried about managing health care cost increases are likely to assign increasing priority to preventive care measures involving diabetes-related foot problems.

• ❑ Teary, Panda and Cook advocate higher levels of routine foot examinations for persons with diabetes, along with further support for individuals at risk of developing foot complications. They call for more effort toward the early diagnosis and treatment of potential foot complications, one benefit of which will be a reduced rate of lower-limb amputations.

▼ ❑ Why do diabetes-related foot problems need more attention from leaders of LTC institutions and hospitals?

• ❑ Teary, Panda and Cook place a special focus on care delivered to older persons in long-term care institutions (LTCs) and hospitals. Why? In the older population we will find that diabetes is often associated with "multiple chronic diseases and comorbidities [including] peripheral arterial disease, sensory neuropathy, and joint malformations".

▼ ❑ What are the core features of the needed educational programs in diabetes-related foot care?

• ❑ Tewary and Pandya have developed a training module whose components include: a presentation by a physicians and trained diabetes educators who use Powerpoint slides to enhance communication, videos, and demonstrations of best practices. These educational materials emphasize “toenail care, periodic skin checks, musculoskeletal examinations, and … pedal pulse assessments”, as well as health-promoting footwear design.

▼ ❑ What are the benefits to institutions of of good educational programs regarding diabetes-related foot problems?

▶ ❑ Testing the application of their training module among groups of care providers at three kinds of institutions, Teary, Panda and Cook found the most persistent benefit to be in increased staff documentation of foot-care assessments. They noted improved documentation in such areas as “skin checks, ulcers, history, pedal pulses”, and greater use of specialist referrals.

▼ ❑ What range of nursing certification is appropriate in deploying such educational programs?

• ❑ Teary, Panda and Cook point to RNs, RPNs and PSWs (called "CNAs" in the USA). They place a special focus on the PSWs because they are the most prominent front-line care deliverers to those that are in the early stages of developing foot problems, since care delivered at the early stages is likely to yield important cost savings to the health care system. They note that where institutions have high rates of staff turnover, there should be consideration of making foot-care education mandatory at entry to employment by new staff.

▼ – References:

• ❑ The professional health-care literature contains several articles that support the general ideas offered by Sweta Tewary, Naushira Pandya and Nicole Cook. Some of this literature is cited below.

• ❑ Alavi, A. and others. "Diabetic foot ulcers: Part II. Management", J Am Acad Dermatology, 2014 Jan;70(1):21. See abstract at—24355276.

• ❑ Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719-1724.

• ❑ Boulton AJ, and others, "Comprehensive foot examination and risk assesment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.” Diabetes Care 2008; 31(8): 1679–1685. A free full text is available at—1679.full.pdf+html .

• ❑ Kruse I, Eldeman S. Evaluation and treatment of diabetic foot ulcers. Clin Diabetes. 2006;24(2):91-93.

• ❑ Mored-Vargas, O.L. and Smith, S.A. "BE SMART: strategies for foot care and prevention of foot complications in patients with diabetes," Prosthetics and Orthotics International, 2015 Feb;39(1):48-60. See abstract at—25614501.

• ❑ Peterson, J.M., and Virden, M.D., "Improving diabetic foot care in a nurse-managed safety-net clinic," J Am Assoc Nurse Pract., 2013 May;25(5):263-71. See abstract at—24170568.

• ❑ Rice, J., Handley, M.C., and Jolley, J. "Comprehensive foot care education in home-based settings: a tool for clinicians", Home Healthcare Now., 2015 May;33(5):275-80. See abstract at—25943220 .

• ❑ Tewary, S., Pandya, N., and Cook, N. "Diabetes Foot Education: An Evidence-Based Study in Long-Term Care", Annals of Long Term Care, Volume 22 - Issue 7-8 - July/August 2014.—diabetes-foot-education-evidence-based-study-long-term-care-0

• ❑ Tewary S, Pandya N, Cook N. Prevalence of foot problems in nursing home residents with diabetes stratified by dementia diagnosis. Annals of Long-Term Care. 2013;21(8):30-34. -

About Diabetes Related Problems

A Help Note for Nurses

by Foot Care Academy


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