Reducing Foot Complications for People with Diabetes

Recommendation 1.0: Physical examination of the feet to assess risk factors for foot ulceration/ amputation should be performed by a health care professional.

Recommendation 1.1: This examination should be performed at least annually in all people with diabetes over the age of 15 and at more frequent intervals for those at higher risk. 

Recommendation 2.0: Nurses should conduct a foot risk assessment for clients with known diabetes. This risk assessment includes the following:  

• History of previous foot ulcers;  
• Sensation;  
• Structural and biomechanical abnormalities;  
• Circulation; and  
• Self-care behaviour and knowledge. 

Recommendation 3.0: Based on assessment of risk factors, clients should be classified as “lower” or “higher” risk for foot ulceration/amputation. 

Recommendation 4.0: All people with diabetes should receive basic foot care education. 

Recommendation 4.1: Foot care education should be provided to all clients with diabetes and reinforced at least annually. 

Recommendation 5.0: Nurses in all practice settings should provide or reinforce basic foot care education, as appropriate. 

Recommendation 5.1: The basic foot care education for people with diabetes should include the following six elements:  

• Awareness of personal risk factors;  
• Importance of at least annual inspection of feet by a health care professional;  
• Daily self inspection of feet;  
• Proper nail and skin care;  
• Injury prevention; and  
• When to seek help or specialized referral.

Recommendation 5.2: Education should be tailored to client’s current knowledge, individual needs, and risk factors. Principles of adult learning must be used. 

Recommendation 6.0: Individuals assessed as being at "higher" risk for foot ulcer/amputation should be advised of their risk status and referred to their primary care provider for additional assessment or to specialized diabetes or foot care treatment and education teams as appropriate.

Recommendation 7.0: Nurses need knowledge and skills in the following areas in order to Recommendations competently assess a client’s risk for foot ulcers and provide the required education and referral:  

• Skills in conducting an assessment of the five risk factors;  
• Knowledge and skill in educating clients; and  
• Knowledge of sources of local referral. 

Recommendation 8.0: Educational institutions should incorporate the RNAO Nursing Best Practice Guideline Reducing Foot Complications for People with Diabetes into basic nursing education curriculum as well as provide continuing education programs in this topic area.

Recommendation 10.0: Organizations should ensure that resources for implementation are available to clients and staff. Examples of such resources include policies and procedures, documentation forms, educational materials, referral processes, workload hours, and monofilaments. 

Recommendation 11.0: Organizations should work with community partners to develop a process to facilitate client referral and access to local diabetes resources and health professionals with specialized knowledge in diabetes foot care. 

Recommendation 12.0: Organizations are encouraged to establish or identify a multidisciplinary, inter-agency team comprised of interested and knowledgeable persons to address and monitor quality improvement in diabetes foot complication prevention. 

Recommendation 13.0: Organizations should consult an infection control team to define appropriate care, maintenance, and replacement of the Semmes-Weinstein monofilament. Such a process may include setting up a protocol for the appropriate maintenance and replacement of the monofilaments. 

Recommendation 14.0: Organizations should advocate for strategies and funding to assist clients to obtain appropriate footwear and specialized diabetes education. For example, the inclusion of funding support through the Assistive Devices Program (ADP) for appropriate footwear and orthotics. 

Recommendation 15.0: Organizations should advocate for an increase in the availability and accessibility of diabetes care and education services for all residents of Ontario. 

Recommendation 16.0: Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:  

• An assessment of organizational readiness and barriers to education.  
• Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.  
• Dedication of a qualified individual to provide the support needed for the education and implementation process.  
• Ongoing opportunities for discussion and education to reinforce the importance of best practices.  
• Opportunities for reflection on personal and organizational experience in implementing guidelines.