Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Levels of evidence supporting the recommendations (Level Ia, Ib, II, III, IV) are defined at the end of the "Major Recommendations" field.
Practice Recommendations
Recommendation 1.0
Physical examination of the feet to assess risk factors for foot ulceration/ amputation should be performed by a health care professional. (Level of Evidence Ib)
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. (Level of Evidence IV)
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
- Self-care behaviour and knowledge
(Level of Evidence IV)
Recommendation 3.0
Based on assessment of risk factors, clients should be classified as "lower" or "higher" risk for foot ulceration/amputation. (Level of Evidence IV)
Recommendation 4.0
All people with diabetes should receive basic foot care education. (Level of Evidence Ib)
Recommendation 4.1
Foot care education should be provided to all clients with diabetes and reinforced at least annually. (Level of Evidence IV)
Recommendation 5.0
Nurses in all practice settings should provide or reinforce basic foot care education, as appropriate. (Level of Evidence IV)
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
- When to seek help or specialized referral
(Level of Evidence IV)
Recommendation 5.2
Education should be tailored to client’s current knowledge, individual needs, and risk factors. Principles of adult learning must be used. (Level of Evidence IV)
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. (Level of Evidence IV)
Education Recommendations
Recommendation 7.0 (Level of Evidence IV)
Nurses need knowledge and skills in the following areas in order to 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
- Knowledge of sources of local referral
Recommendation 8.0
Educational institutions should incorporate the Registered Nurses Association of Ontario (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. (Level of Evidence IV)
Organization and Policy Recommendations
Recommendation 9.0
Organizations should develop a policy that acknowledges and designates human and fiscal resources to support nursing’s role in assessment, education, and referral of clients for appropriate foot care. It is the organization’s responsibility to advocate with policy makers and develop policy that facilitates implementation. (Level of Evidence IV)
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. (Level of Evidence IV)
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. (Level of Evidence IV)
Recommendation 12.0
Organizations are encouraged to establish or identify a multidisciplinary, interagency team comprised of interested and knowledgeable persons to address and monitor quality improvement in diabetes foot complication prevention. (Level of Evidence IV)
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. (Level of Evidence IV)
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. (Level of Evidence IV)
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. (Level of Evidence IV)
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
(Level of Evidence IV)
Refer to the "Description of the Implementation Strategy" field for more information.
Definitions:
Level Ia: Evidence obtained from meta-analysis of randomized controlled trials, plus consensus
Level Ib: Evidence obtained from at least one randomized controlled trial, plus consensus
Level II: Evidence obtained from at least one well-designed controlled study without randomization or evidence obtained from at least one other type of well-designed quasi-experimental study, plus consensus
Level III: Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies, plus consensus
Level IV: Evidence obtained from expert committee reports of opinions and/or clinical experiences of respected authorities, plus consensus
