Nurses’ Role in the Management of Diabetic Foot Among the Elderly

Background

World Health Organization (2022) notes that diabetes has become a global epidemic disorder affecting many countries worldwide. The organization further denotes that evidence from various studies and research work shows an alarming impact of the disease on medical providers, diabetic patients, and the community. According to the CDC (2021), 4 out of 10 people in America are diagnosed with diabetes. While diabetes can affect people from different walks of life, it is more common among the elderly. Mordarska and Godziejewska-Zawada (2017) observe that the elderly in society are the most vulnerable to diabetes. According to the authors, at least a third of people aged above 65 years suffer from a lifestyle disease, with the most common one being diabetes. According to Ishak et al. (2017), the elderly are three times more likely than other populations to develop diabetes. Without effective diabetes management, patients stand the risk of developing chronic conditions like eye, renal, cardiovascular, and foot problems, which significantly deteriorates the individual’s quality of life.

Notably, diabetes dramatically increases the risk of the elderly developing cardiovascular and foot problems. Boulton (2019) explains that foot complications, including ulcers and infections, are common among elderly diabetic patients. Zhang et al. (2017) further define diabetic foot as a neurologic complication developed from diabetes. Costa et al. (2017) has also considered the condition a disorder involving the vascular system and affecting the lower limb. Boulton et al. (2018) also observe that management of diabetes among the elderly is critical in avoiding additional health complications. According to Longo et al. (2019), diabetes management calls for a multidisciplinary approach among medical providers and the community. A study by Buggy and Moore (2017) demonstrated that diabetic patients under the care of a multidisciplinary team realize better health outcomes than those receiving standard therapy. The investigation further denotes that a multidisciplinary team, in this case, is made of general practitioners, nurses, educators, orthotics, podiatrists as well as other medical consultants. But while every member of the multidisciplinary team helps reduce the chances of patients developing further complications, the role of nurses remains more outstanding. This study will investigate nurses’ roles as multidisciplinary team members in preventing and controlling diabetic foot among the elderly.

One of the key challenges nurses face in caring for diabetic patients is improving patient care and health services. WHO (2022) observes that the nursing profession is among the key health groups involved in almost all levels of medical care. Nurses use science and art in providing medical services to get rid of physical, emotional, psychological, spiritual, and social-cultural patient challenges. However, LeRoith et al. (2019) observe that patient care is the primary duty of every nurse, thus making them critical in caring for diabetes patients and, in particular, the management of diabetic feet. Nurses are becoming increasingly important with the rising incidence of diabetes and associated consequences in society. As a result, it is important to realize their involvement in the care of diabetic foot ulcers among the elderly suffering from type 2 diabetes.

Saif‐Ur‐Rahman et al. (2021) note that the elderly population has rapidly grown over the years, increasing the need for effective planning to help control their health. Mordarska and Godziejewska-Zawada (2017) have also demonstrated that the elderly population is at the highest risk of developing diabetes and related complications such as foot ulcers. Therefore, managing diseases such as diabetic foot ulcers among the elderly is important in ensuring they have an improved quality of life and life expectancy. However, Kalra and Sharma (2018) evidence that due to the meagerness of care processes and structures, the existing medical systems cannot meet the unique needs of elderly patients struggling with diabetes and its complications. Results from Leung, Wongrakpanich, & Munshi (2018) suggest that medical practitioners, including nurses, lack the needed skills and abilities to manage the mental and physical needs of elderly patients. There is, therefore, a need for the medical practice to make desired changes in its processes and structures while serving the elderly population.

Consequently, the current study aims to learn more about the role of nurses in the treatment of diabetic foot ulcers among senior type 2 diabetic patients. The study’s findings will considerably contribute to the current literature on diabetic foot treatment, particularly among elderly patients with type 2 diabetes. Additionally, the results will help nurses have clearer insights into their roles while caring for elderly patients with diabetic feet. These findings will help streamline the nursing practice by formulating new policies and operational procedures for caring for the elderly population.

Confidentiality Acknowledgement

In carrying out the investigation, the researcher agrees to keep all the information shared for the study confidential. The report will only be discussed or shared with the investigator and stakeholders directly involved in the investigation. The investigator will also ensure that all research data collected is kept secure throughout the study. Additionally, the researcher will not allow any personal identification information to be accessed by anyone not involved in the study unless with the written permission of the data source. All information shared with the researcher will be coded, ensuring the privacy and confidentiality of the data sources.

Literature Search Strategy

The investigation realized its findings through the use of a systematic literature review. Boland, Cherry, & Dickson (2017) observe that the approach is instrumental in helping an investigator realize new theories and identify research gaps that need to be investigated. The adoption of a systematic review of literature saw the investigation rely on the findings of previous literature in informing the development of new theories on the role of nurses in caring for diabetic feet among the elderly. Through the approach, the researcher compared and contrasted the findings of other investigations related to the subject matter and subsequently developed a theory.

The study relied on previous literature findings from other researchers. It used data and information from previously written research works. The researcher obtained the data from reliable online databases like ScienceDirect, PubMed, CQ researcher, and Web of Science. These databases were deemed suitable for the research search as they provided a high number of healthcare-related investigations and studies.

The main keywords used in the search were ‘nurse’s roles,’ ‘elderly population, diabetes,’ ‘diabetic foot,’ ‘managing diabetic foot among the elderly,’ and ‘diabetic foot ulcers.’ The primary phrases used in the search were “nursing role in diabetes management” and “nursing role in managing diabetic feet among the elderly.” The study also leveraged hand-search, which reviewed the reference list of different studies from the primary search. The hand-search strategy helped the researcher identify more studies directly relating to the current research. During the data search, the investigation only relied on those studies that addressed the subject matter, particularly the role of nurses in caring for diabetic foot among the elderly patients with type two diabetes. The study also picked investigations carried out in the last ten years, which helped the researcher deal with the recent and latest information on the subject matter. Therefore, this research study relied on recently collected, analyzed, and published data. To ensure the authenticity of the study, the researcher used peer-reviewed studies and excluded all investigations that did not address the management of diabetic feet among elderly patients with diabetes.

The review did not include every literature piece on the role of nurses in caring for diabetic foot among elderly patients with type two diabetes. This ensured that the search remained relevant to the research question and topic. For instance, the review did not include literature published on secondary studies, thus eliminating the chances of having data not relevant to specific needs. Additionally, the massive quantity of systematic reviews and literature on diagnostic and treatment measures of IBD gave too much information that could cause the researcher to deviate. The researcher also excluded data that did not provide sensitivity, confidentiality, validity, and reliability to promote data integrity. All research studies that did not give reports on the role of nurses in caring for diabetic foot among the elderly patients with type two diabetes were excluded. Lastly, the researcher neither used studies published in non-English languages nor those that did not specifically focus on the elderly population. The primary search strategy that guided the study was borrowed from the criteria carried out by Marques et al. (2017). The investigation identified a total of 4100 studies from its search strategies. The researcher then screened the studies to help eliminate duplicates and other unwarranted studies that did not meet the inclusion and exclusion criteria. The study managed to identify 11 studies as indicated in the PRISMA flowchart below.

PRISMA FLOWCHART

Figure 1: The PRISMA Flow Chart that facilitated the study selection process

PRISMA is the abbreviation for Preferred Reporting Items for Systematic reviews and Meta-Analyses. The flow chart illustrates the flow of relevant strategies through different phases of the systematic review. It counts the number of records discovered before selecting the preferred records. The process remains transparent since the flow chart reports on decisions made at different stages of the review. At each level, the number of records selected or dropped is noted.

Literature Review

The study leveraged a thematic analysis to analyze the data collected. King, Brooks, & Tabari (2018) consider thematic analysis a method that identifies recurring themes, theories, and concepts from the data collected. With the investigation heavily relying on collected data, using thematic analysis was instrumental in helping the study identify recurring themes and ideas from the data collected. Additionally, various researches have attempted to look into the role of nurses in managing diabetic foot among elderly patients with type 2 diabetes. Previous studies categorize the role of nurses in managing diabetic foot into five distinct roles; (1) Education, (2) care, (3) cooperating in diabetic foot treatment, (4) diabetic foot care at home, and (5) rehabilitation.

Nursing Role in Education

A study by Nazarko (2019) investigated the nurse’s role in managing diabetes and foot problems. The study noted that practicing nurses have a significant role in preventing diabetic foot ulcers. Nurses also participate in the amputation of the patients’ lower limbs through interventions like screening high-risk patients, educating patients, and providing appropriate medical care. The author asserts that patients with diabetic feet, especially those at a high risk of developing foot ulcers, must familiarize themselves with foot care basics. Nguyen et al. (2019) has also argued that education about foot care helps prevent the development of diabetic foot ulcers. Mord et al. (2020) further cements the argument noting that prevention of diabetic foot among elderly patients with type 2 diabetes is achievable through education and screening of patients. Therefore, educating patients can be considered a key role that nurses should carry out in helping patients with diabetic foot ulcers manage their condition.

In the investigation by Warfield (2019), it has been proposed that diabetic foot care education programs should be among the key role for nurses caring for such patients. However, the investigation noted that such programs should be tailor-made to suit every patient. Besides acting as educators, nurses have multiple roles in ensuring the elderly are educated on managing their diabetes foot ulcers. First, nurses have the role of designing educational programs based on the patients’ history and case. Ramirez-Perdomo et al. (2019) observe that nurses can also facilitate patient and family participation in caring for diabetic foot ulcers. This intervention can be done through effective educational programs like helping the patients realize the significance of regular clinic visits, blood tests, the basics of diabetes care, and the prevention of its complications. Therefore, nurses’ role remains essential in helping patients understand how to look after themselves and equipping them with knowledge on how and when to seek help.

According to Kumarasinghe, Hettiarachchi, & Wasalathanthri (2018), educating patients on how to take care of themselves helps in improving their quality of life. A study by these authors observes that hyperglycemia is a modifiable risk factor in diabetic neuropathy and regulating blood sugar levels plays a key role in reducing neuropathy while improving the patient’s quality of life. Essentially, it is argued that practical education on blood glucose control should be given special attention. Similar observations are made by Pourkazemi et al. (2020), who have noted that educating patients suffering from diabetic foot ulcers on controlling their blood glucose and leading suitable lifestyles is instrumental in helping reduce the severity of diabetes and its subsequent complications, such as diabetic foot ulcers. The observations further emphasize the significance of nurses’ role in developing comprehensive educational programs for such patients to manage diabetic foot ulcers. It thus becomes essential for nursing practitioners to be trained on how to train their patients on self-care and when to seek medical care.

Role of Nurses in Care

Apart from educating the patients on looking after themselves, Lucoveis et al. (2018) have demonstrated that nurses also play a crucial role in caring for diabetic foot patients. According to the investigation, three factors may result in gangrene and amputations among elderly patients with diabetic foot ulcers; peripheral neuropathy, peripheral vascular disease, and infection. However, peripheral neuropathy is noted to solely contribute to more than 80% of foot ulcers among the three factors. Subrata and Phuphaibul (2019) have also noted that the first criteria for neurological examination of diabetic patients with a risk of developing foot ulcers are peripheral neuropathy. As the first contact in the early stages of treatment and care for diabetes, nurses that specialize in diabetic foot care must be in a position to screen patients for peripheral neuropathy.

Peimani et al. (2010) state that nurses are in charge of holistic care, including the cultural, emotional, spiritual, and developmental requirements of elderly diabetic patients. The authors agree that a nurse’s primary responsibility is to care for elderly patients with diabetic feet and assist them through their health recovery. Therefore, nurses are the patients’ main caretakers responsible for meeting their needs. This study explains that nurses must examine and monitor patients to make treatment easier, which is part of nurses’ role in care. Throughout the treatment process, the nurse monitors the patient’s development and works in the patient’s best interest. The authors further indicate that care also entails regular checkups on the patients’ emotional and physical well-being and preventing room for the patient to develop further health complications. A nurse’s services go beyond the provision of drugs and other treatments.

Howell et al. (2018) have argued that diabetic foot ulcers examination should be part of every visit a patient makes to a medical clinic. The main objective of regularly screening is to detect diabetic foot problems early and help identify patients at risk. Nurses should also plan the appropriate treatment options required to reduce such risks. Sibbald et al. (2012) explain that nurses perform diabetic foot exams to keep the patient’s feet healthy throughout the treatment and recovery phase. The nurse inquires about the patient’s medical history and any past foot concerns they may have had. The nurse also inspects the patient’s shoes for good fit and ask questions regarding their footwear, comfortability and blisters formation. Sibbald et al. (2012) expound that nurses also look for fungal diseases or fissures in the toenails and recommend the best course of action for the diabetic patient. Therefore, nurses can be argued to play a vital role in screening diabetic patients’ feet, detecting and preventing diabetic foot ulcers, and reporting findings to other practitioners involved in the patient’s care.

Apart from screening and examination, Gitarja et al. (2018) have also noted that nurses are heavily involved in wound dressing and encouraging patients to visit medical institutions for follow-up visits. Such practices such as wound dressing are observed to play a key role in helping reduce infections and treating the affected area. Alfaqih et al. (2019), while in support of wound dressing, have also noted that foot ulcers heal quickly in a moist environment. The investigation further argues that nurses should be trained on the effective dressing of wounds to promote healing and prevent further infection of the affected foot. Off-loading has also been proposed as a care solution. According to Cavanagh & Bus (2010), off-loading is critical in healing plantar ulcers. Daly et al. (2020) have also observed that inadequate off-loading is among the leading factors that delay ulcer healing despite a patient having a sufficiently perfused limb. It is, therefore, apparent that apart from examining and screening the patients for early detection of those at risk of diabetic foot, nurses also play a significant role in providing care for such patients. Therefore, the severity of diabetic foot problems heavily relies on how the nurses care for such issues.

Role of Nurses in Diabetic Foot Care at Home

Part of holistic care for diabetic patients involves home care. Kartika (2021) argues that follow-up of diabetic patients at specified intervals should be part of their care plan. As such, there is a need to refer all older adults with diabetes to diabetes clinics to help in screening and examination for diagnostics and comprehensive regular foot care. Smith-Strøm et al. (2018), while in support of regular follow-ups, argue that daily foot care for diabetics is critical, particularly for those elderly patients that have limited vision due to the condition and, therefore, cannot evaluate their foot. In such scenarios, the investigation observes that home care and visits by nurses are critical in the early detection and prevention of diabetic foot ulcers. Among the elderly, Scain, Franzen, and Hirakata (2018) have noted that home care helps with eyesight and mobility and aids in medication management, improving patients’ quality of life, and monitoring blood sugar levels.

Somayaji et al. (2017) has further argued in favour of home care for the elderly with diabetes by noting that the elderly population cannot manage their health needs due to the unique complications of the condition. Fujii et al. (2020) have also observed that elderly diabetic patients who receive home care realize better health outcomes than those who do not have home care or follow-up visits by medical practitioners. The investigation denotes peripheral vascular diseases, reduced foot sensation, and delayed wound healing as the leading causes for difficulty in foot care. Nurses are thus called upon to evaluate such complications during the clinic and home visits. It further demonstrates that caring for diabetic feet does not end with clinic visits and extends to one’s home. Therefore, nurses can play a critical role in providing home care for diabetes patients, particularly among those with diabetic foot complications.

Role of Nurses in Rehabilitation

According to Odaba (2021), one of the critical duties nurses have while managing patients with diabetic foot ulcers is to help them with movement. This is vital, particularly for patients that have had their foot amputated due to the condition. It is thus, noted that nurses should be able to help train patients on how to use assistive devices. Miikkola et al. (2019), while supporting the argument, have also noted that it is essential for nurses involved in the management of diabetic foot ulcers to identify various types of devices and how to use them to help their patients based on their needs. One can, therefore, argue that nurses’ role in caring for diabetic feet goes beyond providing primary care and ensuring that patients are well versed with assistive devices that can aid in their movement and lead regular everyday lives.

Conclusion

This exhaustive literature search was necessary for providing comprehensive information, data, and literature related to the topic – nurses’ role in managing diabetic foot among the elderly. The search process was made complete by employing five main steps; (1) construct a research question based on the variables and topic (2) use keywords to obtain like-nature studies done by other researchers (3) summarizing the findings of the different research works (4) Using a PRISMA flow chart to visually summarises the screening process employed by the researcher in choosing the appropriate literature works, and (5) summarizing the findings in a methodology matrix.

References

WHO, 2022. Diabetes. [online] Who.int. Available at: https://www.who.int/news-room/fact-sheets/detail/diabetes

CDC, 2021. Diabetes Basics. [online] Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/diabetes/basics/diabetes.html

Mordarska, K. and Godziejewska-Zawada, M., 2017. Diabetes in the elderly. Przeglad menopauzalny= Menopause review, 16(2), p.38.

Ishak, N. H., Yusoff, S. S. M., Rahman, R. A., & Kadir, A. A., 2017. Diabetes self-care and its associated factors among elderly diabetes in primary care. Journal of Taibah University Medical Sciences, 12(6), 504-511.

Boulton, A. J., 2019. The diabetic foot. Medicine, 47(2), 100-105.

Boulton, A. J., Armstrong, D. G., Kirsner, R. S., Attinger, C. E., Lavery, L. A., Lipsky, B. A., … & Steinberg, J. S. (2018). Diagnosis and management of diabetic foot complications.

Zhang, P., Lu, J., Jing, Y., Tang, S., Zhu, D., & Bi, Y., 2017. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Annals of medicine, 49(2), 106-116.

Costa, R. H. R., Cardoso, N. A., Procópio, R. J., Navarro, T. P., Dardik, A., and de Loiola Cisneros, L., 2017. Diabetic foot ulcer carries high amputation and mortality rates, particularly in the presence of advanced age, peripheral artery disease and anaemia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11, S583-S587.

Longo, M., Bellastella, G., Maiorino, M. I., Meier, J. J., Esposito, K., & Giugliano, D., 2019. Diabetes and ageing: from treatment goals to pharmacologic therapy. Frontiers in Endocrinology, 45.

Buggy, A. and Moore, Z., 2017. The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review. Journal of Wound Care, 26(6), pp.324-339.

LeRoith, D., Biessels, G.J., Braithwaite, S.S., Casanueva, F.F., Draznin, B., Halter, J.B., Hirsch, I.B., McDonnell, M.E., Molitch, M.E., Murad, M.H. and Sinclair, A.J., 2019. Treatment of diabetes in older adults: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104(5), pp.1520-1574.

Saif‐Ur‐Rahman, K.M., Mamun, R., Eriksson, E., He, Y. and Hirakawa, Y., 2021. Discrimination against the elderly in health‐care services: a systematic review. Psychogeriatrics, 21(3), pp.418-429.

Kalra, S. and Sharma, S.K., 2018. Diabetes in the Elderly. Diabetes Therapy, 9(2), pp.493-500.

Leung, E., Wongrakpanich, S. and Munshi, M.N., 2018. Diabetes management in the elderly. Diabetes Spectrum, 31(3), pp.245-253.

Boland, A., Cherry, G. and Dickson, R. eds., 2017. Doing a systematic review: A student’s guide.

Marques, A. D. B., Texeira, A. K. S., Moreira, T. M. M., de Carvalho, R. E. F. L., de Melo Fialho, A. V., & Chaves, E. M. C. (2017). Nursing interventions for the prevention of foot ulcers in patients with diabetes: an integrative review. International Archives of Medicine, 10.

King, N., Brooks, J. and Tabari, S., 2018. Template analysis in business and management research. In Qualitative methodologies in organization studies (pp. 179-206). Palgrave Macmillan, Cham.

Nazarko, L. (2019). Diabetes and foot problems: The role of the practice nurse. Practice Nursing, 30(1), 9–15. doi:10.12968/pnur.2019.30.1.9

Nguyen, T.P.L., Edwards, H., Do, T.N.D. and Finlayson, K., 2019. Effectiveness of a theory-based foot care education program (3STEPFUN) in improving foot self-care behaviours and foot risk factors for ulceration in people with type 2 diabetes. Diabetes research and clinical practice, 152, pp.29-38.

Singh, S., Jajoo, S., Shukla, S. and Acharya, S., 2020. Educating patients of diabetes mellitus for diabetic foot care. Journal of family medicine and primary care, 9(1), p.367.

Warfield, T.M., 2019. Implementation of an Evidence-Based Diabetic Foot Care Protocol and Impact on Health Outcomes (Doctoral dissertation, Walden University).

Ramirez-Perdomo, C., Perdomo-Romero, A. and Rodríguez-Vélez, M., 2019. Knowledge and practices for the prevention of the diabetic foot. Revista gaucha de enfermagem, 40.

Kumarasinghe, S.A., Hettiarachchi, P. and Wasalathanthri, S., 2018. Nurses’ knowledge on diabetic foot ulcer disease and their attitudes towards patients affected: A cross‐sectional institution‐based study. Journal of clinical nursing, 27(1-2), pp.e203-e212.

Pourkazemi, A., Ghanbari, A., Khojamli, M., Balo, H., Hemmati, H., Jafaryparvar, Z. and Motamed, B., 2020. Diabetic foot care: knowledge and practice. BMC endocrine disorders, 20(1), pp.1-8.

Nazarko, L., 2019. Diabetes and foot problems: The role of the practice nurse. Practice Nursing, 30(1), pp.9-15.

Nguyen, T.P.L., Edwards, H., Do, T.N.D. and Finlayson, K., 2019. Effectiveness of a theory-based foot care education program (3STEPFUN) in improving foot self-care behaviours and foot risk factors for ulceration in people with type 2 diabetes. Diabetes research and clinical practice, 152, pp.29-38.

Somayaji, R., Elliott, J.A., Persaud, R., Lim, M., Goodman, L. and Sibbald, R.G., 2017. The impact of team-based interprofessional comprehensive assessments on the diagnosis and management of diabetic foot ulcers: a retrospective cohort study. PLoS One, 12(9), p.e0185251.

Mordi, N.A., Mordi, I.R., Singh, J.S., McCrimmon, R.J., Struthers, A.D. and Lang, C.C., 2020. Renal and cardiovascular effects of SGLT2 inhibition in combination with loop diuretics in patients with type 2 diabetes and chronic heart failure: the RECEDE-CHF trial. Circulation, 142(18), pp.1713-1724.

Lucoveis, M.D.L.S., Gamba, M.A., Paula, M.A.B.D. and Morita, A.B.P.D.S., 2018. Degree of risk for foot ulcer due to diabetes: nursing assessment. Revista brasileira de enfermagem, 71, pp.3041-3047.

Subrata, S.A. and Phuphaibul, R., 2019. Diabetic foot ulcer care: a concept analysis of the term integrated into nursing practice. Scandinavian journal of caring sciences, 33(2), pp.298-310.

Peimani, M., Tabatabaei-Malazy, O., & Pajouhi, M. (2010). Nurses’ role in diabetes care; A review. Journal of Diabetes and Metabolic Disorders, 9, 4.

Howell, R.S., Criscitelli, T., Woods, J.S., Gillette, B.M., Brem, H. and Gorenstein, S., 2018. A perioperative approach to increase limb salvage when treating foot ulcers in patients with diabetes. AORN Journal, 107(4), pp.431-440.

Cavanagh, P.R. and Bus, S.A., 2010. Off-loading the diabetic foot for ulcer prevention and healing. Journal of vascular surgery, 52(3), pp.37S-43S.

Gitarja, W.S., Jamaluddin, A., Wibisono, A.H., Megawati, V.N. and Fajar, K., 2018. Wound care management in Indonesia: issues and challenges in diabetic foot ulceration. Wounds Asia, 1(2), pp.13-17.

Daly, B., Arroll, B., Nirantharakumar, K. and Scragg, R.K.R., 2020. Improved foot management of people with diabetes by primary healthcare nurses in Auckland, New Zealand. NZ Med J, pp.39-50.

Somayaji, R., Elliott, J.A., Persaud, R., Lim, M., Goodman, L. and Sibbald, R.G., 2017. The impact of team-based interprofessional comprehensive assessments on the diagnosis and management of diabetic foot ulcers: a retrospective cohort study. PLoS One, 12(9), p.e0185251.

Miikkola, M., Lantta, T., Suhonen, R. and Stolt, M., 2019. Challenges of foot self-care in older people: a qualitative focus-group study. Journal of foot and ankle research, 12(1), pp.1-10.

Odaba, E., 2021. Diabetes foot ulcers: a descriptive literature review on the nurse’s role in the prevention of diabetic foot ulcers.

Scain, S.F., Franzen, E. and Hirakata, V.N., 2018. Effects of nursing care on patients in an educational program for prevention of diabetic foot. Revista Gaúcha de Enfermagem, 39.

Fujii, K., Komoda, T., Maekawa, A. and Nishikawa, M., 2020. Foot care knowledge and practices among Japanese nurses and care workers in-home care and adult service centre: a cross-sectional study. BMC nursing, 19(1), pp.1-15.

Smith-Strøm, H., Igland, J., Østbye, T., Tell, G.S., Hausken, M.F., Graue, M., Skeie, S., Cooper, J.G. and Iversen, M.M., 2018. The effect of telemedicine follow-up care on diabetes-related foot ulcers: a cluster-randomized controlled noninferiority trial. Diabetes care, 41(1), pp.96-103.

Kartika, A.W., Widyatuti, W. and Rekawati, E., 2021. The effectiveness of home-based nursing intervention in the elderly with recurrent diabetic foot ulcers: A case report. Journal of public health research, 10(2).

Alfaqih, M.R., Sinawang, G.W., Faizah, R. and Hermanto, A., 2019. The Management of Diabetic Foot Ulcers Using the Wound Treatment Techniques of Modern Dressing: A Systematic Review. Jurnal Ners, 14(3), pp.177-181.

Sibbald, R.G., Ostrow, B., Lowe, J., Ayello, E.A., Alavi, A., Botros, M., Goodman, L., Woo, K. and Smart, H., 2012. Screening for the high-risk diabetic foot: a 60-second tool (2012)©: diabetes. Wound Healing Southern Africa, 5(2), pp.72-82.