Professional profile and care practices for the treatment of diabetes-related foot ulcers

Souza, Rodrigo Lopes de Paula; Coelho, Manuela de Mendonça Figueirêdo; Costa, Joyce da Silva; Diniz, Jamylle Lucas; Marques, Marília Braga; Lopes, Gabriella Farias; Sousa, Caroline Ribeiro De; Coutinho, Janaína Fonseca Victor

doi:10.37689/acta-ape/2025AO000472

Abstract

Objective: To analyze the professional profile and care practices of stomatherapists in the treatment of foot ulcers related to diabetes in elderly people.

Methods: a cross-sectional study composing 181 stomatherapists in 2021. The inclusion criteria contemplated stomatherapists who cared for or cared for older adults and those who worked in direct care, but who worked in consultancy, advisory, teaching, and research, were excluded. We investigated sociodemographic and professional data and aspects of caring for older adults and analyzed using the Statistical Package for the Social Sciences through bivariate analysis and binary logistic regression.

Results: The average age was 43.18 years, the average time of experience in stomatherapy was 7.51 years, 121 (66.9%) did not carry out an individualized care plan, and 58 (32%) did not use a tool for functional assessment of older adults. There was a significant association between length of training in enterostomal therapy and the use of clinical guidelines (χ²(1)=6.155 p=0.013) and the use of monofilament to assess the feet (χ²(1)=4.236 p=0.040).

Conclusion: It’s important to mention that clinical practice has shown a lack of routine use of functional assessment tools, which impacts the overall quality of care at the intersection of diabetes and geriatric health. Experienced stomatherapists frequently use clinical guidelines and foot evaluation with monofilaments, which favors better care actions. However, the professional profile and care practices did not show statistical differences in most variables investigated.

Resumo

Objetivo: Analisar o perfil profissional e as práticas assistenciais dos estomaterapeutas no tratamento de úlceras do pé diabético em idosos.

Métodos: Estudo transversal incluindo 181 estomaterapeutas desenvolvido em 2021. Os critérios de inclusão contemplaram estomaterapeutas que cuidavam de idosos e atuavam no cuidado direto. Aqueles que atuavam em consultoria, assessoria, ensino e pesquisa foram excluídos. Foram investigados dados sociodemográficos, profissionais e aspectos do cuidado ao idoso. O Statistical Package for the Social Sciences foi utilizado na análise de dados por meio de análise bivariada e regressão logística binária.

Resultados: A média de idade foi de 43,18 anos, o tempo médio de experiência em estomaterapia foi de 7,51 anos, 121 (66,9%) não realizavam plano de cuidados individualizado e 58 (32%) não utilizavam instrumento para avaliação funcional do idoso. Houve associação significativa entre o tempo de treinamento em terapia enterostomal e o uso de diretrizes clínicas (χ²(1)=6,155 p=0,013) e o uso do teste de monofilamento para avaliação dos pés (χ²(1)=4,236 p=0,040).

Conclusão: A prática clínica tem revelado escassez no uso rotineiro de instrumentos de avaliação funcional, o que impacta na qualidade geral da assistência na intersecção entre diabetes e saúde geriátrica. Estomaterapeutas experientes frequentemente utilizam diretrizes clínicas e avaliação dos pés com o teste de monofilamento, o que favorece melhores ações de cuidado. No entanto, o perfil profissional e as práticas de cuidado não apresentaram diferenças estatísticas na maioria das variáveis investigadas.

Descritores
Ferimentos e lesões; Ulcera do pé; Estomaterapia; Pé diabético; Idoso

Resumen

Objetivo: Analizar el perfil profesional y las prácticas asistenciales de los estomaterapeutas en el tratamiento de úlceras de pie diabético en personas mayores.

Métodos: Estudio transversal que incluyó 181 estomaterapeutas, llevado a cabo en 2021. Los criterios de inclusión contemplaron estomaterapeutas que cuidaban a personas mayores y que trabajaban en el cuidado directo. Se excluyeron los que se desempeñaban en consultoría, asesoría, enseñanza e investigación. Se estudiaron datos sociodemográficos y profesionales y aspectos del cuidado de personas mayores. Se utilizó el Statistical Package for the Social Sciences para el análisis de datos mediante análisis bivariado y regresión logística binaria.

Resultados: El promedio de edad fue de 43,18 años, el tiempo promedio de experiencia en estomaterapia fue de 7,51 años, 121 (66,9 %) no utilizaban plan de cuidados personalizado y 58 (32 %) no utilizaban ningún instrumento para la evaluación funcional del paciente. Hubo una asociación significativa entre el tiempo de capacitación en terapia enterostomal y el uso de directrices clínicas (χ²(1)=6,155 p=0,013) y el uso de la prueba de monofilamento para evaluar los pies (χ²(1)=4,236 p=0,040).

Conclusión: La práctica clínica revela escasez de uso rutinario de instrumentos de evaluación funcional, lo que impacta en la calidad general de la atención en la intersección entre diabetes y salud geriátrica. Los estomaterapeutas con experiencia utilizan frecuentemente directrices clínicas y evalúan los pies con la prueba de monofilamento, lo que promueve mejores acciones en el cuidado. Sin embargo, el perfil profesional y las prácticas de cuidado no presentan diferencias estadísticas en la mayoría de las variables investigadas.

Descriptores
Heridas y lesiones; Úlcera del pie; Estomaterapia; Pie diabético; Anciano

Introduction

Wound management requires knowledge of the pathophysiological and therapeutic aspects and the availability of services, human resources, and materials. In addition, the type of wound, the characteristics of the person who will be cared for, and the professional who will carry out the care are essential elements in planning appropriate care.(¹)

Regarding the type of wound, diabetes-related foot ulcers are complex injuries with a high prevalence. According to the International Diabetes Federation (IDF), the frequency of ulcer recurrence ranged from 8% in 2013 to 52% in 2018 in the United States. The prevalence ranges from 10% to 30% on the African continent and from 1 to 17% on the European continent and in Brazil 21%.(²)

People with diabetes who have foot ulcers are primarily elderly and have a mortality rate twice as high as those without ulcers. We can estimate that more than 60% of non-traumatic lower limb amputations occur in people with diabetes, 85% of which are preceded by foot ulcers. In the first year of amputation, around 30 percent of patients die; in the third year, this figure rises to 50 percent, and in the fifth year, to 70 percent.(³)

As far as health professionals are concerned, stomatherapist nurses stand out because they have advanced clinical training in managing people with wounds, thus providing theoretical and practical expertise, including in the management of innovative wound therapy technologies.(⁴,⁵)

Even with specific training, it is essential to consider whether these professionals consider the inherent aspects of the person being cared for, specifically older adults, as they present physiopathological and psychosocial alterations typical of the senescence process, understood as the alterations resulting from the physiological processes of aging. These particularities are fundamental to the functionality of these individuals and paramount to the care and quality of assistance.(⁶,⁷)

The literature points out that late assessment, demographic aspects, comorbidities, and inadequate treatment not using specific guidelines are aspects that influence the prognosis of foot ulcers related to diabetes.(⁸,⁹) However, there is a lack of studies that relate the profile and practice of professional assistance to this care.

In this way, identifying the relationship between the profile and care practices of health professionals in the treatment of foot ulcers related to diabetes will make it possible to fill gaps in knowledge on the subject and, consequently, will offer stomatherapists the opportunity to improve their clinical practice with elderly people, making it possible to develop adequate management and multidimensional monitoring of the individual, thus guaranteeing differential care that meets the needs of this population, reducing hospitalizations and amputations.

Therefore, the aim was to analyze the professional profile and care practices of stomatherapists in the treatment of foot ulcers related to diabetes in elderly people.

Methods

This cross-sectional observational study is defined according to the EQUATOR network guidelines, using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool.(¹⁰) It was carried out from April to August 2021.

The population consisted of stomatherapist nurses associated with Brazil’s Brazilian Nursing Association (SOBEST). In January 2021, we consulted the official SOBEST website. The survey showed a total number of associated enterostomal therapist nurses, corresponding to 339 divided by region: 4% (n=13) from the Center-West region, 5% (n=18) from the North, 14% (n=47) from the South, 22% (n=76) from the Northeast and 55% (n= 185) from the Southeast.

For sample calculation, we used the finite population formula, considering a presumed prevalence of 50%, a tolerable error of 0.05, and a 95% confidence level, resulting in a sample of 180 participants, who were stratified by region, using the distribution percentages of the associates, obtaining the following number of professionals: North: 9; Northeast: 40; Center-West: 7; Southeast: 99; South: 25.

Inclusion criteria were stomatherapists who cared for or cared for older people in their care practice. We excluded specialists with no experience in Enterostomal Therapy (ET) or those who worked exclusively in industry, commerce, consultancy, advisory services, teaching, or research.

The data was collected using an instrument developed in Survey Monkey®, an online questionnaire tool, made up of objective questions that covered sociodemographic and professional data (age, level of education, region in which they work, length of experience with stomatherapy and caring for foot injuries related to diabetes); aspects relating to the assessment of the cognitive and functional capacity of older adults; and aspects relating to the professional’s clinical practice.

The recruitment of participants consisted of a snowball strategy, whereby people who already met the inclusion criteria were asked to indicate new contacts with the desired characteristics from their network, and successively. Data collection began with stomatherapy nurses linked to the Academic League of Stomatherapy Nursing at the Federal University of Ceará (UFC) via social media (WhatsApp, Instagram, and Telegram). When contacted, these professionals were informed about the research and invited to participate. In this way, we reached 288 stomatherapists, representing 85% of the total number of SOBEST members at the time of collection. Of these, we excluded 107, totaling 181 respondents.

The variables for descriptive analysis were: age of the professional; gender; region in which they work; length of time since graduation; degree; length of time as a specialist; length of experience with foot wounds in people with diabetes; whether they use any guidelines that direct clinical practice; years of experience caring for older adults; whether if they carry out a gait assessment of older adults; how many older adults they care for on average per shift; use of assessment instruments; does it take into account the presence of carers; does it assess the presence of pain; does it use equipment to assess the foot; does it offer guidelines for care; how does it offer guidelines for care, does it carry out an individualized care plan for older adults.

For bivariate and multivariate analyses, the independent variables selected for the study were the length of experience as a stomatherapist and in caring for foot injuries related to diabetes. Concerning time as a specialist and time with diabetes, stomatherapist nurses with more experience may have more excellent knowledge, skills, practices, and background in clinical care for diabetes and its complications. Time was dichotomized into “up to five years” and “more than five years,” considering this to be an acceptable period for nurses to specialize and start practicing after graduation.

The classification of the dependent variables is divided into two main groups:

1) Functional assessment care practice: the aim was to assess whether these professionals consider investigating the specificities related to aging during their care. To assess this practice, we asked whether stomatherapists use the classic instruments and tests that exist in the literature and are widely used in clinical practice to assess the functionality of these older adults the Cognitive Assessment Instrument, the Basic Life Assessment Instrument, the Instrumental Daily Life Assessment, the Gait Test Assessment, the Visual Assessment (Jaeger Card) and the Whisper Test.(¹¹)

Care in the assessment of functional capacity investigates the identification of sensory deficits (visual and auditory), the performance of basic activities of daily living, characterized by tasks related to selfcare, such as eating, sphincter control, walking, personal hygiene, the ability to dress and bathe unaided), instrumental activities of daily living, defined as complex tasks associated with the environment in which the individual lives.(¹²)

2) Clinical practice: the aim was to assess the conduct of nursing care for diabetes-related foot ulcers in the elderly through three aspects to be considered: 10) Which clinical guidelines guide the professional’s practice International Working Group on the Diabetic Foot (IWGDF), American Diabetes Association (ADA), Ministry of Health (MS) protocol, Brazilian Diabetes Society (SBD) protocol, scientific articles, Institutional Protocols or their Experience; 20) Clinical assessment use of monofilaments, tuning fork, pins, reflex hammer, assessing the exposed structures of the injury, type of tissue, exudate, aspects of the edges/margins, peri-injured skin, presence of infection, assessment of deformities, calluses, pulses and neurological assessment; 30) Guidance on preventative foot care and injury prevention not walking barefoot, wearing shoes with socks, inspecting shoes before use, drying well between the toes, not immersing the foot in hot water; correct nail cutting, use of emollients, regular appointments to assess the feet. We listed these actions in the existing guidelines for caring for people with diabetes.(¹³,¹⁴,¹⁵,¹⁶)

The data was recorded in a Microsoft Excel spreadsheet version 2016 and exported for analysis using the Statistical Package for the Social Sciences version 23.0 for descriptive analysis of the variables studied (mean, standard deviation, and frequency distribution). Bivariate analysis used the Chi-square and Fisher’s exact tests for the dependent and independent variables. We analyzed the assumption of multicollinearity for the regression, where tolerance was more significant than 0.1, and VIF was less than 10, indicating the absence of multicollinearity, thus meeting this assumption. A value of p<0.05 was considered significant. Binary logistic regression was carried out (enter method).

The research received favorable opinions from the institution’s Ethics Committee, under number 4.613.606 (CAAE: 41874720.1.0000.5054), and all participants signed the Free and Informed Consent Form (FICF).

Results

The sociodemographic characteristics revealed an average age of 43.18 years (±10.23) and a majority of 161 (89.0%) females. The most prevalent region was the Southeast with 87 (48.1%), followed by the Northeast with 48 (25.3%), South with 26 (14.4%), 12 (6.6%) in the North and 08 (4.4%) in the Center-West. In terms of qualifications, 23 (12.7%) had postgraduate degrees stricto sensu. The average time since graduation was 17.16 years (±8.66), with an average of 7.51 (±6.42) years of experience in stomatherapy and an average of 9.35 (±6.95) years of experience in caring for foot wounds in patients with diabetes. These nurses attend to an average of 4.64 (±4.00) older adults per shift and have worked 11.78 (±7.70) years with this clientele. A chi-squared test was carried out to investigate whether there was an association between the length of training in stomatherapy (Table 1) and experience caring for foot wounds in people with diabetes (Table 2) and the dependent variables that characterize clinical practice.

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Table 1
Association between length of experience in enterostomal therapy and functional assessment of older adults, clinical practice of enterostomal therapist nurses and educational actions on preventive measures

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Table 2
Association between time spent working with foot ulcers related to diabetes and functional assessment of older adults, clinical practice of stomatherapist nurses and educational actions on preventive measures

There was a significant association between the length of training in ET and the use of the IWGDF clinical guidelines (χ²(1)=6.155 p=0.013), with analyses of odds ratios showing that the use of the IWGDF guidelines was 2.13 times more likely to be used by professionals with more than five years’ experience in the field. However, the professional’s experience was also 2.11 times more likely to define the behavior of stomatherapists with more than five years’ experience (χ²(1)=6.083 p=0.014). The bivariate analysis also showed a significant association between the length of training in ET and the use of the monofilament for clinical assessment of the feet of older adults with diabetes (χ²(1)=4.236 p=0.040), where this tool has a 1.89 odds ratio of use by professionals with more than five years’ experience. We found a significant association between length of experience with foot wounds in older adults with diabetes and the use of IWGDF clinical guidelines (χ²(1)=8.399 p=0.004), with odds ratio analyses showing that these guidelines are 2.51 times more likely to be used by stomatherapists with more than five years’ experience in caring for wounds in people with diabetes than those with less experience. Neurological assessment of the feet of these individuals is 2.61 times more likely to be carried out by professionals with more experience (χ²(1)=8.616 p=0.003). A binary logistic regression was carried out on the dependent variable use of the IWGDF Guidelines because it was statistically significant concerning the length of training in stomatherapy and length of practice in caring for diabetic foot wounds (Table 3).

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Table 3
Predictor variables in relation to International Working Group on the Diabetic Foot use

The model was statistically significant [c²(2) = 10.256, p = 0.006; Nagelkerke R2 = 0.740] and could adequately predict 63.0% of cases. Of the predictors, only time spent with diabetes-related foot ulcers was statistically significant (exp (b) =2.042 [95% IC: 1.019 – 1.098]). The analyses showed that length of experience in ET and the care of diabetes-related foot ulcers did not differ statistically in most of the variables studied, indicating that length of experience does not significantly affect the care of older people.

Discussion

Regarding care practices and the implications for treating diabetes-related foot ulcers in older adults, the study generally revealed that the ET professional carries out most of the actions necessary for caring for older adults. However, this study highlights relevant points that prompt discussion: the use of an individualized plan, assessment of functional capacity, use of educational resources for self-care, and the use of foot assessment equipment.

A reasonable number of ETs do not use an individualized plan when caring for older adults, and this aspect can interfere with the care provided as individualized care becomes even more relevant in the presence of chronic conditions.(¹⁷,¹⁸) Thus, using an individualized plan, the ET professional will be able to align the particularities of each older person in the aging process, care for diabetes-related foot ulcers, and the unique interaction between these two aspects. Studies show that an individualized plan is vital in managing health conditions according to the patient’s specific characteristics. The care plan centered on older adults is an organizing element of comprehensive health care that allows for appropriate planning and targeted implementation to establish more effective diagnoses, therapies, and preventive, promotional, curative, palliative, and restorative health actions.(¹⁶,¹⁷,¹⁸,¹⁹)

Individualized care for older adults is closely linked to the need to assess functional capacity. The fact that a considerable number of ETs do not assess this capacity in older people with diabetes-related foot ulcers is a cause for concern, as there is no way of drawing up a care plan without knowing which aspects of daily life, whether basic or instrumental, are or are not preserved. Therefore, ETs must use instruments such as the Katz and Lawton Scales as a working tool and thus incorporate functional capacity assessment into their clinical practice. In this sense, research reveals that for basic activities of daily living, having diabetes was the most important factor, increasing the likelihood of being dependent by 7.30 times, which reinforces the need for individualized care in this population.(²⁰)

Knowing the aspects that contribute to or limit functional independence is significant for determining the individualized care plan, respecting the peculiarities of aging following the potential and difficulties of each older adult.(²¹)

In addition, research into the functionality of the older adult becomes imperative since the professional obtains knowledge about basic activities carried out by the individual, such as eating and dressing, among others, which can have a direct impact on self-care and the understanding of how to follow up this care in the home environment.(²²)

Different educational resources aimed at selfcare for foot ulcers related to diabetes were cited in this research and are a fundamental part of treatment. However, it is imperative to discuss two aspects related to older adults: firstly, the adequacy of the material presented, and secondly, how to ensure that these guidelines will or will not be incorporated by older adults, given that, for this, it is necessary to know their functional and cognitive capacity.

It was demonstrated that time of experience can guide better care actions and the different experiences in clinical practice in the treatment of foot ulcers related to diabetes are connected to professionals who have worked in the field for more than five years. Confirming this, another study points out that nursing professionals who have performed the same function for a longer time present more notable adaptations to the work sector, service routines and care activities, developing mechanisms to mitigate stressful events and making them more confident and secure in their care.(²³)

Concerning the use of the International Working Group on the Diabetic Foot (IWGDF), we emphasize that evidence-based guidelines are essential to support high-quality clinical management, as they make it possible to keep up with updates on this subject in order to help define standards for the prevention and care of this condition. The IWGDF emphasizes five steps to prevent diabetes-related foot ulcers: (¹) identify the foot at risk; (²) regularly inspect and examine the foot at risk; (³) educate the person with diabetes; (⁴) ensure the routine use of appropriate footwear; (⁵) and treat the risk factors for ulceration. These steps are essential for effective, quality care, providing early identification of alterations and thus promoting timely treatment.(¹³)

The guideline recommends the approach of the examination and assessment of the tactile sensitivity of the foot using a monofilament, which corroborates the study since more experienced professionals regularly use this instrument. The Semmes-Weinstein 10 g monofilament has been the most favored test for examining the feet due to its ease of use and wide availability. Furthermore, the Semmes-Weinstein monofilament is a reliable instrument that emphasizes its significance for assessing the risk of diabetic foot disease.(²⁴,²⁵)

Finally, we would like to emphasize the pioneering nature of this study in analyzing the professional profile and care practices of stomatherapists and their implications for treating diabetes-related foot ulcers in older adults. The results show that caring for older adults, generally with multiple morbidities and functional incapacity, subject to limitations and dependence, reflects an increase in healthcare needs.

A limitation of the study was the incomplete completion of the form by some participants. Furthermore, even though we reached the total value of the calculated sample, it was impossible to maintain the stratification with sample lag in the Southeast region of Brazil.

Conclusion

It’s important to mention that clinical practice has shown a lack of routine use of functional assessment tools, which impacts the overall quality of care at the intersection of diabetes and geriatric health. It was found that the professional profile about the length of experience in ET and the care of diabetes-related foot ulcers with care practices for older people with diabetes and foot ulcers did not show statistical differences in most variables studied, indicating that length of experience does not appear to have a significant impact on care for older people with this condition, suggesting that, regardless of span of knowledge, there is a certain homogeneity in the care of stomatherapists in the treatment of these lesions in older adults. However, using essential elements such as following clinical guidelines and carrying out foot assessments with monofilament is related to more experienced stomatherapists.

References

¹ Herman TF, Bordoni B. Wound classification. Treasure Island (FL): StatPearls Publishing; 2023.
² International Diabetes Federation. Diabetes Atlas report on diabetes foot-related complications 2022 [cited 2023 Nov 3].. Available from: https://diabetesatlas.org/idfawp/resource-files/2022/12/IDF-DiabeticFoot-Report.pdf
» https://diabetesatlas.org/idfawp/resource-files/2022/12/IDF-DiabeticFoot-Report.pdf
³ International Working Group on the Diabetic Foot. Guía práctica y específica para el tratamiento y la prevención del pie diabético (traducción español). Brussels: IWGDF; 2017 [cited 2023 Nov 3]. Available from: http://iwgdf.org/map-es/
» http://iwgdf.org/map-es/
⁴ Coelho MM, Menezes LC, Oliveira SK, Bonfim AD, Cavalcante VM, Moraes JT, et al. Healing rate in diabetic foot ulcers treated with biomembrane and hydrocolloid powder: randomized clinical trial. Estima. 2021;19:e0621.
⁵ Batista FW, Araújo TM, Brandão MG, Ponte VA. Benefits of ozone therapy in the treatment of foot ulcers in people with diabetes mellitus. ESTIMA. Braz. J. Enterostomal Ther. 2021;19:e1821.
⁶ Ahmed SA, Badi S, Tahir H, Ahmed MH, Almobarak AO. Knowledge and practice of diabetic foot care in Sudan: A cross sectional survey. Diabetes Metab Syndr. 2019;13(4):2431–5.
⁷ Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA; IWGDF Editorial Board. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(1 Suppl 1):e3266.
⁸ Oliver TI, Mutluoglu M. Diabetic foot ulcer. Treasure Island (FL): StatPearls Publishing; 2024.
⁹ Z hang Y, Cramb S, McPhail SM, Pacella R, van Netten JJ, Cheng Q, et al.; Diabetic Foot Working Group, Queensland Statewide Diabetes Clinical Network, Australia. Factors associated with healing of diabetesrelated foot ulcers: observations from a large prospective real-world cohort. Diabetes Care. 2021;44(7):e143–5.
¹⁰ von Elm E,Altman DG, Egger M, Pocock SJ, Gøtzsche PC,Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573–7.
¹¹ Cornejo-Ovalle M, Delgado-Becerra I, Molina X, Masferrer D. [Instrumentos para medir la capacidad funcional intrínseca y la fragilidad de personas mayores en la Atención Primaria en Chile]. Rev Med Chil. 2022;150(7):930-943. Spanish.
¹² Moreira LB, Silva SL, Castro AE, Lima SS, Estevam DO, Freitas FA, et al. Factors associated with functional capacity in the elderly enrolled in the family health strategy. Ciên Saúde Colet. 2020; 25(6):2041–50.
¹³ Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E; IWGDF Editorial Board. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657.
¹⁴ American Diabetes Association. 11. Microvascular complications and foot care: standards of medical care in diabetes-2020. Diabetes Care. 2020;43(1 Suppl 1):S135–51.
¹⁵ Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Diabetic foot manual: strategies for the care of the person with chronic disease. Brasília (DF): Ministério da Saúde; 2016. p. 62.
¹⁶ Sociedade Brasileira de Diabetes. Diretrizes da sociedade brasileira de diabetes 2019-2020. São Paulo: Clannad; 2019. [citado 2023 Mai 3]. Disponível em: https://www.saude.ba.gov.br/wpcontent/uploads/2020/02/Diretrizes-Sociedade-Brasileira-deDiabetes-2019-2020.pdf
» https://www.saude.ba.gov.br/wpcontent/uploads/2020/02/Diretrizes-Sociedade-Brasileira-deDiabetes-2019-2020.pdf
¹⁷ Metzner G, Horstmeier LM, Bengel J, Bitzer EM, Dreher E, Frank F, et al. Local, collaborative, stepped, and personalized care management for older people with chronic diseases results from the randomized controlled LoChro-trial. BMC Geriatr. 2023;23(1):92.
¹⁸ Silva CG, Sena LB, Rolim IL, Sousa SM, Sardinha AH. Nursing care for patients with chronic health conditions: an integrative review. Rev Pesq Cuid Fundamental. 2017;9(2):599-605.
¹⁹ Sillner AY, Madrigal C, Behrens L. Person-centered gerontological nursing: an overview across care settings. J Gerontol Nurs. 2021;47(2):7–12.
²⁰ Araújo GK, Souto RQ, Alves FA, Sousa RC, Ceballos AG, Santos RC, et al. functional capability and associated factors in living in a community. Acta Paul Enferm. 2019;32(3):312–8.
²¹ Bartkeviciute B, Lesauskaite V, Riklikiene O. Individualized health care for older diabetes patients from the perspective of health professionals and service consumers. J Pers Med. 2021;11(7):608.
²² Abdi S, Spann A, Borilovic J, de Witte L, Hawley M. Understanding the care and support needs of older people: a scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC Geriatr. 2019;19(1):195.
²³ Price S, Reichert C. The importance of continuing professional development to career satisfaction and patient care: Meeting the Needs of Novice to Midto Late-Career Nurses throughout Their Career Span. Adm Sci. 2017;7(2):17.
²⁴ Johnson R, Osbourne A, Rispoli J, Verdin C. The diabetic foot assessment. Orthop Nurs. 2018;37(1):13–21.
²⁵ Babitha R, Subathra TA. The Semmes-Weinstein monofilament examination as a single effective screening Tool in Diagnosing Diabetic Peripheral Neuropathy when Compared to Vibration Perception Threshold. Natl J Physiol Pharm Pharmacol. 2020;10(5):419–22.

Edited by

Associate Editor
Ana Lúcia de Moraes Horta, (https://orcid.org/0000-0001-5643-3321), Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

Publication in this collection
28 Mar 2025
Date of issue
2025

History

Received
28 Feb 2024
Accepted
30 Sept 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹ Herman TF, Bordoni B. Wound classification. Treasure Island (FL): StatPearls Publishing; 2023.

[2] ² International Diabetes Federation. Diabetes Atlas report on diabetes foot-related complications 2022 [cited 2023 Nov 3].. Available from: https://diabetesatlas.org/idfawp/resource-files/2022/12/IDF-DiabeticFoot-Report.pdf
» https://diabetesatlas.org/idfawp/resource-files/2022/12/IDF-DiabeticFoot-Report.pdf

[3] ³ International Working Group on the Diabetic Foot. Guía práctica y específica para el tratamiento y la prevención del pie diabético (traducción español). Brussels: IWGDF; 2017 [cited 2023 Nov 3]. Available from: http://iwgdf.org/map-es/
» http://iwgdf.org/map-es/

[4] ⁴ Coelho MM, Menezes LC, Oliveira SK, Bonfim AD, Cavalcante VM, Moraes JT, et al. Healing rate in diabetic foot ulcers treated with biomembrane and hydrocolloid powder: randomized clinical trial. Estima. 2021;19:e0621.

[5] ⁵ Batista FW, Araújo TM, Brandão MG, Ponte VA. Benefits of ozone therapy in the treatment of foot ulcers in people with diabetes mellitus. ESTIMA. Braz. J. Enterostomal Ther. 2021;19:e1821.

[6] ⁶ Ahmed SA, Badi S, Tahir H, Ahmed MH, Almobarak AO. Knowledge and practice of diabetic foot care in Sudan: A cross sectional survey. Diabetes Metab Syndr. 2019;13(4):2431–5.

[7] ⁷ Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA; IWGDF Editorial Board. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(1 Suppl 1):e3266.

[8] ⁸ Oliver TI, Mutluoglu M. Diabetic foot ulcer. Treasure Island (FL): StatPearls Publishing; 2024.

[9] ⁹ Z hang Y, Cramb S, McPhail SM, Pacella R, van Netten JJ, Cheng Q, et al.; Diabetic Foot Working Group, Queensland Statewide Diabetes Clinical Network, Australia. Factors associated with healing of diabetesrelated foot ulcers: observations from a large prospective real-world cohort. Diabetes Care. 2021;44(7):e143–5.

[10] ¹⁰ von Elm E,Altman DG, Egger M, Pocock SJ, Gøtzsche PC,Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573–7.

[11] ¹¹ Cornejo-Ovalle M, Delgado-Becerra I, Molina X, Masferrer D. [Instrumentos para medir la capacidad funcional intrínseca y la fragilidad de personas mayores en la Atención Primaria en Chile]. Rev Med Chil. 2022;150(7):930-943. Spanish.

[12] ¹² Moreira LB, Silva SL, Castro AE, Lima SS, Estevam DO, Freitas FA, et al. Factors associated with functional capacity in the elderly enrolled in the family health strategy. Ciên Saúde Colet. 2020; 25(6):2041–50.

[13] ¹³ Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E; IWGDF Editorial Board. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657.

[14] ¹⁴ American Diabetes Association. 11. Microvascular complications and foot care: standards of medical care in diabetes-2020. Diabetes Care. 2020;43(1 Suppl 1):S135–51.

[15] ¹⁵ Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Diabetic foot manual: strategies for the care of the person with chronic disease. Brasília (DF): Ministério da Saúde; 2016. p. 62.

[16] ¹⁶ Sociedade Brasileira de Diabetes. Diretrizes da sociedade brasileira de diabetes 2019-2020. São Paulo: Clannad; 2019. [citado 2023 Mai 3]. Disponível em: https://www.saude.ba.gov.br/wpcontent/uploads/2020/02/Diretrizes-Sociedade-Brasileira-deDiabetes-2019-2020.pdf
» https://www.saude.ba.gov.br/wpcontent/uploads/2020/02/Diretrizes-Sociedade-Brasileira-deDiabetes-2019-2020.pdf

[17] ¹⁷ Metzner G, Horstmeier LM, Bengel J, Bitzer EM, Dreher E, Frank F, et al. Local, collaborative, stepped, and personalized care management for older people with chronic diseases results from the randomized controlled LoChro-trial. BMC Geriatr. 2023;23(1):92.

[18] ¹⁸ Silva CG, Sena LB, Rolim IL, Sousa SM, Sardinha AH. Nursing care for patients with chronic health conditions: an integrative review. Rev Pesq Cuid Fundamental. 2017;9(2):599-605.

[19] ¹⁹ Sillner AY, Madrigal C, Behrens L. Person-centered gerontological nursing: an overview across care settings. J Gerontol Nurs. 2021;47(2):7–12.

[20] ²⁰ Araújo GK, Souto RQ, Alves FA, Sousa RC, Ceballos AG, Santos RC, et al. functional capability and associated factors in living in a community. Acta Paul Enferm. 2019;32(3):312–8.

[21] ²¹ Bartkeviciute B, Lesauskaite V, Riklikiene O. Individualized health care for older diabetes patients from the perspective of health professionals and service consumers. J Pers Med. 2021;11(7):608.

[22] ²² Abdi S, Spann A, Borilovic J, de Witte L, Hawley M. Understanding the care and support needs of older people: a scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC Geriatr. 2019;19(1):195.

[23] ²³ Price S, Reichert C. The importance of continuing professional development to career satisfaction and patient care: Meeting the Needs of Novice to Midto Late-Career Nurses throughout Their Career Span. Adm Sci. 2017;7(2):17.

[24] ²⁴ Johnson R, Osbourne A, Rispoli J, Verdin C. The diabetic foot assessment. Orthop Nurs. 2018;37(1):13–21.

[25] ²⁵ Babitha R, Subathra TA. The Semmes-Weinstein monofilament examination as a single effective screening Tool in Diagnosing Diabetic Peripheral Neuropathy when Compared to Vibration Perception Threshold. Natl J Physiol Pharm Pharmacol. 2020;10(5):419–22.

Stomatherapy time	Till 5 years	> 5 years	p-value	IC	MIN	MAX
variable	n	n	p-value	IC	MIN	MAX
Functional assessment of older people
Cognitive assessment tool			0.833^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.937	0.514	1.708
No	55	35
Yes	57	34
Basic life assessment instrument			0.713^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.116	0.622	2.002
No	43	47
Yes	41	50
Instrumental Assessment Daily Life			0.188^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.659	0.353	1.229
No	56	34
Yes	65	26
Evaluation gait test			0.950^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.981	0.544	1.771
No	52	38
Yes	53	38
Jaeger/Visual Assessment			0.216^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.542	0.203	1.446
No	78	12
Yes	84	07
Whisper Test			0.330*	0.477	0.116	1.970
No	84	06
Yes	88	03
Clinical practice
Clinical guidelines
IWGDF			0.013^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	2.138	1.168	3.912
No	45	45
Yes	29	62
ADA			0.411^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.278	0.712	2.293
No	50	40
Yes	45	45
MS			0.833^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.068	0.577	1.979
No	31	59
Yes	30	61
SBD			0.107^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.768	0.881	3.550
No	26	64
Yes	17	74
Articles			0.698^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.144	0.580	2.258
No	23	67
Yes	21	70
Institutional protocols			0.494^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.228	0.682	2.211
No	53	37
Yes	49	42
Personal Experience			0.014^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	2.116	1.162	2.234
No	47	43
Yes	31	60
Clinical assessment
Use of monofilaments			0.040^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.896	1.028	3.499
No	40	50
Yes	27	64
Diapason use			0.590^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.176	0.652	2.124
No	54	36
Yes	51	40
Pin use			0.101^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.748	0.893	3.420
No	71	19
Yes	62	29
Use of the Refex Hammer			0.682^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.135	0.618	2.085
No	59	31
Yes	57	34
Evaluate structures exhibition			0.744^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.888	0.434	1.816
No	18	72
Yes	20	71
Evaluates debris type			0.875^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.941	0.442	2.002
No	16	74
Yes	17	74
Evaluates exudate			9.548^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.254	0.598	2.629
No	19	71
Yes	16	75
Evaluates edge/margin aspects			0.820^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.092	0.513	2.322
No	17	73
Yes	16	75
Perilous skin assessment			0.682^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.165	0.561	2.419
No	19	71
Yes	17	74
Evaluates infection			0.820^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.092	0.513	2.322
No	17	73
Yes	16	75
Deformity assessment			0.714^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.863	0.394	1.893
No	14	76
Yes	16	75
Evaluates calluses			0.973^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.014	0.472	2.175
No	16	74
Yes	16	75
Pulse Assessment			0.682^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.165	0.561	2.419
No	19	71
Yes	17	74
Neurological Assessment			0.155^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.530	0.850	2.754
No	53	37
Yes	44	47
Preventive care
Don’t walk barefoot			0.730^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.877	0.415	1.851
No	16	74
Yes	18	73
Wearing Shoes with Socks			0.636^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.850	0.432	1.669
No	21	69
Yes	24	67
Dry between the fingers			0.577^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.802	0.369	1.743
No	14	76
Yes	17	74
Inspect shoe before use			0.442^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.325	0.646	2.718
No	21	69
Yes	17	74
Inspect the feet			0.875^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.941	0.442	2.002
No	16	74
Yes	17	74
Do not immerse feet in hot water			0.910^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.964	0.512	1.817
No	27	63
Yes	55	63
Correct nail cutting			0.584^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.201	0.623	2.316
No	26	64
Yes	23	68
Use of emollients			0.091^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	1.751	0.911	1.366
	No	31	59
Yes	21	70
Guides regular consultations			0.900^α α Chi-Square Test; * Fisher’s Exact Test; Abbreviations: IWGDF International Working Group on the Diabetic Foot; ADA American Diabetes Association; MS Ministry of Health protocol; SBD Brazilian Diabetes Society	0.958	0.493	1.863
No	23	67
Yes	24	67

Time working with foot wounds of people with DM	Till 5 years	> 5 years	p-value	IC	MIN	MAX
Variable	n	n	p-value	IC	MIN	MAX
Functional assessment of older people
Cognitive assessment tool			0.168	1.579	0.822	3.031
No	42	19
Yes	70	50
Basic life assessment instrument			0.035	1.951	1.045	3.642
No	35	26
Yes	49	71
Instrumental assessment daily life			0.001	3.643	1.689	7.859
No	51	10
Yes	70	50
Evaluation gait test			0.405	1.307	0.696	2.456
No	38	23
Yes	67	53
Jaeger/Visual assessment			0.081	2.974	0.832	10.637
No	58	03
Yes	104	16
Whisper test			0.455	1.827	0.368	9.076
No	59	02
Yes	113	07
Clinical guidelines
IWGDF			0.004	2.519	1.339	4.738
No	34	27
Yes	40	80
ADA			0.757	1.103	0.594	2.045
No	33	28
Yes	62	58
MS			0.883	1.050	0.548	1.012
No	21	40
Yes	40	80
SBD			0.856	0.935	0.451	1.937
No	14	47
Yes	29	91
Articles			0.077	0.496	0.226	1.088
No	10	51
Yes	34	86
Institutional protocols			0.284	0.713	0.384	1.326
No	31	30
Yes	71	49
Personal experience			0.683	0.878	0.470	1.640
No	25	36
Yes	53	67
Clinical practice
Clinical assessment
Use of monofilaments			0.078	1.762	0.937	1.316
No	28	33
Yes	39	81
Diapason use			0.142	1.612	0.851	3.053
No	40	21
Yes	65	55
Pin use			0.137	1.750	0.833	3.676
No	49	12
Yes	84	36
Use of the reflex hammer			0.200	1.538	0.794	2.979
No	43	18
Sim	73	47
Evaluates structures exhibition			0.397	1.375	0.657	2.880
No	15	46
Yes	23	97
Evaluates debris type			0.721	1.155	0.525	2.538
No	12	49
Yes	21	99
Evaluates exudate			0.202	1.630	0.766	3.469
No	15	46
Yes	20	100
Evaluates edge/margin aspects			0.444	1.354	0.622	2.950
No	13	48
Yes	20	100
Perilous skin assessment			0.259	1.537	0.727	3.252
No	15	46
Yes	21	99
Evaluates Infection			0.721	1.155	0.525	2.538
No	12	49
Yes	21	99
Deformity assessment			0.707	1.169	0.517	2.645
No	11	50
Yes	19	101
Evaluates calluses			0.616	1.224	0.554	2.706
No	12	49
Yes	20	100
Pulse Assessment			0.259	1.537	0.727	3.252
No	15	46
Yes	21	99
Neurological assessment			0.003	2.612	1.364	5.005
No	42	19
Yes	55	65
Prevention
Don’t walk barefoot			0.306	1.489	0.692	3.204
No	14	47
Yes	20	100
Wearing shoes with socks			0.761	1.116	0.550	2.263
No	16	45
Yes	29	91
Dry between the fingers			0.517	1.302	0.585	2.895
No	12	49
Yes	19	101
Inspect shoe before use			0.397	1.375	0.657	2.880
No	15	46
Yes	23	97
Inspect the feet			0.721	1.155	0.525	2.538
No	12	49
Yes	21	99
Immerse feet in hot water			0.855	0.939	0.479	1.841
No	18	43
Sim	37	83
Correct nail cutting			0.599	1.202	0.606	2.385
No	18	43
Yes	31	89
Use of emollients			0.390	1.341	0.686	2.623
No	20	41
Yes	32	88
Guides regular consultations			0.677	1.159	0.578	2.324
No	17	44
Yes	30	90

Predictor variables	Wald	Df	Sig.	Exp(B)	95%CI for EXP(B)
Predictor variables	Wald	Df	Sig.	Exp(B)	Inferior limit	Superior limit
Enterostomal therapy experience	1.916	1	0.166	1.605	0.821	1.136
Foot ulcers experience related to diabetes	4.047	1	0.044	2.043	1.019	1.098
Constant	6.080	1	0.014	0.220	-	-