The population of the United States is aging. In 2009, there were 39.6 million people aged 65 years or older living in the United States, representing 12.9% of the population. By 2030, this cohort is expected to increase to 72.1 million persons, who will represent 19% of the population.1 The prevalence of chronic diseases in the elderly that impact foot health and self-care abilities is significant and is likely to increase as this population increases. At present, 41% of older persons have hypertension, 49% have arthritis, and 18% have diabetes mellitus. Persons with diabetes mellitus and hypertension have an increased risk for peripheral arterial disease.2 Peripheral arterial disease increases with age; it affects 12% to 20% of adults aged 65 years and older.

Visual impairment in the elderly includes cataract, age-related macular degeneration, and glaucoma. The prevalence of diseases of the eye increases with age. Between the ages of 60 and 69 years, 20% of elders will develop cataracts. This percentage increases to 42.8% between the ages of 70 and 79 years and to 68.3% of persons over 80 years of age.3 Similar increases in prevalence occur with age-related macular degeneration and glaucoma. Dementia and Alzheimer's disease also increase with age and affect 13.9% and 9.7%, respectively, of the population over the age of 71 years.4 These visual and cognitive deficits impair the elderly persons' ability to care for their feet and limit the effectiveness of patient education. Nevertheless, proper foot and nail care is essential to prevent complications such as cellulitis, osteomyelitis, and amputation. However, current Medicare Part B coverage for routine foot care is limited to those with neuropathy or specific systemic diseases resulting in severe circulatory problems or when there is clinical evidence of mycosis with ambulation limitations, pain, or secondary infection.5,6 The Centers for Medicare & Medicaid Services states that Medicare covers foot examinations and treatment for diabetes-related nerve damage at 80% coverage plus the Part B deductible for outpatient treatment. Specific criteria for Medicare coverage of diabetes neuropathy in either foot includes a foot examination every 6 months by a podiatrist or other foot care specialist, unless the client has seen a foot care specialist for some other foot problem during the past 6 months.5,6 These limitations create an opportunity for nurses with specialized knowledge and skills to teach patients about proper foot and nail care, assess and manage common foot problems, and refer patients to others as needed. The purpose of this article is to describe the preparation, role, and opportunities for CFCN nurses and to increase awareness of the value of this specialty practice in an aging population.

Diabetes Mellitus and Limb Amputation

Approximately 23.6 million Americans (7.8%),7 and 246 million people worldwide (5.9%), have diabetes mellitus.8 Complications of diabetes include heart disease, stroke, hypertension, renal disease, retinopathy, peripheral arterial disease, and peripheral neuropathies.9 Peripheral neuropathy can lead to an insensate foot, nonhealing foot ulcers, and an increased risk for amputation. In 2004, more than 71,000 lower extremity amputations were performed due to complications of diabetes in the United States alone.9 The average cost for hospitalization for a lower limb amputation was $30,422; professional fees, rehabilitation, and outpatient follow-up care represent additional financial burden for patients and the health care system.10 Studies are still needed to assess the global cost of lower extremity amputation, but the International Working Group on the Diabetic Foot8 reports that 1 million people with diabetes undergo amputation annually. This comparatively high incidence of limb amputation may be partly attributable to the fact that 80% of persons with diabetes live in developing countries and lack access to the standard of care available in developed countries. However, even in developed countries, a significant percentage of amputations in persons with diabetes are deemed preventable with appropriate education and foot and nail care. Management of peripheral vascular disease is considered the most important factor in the outcome of a diabetic foot ulcer. Therefore, circulatory assessment and prompt referral for signs and symptoms of impaired circulation is an essential part of any prevention program.8

Nurse-Provided Foot Care

The risks associated with self-care and care by untrained persons has led to a rise in nurse involvement in this aspect of care. The Wound, Ostomy and Continence Nurse Certification Board (WOCNCB) began certification as a means of standardizing and elevating the quality of foot care and the role of the foot care nurse.11 Important milestones in the development of this certification are summarized in Table 1. The qualifications for certification are a current RN license and completion of one of the following criteria: (1) completion of a formal foot and nail program that includes 5 hours of didactic instruction and 3 hours of clinical practice and (2) completion of an experiential pathway including 5 hours of continuing education and 8 hours of clinical practice under supervision of an expert. After April 1, 2011, the programs and clinical practice must have been completed within the past 5 years.12 The topics covered on the examination include physical and risk assessment, nursing interventions for skin and nail care, patient education, and referral.12

TABLE 1. Milestones in CFCN Certification Development

Foot care encompasses 1 or more of the following nursing interventions: assessment, hygienic skin and nail care, interventional skin and nail care, patient education, and referral. The primary goals of nursing care and patient education are (1) prevention of thermal, mechanical, and chemical injuries to the feet; (2) early detection of foot and nail problems; (3) maintenance of skin and nail integrity or referral when indicated; and (4) enhancement of patient self-care and monitoring skills.13

Assessment

Assessment begins with a brief health history that includes a review of disease processes, previous foot problems, medications, and home remedies. It is also important to assess self-care practices, and barriers to self-care such as vision problems, difficulty reaching the feet due to arthritis or obesity, or cognitive deficits.14 Assessment of the foot comprises 2 major components, inspection and palpation. The certified foot and nail care nurse focuses on the condition of the skin and nails, perfusion status, and sensorimotor function. The skin is assessed for temperature, presence of hair, integrity, calluses, edema, erythema, and discoloration. The area between the toes is checked for moisture, cracks, and fissures that increase risk for infection.15,16 Nails are inspected for thickening of the plate, subungual debris, and discoloration, and the skin at the lateral borders (nail folds) is assessed for evidence of infection such as erythema, edema, and drainage.17

Circulation is assessed by palpation of the dorsalis pedis and posterior tibial pulses. The CFCN also assesses skin temperature and color, presence or absence of hair, edema, and capillary refill.18 Capillary refill is evaluated by elevating the foot slightly and pressing the plantar surface of the toe pad; normal capillary refill time is approximately 3 seconds.9 However, capillary refill time can be influenced by environmental factors such as room temperature and variability among examiners. Therefore, this assessment should not be the only factor considered when making clinical judgments.19 Ideally a screening Ankle Brachial Index (ABI), also referred to as Ankle Arm Index, is conducted by measuring the systolic blood pressure of the arm and ankle on the same side of the body. The ankle pressure is then divided by the arm pressure. Normal flow rate is indicated by a ratio of 1.0, and values less than 1 indicate compromised blood flow at rest. For example, an ABI of 0.6 indicates 60% blood flow at rest. An abnormal ABI, as well as other signs and symptoms of venous or arterial insufficiency, alerts the nurse to the need for referral for further evaluation (Table 2).20

TABLE 2. Signs and Symptoms of Venous and Arterial Insufficiency

Pedal sensations are assessed by asking about numbness, tingling, burning, or pain since these symptoms raise the suspicion of peripheral polyneuropathy affecting the feet. The nurse uses a 128-Hz tuning fork to determine if vibratory sensation is perceived at the interphalangeal joint of the great toe for at least 10 seconds. This assessment is particularly important because loss of vibratory sensation occurs earlier than loss of protective sensation.20 Protective sensation is evaluated using a 10-g nylon 5.07 Semmes-Weinstein monofilament placed with just enough pressure to bend it slightly on designated areas of the plantar surface of the foot (Figures 1 and 2). Loss of sensation signals the need for teaching regarding protection of the feet such as always wearing socks and properly fitting shoes, never walking barefoot, checking inside shoes before putting them on, and avoiding temperature extremes while walking. These educational points assist in reducing the risk of foot injury for persons with insensate feet.21

FIGURE 1. MONOFILAMENT AND DIAGRAM OF SITES FOR EVALUATION OF PROTECTIVE SENSATION.

FIGURE 2. THE APPROPRIATE AMOUNT OF PRESSURE APPLIED TO THE FOOT CAUSES A SLIGHT BEND IN THE MONOFILAMENT.

Musculoskeletal assessment includes evaluating active and passive range of motion of feet and ankle joints, muscle strength and tone, gait, and balance. To assess active range of motion, the patient is asked to extend and flex the foot and rotate the ankles. The nurse then asks the patient to relax as the foot is gently moved through a normal range of motion. Muscle strength is evaluated by asking the patient to move the foot against resistance. Flexion and extension of the toes are also assessed.22

The foot is inspected for bunions, hammertoes, claw toes, or Charcot deformity. Table 3 describes the characteristics of each of these bony deformities. If Charcot osteoarthropathy is suspected, the patient should be referred immediately for joint immobilization and long-term management.25 In the final step of assessment, the nurse checks the shoes for any foreign objects, moisture, or abnormal wear patterns affecting one area of a shoe, followed by an assessment of the shoe size and type.22 Special attention is paid to ill-fitting shoes because they cause repetitive mechanical stress, a common cause of foot ulcers. One method to determine if current shoes are appropriate for the person's feet is to have them stand and place the feet in stockings on a blank piece of paper. The nurse then traces the outline of the foot with a pen or marker. Their shoe is then placed over the drawing to note any areas where the foot is wider or longer than the shoe. This emphasizes pressure points in areas of the foot that are at risk for mechanical stress and ulcer development. Shoes should allow for a ¹/₂-inch space beyond the longest toe and be wide enough to allow the upper shoe material (the vamp) at the top of the foot to be rolled between the index finger and thumb.26

TABLE 3. Characteristics and Pathology of Bony Deformities

Collectively, these assessments and measurements enable the CFCN to determine the patient's risk for lower extremity amputation (Table 4).21 Assessment also enables the nurse to identify appropriate care and design an individualized patient education program. The Lower Extremity Amputation Prevention program of the US Department of Health and Human Services has established guidelines for care, frequency of follow-up, and footwear selection based on risk category (Table 5).27 This program also provides printer-friendly foot evaluation documentation forms; these forms are accessible at http://www.hrsa.gov/leap/.

TABLE 4. Risk Categories for Lower Extremity Amputation

TABLE 5. Comprehensive Management Guidelines Based on Risk Category

Practice Scope and Setting

Nail debridement requires use of appropriate clippers to trim the free edge of the nail along the natural curve of the toe (Figure 3). After defining the free edge of the nail with an orange stick, file, or fine curette, the nurse can trim the nail with small cuts leaving at least 1/16 inch of free nail and smoothing the nail edge with an emery board or stainless steel diamond nail file. Loose debris under the nail can be removed gently with a curette or file. Care should be taken to avoid cutting the skin to prevent an entry point for potential bacterial or fungal pathogens.13,20,22

FIGURE 3. CLIPPERS AND CURETTE FOR NAIL DEBRIDEMENT.

When debriding mycotic and other dystrophic nails, we recommend a high-velocity electric podiatry file with a variety of burrs rather than the commonly used Dremel (Figures 4 and 5). L. Roehrick has 15 years experience working with rotary tools; during the first 6 years, she used a Dremel, as this is the type of tool she was trained to use. She switched to the electric podiatry files 9 years ago and since then has developed techniques of debriding calluses without the use of the scalpel, and reducing thick mycotic nails painlessly and effectively in just minutes. In Roehrick's experience the use of an electric podiatry file allows better control of the hand piece due to its lightweight and slender design. The higher speed of the file enables the nurse to apply less pressure, reducing any heat or discomfort that patients often feel with the low-speed rotary tools. After the toenails have been trimmed, the nurse uses the podiatry file with an appropriate burr. Usually a carbide burr is selected for thick nails and diamond for calluses and skin, to remove the hypertrophic or mycotic nail tissue and reduce thick calluses, respectively. The patient is informed that he or she may feel vibration or a "tickling" sensation, but the procedure should not cause pain. The nurse moves the burr gently and smoothly over the hypertrophic nail tissue from the proximal to the distal portion of the nail. When the nail is at the appropriate length and thickness, the nurse may then switch to a diamond bur to smooth any callus on the tip of the toe and the nail grooves (Figure 6).

FIGURE 4. HAND-HELD PORTABLE PODIATRY FILE.

FIGURE 5. VARIOUS BURRS (DRILL BITS) TO USE TO SMOOTH CALLUSES AND DEBRIDE DYSTROPHIC NAILS.

FIGURE 6. (A) TOENAIL AND CALLUS BEFORE DEBRIDEMENT. (B) RESULTS OF DEBRIDEMENT OF THE TOES IN (A) WITH THE ELECTRIC PODIATRY SUCTION FILE USING A CARBIDE BURR TO REDUCE THE NAIL AND A DIAMOND BURR TO SMOOTH CALLUSES.

Callus reduction can be accomplished with an electric podiatry file, a pumice stone, or emery board, depending on the size and thickness of the callus. If a pumice stone is used, the nurse should employ gentle smoothing motions in one direction to avoid a scrubbing technique. Patients, especially those with diabetes or circulatory problems, should be instructed to avoid acid-containing corn removers as these can injure tissue and lead to infection.2

Infection control is an essential aspect of CFCN specialty practice when providing nail debridement and callus reduction. The provider protects the patient with disinfected or sterilized instruments and single-use items. Beuscher22 states that proper cleaning of equipment is the single most important tool for preventing infection. In addition, the nurse applies gloves, disposable gown, and cap when debriding with an electric podiatry file or electric podiatry suction file as illustrated in Figure 7. Eye protection (with magnification if required) and single-use disposable respirators, or the N-95 mask with disposable filters, reduce exposure to microbial dust. These precautions are necessary because the nurse may inhale dust containing microbials when reducing calluses and nails leading to rhinitis or asthma. Risks of conjunctivitis or eye injury are also present when appropriate eye protection is not worn. Evidence-based risk management strategies to minimize exposure to nail dust include effective and efficient dust extraction systems, proper maintenance of equipment, appropriate drilling technique, education and training, and personal protective equipment.28

FIGURE 7. NURSE WEARING APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT TO DECREASE EXPOSURE TO MICROBIAL DUST.

Padding prominent bony structures can reduce the risk of repetitive mechanical stress caused by pressure from shoes. Padding for at-risk toes is available in nonadherent tubular silicone gel or foam, both of which can be held in place with socks. Commercially available pads with adhesive should be avoided to prevent skin damage. Lamb's wool can also be placed between toes to provide cushioning and absorption of excess moisture. Prominent metatarsal heads on the plantar surface of the foot can be padded with nonadherent silicone pads.22 Adhesive pads should not be used on the skin but can be applied to commercially available foam insoles to redistribute pressure from affected areas.29

A review of foot and ankle exercises and a foot massage with an emollient (a type of moisturizer) complete a typical care episode. We have produced several of our own emollients, using organic olive oil, herbs, beeswax, cocoa butter, and essential oils. We find that these compounds are well received by patients whose cultural group values natural herbal products. An emollient's oil base prevents the loss of water from the skin, resulting in smoother, softer skin, which is less likely to crack and itch.30

Patient Education

Effective care requires a partnership between patient and nurse, because a well-informed patient can make better self-care decisions.25 Prevention of injury to the foot is a major goal of patient education for patients with diabetes mellitus or other conditions that compromise perfusion or sensation of the feet.31 For the CFCN, educating the patient regarding proper foot care is a component of every encounter. For example, during assessment, inquiry is made about usual care of the feet, shoe type, and frequency of foot inspection.27 In addition, patients with diabetes mellitus are asked about general disease management and current blood glucose levels. Additional educational opportunities will present during a discussion of self-care practices. Such opportunities may include counseling about daily hygiene, use of emollients, nail care, managing corns and calluses, foot wear, and foot exercises. A brochure about foot care, titled "Take Care of Your Feet for a Lifetime," is available in English and Spanish from the US Department of Health and Human Services.32 Key content from this brochure is summarized in Table 6.

TABLE 6. Summary of Essential Topics in Foot Care Education for the Patient With Diabetes

Applying principles of adult learning and cognitive-behavioral theory can facilitate behavior change related to foot care.33 Knowledge gained is not always applied, and the nurse must try to discover how the patient's experience and acceptance of the diagnosis impact the desired behavioral change. Adult learning principles emphasize using a problem-oriented strategy and "cold, hard facts" delivery to influence behavior change. For example, when a problem is discovered, a "teachable moment" occurs and the nurse can highlight the reasons for behavior change. Using pictures instead of simply describing diabetes ulcers may heighten seriousness and vulnerability to foot complications. Cognitive-behavioral theory personalizes the effect of disease on lifestyle by identifying personal feelings and personal challenges. Application of these principles sets the stage for personal respect, trust, and eventual educational focus on the health issue.33

Patient education also must incorporate cultural factors. Purnell34 advises health care providers to recognize, respect, and integrate patients' cultural beliefs and practices into the health care plan, including traditional practices, religious beliefs, and beliefs concerning responsibility for health. Integrating cultural values into educational nursing interventions has had positive outcomes.35 For example, Zarate-Abbott and colleagues35 work primarily with Hispanic elders and have integrated the relationship concepts of personalismo (a relationship that develops from formal to personal through repeated contact), respeto (communication in the third person and assurance of privacy), and dignidad (recommendations for realistic, cost-effective interventions). This strategy increased receptiveness to the information provided.

Age is another factor that is important during assessment and presents educational opportunities during the foot care session. When working with an elderly client over time, repeated small doses of information are often necessary to affect foot care behavior change.36 Offering ongoing foot health education at every visit is an evidence-based strategy for improving outcomes.25 Osteoarthritis affects an estimated 27 million adults in the United States; 41% have limited mobility due to their disease.37,38 Maintaining foot health is imperative for these patients in particular, since falls are a major cause of morbidity.39 Persons with impaired mobility and osteoarthritis should be educated about maintaining a foot safe environment such as wearing shoes with a proper fit. In addition, integrating simple range-of-motion exercises to maintain mobility of the joints is beneficial.40 Demonstration of exercises for foot joints, especially for older persons with arthritis who can develop problems with gait and balance, can become part of the foot care session.

Referrals

Certified foot and nail care nurses interact with patients, lay care providers, and other specialists to increase awareness of the importance of foot care and to improve foot health. The primary long-term goal of our services is to decrease the incidence of intractable infection and limb loss. The critical nature of these goals is underscored by the aging population and predicted increases in associated conditions such as diabetes. The Centers for Disease Control and Prevention estimates that by 2050 as many as 1 in 3 Americans will have diabetes mellitus.41 Given these trends, the need for the CFCN to promote foot and nail health and prevent complications is imperative.

KEY POINTS

1. US Department of Health and Human Services. Agency on aging. Aging statistics, 2009. Retrieved October 18, 2010 from http://www.aoa.gov/AoARoot/Aging_Statistics/index.aspx. [Context Link]

2. US Department of Health and Human Services, National Heart, Lung and Blood Institute. Diseases and conditions index, peripheral artery disease, 2010. http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_risk.html. [Context Link]

3. US Department of Health and Human Services, National Institutes of Health, National Eye Institute. Prevalence of blindness data tables, 2010. Retrieved October 18, 2010 from http://www.nei.nih.gov/eyedata/pbd_tables.asp. [Context Link]

4. Plassman BL, Langa KM, Fisher GG, . Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007; 29(1/2):125-132. doi: 10.1159/000109998. [Context Link]

5. US Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare coverage of diabetes supplies & services. CMS Publication No. 11022. Retrieved October 11, 2010 from http://www.medicare.gov/Publications/Pubs/pdf/11022.pdf. Published 2008. [Context Link]

6. Wisconsin Physicians Service Insurance Corporation, 2009. Foot care questions and answers. Retrieved October 11, 2010 from http:www.wpsmedicare.com/part_b/education/foot_qa.pdf. [Context Link]

7. US Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes statistics, 2007. National Diabetes Information Clearinghouse. http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. Accessed November 20, 2009. [Context Link]

8. International Working Group on the Diabetic Foot. International Consensus on the Diabetic Foot [DVD]. Amsterdam, the Netherlands: International Diabetes Federation; 2007. [Context Link]

9. US Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Diabetes Complications. National Diabetes Information Clearinghouse. http://diabetes.niddk.nih.gov/complications/index.htm. Accessed November 20, 2009. [Context Link]

10. Reiber GE, LeMaster JW. Epidemiology and economic impact of foot ulcers and amputation in people with diabetes. In: Bower JH, Pfeifer MA, eds. Levin and O'Neal's The Diabetic Foot. Philadelphia, PA: Mosby Elsevier; 2008:3-22. [Context Link]

11. Wound, Ostomy and Continence Certification Board. Foot care exam eligibility requirements, 2010. Retrieved November 15, 2010 from http://www.wocncb.org/become-certified/foot-and-nail/eligibility.php. [Context Link]

12. Wound, Ostomy and Continence Certification Board. Examination handbook, certified foot care nurse, 2010. Retrieved November 15, 2010 from http://www.wocncb.org/pdf/WOCNCB_handbook.pdf. [Context Link]

13. Kelichi TJ. Foot and Nail Care for Registered Nurses [DVD]. Charleston, SC: Medical University of South Carolina College of Nursing; 2005. [Context Link]

14. Leenerts MH, Teel CS, Pendleton MK. Dimensions of self-care for health promotion in aging. J Nurs Scholarsh. 2002;34(4):355-361. [Context Link]

15. Sherman FT. Avoiding hospitalization for cellulitis. Geriatrics. 2001;56(8):3-4. [Context Link]

16. Kelichi TJ. Options in practice: patient with dystrophic toenails, calluses, and heel fissures. Wound Ostomy Continence Nurs. 1997;24:237-242. [Context Link]

17. Yeager BA. Primary prevention. In: Gabel LL, Haines DJ, Papp KK, eds. The Aging Foot: An Interdisciplinary Perspective. Columbus, OH; Century Graphics; 2004:5-1-5-13. [Context Link]

18. Knudsen D, Yeager BA. Physical examination. In: Gabel LL, Haines DJ, Papp KK, eds. The Aging Foot: An Interdisciplinary Perspective. Columbus, OH: Century Graphics; 2004:1-1-1-16. [Context Link]

19. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby's Guide to Physical Examination. 4th ed. St Louis, MO: Mosby; 1997. [Context Link]

20. Kelichi TJ. Foot and nail care. Lectures presented at Foot Care Extraordinaire Nursing Education Program; October 23-27, 2008; Santa Rosa, CA. [Context Link]

21. US Department of Health and Human Services. Health Resources and Services Administration. Lower extremity amputation prevention. http://www.hrsa.gov/leap. Accessed September 30, 2009. [Context Link]

22. Beuscher TL. Foot and nail care. In: Bryant R, Nix D, eds. Acute and Chronic Wounds: Current Management Concepts. Philadelphia, PA: Mosby Elsevier; 2007:337-360. [Context Link]

25. US Department of Health and Human Services. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Clinical guidelines for type 2 diabetes. Prevention and management of foot problems. National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?doc_id=5062&nbr=003546&string=diab. Published 2004. Accessed November 12, 2009. [Context Link]

26. Hoard A, Hupp D. Footwear for injury prevention. Lecture presented at Comprehensive Management of the Neuropathic Foot Seminar, The National Hansen's Disease Programs; September 23-25, 2009; Baton Rouge, LA. [Context Link]

27. Brasseaux D. Lower extremity amputation prevention in the neuropathic limb. Lecture presented at Comprehensive Management of the Neuropathic Foot Seminar, The National Hansen's Disease Programs; September 23-25, 2009; Baton Rouge, LA. [Context Link]

28. Burrow JG, McLarnon NA. World at work: evidence based risk management of nail dust in chiropodists and podiatrists. Occup Environ Med. 2006;63:713-716. Doi: 10.1136/oem.2006.027565. [Context Link]

29. Lichau K. Padding workshop. Lecture presented at Foot Care Extraordinaire Nursing Education Program; October 23-27, 2008; Santa Rosa, CA. [Context Link]

30. Kelechi TJ, Stroud S. The four Vs for foot care. Adv Nurse Pract. 2004;12:;67-84. [Context Link]

31. Haas L. Lower-limb self-management education. In: Bowker JH, Pfeifer MA, eds. In Levin and O'Neal's: The Diabetic Foot. Philadelphia, PA: Mosby Elsevier; 2008:563-572. [Context Link]

32. US Department of Health and Human Services. Public Health Service. Take Care of Your Feet for a Lifetime: A Guide for People With Diabetes. Bethesda, MD: National Institutes of Health; revised July 2003. NIH Publication No. 07-4285. [Context Link]

33. Kiely CL. Diabetic foot care education: it's not just about the foot. J Wound Ostomy Continence Nurs. 2006;33(4):416-421. [Context Link]

34. Purnell L. The Purnell model for cultural competence. J Multicultur Nurs Health. 2005;11(2):7-15. [Context Link]

35. Zarate-Abbott P, Etnyre A, Gilliland I, . Workplace health promotion: strategies for low-income Hispanic immigrant women. AAOH N J. 2008;56(5):217-222. [Context Link]

36. Etnyre A, Zarate-Abbott P, Deliganis J, . A foot care program for Hispanic elders:how evidence directed development. Poster presented at Eighth Annual Summer Institute on Evidence Based Practice; July 9-11, 2009; San Antonio, TX. [Context Link]

37. Lawrence RC, Felson DT, Helmick CG, . Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: part II. Arthritis Rheum. 2008;58(1):26-35. [Context Link]

38. Covinsky KE, Lindquist K, Dunlop DD, . Effect of arthritis in middle age and older- age functioning. J Am Geriatr Soc. 2008;56:23-28. [Context Link]

39. Centers for Disease Control and Prevention. Falls among older adults: an overview. http://www.cdc.gov/ncipc/factsheets/adultfalls.htm. Accessed August 10, 2008. [Context Link]

40. Mayo Foundation for Medical Education and Research. Exercising with arthritis: improve your joint pain and stiffness. http://www.mayoclinic.com/print/arthritis/AR00009/METHOD=print. Published August 16, 2008. Accessed October 4, 2009. [Context Link]

41. Boyle JP, Thompson TJ, Gregg EW, . Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metrics. 8:29. doi: 10.1186/1478-7954-8-29. [Context Link]