*The Noble Foot* Standing on a Firm Foundation

Shawneen Schmitt, RN MSN MS CWOCN CFCNWebsite Presentation

forWOCN – NCR - 2011

• This is to inform you that there is no endorsement of any products used in this presentation. It is used for educational purposes only.

• There is no conflict of interest present.

• This presentation is not to be duplicated unless written consent is given by the author.

Presentation Outcomes• The participant will be able to:

• Describe the A&P of the foot & nail• Identify health care challenges related to the

foot & nails• Synthesize the assessment process for foot

and nails• Create a plan that reflects the appropriate

standards for foot & nail care practice

People’s feet come in different

shapes, sizes, colors and

have taken many paths to accomplish so

much in a lifetime

Anatomy and Physiology of the Foot

Foot Structures• 26 bones

• Toes (19 bones)• Phalanges• Metatarsals

• Mid-foot (5 bones)• Cuneiforms• Cuboid• Navicular

• Hind-foot (2 bones)• Talus• Calcaneus (heel)

• 33 Joints• 100 ligaments and tendons

Types of Foot

Arches

Types of Nerve Responses• Autonomic• Sensory• Motor

Nerve Related Disease (Neuropathy)

• Autonomic (Involuntary)• Edema• Xerosis (Dry skin)• Brittle dry nails

• Sensory• Burning• Numbness• Tingling• Pain• Insensate

• Motor (Movement)• Foot drop• Shuffling and/or tripping• Hammer and/or claw toes

http://www.footmaxx.com/clinicians/anatomic.html

Foot Motion

Normal Aging of the Foot• Decrease in circulation with increase in vessel

calcification especially due to diabetes and arteriosclerosis

• Reduction in joint movement• Decrease in skin moisture• Reduction in fat pad thickness over bony

prominences• Loss of sensory cells• Changes in foot structures

Contributing Factors for Foot Disorders

• Peripheral Vascular Disease• Arterial• Venous

• Diabetes• Arthritis• Osteoporosis/Osteomyelitis • Fractures/Trauma• Central Nervous System Dysfunction• Deformities

Symptoms Related to Changes in the Foot’s Shape

• Pain when wearing shoes• Pain when weight bearing such as walking• Development of corns and callous and

ingrown toenails• Inability to find appropriate fitting shoes• Increase in aching joints• Intensify development of bunions, claw and

hammer toes• Enhancing of flat or cavus (high arch) foot

formation

Common Foot Problems

Anatomy of the Nails

Interesting Nail Facts• Nails grow approximately 0.1 mm per day or 3 mm

per month.• Nails grow faster in daytime and summer.• Fever and serious illness slow growth rates.• Pregnancy enhances growth.• Nails grow more rapidly in men and younger

people than• in women and the elderly.• Toenails grow 1⁄2 to 1⁄3 the rate of fingernails

Kechiijian P. How do nails grow? Nails. May 1993:78 –79.

Finger and Toe Nails Can Tell a Story of a Person’s Health

Nail Challenges

Common Nail Disorders

http://www.lib.uiowa.edu/hardin/md/nailspictures2.html

Foot Inspection/Assessment

• Check the condition of the skin• Intact • Dry and cracked• Moist and macerated• Rash/fungus• Red/inflamed• Warm or cool• Odor

• Determine capillary refill < 3sec• Check for edema • Check for presence of hair• Fat pads over bony areas• Stance and gait• Any pain

• Description• Problems

• Callous• Corns• Blisters• Deformities

http://www.diabeticfoot.org.uk/

Monofilament Sensory Test

• Need to use a 5.07 (10g) monofilament• Test sites with a pressure to bend filament• Be sure person has eyes closed

If problem palpating pulses use a Doppler and mark site with a marker

where blood flow is heard

Checking for sensory-motor neuropathy• Loss of protective sensation• Diminished vibration sensation• Determine muscle weakness

Evaluate Swelling of the Feet

-When doing a foot/nail assessment – Teach the person about appropriate

foot & nail care at the same time

Teach Healthy Lifestyles and

Self-Care

Evidence Based Practice and Quality Assurance

• Educating diabetics about foot care has proven helpful in reducing foot ulcers and amputations, particularly in high risk patients. Nevertheless, studies have shown that diabetic patients are not offered adequate foot care. In one study examining several aspects of foot care in patients with diabetes, 28% of patients reported that they had not received foot education from their physician. Moreover, the presence of risk factors for lower limb complications was not associated with a greater chance of receiving foot education. The same study noted that patients who had received foot education and had their feet examined by their physician were more likely to perform self inspection. When combined with a comprehensive approach to preventive foot care, patient education can reduce the frequency and morbidity of limb threatening diabetic foot lesions."

American Society for Plastic Surgeons (ASPS), Physician Consortium for Performance Improvement®, National Committee for Quality Assurance (NCQA). Chronic wound care physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Aug. 35 p. [19 references]

Evidence Based Practice and Quality Assurance

• Educate the patient about the importance of optimizing glycemic control, using appropriate footwear at all times, avoiding foot trauma, performing daily self-examination of the feet, and reporting any changes to health care professionals. (Lipsky et al., Infectious Diseases Society of America [IDSA], 2004)

• Patient and family education assumes a primary role in prevention. Diabetic patients at risk for foot lesions must be educated about risk factors and the importance of foot care, including the need for self-inspection and surveillance, monitoring foot temperatures, appropriate daily foot hygiene, use of proper footwear, good diabetes control, and prompt recognition and professional treatment of newly discovered lesions. (Frykberg et al., American College of Foot and Ankle Surgeons [ACFAS], 2006)

• Good foot care and daily inspection of the feet will reduce the recurrence of diabetic ulceration. (Wound Healing Society [WHS], 2006)

This is NOT Good Foot Care

This is NOT Good Foot Care

Safe Nail Care Implements

for the Patient

Things to Avoid

Nail Care Indicators• Consider professional care when an individual

has:• Poor or no eyesight (glaucoma, macular

degeneration)• Unable to reach feet (obesity, arthritis )• Impaired circulation the “at risk” person

(diabetic neuropathy, PVD)• Unable to use equipment safely (CVA)• Abnormal nails (thick, fungal)• No significant person to help with care

Nail Care Technique• The nail should be cut on a marginal curve or

follow the natural nail curve/shape NOT straight across

• The nail should not be cut in one piece but in small sections or nips

• After cutting, the nail should then be filed in one direction until smooth

• Then check between toes to remove any nail debris

• Finally, apply a thick lotion/cream to foot to re-moisturize the skin and cuticles but do not apply between the toes.

Reflexology Foot MassageIs used for relaxation and increase localized blood flow

is an alternative medicine method involving the practice of massaging or applying pressure to parts of the feet

Good Foot Care

http://www.webmd.com/skin-problems-and-treatments/slideshow-common-foot-problems

What Could Happen to the Person (Diabetic) Doing Nail

“Self-Surgery”?

What Could Happen to the Person (Diabetic) Who Does Not Protect Feet?

This is What May Happen!!

-Tissue Injury- A Physiological Cascade Response

• Injury of tissue occurs• Bruising• Break in the skin

• Tissue edema/inflammation• Impaired circulation (micro-circulation)

• Impaired tissue perfusion• Impaired tissue oxygenation

• Capillary thrombosis• Tissue ischemia• Tissue death/necrosis

Wound Care Approaches

for Limb Saving

Team Approach• Physical Therapy

• Cryotherapy• Heat therapy• Hydrotherapy/pulse

lavage• Ultrasound • E-stim• Massage• Exercises

• Nutrition• Protein• Calories• Vitamins & Minerals

• Pharmacy• Antimicrobial• Topicals• Analgesics• Anti-inflammatory

• Podiatry• Surgical intervention• Orthotic management• Casting

• Doctors/Nurse Specialists• Wound care• Symptom management• Education/prevention

Goals for Quality for Wound Healing

• Time enhancement• Moisture management• Stage/diagnose

accurately• Monitor closely• Determine cause of

chronicity• Infection control• Debride appropriately • Off-load/pressure relief

• Utilize evidence based standard practices

• Provide pain relief• Apply appropriate

dressings/therapies• Use a collaborative

approach• Adequate nutrition • Patient “buy-in”

• Lifestyle changes• Education

Evidence Based Practice and Quality Assurance

• A moist wound environment is essential to accelerate wound healing. Nevertheless, "wet to dry and gauze dressings are the most widely used primary dressing material in the United States" and evidence suggests that they are used inappropriately. In a recent study examining wound care practices, the use of dressings to maintain moist wound conditions ranged from 41.7% to 58.5% for diabetic and venous ulcers, respectively. Wet-to-dry dressings should not be utilized in the care of patients with chronic wounds as they may actually impede healing and are associated with an increased risk of infection, prolonged inflammation, and increased patient discomfort.

American Society for Plastic Surgeons (ASPS), Physician Consortium for Performance Improvement®, National Committee for Quality Assurance (NCQA). Chronic wound care physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Aug. 35 p. [19 references]

Evidence Based Practice and Quality Assurance

• Use clinical judgment to select a wound dressing that facilitates continued moisture. Wet-to-dry dressings are not considered continuously moist. Continuously moist saline gauze dressings are as effective as other types of moist wound healing in terms of healing rate, although they may have other drawbacks such as maceration of the peri-ulcer skin, practicality of use, and cost effectiveness. It can also be very difficult, practically, to keep gauze dressings continuously moist.

(Wound Healing Society [WHS], 2006)

The Most Challenging Foot Disorder

Charcot Foot

OtherChallenging

Feet

Common Foot Challenges

http://www.webmd.com/skin-problems-and-treatments/slideshow-common-foot-problems

Methods of Offloading Pressure

Principles of Orthotic Management• Redistribution• Accommodation• Stabilization• Compensation• Rest• Immobilization• Containment

Evidence Based Practice and Quality Assurance

• Offloading is a mainstay in the prevention and treatment of diabetic foot ulcers. Despite its importance in the care of patients with diabetic foot ulcers, a recent study examining wound care practices found that approximately 23% of patients with diabetic ulcers had no documentation of offloading devices.

American Society for Plastic Surgeons (ASPS), Physician Consortium for Performance Improvement®, National Committee for Quality Assurance (NCQA). Chronic wound care physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Aug. 35 p. [19 references]

• Relieving pressure on the diabetic wound is necessary to maximize healing potential. Acceptable methods of offloading include crutches, walkers, wheelchairs, custom shoes, depth shoes, shoe modifications, custom inserts, custom relief orthotic walkers (CROW), diabetic boots, forefoot and heel relief shoes, and total contact casts. (Wound Healing Society [WHS], 2006)

Types of Foot Protection

Check the Shoes

Good Supportive Shoes with a Wide Toe Box

Throw Away the Poorly Fitting

Shoes/Slippers

Medicare Coverage for Special Footwear

• Usually covered under Medicare Part B• Need a physician/podiatrist prescription• If you qualify, entitled to

• One pair of depth shoes (athletic or walking shoes with a higher toe box)

• Up to three shoe inserts OR• One pair of custom-molded shoes and two

additional inserts• Will need to pay approximately 20% of the total

FYI - Documentation and Medicare • With the increasing costs and services associated with

debridement and the potential overuse of these procedures, documenting the wound characteristics prior to debridement is important to confirm the medical necessity of the procedure. A review of surgical debridement services billed to Medicare in 2004, by the Office of the Inspector General, found that 29% of services had no documentation or insufficient documentation to determine whether the services were medically necessary or were coded accurately. Another important purpose of assessing and documenting the characteristics of the wound is to monitor wound progress and subsequently evaluate the treatment regimen and make any necessary adjustments.

American Society for Plastic Surgeons (ASPS), Physician Consortium for Performance Improvement®, National Committee for Quality Assurance (NCQA). Chronic wound care physician performance measurement set. Chicago

(IL): American Medical Association (AMA); 2008 Aug. 35 p. [19 references]

Is this an oxymoron?

On behalf of all the unique and beautiful feet in the world….I thank you!

References/Resources• Alavi, A., Woo, K., Sibbald, R. G. (2007). Common Nail Disorders and Fungal

Infections. Advances in Skin & Wound Care. 20(6):346-357• Baranoski, S. and Ayello, E. (2004). Wound Care Essentials, Practice Principles.

Philadelphia; Lippincott, Williams & Wilkins• Edmonds, M., Foster, A., and Sanders, L. (2004). A Practical Manual of Diabetic

Foot Care. Malden, MA. Blackwell Publishing. • Sussman C. (1999) Wound Care: Patient Education Resource Manual.

Gaithersburg, MD, Aspen Publishers Inc. • Turner, W. and Merriman, L. (1997). Clinical Skills in Treating the Foot. St. Louis;

Elsevier.• Westley, C. and Glick, D. (1997). Foot Care: An Innovative Nursing Service in a

Community Nursing Center, Journal of Community Health Nursing. 14(1):15-21.• http://www.globalwoundacademy.com/gwa/usa/aboutgwa.htm• http://www.medicinenet.com/foot_problems_pictures_slideshow/article.htm• http://professional.diabetes.org/• http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=208

2&doc=13297• http://www.webmd.com/skin-problems-and-treatments/slideshow-common-foot-

problems