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*The Noble Foot*

Standing on a Firm Foundation


Shawneen Schmitt, RN MSN MS CWOCN CFCN
Wisconsin Pressure Ulcer Coalition - Metastar
June 1, 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

Peoples 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) Sensory
Edema
Xerosis (Dry skin)
Brittle dry nails

Burning
Numbness
Tingling
Pain
Insensate

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

Foot Motion

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

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 Foots 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 12 to 13 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 Persons Health

Nail Challenges

Common Nail Disorders

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

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

http://www.diabeticfoot.org.uk

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

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 selfinspection 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

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 remoisturize the skin and cuticles but do not apply
between the toes.

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

Foot Massage
Is used for relaxation and increase
localized blood flow

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 InjuryA 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

Other
Challenging
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=20
82&doc=13297
http://www.webmd.com/skin-problems-and-treatments/slideshow-common-footproblems