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*The Noble Foot* Standing on a Firm Foundation. Shawneen Schmitt , RN MSN MS CWOCN CFCN Website Presentation for WOCN – 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.

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the noble foot standing on a firm foundation

*The Noble Foot* Standing on a Firm Foundation

Shawneen Schmitt, RN MSN MS CWOCN CFCN

Website Presentation

for

WOCN – NCR - 2011

slide2

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
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
slide4

have taken

many paths to accomplish so much in a lifetime

People’s feet come in different shapes, sizes, colors and

foot structures
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
slide12

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

Nerve Related Disease (Neuropathy)
slide14

Foot Motion

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

normal aging of the foot
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
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
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
interesting nail facts
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.

common nail disorders
Common Nail Disorders

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

slide25

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
slide27

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/

slide30

Checking for sensory-motor neuropathy

    • Loss of protective sensation
    • Diminished vibration sensation
    • Determine muscle weakness
slide32

-When doing a foot/nail assessment – Teach the person about appropriate foot & nail care at the same time

evidence based practice and quality assurance
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 assurance1
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)
slide40

Things to Avoid

Safe Nail Care Implements

for the Patient

nail care indicators
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
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.
slide43

Reflexology Foot Massage

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

Is used for relaxation and increase localized blood flow

good foot care
Good Foot Care

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

tissue injury a physiological cascade response
-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
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

Team Approach
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

Goals for Quality for Wound Healing
evidence based practice and quality assurance2
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 assurance3
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)

slide58

Other

Challenging Feet

common foot challenges
Common Foot Challenges

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

principles of orthotic management
Principles of Orthotic Management
  • Redistribution
  • Accommodation
  • Stabilization
  • Compensation
  • Rest
  • Immobilization
  • Containment
evidence based practice and quality assurance4
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)
medicare coverage for special footwear
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
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]

references resources
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=2082&doc=13297
  • http://www.webmd.com/skin-problems-and-treatments/slideshow-common-foot-problems
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