The noble foot standing on a firm foundation
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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

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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.

  • 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


have taken

many paths to accomplish so much in a lifetime

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


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


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)


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 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


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 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


Things to Avoid

Safe Nail Care Implements

for the Patient


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 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

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


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


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 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=2082&doc=13297

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


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