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*The Noble Foot* Standing on a Firm Foundation

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Presentation on theme: "*The Noble Foot* Standing on a Firm Foundation"— Presentation transcript:

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

2 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.

3 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

4 People’s feet come in different shapes, sizes, colors and have taken
many paths to accomplish so much in a lifetime

5 Anatomy and Physiology of the Foot

6 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





11 Types of Foot Arches

12 Types of Nerve Responses
Autonomic Sensory Motor

13 Nerve Related Disease (Neuropathy)
Sensory Burning Numbness Tingling Pain Insensate Motor (Movement) Foot drop Shuffling and/or tripping Hammer and/or claw toes Autonomic (Involuntary) Edema Xerosis (Dry skin) Brittle dry nails

14 Foot Motion

15 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

16 Contributing Factors for Foot Disorders
Peripheral Vascular Disease Arterial Venous Diabetes Arthritis Osteoporosis/Osteomyelitis Fractures/Trauma Central Nervous System Dysfunction Deformities

17 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

18 Common Foot Problems

19 Anatomy of the Nails


21 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.

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

23 Nail Challenges

24 Common Nail Disorders

25 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


27 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


29 If problem palpating pulses use a Doppler and mark site with a marker where blood flow is heard

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

31 Evaluate Swelling of the Feet

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



35 Teach Healthy Lifestyles and Self-Care

36 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]

37 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)

38 This is NOT Good Foot Care

39 This is NOT Good Foot Care

40 Safe Nail Care Implements
Things to Avoid Safe Nail Care Implements for the Patient

41 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

42 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.

43 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

44 Good Foot Care

45 What Could Happen to the Person (Diabetic) Doing Nail “Self-Surgery”?


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


49 This is What May Happen!!

50 -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

51 Wound Care Approaches for Limb Saving

52 Team Approach Physical Therapy Pharmacy Cryotherapy Antimicrobial
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

53 Goals for Quality for Wound Healing
Utilize evidence based standard practices Provide pain relief Apply appropriate dressings/therapies Use a collaborative approach Adequate nutrition Patient “buy-in” Lifestyle changes Education Time enhancement Moisture management Stage/diagnose accurately Monitor closely Determine cause of chronicity Infection control Debride appropriately Off-load/pressure relief

54 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]

55 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)

56 The Most Challenging Foot Disorder

57 Charcot Foot

58 Other Challenging Feet

59 Common Foot Challenges

60 Methods of Offloading Pressure

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

62 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)

63 Types of Foot Protection

64 Check the Shoes

65 Good Supportive Shoes with a Wide Toe Box

66 Throw Away the Poorly Fitting Shoes/Slippers

67 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

68 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]

69 Is this an oxymoron?

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

71 References/Resources
Alavi, A., Woo, K., Sibbald, R. G. (2007). Common Nail Disorders and Fungal Infections. Advances in Skin & Wound Care. 20(6): 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.

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