*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
• Wisconsin Pressure Ulcer Coalition - Metastar
• June 1, 2011

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• 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.

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Presentation Outcomes

• The participant will be able to
• Describe the AP 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

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have taken many paths to accomplish so much in a
lifetime
Peoples feet come in different shapes, sizes,
colors and
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Anatomy and Physiology of the Foot
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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

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Types of Foot Arches
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• Types of Nerve Responses
• Autonomic
• Sensory
• Motor

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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

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Foot Motion

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

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Contributing Factors for Foot Disorders

• Peripheral Vascular Disease
• Arterial
• Venous
• Diabetes
• Arthritis
• Osteoporosis/Osteomyelitis
• Fractures/Trauma
• Central Nervous System Dysfunction
• Deformities

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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

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Common Foot Problems
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Anatomy of the Nails
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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
  199378 79.

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Finger and Toe Nails Can Tell a Story of a
Persons Health
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Nail Challenges
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Common Nail Disorders
http//www.lib.uiowa.edu/hardin/md/nailspictures2.
html
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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 lt 3sec
• Check for edema
• Check for presence of hair
• Fat pads over bony areas
• Stance and gait
• Any pain
• Description
• Problems
• Callous
• Corns
• Blisters

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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/
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If problem palpating pulses use a Doppler and
mark site with a marker where blood flow is heard
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• Checking for sensory-motor neuropathy
• Loss of protective sensation
• Diminished vibration sensation
• Determine muscle weakness

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Evaluate Swelling of the Feet
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-When doing a foot/nail assessment Teach the
person about appropriate foot nail care
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Teach Healthy Lifestyles and Self-Care
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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

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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)

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This is NOT Good Foot Care
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This is NOT Good Foot Care
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Things to Avoid
Safe Nail Care Implements
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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

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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.

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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
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Good Foot Care
http//www.webmd.com/skin-problems-and-treatments/
slideshow-common-foot-problems
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What Could Happen to the Person (Diabetic) Doing
Nail Self-Surgery?
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What Could Happen to the Person (Diabetic) Who
Does Not Protect Feet?
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This is What May Happen!!
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-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

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Wound Care Approaches for Limb Saving
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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

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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

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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
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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)

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The Most Challenging Foot Disorder
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Charcot Foot
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Other Challenging Feet
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Common Foot Challenges
http//www.webmd.com/skin-problems-and-treatments/
slideshow-common-foot-problems
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Methods of Offloading Pressure
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Principles of Orthotic Management

• Redistribution
• Accommodation
• Stabilization
• Compensation
• Rest
• Immobilization
• Containment

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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)

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Types of Foot Protection
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Check the Shoes
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Good Supportive Shoes with a Wide Toe Box
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Throw Away the Poorly Fitting Shoes/Slippers
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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

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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
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Is this an oxymoron?
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On behalf of all the unique and beautiful feet in
the world.I thank you!
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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/Display
  Organization.aspx?org_id2082doc13297
• http//www.webmd.com/skin-problems-and-treatments/
  slideshow-common-foot-problems