The Noble Foot - North Central Region of the WOCN

*The Noble Foot*
Standing on a Firm Foundation
Shawneen Schmitt, RN MSN MS CWOCN CFCN
Website Presentation
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
People’s 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
Types of Nerve Responses
Nerve Related Disease (Neuropathy)
• Autonomic (Involuntary) • Sensory
• Edema
• Xerosis (Dry skin)
• Brittle dry nails
• Motor (Movement)
• Foot drop
• Shuffling and/or tripping
• Hammer and/or claw toes
Foot Motion
Normal Aging of the Foot
• Decrease in circulation with increase in vessel
calcification especially due to diabetes and
• Reduction in joint movement
• Decrease in skin moisture
• Reduction in fat pad thickness over bony
• 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
Common Foot
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
•Check the condition of the skin
• Dry and cracked
•Moist and macerated
•Warm or cool
•Determine capillary refill < 3sec
•Check for edema
•Check for presence of hair
•Fat pads over bony areas
•Stance and gait
•Any pain
• Corns
Sensory Test
•Need to use a 5.07 (10g) monofilament
•Test sites with a pressure to bend filament
•Be sure person has eyes closed
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
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
for the Patient
Things to
Nail Care Indicators
• Consider professional care when an individual
• Poor or no eyesight (glaucoma, macular
• 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
• 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
• Finally, apply a thick lotion/cream to foot to remoisturize the skin and cuticles but do not apply
between the toes.
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
What Could Happen to the
Person (Diabetic) Doing Nail
What Could Happen to the
Person (Diabetic) Who
Does Not Protect Feet?
This is What May
-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
for Limb
Team Approach
• Physical Therapy
• Cryotherapy
• Heat therapy
• Hydrotherapy/pulse
• 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
• Monitor closely
• Determine cause of
• Infection control
• Debride appropriately
• Off-load/pressure relief
• Utilize evidence based
standard practices
• Provide pain relief
• Apply appropriate
• Use a collaborative
• 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
Common Foot Challenges
Methods of Offloading
Principles of Orthotic Management
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
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!
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;
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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