thenoblefoot_wpuc_6-1-11

8/10/2019 TheNobleFoot_WPUC_6-1-11

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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 A&P of the foot & nail

Identify health care challenges related to thefoot & 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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Peoples feet

ome in differentshapes, sizes,

colors and

have taken

many paths toaccomplish so

much in a lifetime


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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 ofFoot

Arches


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Types of Nerve ResponsesAutonomic

Sensory

Motor


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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


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

Foot Motion


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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) footformation


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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 12 to 13 the rate of fingernails

Kechiijian P. How do nails grow? Nails. May 1993:7879.


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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

F t


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Foot

Inspection/AssessmentCheck the condition of the skin

IntactDry and cracked

Moist and macerated

Rash/fungus

Red/inflamed

Warm or cool

OdorDetermine capillary refill < 3sec

Check for edema

Check for presence of hair

Fat pads over bony areas

Stance and gait

Any painDescription

Problems

Callous

Corns

Blisters

Deformities


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M fil t


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http://www.diabeticfoot.org.uk/

Monofilament

Sensory TestNeed to use a 5.07 (10g) monofilament

Test sites with a pressure to bend filament

Be sure person has eyes closed


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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 neuropathyLoss of protective sensation

Diminished vibration sensationDetermine 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 andSelf-Care


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Evidence Based Practice

and Quality Assurance

Educating diabetics about foot care has proven helpful in reducingfoot ulcers and amputations, particularly in high risk patients.Nevertheless, studies have shown that diabetic patients are notoffered adequate foot care. In one study examining several aspectsof 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 notassociated with a greater chance of receiving foot education. Thesame study noted that patients who had received foot education andhad their feet examined by their physician were more likely toperform self inspection. When combined with a comprehensive

approach to preventive foot care, patient education can reduce thefrequency and morbidity of limb threatening diabetic foot lesions."

American Society for Plastic Surgeons (ASPS), Physician Consortium for Performance Improvement, NationalCommittee 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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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 riskfactors 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 NOTGood Foot Care


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This is NOTGood Foot Care

Things to


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Safe Nail Care

Implements

Things to

Avoid


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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 straightacross

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 used for relaxation and increase

localized blood flow

is an alternative medicine

method involving the practiceof massaging or applying

pressure to parts of the feet
http://en.wikipedia.org/wiki/Alternative_medicinehttp://en.wikipedia.org/wiki/Foothttp://en.wikipedia.org/wiki/Foothttp://en.wikipedia.org/wiki/Alternative_medicine


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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 NailSelf-Surgery?


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This is What May

Happen!!

Ti I j


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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

W d C


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Wound Care

Approaches

for LimbSaving


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Team Approach

Physical Therapy

Cryotherapy

Heat therapy

Hydrotherapy/pulselavage

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

G l f Q lit


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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 basedstandard practices

Provide pain relief

Apply appropriate

dressings/therapies

Use a collaborative

approach

Adequate nutrition

Patient buy-in

Lifestyle changes

Education

E id B d P ti


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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 examiningwound 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 patientswith 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]

E id B d P ti


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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 ofmoist 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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Charcot

Foot


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Other

ChallengingFeet


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Common Foot Challenges



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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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Offloading is a mainstay in the prevention and treatmentof diabetic foot ulcers. Despite its importance in the careof patients with diabetic foot ulcers, a recent studyexamining wound care practices found thatapproximately 23% of patients with diabetic ulcers hadno documentation of offloading devices.

American Society for Plastic Surgeons (ASPS), Physician Consortium for Performance Improvement, National Committee for QualityAssurance (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 necessaryto maximize healing potential. Acceptable methods of

offloading include crutches, walkers, wheelchairs,custom shoes, depth shoes, shoe modifications, custominserts, custom relief orthotic walkers (CROW), diabeticboots, forefoot and heel relief shoes, and total contactcasts. (Wound Healing Society [WHS], 2006)

Types of Foot Protection


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Types of Foot Protection

Check the Shoe


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Good Supportive Shoes


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with a Wide Toe Box

Throw Away the


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Throw Away the

Poorly Fitting

Shoes/Slippers

Medicare Coverage for


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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 walkingshoes with a higher toe box)

Up to three shoe inserts OR

One pair of custom-molded shoes and twoadditional inserts

Will need to pay approximately 20% of the total

FYI D t ti d M di


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FYI - Documentation and Medicare

With the increasing costs and services associated with

debridement and the potential overuse of theseprocedures, documenting the wound characteristicsprior to debridement is important to confirm the medicalnecessity of the procedure. A review of surgicaldebridement services billed to Medicare in 2004, by the

Office of the Inspector General, found that 29% ofservices had no documentation or insufficientdocumentation to determine whether the services weremedically necessary or were coded accurately. Anotherimportant purpose of assessing and documenting the

characteristics of the wound is to monitor woundprogress and subsequently evaluate the treatmentregimen 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?


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y

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


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R f /R


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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 DiabeticFoot 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 aCommunity 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=20

82&doc=13297

http://www.globalwoundacademy.com/gwa/usa/aboutgwa.htmhttp://www.medicinenet.com/foot_problems_pictures_slideshow/article.htmhttp://professional.diabetes.org/http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=2082&doc=13297http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=2082&doc=13297http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=2082&doc=13297http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=2082&doc=13297http://professional.diabetes.org/http://www.medicinenet.com/foot_problems_pictures_slideshow/article.htmhttp://www.globalwoundacademy.com/gwa/usa/aboutgwa.htm

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