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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]
Evidence Based Practice
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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 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
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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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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 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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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 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
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
Evidence Based Practice
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Evidence Based Practice
and Quality Assurance
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.webmd.com/skin-problems-and-treatments/slideshow-common-foot-problems
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