*The Noble Foot* Standing on a Firm Foundation

1. *The Noble Foot* Standing on a Firm Foundation Shawneen Schmitt, RN MSN MS CWOCN CFCN Website Presentation for WOCN – NCR - 2011

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

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. 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 Nerve Related Disease (Neuropathy)

14. Foot Motion http://www.footmaxx.com/clinicians/anatomic.html

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 http://www.lib.uiowa.edu/hardin/md/nailspictures2.html

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

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. 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 http://www.webmd.com/skin-problems-and-treatments/slideshow-common-foot-problems

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