ABSTRACT

THE EFFECT OF FOOT AND NAIL CARE EDUCATION IN UTILIZATION

OF A FOOT MODEL

By

Susan M. Mason

December 2011

Diabetes related complications are the leading cause of non-traumatic

amputations in the United States. Approximately 23.6 million Americans (7.8%) and 246

million people worldwide (5.9%) have diabetes mellitus. Complications of diabetes

include heart disease, stroke, hypertension, renal disease, retinopathy, peripheral arterial

disease, and peripheral neuropathies. Peripheral neuropathy can lead to an insensate foot,

non-healing foot ulcers and an increased risk of amputation. In 2004, more than 71,000

lower extremity amputations were performed due to complications of diabetes in the

United States alone. The average cost for hospitalization for a lower limb alone was

$30,422; professional fees, rehabilitation, and outpatient follow-up care represent an

additional financial burden for patients and the health care system. This comparatively

high incidence of limb amputation in persons with diabetes is deemed preventable with

appropriate education and foot and nail care. Ten nurses were conveniently selected to

participate in a study that examined the effectiveness of a foot model as a teaching tool.

The study found there was a significant difference with the participants' teaching practice
1
when the foot model was utilized as a visual aid to demonstrate information in the areas

of foot and lower limb anatomy and physiology, biomechanics of ambulating, sensory

and autonomic neuropathy and its effect on the foot and skin care.

2
THE EFFECT OF FOOT AND NAIL CARE EDUCATION IN UTILIZATION

OF A FOOT MODEL

A PROJECT REPORT

Presented to the School of Nursing

California State University, Long Beach

In Partial Fulfillment

of the Requirements for the Degree

Master of Science in Nursing

Committee Members:

Savitri Singh-Carlson, Ph.D. (Chair)

David Kumrow, Ed.D.
Beth Keely, Ph.D.

College Designee:

Loucine M. Huckabay, Ph.D.

By Susan M. Mason

B.S.N., 1995, Brunei University, United Kingdom

December 2011
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 ACKNOWLEDGEMENTS

A debt of gratitude is extended to the staff of the CSULB School of Nursing for

their support, and the many accommodations they made to support this project endeavor.

My sincere thanks to the members of my direct project committee, Savitri Singh-

Carlson, Ph.D., Chair, Beth Keely, Ph.D., and David Kumrow, Ed.D. I feel very

fortunate to have had the opportunity to pursue this project which your commitment

helped make possible for me. It was the most rewarding educational experience of my

life. Your dedication to higher education and to nursing was demonstrated by your

selfless donation of time and effort toward the development of this project. Thank you

for your guidance and patience.

I am in debt to my business colleague Shelly Burdette-Taylor who was

wonderfully supportive, yet consistently motivating, and on many occasions intentionally

challenging with her blend of "can do" spirit and "how to" expertise. In addition, I thank

all of the wound ostomy continence nurses attending the foot and nail program, for

participating in my project.

Last and most importantly, there are no words that can sufficiently convey my

love and deepest gratitude for my husband, Steven. Your love, support, encouragement,

tolerance and the many sacrifices you made to see this long arduous endeavor to its end

were extraordinary and precious gifts.

iii
 TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS iii

CHAPTER

1. INTRODUCTION 1

Statement of the Problem 2

Statement of the Purpose 4
Significance of the Problem 4
Summary 6

2. LITERATURE REVIEW 8

Theoretical Framework 9
Literature Review 9
Summary 12

3. METHODOLOGY 13

Design 13
Sample 13
Data Collection 13
Data Analysis 14
Summary 14

4. FINDINGS 15

Demographic Characteristics 15
Evaluation of Data Analysis 16
Additional Findings 17
Summary 17

IV
CHAPTER Page

5. DISCUSSION 19

Brief Summary of Findings 19

Limitation of the Project 21
Recommendations 21
Summary 21

APPENDICES 23

A. DATA COLLECTION TOOL AND DEMOGRAPHIC DATA SHEET 24

B. FOOT CARE TEACHING PROGRAM AND FOOT CARE KNOWLEDGE

TEST 30

C. MEDICAL TEACHING FOOT MODEL: LEGACY EZ2B/VATA

WILMA0950 51

REFERENCES 55

v
 CHAPTER 1

INTRODUCTION

The Agency for Health Research and Quality (AHRQ) estimates that 650,000 new

cases of diabetes occur each year. Diabetes mellitus related complications are the leading

cause of non-traumatic amputations in the United States (Patout, Birke, Horswell,

Williams, & Cerise, 2000). In 2004, more than 71,000 lower extremity amputations were

performed due to complications of diabetes in the United States alone. Singh,

Armstrong, and Lipsky (2005) have estimated that approximately 25% of diabetic

patients develop a foot ulcer in their lifetime, and more than half of these ulcers become

infected. Infected foot ulcers proceed up to 85% of diabetic related lower extremity

amputations. Furthermore, a patient with diabetes mellitus who undergoes an amputation

is 30% to 50% more likely to undergo a second amputation (Allie, 2007). Studies

indicate a 6% mortality rate for those undergoing amputation and this rate rises to 16% if

the person also requires hemodialysis for end stage renal disease (O'Hare et al., 2004).

Hence, a compromised vascular system of the lower extremity is the single most

important factor that could, by itself, necessitate an amputation. Reiber and LeMaster

(2008) estimated annual cost to the healthcare system for diabetic foot ulcers and

peripheral vascular disease leading to amputations are approximately $400 million.

These data point to the urgent need for healthcare services to reduce the incidence of

amputation in the diabetic population.

1
 The risk associated with self-care and care by untrained persons has led to a rise

in nurse involvement in this aspect of care. The Wound Ostomy and Continence Nurse

Certification Board (WOCNCB) began Foot Care Nurse Certification (CFCN) as means

of standardizing and elevating the quality of foot care and the role of the foot care nurse

(WOCNCB, 2010).

Da Agony of De Feet is a foot and nail program that was established by TayLord

Health, LLC to meet the needs of RNs preparing to sit for the CFCN. Therefore, this

project will determine the effectiveness of the foot model as a teaching tool with nurses

from this program.

Statement of the Problem

An evaluation was conducted to see whether utilizing a foot model as an

educational tool would improve nurses teaching practices. It is anticipated that there

would be an improvement in nurses' teaching practice after they completed the 3-day Da

Agony of De Feet foot and nail program.

Adult learning principles are necessary in designing health care curricula as adult

learners bring a reservoir of experiences to the learning situation (Knowles, 1975). With

the utilization of education based on research, nurses and patients will move from

competent to expert in foot care by utilizing their intellectual orientation, integrating

knowledge, and refocusing their decision-making process to ensure positive outcomes

(Benner, 1984).

2
 Expertise develops when individuals test and refine propositions, hypotheses and

principal based expectations in actual practice (Benner, 1984). In order to assess

performance skills, the learner must do the action in question and have in return

demonstration of that skill rated. The foot model allows for that actual practice in a non-

threatening learning situation but specific to the learner and his or her needs. Patients and

clinicians need easily manipulated tools to deliver educational content to adult learners.

Styles of learning are also important to address with the adult learners (Bigge & Shermis,

1992). Most individuals are visual or kinetic learners; few are actual auditory learners.

The foot model is utilized to teach foot care, ambulation issues, toenail reduction and skin

care. In addition, selection of footwear can be discussed illustrating problems that can

arise due to improper fit or style.

Individuals become ready to learn what is required when confronted by life

changing conditions (Rubin, 1998). However, each individual has a somewhat different

pattern of readiness to learn. Self-directed learners are not motivated by internal

incentives. The internal incentive of the patient may be fear of the unknown or simply a

concern that they have identified at high risk for an amputation. Routine foot

examinations are often overlooked by health care providers but, establishing a

comprehensive foot care program incorporating the patient as the co-manager of his or

her own care allows for utilization of adult learning principles and empowers the patient

to govern care and outcomes (Johnson, Newton, Jiwa, & Goyder, 2005)).

Another type of adult learning practice is to assist individuals to think through

their problems and plan how to handle certain situations (Benner, 1984). The foot model

3
allows for hands-on learning taking place with the ability to change the situation and

work through the foot care issues that apply directly to them. Return demonstration

allows for continued learning and corrections as needed to ensure appropriate retention of

information to meet specific learner concerns and outcomes.

Utilizing adult learning principles in patient education is the key in the transfer

and application of foot care k knowledge (Gloe et al., 1998). Devices such as the foot

model to complement educational intervention by the advanced practice nurse may prove

to be an invaluable instrument in teaching basic foot care to the diabetic population at

risk for amputation of the lower extremity.

Statement of the Purpose

The purpose of this project is to evaluate the effectiveness of utilizing a foot

model as an educational tool with nurses when teaching basic foot and nail care. These

nurses have utilized the foot model in their practice as an educational tool when teaching

basic foot and nail care to individuals who have been identified at risk for limb loss.

The Medical Teaching Foot was designed to:

1. Individualize the anatomy of the foot.

2. Modify for types of musculoskeletal and nail deformities.

3. Describe the neuropathic and vascular issues with the use of overlays.

4. Describe skin and toenail conditions.

Significance of the Problem

In the United States, more than 82,000 limbs are amputated annually on people

with diabetes and lower extremity arterial disease (Centers for Disease Control and

Prevention [CDC], 2010). Most of these people are elderly, debilitated, of ethnic origin,
4
and with a history of underlying lower extremity disease or diabetes for greater than 10

years. The primary contributing factor, in over 90% of the subjects, that lead to a wound

and subsequent lower extremity amputation was irritation caused by shoes (Giacalone,

Krych, & Harkless, 1994). The cost of one amputation is estimated to be at no less than

$43,100 for a minor amputation, and over $63,100 for a major amputation, leading to

estimated costs of between $70 and $80 billion spent annually on diabetic foot ulcers and

amputations ( Driver , Gabbi, Lavery, & Gibbon, 2010). There are 246 million people

worldwide (5.9%) with diabetes mellitus, 23.6 million Americans (7.8%) are diagnosed

with diabetes, and approximately 6.2 million are undiagnosed in the United States (CDC,

2010). Type 2 diabetes, obesity, and an aging population have been identified as the

leading reasons for the increase in lower extremity wounds that lead to amputation and in

turn a significant economic burden.

Snyder et al. (2010) specifically address a 55% reduction in lower extremity

amputation (LEA) frequency and an annual foot examination for at least 75% of the

patients with diabetes. Research has shown that appropriate involvement in medical

management of diabetes may reduce the chances of a client succumbing to a non-

traumatic amputation. In fact, poorly managed diabetes causes greater than 60% of the

lower-limb amputations in the United States not due to trauma (Goodridge et al., 2006).

Research has also demonstrated that the more involved and active role clients play in

their own care, including foot care, the less chance they will result in an amputation

(Nash, Bellew, Cunningham, & Mcculloch, 2005). The Consensus Statement on Diabetic

Foot Ulceration published by the American Diabetes Association (ADA) in 2010 requires

5
annual foot examination for all people with diabetes. The examination is to include a test

for protective sensation, evaluation of foot structure and biomechanics, measurement of

vascular status, and assessment of skin integrity, risk identification, prevention strategies

for high-risk clients. Patient and provider education are all essential components for

prevention of injuries that lead to amputation (ADA, 2010).

Education and individual counseling regarding daily examination, how to perform

a pedicure, and usage of footwear was offered in one study (Viswanathan, Madhavan,

Rajaseker, Chamukuttan, & Ambady, 2005). Pictures of complications were shown to

emphasize foot care needs. Family members were requested to support foot care

assessment and assistance at home. The results showed that there were less frequent

recurrence of ulcers and a faster healing process in subjects adhering to the foot care

advice provided (Neder & Nadash, 2003; Viswanathan et al., 2005). Adequate support

networks and continuous and individualized education are factors shown to promote

behavior change to ensure success in diabetes management and prevention of

amputations. These methods evaluate then educate based on findings. The more

individualized the approach to education is, the greater the effectiveness of improving

foot care knowledge, self-reported foot care practices, and self-efficacy of patients with

diabetes (Neder & Nadash, 2003). Given these trends, the need for the CFCN to promote

foot, nail health, and prevent complications is imperative.

Summary

This chapter has presented the introduction, the background of the problem and

the problem statement. In addition, it has presented the purpose and significance of the

6
problem. Literature substantiates that 50% of all amputations on people with diabetes

could be prevented with proper and prompt professional evaluation, intervention and

intensive patient education. It was also emphasized that there was a great need for the

certified foot and nail nurses to interact with patients, lay care providers, and other

specialist to increase awareness of the importance of foot care and to improve foot health.

7
 CHAPTER 2

LITERATURE REVIEW

This chapter will provide a review of current literature and the theoretical

framework for this directed project. To the relevant literature a comprehensive search of

English language articles published between 1984 and 2010 was performed using OVID,

Medline, CINAHL, EMBASE, The Cochrane Wounds Group database within Cochrane

Collaboration Library, the Agency for Healthcare Research and Quality (AHRQ)

Clinician Practice Guidelines, and the National Guideline Clearing House database of

evidence based clinical practice guidelines. The search term combination captured the

concepts "foot model" using a wide range of index terms, free text words and word

variants. Bibliographies of key articles also were searched to supplement the literature

search.

The review of literature will present studies that have been completed in the area

of utilizing a foot model and education interventions. The researcher was unable to find

studies that directly related to the area of evaluating nurses' knowledge from a foot and

nail program. While research regarding the impact of foot care intervention is available,

none examined evaluating whether utilizing a foot model as an educational tool would

improve the effectiveness of nurses' teaching practices. However, studies were

discovered that provide partial insight to the problem statement. This literature review

8
will present research studies in the following areas: (a) foot teaching model and (b)

educational interventions.

Theoretical Framework

The work of Dorothea E. Orem will serve as the theoretical framework. Orem's

general theory of nursing is comprised of the related three related theories: (a) Self-Care

Theory, (b) Self Care Deficit Theory of Nursing, and (c) Nursing Systems Theory (Polit

&Hungler, 1991).

The focus of Orem's general theory of nursing is self-care. It encompasses the

activities a person is able to perform without assistance from another person. This is the

goal of patients with diabetes mellitus that are at risk for limb loss. It is important that

patients with diabetes are able to provide self-care to ensure they provide adequate foot

and nail care. This theoretical framework is a fit with this project because nurses can

utilize the importance of self-care when working with patients with diabetes that are at

risk for limb loss.

In a supportive educative system, the function of the nurse is to assist patients

with diabetes in acquiring skills, knowledge, decision-making, and behavior control. A

comprehensive foot and nail program utilizing adult learning principles in patient

education is the key in the transfer and application of foot care knowledge ( Gloe,etal.,

1998). Devices such as the medical foot model to complement educational intervention

by nurses is an invaluable instrument in teaching basic foot care to patients at risk for

limb loss.

9
 Literature Review

Foot Teaching Model

Burdette-Taylor (2005) conducted a randomized two group pilot study over 6

months of a VA (Veterans' Affairs) hospital outpatient department. The study included

23 veterans identified at high risk for limb loss. The sample was 100%) male. The goal

of the study was to determine the effectiveness of a basic foot and nail care program

utilizing a soft foot model as a teaching tool. The majority of the subjects had a lower

extremity arterial disease, with diabetes type 2 as a second incidence. Of all the subjects,

78%o had a foot deformity with 30%) having Charcot foot. Most (80%) stated that they

had previous foot education. Of those enrolled with ulcers, 43%) had ulcers on their legs

and 30% had ulcers on their feet. There was no significance difference between the

groups on the baseline knowledge score by t test. For equality of means, there was a

slightly higher score for the group that used the soft foot model, but the difference was

not statistically significant. Of the three opportunities for knowledge, testing participants

universally did better after review of contents with or without the soft foot model. This

study had limitations due to the relatively small number of participants (N= 23), the lack

of gender diversity (100%) male), and the lack of testing for validity and reliability of the

instruments.

Teaching Interventions

Education can be provided in a variety of environments by a variety of

professionals including generalists, endocrinologists and nurses. A study that focused on

nurse case-managed diabetic patients reported that nurses are able to provide the

10
necessary and fundamental components for a successful self-management (Caravalho &

Saylor, 2000). There has been an increase in the practice of outpatient management and

teaching in the past few decades. A study in Colorado reported that the outpatient care

has increased from 6% in 1978 to 38% in 1988 (Kostraba et al., 1992). The rise in

outpatient management and education is due to the several advantages that it provides to

its recipients. A satisfactory metabolic control could be achieved in an outpatient setting.

A good metabolic control is related to reduced hospital re-admissions and reduced

diabetes-related complications such as lower extremity limb loss due to amputations.

One study was composed of 121 subjects with diabetes who were divided into those who

received inpatient and outpatient care, and the study reported that fewer outpatient

patients were readmitted for diabetes-related complications (Chase et al., 1992).

Outpatient care is also more cost effective than inpatient care. The average cost of

treatment received per patient in an outpatient setting is estimated to be > $625.00. This

is in comparison to $3,000.00 for the patient receiving inpatient care (Banion,

Klingensmith, Giardino, & Radcliffe, 1987).

A higher risk for hypoglycemia and diabetic ketoacidois after the initial diagnosis

is one of the disadvantages of outpatient management since there is no constant

supervision. However, according to Siminerio, Charron-Prochownik, Banion, &

Schrelner (1999), it was found that both outpatient and inpatient care were both effective

in preventing severe hypoglycemia and/or diabetic ketoacidosis requiring hospitalization.

The above literature shows that there has been adequate research done on

comparing the effectiveness of inpatient and outpatient teaching of the management of

11
diabetes. Several of the research studies focused on issues such as the rising incidence of

outpatient diabetes management and the effectiveness of outpatient and inpatient diabetes

education, in promoting adherence to management and evaluation of diabetes education

programs (Siminerio et al., 1999).

Summary

This chapter provided the review of the literature where each researcher

emphasized the importance for education to start at the time of diagnosis via a healthcare

provider competent with the management of diabetic practices. Hence, through the foot

and nail program, nurses gain knowledge and skill to provide the care that can improve

foot and nail care for the diabetic population. Finally, education-teaching tools remain

the cornerstone of diabetes management and should be carried out by all members of the

multidisciplinary team to provide effective education.

12
 CHAPTER 3

METHODOLOGY

This project will utilize descriptive statistics to analyze the data. This chapter

contains the design, the sample selection, data collection, data analysis and the summary.

Design

A descriptive design was utilized to evaluate the effectiveness of the teaching foot

model with all the participating nurses in the foot and nail care program. This

methodology was a good fit for this project.

Sample

A convenient sample was drawn from nurses enrolled in the foot and nail care

program. Ten nurses who participated in the program were chosen to be evaluated.

Demographic data was evaluated for these participants.

Data Collection

Data was collected via evaluation surveys, which described the effectiveness of

the teaching foot model in foot care. For the teaching model of basic foot and nail care,

the program included pre-test and post-test surveys. For this project, the participants

were surveyed to evaluate their perception of the effectiveness of the model. The surveys

were done at the end of the program.

13
 Data Analysis

As shown in Appendix A, the descriptive data statistics were generated as

demographic, pre-test and post-test. Each participant completed the demographic, pre-

test prior to the foot, and nail program. The post-test was completed at the end of the

program.

Summary

This chapter presented has presented the methodology used to evaluate the

effectiveness of the teaching foot model with all participating nurses in the foot care

program. The data collection identified from all participants the increased awareness of

foot care, footwear, and knowledge of when to report minor injuries. The environment

was non-threatening and using the foot model enhanced information being conveyed to

utilize in self-management of basic foot care.

14
 CHAPTER 4

FINDINGS

This project was designed to evaluate the effectiveness of utilizing a foot model

as an education tool with a foot and nail program to improve nurse-teaching practice.

This chapter presents the findings of the project in the order of: (a) demographic

characteristics, (b) results of evaluation data analysis, and (c) additional findings.

Demographic Characteristics

Demographic characteristics evaluated included age, gender, ethnicity, highest

level of education received, job title, place of work, wound experience, and length of time

since attending an educational lecture or reading a book or journal article on foot and nail

care.

All participants were female nurses. The youngest was 31 years old and the

oldest was 52 years old. The three ethnicity groups were mainly Caucasian, followed by

Asian then Hispanic, and all were able to speak and understand English. All had a

bachelor's degree and two had master's degree. The majority received their degrees in

the United States, while the remaining were educated in other countries, which included

the Philippines and Australia. Two were nurse practitioners and eight were registered

nurses. The majority of the participants were employed by hospitals; the remainder were

15
employed by home health agencies, skilled nurse facilities and outpatient clinics. All

were employed fulltime as certified wound, ostomy and continence nurses (WOCN).

The years of wound experience ranged from 2.5 years to 19 years. All of the nurses had

completed the pre course work and within the last year had attended lectures or read a

journal article.

Evaluation of Data Analysis

The evaluation of the 10 participating nurses' knowledge and management on

basic foot and nail care was as follows: foot inspection, foot cleaning, nail cutting and

footwear.

Foot Inspection

All of the participants correctly answered post-test that people with diabetes are

instructed to examine their feet daily for reddened area, blisters, corns, calluses, or open

areas. This is a statistically significant difference between the scores of the pre-test

where only two participants instructed daily feet checks. Prevention of injury to the foot

is a major goal of patient education for patients with diabetes mellitus or other conditions

that compromise perfusion or sensation of the feet (Hass, 2008). For the nurse educating

the patient regarding proper foot care this is a component of every encounter.

Foot Cleaning

The ADA (2004) recommendation for foot cleaning is once a day with warm

water without soaking. There was a statistically significant difference noted post-test to

the questions: foot cleansing is once a day with warm water, type of cleansers soap and

water, washing and drying in between the toes, and soaking feet versus non-soaking.

16
Nail Cutting

Participants were asked what they used and how they cut toenails. The difference

was not statistically significant that the majority used nail clippers to cut toenails straight

across. Nail debridement requires use of appropriate clippers to trim free edge of nail

along the natural curve of the toe. Care should be taken to avoid cutting the skin to

prevent an entry point for potential bacterial or fungal pathogens (Kelichi, 2008).

Footwear

People with diabetes are advised to always wear foot protection, never to go

barefoot, wear only cotton socks and to check inside and outside of shoes for any foreign

objects. Special attention is to be paid to ill-fitting shoes because they cause receptive

mechanical stress, and cause foot ulcers. Shoes should allow for a half inch space

beyond the longest toe and be wide enough to allow the upper shoe material at the top of

the foot to be rolled between the index finger and thumb. The questions (diabetic patients

require compression socks, shoes are not to be worn if foot ulcers are present, and how to

buy shoes) showed a significantly different score post-test (ADA, 2010).

Additional Findings

No statistically significant difference was associated between knowledge and

ethnicity. However, there was a statistically significant difference between knowledge

and years of wound experience.

Summary

This chapter presented the findings and the results of the demographic

characteristics in addition to the evaluation of the data analysis and additional findings.

17
The evaluation of the findings indicate that, in the presence of a comprehensive foot and

nail program, nurse-teaching practices and knowledge of basic foot improved. The

findings add to the body of evidence-based strategies for the prevention of limb loss with

the diabetic population (ADA, 2010). They also support the WOCNCB guideline

recommendations related to standardizing and elevating the quality of foot care and the

role of the foot care nurse (WOCNCB, 2010).

18
 CHAPTER 5

DISCUSSION

This chapter will present a brief summary of findings, limitations of the project,

and recommendations for future research. This chapter will conclude with a summary.

Brief Summary of Findings

In an effort to facilitate change about self-care foot practices for individuals

identified to be at risk for limb loss, the project was designed utilizing adult learning

principles. Adult learning principles are necessary in designing health care curricula as

adult learners bring a reservoir of experience to the learning situation (Knowles, 1975).

With the utilization of education based on research, nurses and clients will move from

competent to expert in foot care by utilizing their intellectual orientation, integrating

knowledge, and refocusing the decision-making processes to ensure positive outcomes

(Benner, 1984). In order to assess performance skills, the learner must do the action in

question and have return demonstration of that skill rated (Benner, 1984).

The foot model allowed actual practice in a non-threatening learning situation, but

specific to the participants' needs. Nurses easily manipulate the foot model to deliver

educational content. Most individuals are visual or kinetic learners, few are actual

auditory learners. The foot model was utilized to teach foot care, ambulation issues,

toenail reduction, skin care, and simulate musculoskeletal deformities. In addition,

19
selection of footwear was discussed illustrating problems that can arise due to improper

fit or style.

When planning and implementing an educational program, readiness to learn is

another factor to take into consideration. Individuals become ready to learn when

confronted by life-changing conditions (Rubin, 1998). The internal incentives could be

fear of the unknown, or simply a concern they have been identified at high-risk for limb

loss. Routine foot examinations are often overlooked by health care providers but by

establishing a comprehensive foot care program and empowering the client and caregiver

as co-managers of their own care allows for utilization of adult learning principles and

ownership of care and outcomes as Orem's general theory of nursing.

The foot model allowed hands-on learning to take place with the ability to change

the situation and work through the foot care issues, which apply directly to the

participants. Return demonstrations allowed for continued learning, corrections as

needed, and retention of information. Utilizing adult learning principles, education is the

key in the transfer and application of foot care knowledge (Gloe et al., 1998). Devices,

such as the foot model, complement educational intervention and proved to be an

invaluable instrument in teaching basic foot care for the participants of the project.

One notable finding that gave some cause for concern was that all participants did

not receive any input on the topic of foot and nail care during their basic RN training.

Overall, the participants demonstrated a good level of knowledge with regards to foot and

nail care, although some deficits were apparent. This supports the findings from

20
WOCNCB, that there is a need for nurses involved with patients at risk for lower limb

loss to receive formal training on foot and nail care.

Limitations of the Project

First, it must be acknowledged that the findings were based on evaluations of a

convenient sample raising the possibility of predictable outcome. Second, generalization

of the findings will need to be applied with some caution, given the participants were all

from one foot and nail school, female and WOCN certified. Therefore, the findings did

not reflect the knowledge level of other healthcare providers. However, the findings

should still prove useful for future curriculum planning, given that the extent and nature

of nurse education on this topic is imperative. And finally time was not sufficient.

Recommendations

A recommendation for future research would be to use a larger sample and/or a

more diversified sample population that would include an equal number of men and

women in order to make the results more representative. Another recommendation is to

involve other foot and nail school and disciplines, such as LVN, physiotherapist, and RN

without the WOCN certification.

Summary

The foot model is an effective educational tool that is practical, easy to use, and

non-threatening to the learner and easily manipulated for individuality in the teaching

learning milieu. Education is an essential component of foot care behavior to prevent

injuries leading to amputation. With the foot model, it meets the need of visual and

kinetic learners, improves compliance, improves knowledge, prevents or delays

21
ulcerations, prevents or delays loss of limb in high-risk populations, and could possibly

promote retention of information learned.

22
APPENDICES

23
 APPENDIX A

DATA COLLECTION TOOL AND DEMOGRAPHIC DATA SHEET

Appendix A Demographic Questionnaire

1. Sex Male Female

2. What is your age?

3. What is your ethnic background?

4. What is the highest grade you have completed at school?

5. Educational background: AND_BSN MSN DNP Ph.D Other

6. Where did you receive your education as listed above?

7. Type of license : RN NP Other

8. What is your current clinical specialty?

9. What is your current work setting?

10. How many years of work experience do you have with wound care?

11. How many year of work do you have with foot care?

12. Have you completed a formal education of foot and nail care?

13. What methods do you use when giving health education information to your
patients?

25
Appendix A
Foot and Nail Care Course Evaluation Report and Feedback: Summary
Location: Silverado Senior Living
Number in Attendance: 15 Registered; 10 attended; 8 RN, 2 NP, WOCN/CWCN

Liked the MOST:

• Instructor down to earth, easy to talk to and ask questions
• Location, comfort, food, great place
• Hands on session, lots of information
• The other participants were very engaged
• Ease of learning
• Instructor experiences and photos; especially the military, also
the wonderful compression hose
• Nice facility, surroundings, and food
• Good environment; pleasant company
• Having instructor demonstrate proper technique
• Food was really good
• Liked the Jeopardy and letting us know what info/questions were
typically on the exam
Liked the Least:
• Too far from home - come to HOUSTON
• Liked everything - No complaints
• Could be longer to cover more information
• Liked all the program
• Would like more anatomy content and physiology
Suggestions to Improve:
• Might see worse stuff in a bad nursing home
• More descriptions of terms
• Board certification exam review
• More on off-loading/padding
• Add more test review
26
APPENDIX A
Foot and Nail Care Course Evaluation Report and Feedback: Summary
• Add more off-loading hands on practice
• More hints of actual cutting of nails; regular and dystrophics
• More photos
• Have a computer available with internet for us to look up things
we don't know to take advantage of the learning moment even if
during a break
Take home messages to implement:
• Refer anything out of your scope of practice
• Patient teaching and reinforce to prevent amputation
• Vicks for one year to treat onychomycosis
• Alcohol pad for under ingrown nail
• Tea tree oil in the water for hygiene
• Identify risk factors
• Teaching - Assessment - Interventions
• Education of other care providers
• Education of proper foot care
• Foot hygiene before assessment; interventions based on
assessment
• Use alcohol for Doppler
• Telegangiogenisis - scattered veins of LE's
• Preventive foot care teaching and care
• Intervention foot care techniques
• Preventing foot/limb loss
• Good hygiene=infection prevention
• Education-check feet every day
• Compression for long-term; Prevention and good shoe wear
• Investigate (Google) everything; will need at least three sources
• WOCN standards are gold standard for testing
• Thorough assessment of feet
• Shoe assessment - Skin care
• ABI before Compression
• Definitions to appropriately describe foot and nail conditions
27
 Foot and Nail Education Evaluation

Date Location
Topic

To assist in evaluating the effectiveness of this educational program, please complete

this form and return. In exchange, you will receive a Certificate of Completion to keep
in your records.

1. My degree/area of specialty /place of work

2. Please rate the appropriate sections.

Excellent Good Fair Poor

Overall Organization

Program Organization

Program Topic Selection

Instructional Materials

Foot Model: Wilma

Foot Model: EZ2B

Apparent Accuracy of Content

3. What did you like the most?

4. What did you like the least?

5. Were the objectives met?

6. What suggestions do you have to improve this particular program?

7. If so, please identify a topic area you may be interested.

8. List three take home and implement messages from this educational
program.

28
Foot Care Knowledge Test

Circle True or False with each statement.

True False 1. There are 26 bones in the foot.

True False 2. Attention to your feet is necessary only once per week.

True False 3. Foot care includes cleaning, drying, and moisturizing the feet
daily.

True False 4. You need to look at all parts of your feet before you put on your

socks.

True False 5. It is important to buy shoes first thing in the morning.

True False 6. Everyone has the same size foot on the left and right.

True False 7. When buying shoes, be sure that there is a thumbnail's distance

between the longest toe and the tips of your shoes.

True False 8. Buy shoes with rubber non-skid soles.

True False 9. Corns and calluses should be cared for at home using a sharp
object.
True False 10. Athletes Foot is a common fungal infection of the feet and should
be treated by a foot doctor.
True False 11. Ingrown toenails are not at risk of importance and need not be
addressed.

True False 12. Any trauma caused by pressure, friction, infection or injury should
be seen by a health care provider specializing in feet and wounds.

Seek professional help:

True False 13. If you have toenails that are too thick to cut with a toenail clipper.

True False 14. If there is a sudden change in the color, sensation or temperature
of your feet.
True False 15. If you have sores on your feet that are not healing or are draining.
29
 APPENDIX B

FOOT CARE TEACHING PROGRAM AND FOOT CARE KNOWLEDGE TEST

Appendix B

Foot Care Teaching Program

View video: Caring for your Feet.... The Carville Approach

Three sections include:
1. LEAP-Lower Extremity Amputation Program - 13 mins.
Statistics on Mortality, Morbidity, Quality of Life
Discusses Magnitude of Risk and Actual Amputations
Determine Loss of Protective Sensation
Foot Screening: The Carville Approach - 13 mins.
Demonstrates Use of Monofilament Testing
Compare and Identify Musculoskeletal Conditions Increasing the Risk of
Injury Leading to Ulcerations
Discusses Risk/Management Evaluations for Necessary Follow-up
Establishes Questions for Screening: History of Chronic Disease, MS
Deformity, Strength Testing, Monofilament Testing, Evaluation of Perfusion,
Dermatological Conditions and Evaluations of Lower Extremity Edema
3. Caring for Your Feet - 15 mins.
• Self-Inspection
o Physical assessment of Tenderness, Swelling, Redness, Pressure
Areas
o Evaluate Sock and Footwear
o Demonstrates Use of Mirror to Evaluate Plantar Surface
o Concentrate on Web Spaces; Note any Callus Formation, Changes
in Appearance and Sensation.
• Skin Care
o Teach Use of Moisturizers, Foot Hygiene, Dry Well Between Web
Spaces, No Alcohol, Hot Water Bottles, or Soaking
o Toenail Needs-Trimming, Filing
• Footwear Selection
o Therapeutic - Extra wide/Extra depth footwear
o Use of socks that are not 100% cotton; need a blend of materials;
beware of socks with seam or elastic garters
o Use of socks to keep feet warm
o Avoid barefoot
Handouts included for teaching session:
1. Get to Know Your Feet (the nerves in your feet, ways to keep feet healthy, shoes,
socks)
2. Foot Fitness-Give them good care (foot hygiene, corns, calluses, itching, peeling,
ingrown toenails, foot ulcers, when to seek professional help)

31
 3. Diabetic Foot Care (general care of feet, proper shoe wear, exercise and you,
toenail care)

Reference: Gillis W. Long, Hansen's Disease Center, Rehabilitation Branch, Carville, LA

70721

32
 National Association of Diabetes Centres Australasian Podiatry Council

Basic Foot Assessment Checklist

1. Ask the patient neuropathic symptoms Y N
rest pain Y N
intermittent claudication Y N
previous foot ulcer Y N
amputation Y N

specify SITE DATE

2. Look at both feet infection Y N

ulceration Y N
calluses or corns Y N
skin breaks Y N
nail disorders Y N 1

LEFT RIGHT |
3. Check foot pulses Dorsahs pedis Y N Y N j
Posterior tibial Y N Y N

LEFT RIGHT |
4. Test for neuropathy Monofilament * Y N Y N

*'detected at sites marked

Left Right

5. Assess footwear style Good Poor

condition Good Poor
fit Good Poor

6. Assess education need

Does the patient understand the effects of diabetes on foot health ? Y N
Can the patient identify appropriate foot care practices ? Y N
Are the patient's feet adequately cared for ? Y N

7. Assess self care capacity

Does the patient have impaired vision ? Y N
Can the patient reach own feet for safe self care ? Y N
Are there other factors influencing ability to safely care for own feet ? Y N

All people with dabetes need to have their feet assessed with these 7 simple steps
every 6 months or more often if problems are identified

National Foot Care Project

 National Association of Diabetes Centres Australasian Podiatry Council

AGtIOn PlSn following Basic Foot Assessment

DATE OF REFERRAL / /

PATIENT NAME SERVICE PROVIDER.

Is the foot high risk? Yes • NoQ (nhdnckhiMitis)

If yes, why ? • history of previous foot ulceration or problems

• peripheral neuropathy
• peripheral vascular disease
• foot deformity
• other

Action*
Record details of personnel referred to. Where resources are unavailable, indicate and describe
alternative care provision

* Ulceration or significant infection

referred to multidisciplmary team

* 'High risk' foot

referred to podiatrist and/or
multidisciplmary team

referred for medical assessment at

least every 6 months and foot
examination every 3 months

* Active foot problem

referred to podiatrist

* Symptomatic peripheral vascular disease

referred to vascular surgeon

involving endocrinologist / physician

* Symptomatic peripheral neuropathy

• referred to endocrinologist
* Foot deformity or abnormality
• referred to podiatrist

* Inadequate knowledge or foot care practices

referred to
or education provided U Yes

*The patienrs General Practitioner or Local Medical Offlcer w l l usually be

responsIHe for coordinating the patienrs care and should be
informed of referrals, Interventions and progress

National Foot Care Project

Review of the Literature 2010

Foot Care

F3 TITLE: Foot and Nail Care

AUTHOR: Howes-Trammel, S., Bryant, RA, Nix, D.P.

SOURCE: Acute and Chronic Wound Care, Ch 15, Elsevier, Inc.

ARTICLE TYPE: Chapter of Book

DESCRIPTION/RESULTS:

• Foot problems occur in at least 75% of Americans with the top

three conditions being toenail disorders, foot deformities, and
corns/calluses.
• Most of the foot problems and wounds can be prevented with
proper foot care, foot wear, massage, education, and timely
referral.
• Foot and nail care needs to be integrated into everyday nursing
practice, thus keeping the skin healthy, intact, and minimizing the
risk of trauma or malformation and promoting comfort and
ambulation.
• Understanding how to do a thorough foot exam specific to
perfusion and sensory neuropathy could facilitate a reduction in
half of the wounds leading to amputations.
• Guidelines have been drafted specific to the foot and nail care for
cuticles, skin, nails, and identification of diseases, conditions, and
deformities.
• Therapeutic foot wear and off-loading intervention coupled with
motivation to wear the shoes allows for prevention of injury
through continued ambulation with a greater quality of life and
independence.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE:

• Foot and nail care is a new specialty nursing but a very old
practice that just needs to be encouraged, educated, and
35
 • facilitated in every setting to help reduce pain and suffering,
minimize injuries leading to wounds and amputations, and facilitate the
promotion of comfort.
• Foot care nurses must understand, educate, and refer their clients
about the risk factors, signs, symptoms of various presentations,
thorough assessment and treatment guidelines for foot and nail
care issues.
• Foot and nail disorders are predominantly a reflection of the
patient's overall health status.
• Foot and nail care nurses need to educate family and caregivers
on problems that should be reported, hygiene, age-specific
changes, plans for preventing foot disorders, and lifestyle choices.

36
 Foot and Wound Care with an Emphasis in LE Ulcers

Foot Care
with CMS Emphasis on
Diabetic Foot Care Initiative
Assessment
History (5), Physical
(25), Risk (7), Foot
Wear & Mobility (3) n
LEVD
Nursing
Interventions
Skin (15) &
Nail Care (10)

LEAD&
LEND
understanding
LE Wounds
And
Lymphedema

!%j Aims & Objectives Foot Anatomy

- Keep the feet normal > 26 bones
> Lessen foot defects
* Encourage buying better types of shoes which fit the feet > 33 joints
as to size and style > 107 ligaments
- Encourage manufacturers to make shoes comfortable,
good looking, and within average income > 19 muscles
• Improve posture by proper use of feet
- Encourage walking as a recreation
> 250,000 sweat glands
- Arouse an appreciation for the alertness and vigor of a
well-shod, well-poised person which is an expression of
life, joy, and health
• Jacobson, Mane (1933) Foot Hygiene as Based on A 8s P

Foot Care Facts Most signs and symptoms

> 3 out of 4 Americans experience serious associated with risk for lower-
foot problems in their lifetime extremity ulceration and
> Foot ailments can be your first sign of amputation
more serious medical problems such as
* Arthritis - # 1 crippling disability in America
* Diabetes
* Nerve disorders
* Circulatory disorders
can be identified with a quick, but
* Gout thorough, foot inspection and
» Raynards Disease history.
* Chilblain - Frostbite
 Conditions leading to Amputation
> Circulation
> Neuropathy
Significance
> Immediate mortality of patients receiving
an AKA is 5%
> Subsequent amputation of the other limb
within 2-3 yrs is 50-84%
> 5-yr survival rate of less than 50%
> Prevention of LEND must be implemented
> Ongoing assessment once DX to prevent
devastating projected outcomes
Conduct Foot and LE Exam
> Dermatologic status
> Presence of calluses
> Localized inflammation of foot
> Edema
> Adequacy of perfusion status
> Musculoskeletal /biomechanical status
Overview
> Background
• CDC - 2.4% per 100,000 people rising to 8%
per 100,000 rising with age
• Peripheral Neuropathy most common
complication - accounts for most
hospitalizations
0 Wounds causes 50-70% of non-traumatic
amputations in USA
• Many of present day practices originated with
research with Hansen's Disease
Sensory Neuropathy
> Loss of protective sensation, numbness,
impaired temperature perception
> Paresthesias, pain
> Loss of vibration and position sensation,
sensory ataxia
Dermatologic Status
> Skin appearance - color, texture, turgor
> Presence of calluses -
discoloration/subcallus hemorrhage
> Lipodermatosclerosis
> Necrobiosis lipoidica
> Anhydrosis xerosis - fissures/cracks,
especially on heels
> Plantar Warts - HPV
 Nails Tinea Pedis
> Onychomycosis > Interdigital maceration
> Dystrophic nails > Fissuring
> Paronychia >Dry
> Hypertrophy > Scaly
> Subungal hematoma > Circular lesions on plantar surface m 1
> Severe fungal infections

Assess for Presence of Calluses Assess for Edema

y Callus is the most destructive skin lesion for r Localized or generalized
people with peripheral neuropathy r Dependent or pitting
r Elevated blood glucose levels may cause the r Unilateral edema may be a heralding sign of
tissue to become rigid, inflexible, and more Charcot deformity (neuropathic fx) especially in
resistance to collagens digestion the presence of warmth and bounding pulses
r Initial callus formation may increase pressure
r Co-morbid conditions
below the callus, and an ulcer may develop that
. CHF
is not visible or palpable
• Nephropathy
r Hemorrhage into a callus is a heralding sign of
. LEVD
ulceration (B Level of Evidence)

Assess Perfusion Status Pulses

> Reduced skin temperature > Presence of palpable pulses does not rule
> Capillary refill > 3 seconds out LEAD
> Venous refill time > 20 seconds • Palpate both dorsahs pedis and posterior tibial
pulses
> Limb color changes • Absence of both pulses is indicative of LEAD
. Pallor on elevation
• Dependent rubor
> Presence of paresthesia
> Presence/absence of pedal pulses
 Assess Musculoskeletal /
Biomechanical Status
> Muscle group strength testing
• Passive and active
• Weight bearing and nonweight bearing
> Presence of foot deformities
> Gait evaluation
> Pressure mapping to identify sites of high
pressure (A Level of Evidence)
Asses Patients' Routine Foot Care
> Daily cleansing
> Daily moisturizing
> Self-foot examinations
. Frequency performed
• Visual impairment limiting foot inspection
• Limited range of motion affecting foot
visualization
> Toenail care
> Barefoot and stocking foot walking
Identifying Individuals at Risk for
Foot Ulceration
> LOPS - Loss of Protective Sensation
> History of previous ulceration
> Elevated plantar pressure
> Rigid foot deformity
> Poor diabetes control (HgA1c 7%)
> Duration of diabetes > 10 years
Assess Neurological Status
> Light pressure using a 10-g Semmes-
Weinstein Monofilament Exam (SWME)
Level of Evidence = A
> Vibratory sense using a tuning fork 128
cps (on-off method)
> Deep tendon reflexes of ankle and knee
Assess Patients' Footwear
> Shoe design - shape, width, depth toe box
> Shoe fit to foot
> Patterns of wear
• External examination
• Insole and lining examination (bottoming out)
> Use of insoles, orthosis
. Commercially available
. Customized
Lower-Extremity Amputation Prevention
(LEAP)
> Foot screening
> Patient education
> Appropriate footwear selection
> Daily inspection of the foot by the patient
> Management of simple foot problems

Education is essential to
prevent LEND
Risk factors and appropriate
management strategies should be
taught
Shoe-Fitting Recommendations
r Shoes should be fitted in the afternoon to allow for foot
edema
> Patients should stand and walk when being fitted for new
shoes
^ Socks and stockings that would normally be worn with
the shoes should be worn when fitting new shoes
^ Both feet should be measured, and shoes fitted to the
larger foot
r Wearing of new shoes should be increased gradually 1 -2
hours at a time with routine foot inspection to check for
areas of pressure following each wear session
Offloading
> Ensure adequate offloading of pressure
through wound closure and beyond
> Utilize assistive devices to provide
support, balance, and offloading of the
affected site
• Walking splints
• Wedge sole shoes
• Healing shoes with large toe box
Education Patient/Caregiver
> Routine, daily self-care measures
> Early recognition and prompt reporting of
potential foot problems
> Routine foot surveillance by healthcare
Footwear as a Benefit
Diabetes diagnosis
And one or more of the following
* Hx of partial or complete foot amputation
* Hx of previous foot ulceration
* Current foot ulceration
» Foot deformity
* Hx of pre-ulcerative callus formation
* Documented neuropathy with evidence of callus
formation
* Poor or impaired circulation
Management of Edema
> Monitor patients with neuropathy as they
may have no sensation of pain related to
the compression bandage
> Refer for further evaluation for cellulitis,
osteomyelitis, atypical ulcers, and new
onset or diagnosis Charcot foot
> Compression socks/stockings (hello)
 PQRI - Physician Quality Reporting Initiative for
Comprehensive Diabetic Foot Exam Foot Exam continued
> Documented evaluation of: > Dermatological findings
• Motor- ROM, gait analysis • Skin
• Sensory • Nails
° Reflexes > Noted history of:
• Vibratory • Previous ulceration
• Proprioception • Amputation
• Sharp/dull
9
Semmes-Weinstein monofilament testing
> Vascular testing
• Noted structural abnormalities • Grading of pulses - DP/PT
• Subpapillary venous plexus filling time

Significance to Health Care Summary

> Four states with highest level of Medicare
spending is - LA, TX, FL, and CA
> Reimbursement should reward tx's that are
therapeutic and reduce utilization
^ Estimated cost of a foot ulcer is $4,595 per
episode with total national cost of $5 billion
> Estimated cost of a LEA is $30,000 per event
with total national cost of $1.6 billion
> Number one and two interventions to prevent a
foot ulcer is a foot exam and therapeutic shoes
> Growing health care problem
> Implement programs for lifelong wound
and amputation prevention
> Once a wound consider what is clinical
efficacious and cost-effective
> Education is also prevention
> Use guidelines based on EBP to support
treatment

Most Common Post amputation

Complaints Leading to Litigation
Levin, ME, 1997
> Failure to educate the patient about proper
foot care
> Failure or delay in seeking consultation
> Failure to culture the wound, to culture for
anaerobes, or both
> Failure to perform a neurologic or vascular
examination
> Failure to recognize a worsening infection

2010 Recommendations on
Advancing the Standard of Care
for Treating Neuropathic Foot
Ulcers in People with Diabetes
Overview
• Background
- Worldwide 171 million with projection to 366
million by 2025
- CDC - 2 4% per 100,000 people rising to 8% per
100,000 rising with age
- Peripheral Neuropathy most common
complication - accounts for most hospitalizations
- Wounds causes 50 70% of non traumatic
amputations in USA
- Many of present day practices originated with
research with Hansen's Disease
that integrates
"individual clinical expertise with t h e
best available external clinical
evidence from systematic research"
Objectives
• Describe essential steps in conducting an assessment
to include general, neurologic, and vascular
• Define differences between non neuropathic
/neuropathic foot/ulcer evaluation for wound
documentation
• Classify uninfected, mild, moderate, and severe
infection severity for neuropathic foot ulcer
• Describe four major treatment categories of
importance based on EBP
• Discuss the WOCNCB -Board Certification in Foot
and Nail Care in an effort to reduce amputations
Evidence-Based Medicine is
defined as...
"the conscientious, explicit, and
judicious use of current best
evidence in making decisions about
t h e care of patients"
Significance
• Immediate mortality of patients receiving an AKA is 5%
• 30 40% of patients are not being treated to EBP guidelines
• 20 30% of care is inappropriate unnecessary or dangerous
• Subsequent amputation of the other limb within 2 3 yrs is 50
84%
• 5 yr mortality rate with PN and LEAD DFUs is (PN) 45% and
(LEAD) 55% respectively
• Prevention of LEND must be implemented
• Ongoing assessment once DX to prevent devastating
projected outcomes
 History and Physical Exam
Pertinent Lab Results
Assessment
• General • Fasting blood glucose • Blood urea nitrogen
levels (BUN)
- Duration of diabetes and glycemic control - A1C < 7%
• 2-hr postprandial blood • Creatinine
- Presence of other diabetes associated co morbidities -
ESRD, CAD sugars • Erythrocyte
- Review of Systems and Family HX • Glucose tolerance sedimentation rate
testing (ESR) |
- Laboratory screening-CBC, Lipid Profile
- Nutritional evaluation - R/0 malnutrition • Hemoglobin A - l C • Vitamin B-12
(HbAlC) (cyanocobalamm)
- Previous wound healing problems - prior therapies/
response • C-reactive protein • Thyroid-stimulating
- Quality of Life - Pain, ADL, worse or better? h o r m o n e levels

- SMOKING-zero tolerance

Risk Profile Markers Etiology of Neuropathy

• Elevated 2-hour glucose tolerance test (140-
200 mg/dl)
- Impaired glucose tolerance may be the first
marker of small fiber neuropathy (prediabetes)
- Long-term blood glucose control (TGC) is
important to prevent PN (A Level of Evid)
• Elevated HbAlC - those above 6.5% have
increased microvascular/neuropathic
complications (A Level of Evid)
• Components of Peripheral Neuropathy
- Sensory - alters tactile sensation
- Motor - alters biomechanics and muscles
- Autonomic - sympathetic alteration
• Overall Management Goals
- ID patients with LEND who are at risk for developing
wounds
- ID patients whose current wounds are caused or
complicated by LEND
- Implement appropriate strategies and plans

Physiological Aspects Sensory Neuropathy

• Neuropathy occurs as a result of damage to specific • Loss of protective sensation (LOPS),
nerve structures (axon, cell body and/or myelin
sheath) numbness, impaired temperature perception
• As a result of hyperglycemia and insulin deficiency • Paresthesias, pain
• Contributes to progressive functional and structural
defects that damage peripheral nerve tissue and • Loss of vibration and position sensation,
produce neurological defects sensory ataxia
• These neurological defects alters the protective
mechanism and reduces or alters the perception of
temperature, touch, and pain
 Assess Neurological Status Motor Neuropathy
• Light pressure using a 10-g Semmes-Weinstem • Motor loss (tripping, inability to climb stairs,
Monofilament Exam (SWME) Level of gait alteration)
Evidence = A • Muscle weakness, muscle atrophy
• Vibratory sense using a tuning fork 128 - HZ • Anatomical manifestations (foot drop, claw
(on-off method) toes)
• Deep tendon reflexes of ankle and knee

Autonomic Neuropathy Assess Perfusion/Vascular• Status

• Decreased vasomotor activity with anhydrosis • Reduced skin temperature
of feet • Capillary refill > 3 seconds
• Vasodilatation, arteriovenous shunting, • Limb color changes
edema - Pallor on elevation
• Increased atherosclerotic plaque formation - Dependent rubor
• Possible disturbed microvascular circulation to • Presence of paresthesia
cutaneous tissue • Presence/absence of pedal pulses --femoral,
popliteal, dorsahs pedis, and posterior tibialis

Perfusion Status Continued Secondary and Tertiary Tier Eval

• ABI - may be falsely elevated in people with • Segmental Pressure Volume
diabetes as the vessels may be calcified and • Skin Perfusion Pressure
noncompressible - Low ABI = High Vascular
• Trancutaneous Oxygen Measurement (TCP02)
Disease - False HIGH in PWD
• Imaging - Tertiary 3 rd degree with VASCULAR
• Toe pressures (TP) is indicated for PWD and
-Angiograms
LEND suspicious of LEAD
- Duplex ultrasound
- TP < 30 mmHg indicates LEAD and predictive of
- Magnetic resonance angiography
failure to heal
- C02 angiography
 Foot and Ulcer Evaluation Screening for Complications
• Dermatologic changes - callus, MS deformity Cellulitis
• Ulcer characteristics - location, shape, size Gangrene
• Probe for sinus tract or probe-to-bone Osteomyelitis
• Condition of wound edges, bed, base Charcot deformity (neuropathic
• Presence of necrosis osteoarthropathy)
• Wound associated pain Wound depth - most important clinical
measurement of delayed healing
Ankle mobility - key factor with plantar ulcers

WOCN further Guidance Management of Edema

• Localized inflammation with palpation and
thermometry Monitor patients with neuropathy as they
may have no sensation of pain related to the
• Edema - pitting/non, local/general,
compression bandage
bi/unilateral
Refer for further evaluation for cellulitis,
• Perfusion - skin temp, capillary refill
osteomyelitis, atypical ulcers, and new onset
• Ischemic skin changes - purpura, shiny, taut, or diagnosis Charcot foot
hair loss, dystrophic nails, atrophy of muscle
Compression socks/stockings (hello)
• MS/biomechanical-deformities, gait, muscle
weakness

Pain Classic Pain Presentations

• Presence or absence of pain • LEAD w/o LEND N e u r o p a t h i c w or w/o LEAD
• Description of pain - Sharp - Burning, Itching
- Superficial or deep
- Shooting - Shooting, Electrical
- Constant aching or stabbing
- Present at night - Parasthesias
- Dull or sharp
- Burning or cool - With claudication - Numbness
• Altered sensation not described as pain - Wounds are small - Unrelenting
- Numbness punctate and very - Difficult to treat
- Warm / cool painful with touch,
- Increases with age
- Prickling treatment, and sensitive
to product ingredients - Duration of disease
- Tingling
- Poor glucose control
- Stocking Glove' pattern
 Pain Continued
• Pain worse at night Description of neuropathic pain
• Pain gradually worse during the day may be specific to the disease
• Allodynia or intolerance to touch (bed sheets
touching legs)
state
• Response to analgesic (topical or systemic)
Impaired glucose tolerance may
• Alleviating or aggravating factors
trigger a pain described as burning
• Severity of pain as measured by an (Poncelet, 1998)
established pain scale

Wound Classification Systems Infection Evaluation

• Wagner - uses six wound grades (0-5) to
• PWD fail to present with classic symptoms of
assess ulcer depth - used for HBO evaluation
infection instead we look for secondary signs
- Wagner, 1981
- Exudates
• LIT- has shown to be better predictor of - Delayed healing
clinical outcome
- Friable or discolored granulation tissue
- Uses matrix of grades (0-3) and scales (A-D)
- Foul odor
- Measures wound depth
- Pocketing at wound base
- Presence of infection/ischemia
-Wound breakdown
- Lavery, Armstrong, Harkless, 1996

Markers of Infection of Bone Screening for HBO Therapy

• Erythrocyte sedimentation rate
• Ischemic and infected Neuropathic Foot
• C-reactive protein
Ulcers
• Positive probe-to-bone test
• Selection based on
• Bone histology and culture (never routine - Periwound hypoxia by TCP02 <50mmHg with =
tissue culture) 30mmHg defining critical limb ischemia
• Radiographs (bilateral) - may lag 2 weeks - Demonstration of periwound blood flow raise the
• MRI - most specific and sensitive TCP02 = 200mmHg with intervention

• Bone scans - inaccurate for this population • Recalcitrant osteomyelitis

(blood flow dependent) • Progressive necrotizing infection
 Treatment of Neuropathic Foot Wound Environment
Goal is expeditious wound closure • Debridement
- MWH - with standard procedures initial if after 4 • Control of inflammation
weeks and less than 50% closure must consider
• Control of infection
alternative and advanced therapeutic methods
- Management of arterial disease • Moisture control
• Endovascular techniques - ballon angioplasty - should • Excision of wound edges
be employed predominantly in large vessel disease
• Excision of periwound callus
• Bypass surgery - more durable in LE of PWD
- Consider controversial and long term studies needed

Debridement Infection Control

Surgical gold standard
Stimulates production of growth factors
83% with debridement healed compared to
20% who received less frequent debridement
VLUs and DFUs had higher median wound
area reduction with weekly debridement
Maintenance debridement should be
conducted especially if wound not closing
• Foot ulcer infection should be dx clinically
- Uninfected - wound lacking purulence/mflam
- Mild > 2 manifestations of inflammation
• Erythema, pain, tenderness, warmth, induration etc
- Moderate - as above with > 1 of characteristics
• Lymph streaking, deep-tissue abscess, gangrene etc
- Severe - as above with systemic toxicity or
metabolic instability
• Fever, chills, tachycardia, hypotension, confusion etc

Bone Infection DX and Treatment TX of Osteomyelitis

• Culture Levine Technique-1976 • Difficult to cure
- Accurate and consistent with quantitative biopsy • Bone should be debnded
- Rotate a culture swab in one area of the ulcer bed • IV antibiotics for a max of 2 weeks if all bone
with gentle pressure
resected
• DFUs - polymicrobial, predominantly aerobic,
• IV antibiotics for 4-6 weeks if just debrided
gram-positive, cocci organisms - STAPH
• Several months of oral antibiotic therapy
Aureus most common
• ID consult
• Osteomyelitis often underlies infected DFU

Offloading
• True offloading is crucial to decrease pressure
and strain rate (force divided by time)
• Obese patients put 2-2.5 x their body weight
on the wound with each step
• Key to effective offloading is have an ankle
brace fixed to the foot bed
Hyperbaric Oxygen Therapy
(HBOT)
• HBOT - level 1A evidence - for healing
wounds and reducing amputation
• Medicare Guidelines
- Type I or II DM, LE wound due to DM
-Wagner III or higher
- Failed Standard of Care - little/no healing in 30
days
- Wound re-evaluated every 30 days
- Continued HBOT d/c if no healing in 30 days
Foot and Nail Care Board Prep and
EXAM is about Prevention
• Identifying Individuals at Risk for Foot
Ulcerations
• Performing Neuropathic Foot Screen
• Initiating Lower-Extremity Amputation
Prevention (LEAP) Model
• Educating Patients/Caregivers
Offloading Techniques with
Reproducible ability to Heal Wounds
• Total Contact Cast - gold standard
- Molds the bottom of the cast to the bottom of
foot causes the entire sole to participate in
distribution
• Cast walkers - DH, CAM, 3-D walker
• Charcot Restraint Orthotic Walker - CROW
• Ankle Foot Orthosis (AFO) in shoes
• Custom sandals with three layers of foam
Advanced Therapies
• Percentage of Area Reduced (PAR) is the
indicator if a wound will heal at 12 weeks
- Assess the wound at 4 weeks - if less than <50%
Advanced Therapy should be considered - as this
is the clinical decision point - not as a "last resort"
- NEW STANDARD to incorporate into EBP
• Human skin equivalents (HSEs)
• Wound modulators
• Growth factors
Objectives
• Describe essential steps in conducting an assessment
to include general, neurologic, and vascular.
• Define differences between non-neuropathic
/neuropathic foot and ulcer evaluation for wound
documentation.
• Classify uninfected, mild, moderate, and severe
infection severity for neuropathic foot ulcer.
• Describe four major treatment categories of
importance based on EBP.
• Discuss the WOCNCB -Board Certification in Foot
and Nail Care in an effort to reduce amputations.
Most Common Postamputation Complaints
Leading to Litigation
Levin ME 1997
• Failure to educate the patient about proper
foot care
• Failure or delay in seeking consultation
• Failure to culture the wound, to culture for
anaerobes, or both
• Failure to perform a neurologic or vascular
examination
• Failure to recognize a worsening infection
Complaints Leading to Litigation...
• Failure to hospitalize or delayed
hospitalization in the face of worsening
infection
• Failure to control blood glucose
• Failure to inform the patient of the signs &
symptoms of worsening infection
Act as a
Proactive Patient Advocate
Purpose To keep the feet so comfortable that
they will do the work required of them with the
minimum of conscious effort, this freeing the
personality for the business of business and
pleasure
Jacobson M (1933) Foot hygiene as based on anatomy
and physiology American Journal of Nursing 33 11 Nov
pp 1041 1044
Summary
• Growing health care problem
• Implement programs for lifelong wound and
amputation prevention
• Once a wound consider what is clinical
efficacious and cost-effective
• Education is also prevention
• Use guidelines based on EBP to support
treatment
Our Goals in Foot and Nail Care
Thorough History
Thorough Physical Assessment
Identification of Those at Risk
Appropriate and Immediate Referral
Aggressive Team Intervention
Deliberate Plan of Care to Prevent Initial Injury
Deliberate Plan of Care to Prevent Recurrence
References
Snyder, R J, Kirsner, R S , Warnner, R A (2010)
Consensus Recommendations on Advancing the
Standard of Care for Treating Neuropathic Foot Ulcer
in Patients with Diabetes WOUNDS, April, 2010, pp
1-23
Rogers, LC (2010) Understanding the 2010
Consensus Recommendations for Diabetic Foot Ulcer
Care Podiatry Management, Nov/Dec, 2010, pp
131-133.
WOCN Clinical Practice Guidelines (2004) Lower
Extremity Neuropathic Disease www.wocn.org.
 APPENDIX C

MEDICAL TEACHING FOOT MODEL: LEGACY EZ2B/VATA WILMA 0950

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REFERENCES

55
 REFERENCES

Allie, D.E. (2007). Emerging vascular approaches for healing diabetic ulcers. Podiatry
Today, 20(7), 44-54.

American Diabetes Association (ADA). (2004). Preventive foot care in diabetes.

Diabetes Care, 27, S63-S64.

American Diabetes Association (ADA). (2010). Standards of medical care in diabetes.

Diabetes Care, 33, S11-S61.

Anderson, L., & Wilson, S. (1997). Critical incident technique. In D.L. Whetzel & G.R.
Wheaton (Eds.), Applied measurement methods in industrial psychology (pp. 89-
112). Palo Alto, CA: Davies-Black.

Banion, C , Klingensmith, G., Giardino, D., & Radcliffe, J. (1987). Efficacy of outpatient
management of new onset diabetes in children. Diabetes, Jr5(Supp. 1), 118 A.

Benner, P. (1984). From novice to expert: Excellence in power in clinical nursing

practice. Menlo Park, CA: Addison-Wesley.

Bigge, M.L., & Shermis, S.S. (1992). Learning theories for teachers (5th ed.). New York,
NY: HarperCollins.

Burdette-Taylor, S. (2005). Use of 3D soft model (EZ Medical Teaching Foot) for a foot
care program for a Veterans Affairs patient population. Journal of Wound,
Ostomy and Continence Nursing, 32(Supp. 3), S3.

Caravalho, J.Y., & Saylor, C.R. (2000). An evaluation of a nurse case-managed program
for children with diabetes. Pediatric Nursing, 26(3), 296-300, 328.

Centers for Disease Control and Prevention (CDC). (2004). Data and trends—Diabetes
Surveillance System: Prevalence of diabetes: Number of persons diagnosed with
diabetes, United States 1980-2002. Retrieved November 19, 2006, from
http://www.cdc.gov/diabetes/statistics/lea/table 1 lk.htm

Chase, H.P., Crew, K.R., Satish, G., Crews, M.J., Cruickshanks, K.J., Klingensmith, G.,
. . . . Hammond, R.F. (1992). Outpatient management vs. in hospital management
of children with new onset diabetes. Clinical Pediatrics, 37(8), 450-456.

Driver, V.R., Gabbi, M., Lavery, L.A., & Gibbons, G. (2010). The costs of diabetic foot:
The economic case for the limb salvage team. Journal of Vascular Surgery, 52(6),
1751.

56
Dunn, S.M., Bryson, J.M., Hoskins, P.L., Alford, J.B., Handelsman, D.J., & Turtle, J.R.
(1984). Development of the diabetes knowledge (DKN) scales: Forms DKNA,
DKND, and DKNC. Diabetes Care, 7(1), 36-40.

Giacalone, V.F., Krych, S.M., & Harkless, L.B. (1994). The University of Texas Health
Science Center of San Antonio: Experience with foot surgery in diabetes. Journal
of Foot and Ankle Surgery, 33, 590-597.

Gloe,D., Schoenly, L., Dugan, J., Cromer, M., Munroe, C , Sikma, S., & NNSDO
Research Committee. (1998). Outcomes research in staff development: Reviews
and recommendations (1985-1995). Pensacola, FL: National Nursing Staff
Development Organization.

Goodridge, D., Trepman, E., Sloan, J., Strain, L.A., Mclntyre, J., & Embil, J.M. (2006).
Quality of life of adults with unhealed and healed diabetic foot ulcers. Foot and
Ankle International, 27(4), 274-280.

Hass, L. (2008). Lower limb self management education. In J.H. Bowker & M.A. Pfeiffer
(Eds.), Levin and O'Neal's the diabetic foot (pp. 563-572). Philadelphia, PA:
Mosby Elsevier.

Johnson, M., Newton, P., Jiwu, M., & Goyder, E. (2005). Meeting the educational needs
of people at risk of diabetes-related amputation: A vignette study with patients
and professionals. Health Expectations, 8(4), 324-333.

Kelichi, T.J. (2008, October 23-27). Foot and nail care. Lecture presented at Foot Care
Extraordinaire Nursing Education Program, Santa Rosa, CA.

Kostraba, J.N., Gay, E.C., Rewers, M., Chase, H.P., Klingensmith, G.J., & Hammon,
R.F. (1992). Increasing trend of outpatient management of children with newly
diagnosed IDDM. Diabetes Care, 15(1), 95-100.

Knowles, M.S. (1975). Self-directed learning: A guide for learners and teachers.
Englewood Cliffs, NJ: Cambridge.

Nash, T., Bellew, J.W., Cunningham, M., & McCulloch, J. (2005). Identifying cause of
advancement to amputation in patients with diabetes: The role of medical care and
patient compliance. Wounds, 77(2), 32-36.

National Institue of Diabetes and Digestive and Kidney Disease of the National Institute
of Health (NIDDK). (1999). Diabetes statistics of the United States (NIH

57
 Publication No. 99-3926). Retrieved November 20, 2006, from http://niddk.nih.
gov/health/diabetes/pubs/diabetes/pubs/dmstats

Neder, S., & Nadash, P. (2003). Individualized education can improve foot care for
patients with diabetes. Home Healthcare, 27, 837-840.

O'Hare, A.M. Feinglass, J., Reiber, G.E., Rodriguez, R.A., Daley, J., Khuri, S.,
. . . . Johansen, K.L. (2004). Postoperative mortality after nontraumatic lower
extremity amputation in patients with renal insufficiency. Journal of the American
Society of Nephrology, 15, 427-434.

Patout, C.A., Jr., Birke, J.A., Horswell, R., Williams, D., & Cerise, F.P. (2000).
Effectiveness of a comprehensive diabetes lower-extremity amputation prevention
program in a predominantly low-income African-American population. Diabetes
Care, 23(9), 1339-1342.

Peyrot, M., & Rubin, R.R. (1994). Structure and correlates of diabetes-specific locus of
control. Diabetes Care, 17, 994-1001.

Pogash, L.M., Robbins, J., Anderson, L.C., Hawley, G., Krein, S., Vosburg, F., & Cutler,
F. (2006). Decreases in lower extremity amputation rates in the Veterans Health
Administration. Diabetes, 49, A222.

Polit, D.F., & Hungler, B.P. (1991). Nursing research: Principles and methods.
Phildelphia, PA: Lippincott.

Reiber, G.E., & LeMaster, J.W. (2008) Epidemiology and economic impact of ulcers and
amputation in people with dabetes. In J.H. Bowker & M.A. Pfeiffer (Eds.), Levin
and O'Neal's the diabetic foot (pp. 3-22). Philadelphia, PA: Mosby Elsevier.

Rubin, R. (1998). The challenges of the millennium: Are we ready or not? Diabetes
Spectrum, 11, 121-123.

Siminerio, L.M., Charron-Prochownik, D., Banion, C , & Schrelner, B. (1999).

Comparing outpatient and inpatient diabetes education for newly diagnosed
patients. The Diabetes Educator, 25(6), 895-906.

Singh, N., Armstrong, D.G., & Lipsky, B.A. (2005). Preventing foot ulcers in patients
with diatebes. JAMA, 293(2), 271-228.

Snyder, R.J., Kirsner, R.S., Warriner, R.A., Lavery, L.A., Hanff, J.R., & Sheehan, P.
(2010). Consensus recommendations on advancing the standard of care for

58
 treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound
Management, Jc5(Supp. 4), S1-S24.

Visnathan, V., Madhavan, S., Rajaseker, S., Chamukuttan, S., & Ambady, R. (2005).
Amputation prevention initiative in south India: Positive impact of foot care
education. Diabetes Care, 8(5), 1019-1021.

Wound Ostomy and Continence Nurse Certification Board. (2010). Foot care exam
eligibility requirements. Retrieved November 15, 2010, from http://www.wocncb.
org/become-certified/foot-and-nail/eligibility.php

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