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ENHANCED LOWER EXTREMITY AND FOOT ASSESSMENT. ‘ : if}?
WITH RECOMMENDATIONS FOR TEACHING v '

Schelariy Project for the Degree of M 8 Ne:
MICHIGAN STATE UNIVERSITY .,
WENDY A EHNIS 8; MARGHERITA P CLARK
1999

 

' LIBRARY
Michigan State
University

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/01 c:/ClRC/DaleDue.p65-p.15

 

Enhanced Lower Extremity and Foot Assessment with

Recommendations for Teaching

BY
Wendy A. Ehnis
&

Margherita P. Clark

A Scholarly Project
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Masters of Science in Nursing
College of Nursing

1999

Abstract

Lower extremity and foot assessment leads to early
intervention for potentially disabling disorders. At—risk
diabetic populations experienced 54,000 non—traumatic
amputations (Centers for Disease Control (CDC), 1995); an
estimated 50—75% could be avoided with early recognition and
treatment. A key component in maintaining mobility is the
promotion of regular foot care, prevention of lower
extremity injuries and prompt intervention for
complications. The advanced practice nurse (APN) is in a
unique position to identify, document and manage assessment
findings critical in determining optimal patient outcomes.
The purpose of this project is to create an educative
product (assessment tool and Web site) utilizing the APN’s
knowledge base and professional expertise; individually
mapping areas for concentrated future learning.
Additionally, the development and use of the Enhanced Foot
Assessment Tool ensures continuity with each assessment. A
teaching—learning model is the framework for this project,
encouraging APNs to enrich their professional knowledge base
specific to lower extremity and foot care; developing the
link between theory and practice. Future implications
include increasing awareness among APNs of the importance of
lower extremity and foot care, standardized documentation

for measurable patient outcomes, and potential for research.

Acknowledgements

We would like to convey our gratitude for the collegial
relationship formed with our committee members: Louise
Selanders R.N., Ph.D., committee chairperson; Sharon King
R.N., Ph.D., committee member; and Kate Lein R.N., M.S.N.,
committee member. Their scholarly support extends beyond the
pages of this project to encompass the community commitment
of providing foot care. All of us value the experience of
providing foot care as an expression of caring.

From Margie: To Dan, M.O.E.P., thank you for your
unconditional love and support. I couldn’t have done this
without you! To Nello and Assunta Procaccini, parents who
were great teachers. Lastly, my nursing mentors, Dorothea
Milbrandt, Dorothy Linau—Mirkil, and Pat Hays.

From Wendy: To Bob, Ben and Tanner, thank you for the
years of understanding and love. You always come first.

From Margie and Wendy: The duality of this project is

pure and simple: the left and right hand meet in symmetry.

Table of Contents
Introduction.
Prevalent Foot Problems.
Changes Associated with Aging.
Advanced Practice Nurse Implications
Scope of Project.
Conceptual Framework.
Review of Literature.
Skin
Research.
Hyperkeratoses
Research.
Bony Deformities
Research.
Footwear and Self-Care Practices
Research.
At Risk Diabetic Populations
Research.
Fungal Infections.
Research.
Summary of Literature Review.
Teaching—Learning Project Development
Overview
Computer Assisted Instruction.

Creation of the Web Site

10

11

12

2O

20

21

22

25

26

27

28

29

29

32

33

35

35

37

37

39

40

Standardized Assessment for Lower Extremity and Foot Care.42

Use of Enhanced Foot Assessment Tool . . . . . . . . . . .46
Use of the Front Page of Assessment Tool. . . . . . .47
Use of the Back Page of Assessment Tool . . . . . . .48
Evaluation of Project . . . . . . . . . . . . . . . . . .50
Practice. . . . . . . . . . . . . . . . . . . . . . .50
Education . . . . . . . . . . . . . . . . . . . . . .50
Research . . . . . . . . . . . . . . . . . . . . . .50
Future Implications . . . . . . . . . . . . . . . . .51
References .53
Appendix A Quickstart guide to PILOT Electronic Mail . . .64
Appendix B Using Terminal Software to Dial in to MichNet/MSU

Appendix

Appendix

Appendix

Appendix

.67
Foot Care (1660). . . . . . . . . . . . . . . .69
Enhanced Lower Extremity and Foot Assessment Tool
Front Page. . . . . . . . . . . . . . . . . . .71
Enhanced Lower Extremity and Foot Assessment Tool
Back Page . . . . . . . . . . . . . . . . . . .72

Web Site <http://pilot.msu.edu/~clarkm10/>. . .73

Figure 1
Figure 2

Figure 3

Table of Figures

13

18

73

Introduction

A key component in maintaining physical independence is
the promotion of regular foot care and the prevention of
potentially debilitating foot injury or loss of function.
Early detection and management of foot injury can effect a
difference between limb—threatening complications and a
return to full potential. Healthy feet are a prerequisite
for balance and stable ambulation. Immobility can be
considered a strong risk factor in predicting systematic
diminution of physical and psychological health.

Concomitant illness may attack the integrity of foot
tissues and underlying structures. Accelerated
atherosclerosis of the diabetic cardiovascular system,
diabetic retinopathy and sensory polyneuropathy all
contribute to a higher risk of poor tissue perfusion,
trauma, ulceration, gangrene and lower extremity amputation
for the diabetic patient. The National Institutes of Health
estimated the prevalence of diabetes in the United States in
1995 at 16 million individuals. Diabetes mellitus,
complications notwithstanding, ranks as the 7th most common
principal diagnosis requiring patients to be seen by their
primary care provider (Ostergaard & Schmittling, 1997).

Alarming statistics for lower extremity amputations
reveal that 50—70% of all non-traumatic lower extremity

amputations involve diabetic patients (Ahroni, 1993); the

Centers for Disease Control (CDC) reports 54,000 such
procedures are performed yearly (1995). Through early
detection and treatment, the CDC estimated that half of
these lower extremity amputations are preventable.
Recommendations by both The American Diabetes Association
(ADA, 1996) and the CDC include an examination of the feet
of diabetic patients by the primary care provider at every
visit.

Prevalent Foot Problems

 

Onychomycosis represents 50% of all nail disease and
the most difficult to treat of all skin mycoses (Elewski,
1996). Fungal infections of the toenails are almost always
caused by a dermatophyte fungi, with distal and lateral
subungual onychomycosis being the most common (Roberts,
1993). These molds, and occasionally yeast, infect an
already diseased or traumatized nail. Arterial circulatory
disorders, peripheral nerve disease, disturbances of the
venous and lymphatic drainage systems, as well as chronic
paronychia are common predisposing factors (Haneke, 1991).
Onychomycosis may cause disturbances in nail growth with
loosening or separation of all or part of the nail plate
from the nail bed at the free edge (Helfand, 1989). Anti-
fungal drug treatments remain difficult to accomplish
because predisposing factors are usually not amenable to

therapy. Patience, combined with optimal patient

compliance, are mediators. A high recurrence rate is
estimated at 80-90% (Haneke, 1991).

A survey of 813 bunionectomies revealed that 94%
involved females (Conkling, 1994). Medical costs and
associated time off work are estimated at $3.5 billion per
year (American Academy of Orthopaedic Surgeons & the
National Shoe Retailers Association, 1995).

Changes Associated with Aging

 

The process of normal aging inherently involves
adaptation to change. Physical challenges are observed in
every organ during the lifespan continuum. The epidermis of
the skin thins, and the dermis decreases in elasticity and
vascularity. Nails become brittle, with a 30-50% slower
growth rate. Slowed cell reproduction and repair, coupled
with a diminished immune response sets the stage for delayed
healing of trauma or ulceration. The pumping ability of the
heart slows and venous return is delayed. Increased systolic
blood pressure interfaces with added vascular resistance at
the cellular level, precipitating foot edema, impaired
sensation, and a diminished response to pedal insult.

Bony landmarks become more prominent as subcutaneous
fat decreases in the periphery. Joints develop increased
potential for stiffness, deformity, inflammation and pain.
Muscular changes create slowed movement and reflexes

diminish. Neurologically, decreased proprioception and

impaired balance may result in gait disturbances or
imbalance. Potential implications exist for impaired
mobility, loss of function, injury from falls and concurrent
decreased independence.

Advanced Practice Nurse Implications

 

Many nurses possess limited assessment skills and
minimal clinical expertise in dealing with lower extremity
care. Many are unaware that foot care is within the scope of
nursing practice. However, foot care is an integral part of
optimal health maintenance and, historically, a missed
nursing opportunity. Clearly, the value of a standardized
tool for lower extremity assessment and care by nurses
should not be minimized. Indeed, the ability to
differentiate normal changes from pathological threat and
detection of problems followed by initiation of appropriate
care and ongoing patient education is integral to nursing
and the promotion of health.

The value of the advanced practice nurse (APN) in
providing expert knowledge, coupled with empirically
informed decision making skills, enables the APN to function
in a number of roles. As a facilitator, the APN may
coordinate teaching-learning opportunities that enhance
reciprocal learning. The role of the APN in primary care is

multidimensional. The American Nurses' Association’s (ANA)

10

former Council of Nurses in Advanced Practice defines the
APN (as cited in Hickey, Ouimette, & Venegoni, 1990):
Nurses in advanced clinical practice have a graduate
degree in nursing. They conduct comprehensive health
assessments, demonstrate a high level of autonomy and
expert skill in the diagnosis and treatment of complex
responses of individuals, families, and communities to
actual or potential health problems. They formulate
clinical decision to manage acute and chronic illness
and promote wellness. Nurses in advanced practice
integrate education, research, management, leadership,
and consultation into their clinical role and function
in collegial relationships with nursing peers,
physicians and others who influence the health
environment (p. 22).
This definition clearly illustrates the multidimensional
roles of the APN with concrete applications for lower
extremity assessment.
Scope of Project
The purpose of this scholarly project is to establish
an enhanced lower extremity and foot assessment tool that
may be utilized in a variety of nurse-managed settings such
as ambulatory primary care, subacute or extended care,
parish nursing clinics, or applied in advanced nursing

education and research. Traditional orientation materials

11

will be augmented by the creation of a World Wide Web (WWW)
site utilizing an interactive format and use of digitized
photographs of common foot disorders and abnormalities.
Traditional roles of the APN will be expanded to explore the
possibilities of an approach that is intrapreneurial in foot
care. The conceptual framework that guides this project is
the teaching—learning model, which adapts well to the adult
learner.
Conceptual Framework

The framework upon which this project is based is
grounded by the principles of teaching—learning theory. All
teaching—learning events consist of five elements (Clark,
1987). These elements, as depicted in Figure 1, consist of
characteristics of adult learners, the characteristics of
the facilitator, contextual factors, teaching—learning
theories, and teaching techniques and methods.

Historically, instruction has been defined as the
methods, approaches, and techniques used by teachers to
influence intellectual, physical and emotional behaviors in
a desired direction (Gronlund, 1971). It has also been
postulated that members of a professional discipline are
prone to develop learning styles that reflect the
predominant learning patterns and demands of their

discipline (Kolb, 1984).

12

Elements of the Learning Environment

 

 

Contextual Characteristics Teaching— Characteristics Teaching
Factors E of the LearnersE iLearning of the Methods
Theories Facilitator

 

1

The Teaching-Learning Transaction

Figure 1. The Teaching—Learning Event (Clark, 1987)

 

Successful functioning in nursing was thought to be
based on positive negotiation of required competencies,
aligned with a predominantly concrete learning style
(Christiansen, 1979; Merritt, 1983)..Concrete approaches to
learning rely on experience and active experimentation,
producing a task-oriented individual who learns primarily by
trial and error (Goldrick, 1993).

Highfield’s study in 1988 stated that, of 54 nursing
students, the predominant learning styles (46%) were
abstract, with use of assimilation and convergence.
Participants were non-traditional nursing students, with a
mean age of 28. Reflective observation and inductive
organization of the material was observed. Laschinger and
Boss (1983) identified increased use of abstract learning in

baccalaureate nursing students versus diploma students.

13

In a study of 303 critical care nurses, operating room
nurses and infection control practitioners, 64% had an
abstract learning style and preferred a self—directed,
discovery approach to learning. Identified preferred
strategies included live demonstrations, clinical practice,
case studies, simulations, computer—assisted instruction and
student-led seminars. The use of reason and logic, the
testing of theories and ideas, analyzing of quantitative
data and the design of experiments were all suggested
components of a maximized teaching-learning strategy
(Goldrick, Gruendemann & Larson, 1993).

Developing links between theory and practice promotes
conceptual understanding, development of reasoning skills
and self—directed learning strategies (Barrows, 1985). A
constructivist philosophy focuses on the learner’s existing
knowledge base as a basis for conceptual change (Creedy,
Hand, & Horsfall, 1992). The adoption of a teaching—learning
model specific to nursing education reflects both
constructivist philosophy and Mezirow's (1991) theory of
adult education. Unlike the ”invariant age-related steps and
stages” of growth and development in children, the missing
dimension of meaning is recognized as integral with the
learning process of adults.

Piaget (1973) refers to what is 'known’ as being

constructed by the knower in the process of adapting one’s

14

experiences to the reality of the environment. Piaget
postulates that either the minor negotiation of assimilation
(filtering experiences in accordance with what is already
known) or accommodation occurs. Accommodation reflects an
imbalance between experiences and one’s current level of
understanding. This state of imbalance precipitates new
cognitive construction. A major difference between experts
and novices, identified by Creedy et al. (1992), reflects
that experts are able to organize their knowledge; thus it
can be used efficiently and effectively.

Teaching-learning strategies utilized in nursing
education may vary in form, but these authors believe that
basic delineators are universally present. Just as Leininger
(1988) defines culture as the ”learned, shared, and
transmitted values, beliefs, norms and lifeway practices of
a particular group that guides thinking, decisions and
actions in patterned ways" (p. 158); so do nurses define
theoretical springboards for their growth and conceptual
changes within the scientific discipline of professional
nursing.

This suggestion of perspective also complements
Mezirow's (1991) theory of perspective transformation,
wherein, unexpected events that cannot be understood using
prevailing meaning schemata lead to a critique of existing

assumptions. Restructuring of ”old meaning schemes and

15

perspectives are brought into consciousness and negated, or
they are modified and synthesized with a more insightful new
viewpoint” (Mezirow, 1985, p. 24). This transformation,
which occurs during the learning process, may be closely
intertwined with tension or threat to self—esteem.

Homogeneity among group members, promotion of a mutual
sense of trust, a fund of shared information and
experiences, and a safe climate for exploration and
evaluation of actions and beliefs spur adult risk-taking and
learner empowerment (Callin, 1996). “When the focus is
placed on process, the learner takes an active role in
acquiring and using knowledge" (Marcinek, 1993, p. 14).
”Content is essential but varies with the individual
learner’s need, whereas process remains stable and common to
all learners” (p. 15).

Teaching—learning strategies incorporate the learner’s
acquisition of an integrated body of knowledge with an in-
depth assessment of problem—solving and critical thinking
skills. Utilization of this reflective approach enhances
growth, and allows the student to develop personal and
professional skills that transcend the immediacy of the
prescribed tutorial. The stimulation of interpretation,
correlation, and arrangement of knowledge within one’s
schemata empowers the individual to transfer learning from a

specific setting to a lifelong process.

16

Philosophic assumptions integral to the teaching
learning conceptual model are based on three beliefs: (1)
teaching—learning is a process, not a product, (2) the
process is implemented in a relationship between experts,
(3) communication is the essential element of the process
(Leddy, 1998).

Viewed as a process, a special teaching-learning
opportunity is represented by the diagram in Figure 2. A
teaching-learning module has been created for Enhanced Lower
Extremity and Foot Assessment wherein the specific content
is not necessarily predetermined in it’s entirety, but
evolves to become more meaningful to the learner.

This dynamic process is focused within a collaborative
relationship between the teacher and the learner. As
participation ensues, ”learning leads to new action and new
problem solving, which enable individuals and systems to
continue to learn". (Argyris, 1982, p. 160)

The varied roles of the APN become evident as the
teaching learning process is implemented in a relationship
between experts. Expert knowledge and organization of
subject matter, skill in instructive techniques, and the
ability to act as a resource for colleagues augment the
association of complex relationships that promote transfer
of learning from the classroom to clinical practice.

Individualized instruction can provide avenues of positive

17

feedback. A mutually validating relationship occurs which
”links power to the ability to bring about change” (Jacano &

Jacano, 1995, p. 21).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reevaluate & Analyze
Learning Needs
for Self-Directed
APN Learning
APN Facilitator: APN-Learner:
I Advanced Lower Extremity and Foot I Basic Lower Extremity and Foot
Assessment Skills Assessment Skills
I Advanced Nursing Knowledge I Basic Nursing Knowledge
I Advanced Application Experience I Minimal Application Experience
Teaching-
Lummm;
Theories
Teaching Methods: Contextual Factors:
I Traditional Written Material I Scope of Nursing Practice
I Web Site I On-line Computer Access
I Application of Enhanced Lower I Self-paced Format
Extremity and Foot Assessment Tool

 

 

 

 

 

Figure 2. Utilization of Teaching—Learning Model in Enhanced
Lower Extremity and Foot Assessment (Clark—Ehnis, 1998)

Communication is considered the essential element for
effective teaching-learning. Three characteristics necessary

for effective communication are empathy, respect and

18

genuineness. Only then, is full advantage taken of both
parties’ expertise, in communication designed to elicit
mutual responsibility (Leddy, 1998). The empowerment
engendered by this communion provides a framework for
creative thinking.

Teaching—learning begins with assessing a point of
reference for learning. Identification of the learner’s
needs is followed by a mutual prioritization. An inclusive
plan with measurable objectives delineates the information
to be disseminated. Implementation of the plan utilizes
creative interpretation and may include all techniques
available to enhance learning. The format may be enhanced by
such tools as observation and assessment scales, self—
directed learning exercises, onesite demonstration, visual
images, modeling, ’hands—on’ practical experience, on-line
(World Wide Web) and CD—ROM references, interpretative
discussion, and case scenarios. The documented evaluative
tool completes the model allowing for an analysis of the
degree of integration of knowledge.

Supportive mutuality permeates the successful teaching-
learning experience. As Watson (1988) states, nursing ”must
shift from oppressive interactions to liberating
interactions” (p. 4). This paradigm shift allows learning to

be ”characterized by anticipatory-participatory behaviors,

19

shared power, and the absence of separation of doing from
knowing and being” (Watson, 1988, p. 2).

In summary, three elements of critical thinking skills,
knowledge and experience, are common to both the teacher and
the learner. The provider—learner is accountable for
evaluating and analyzing the learner's specific learning
needs. This self—directed endeavor may be accomplished
independently or collaboratively. Internalization of this
process allows for unlimited utilization of the teaching
protocol, reassessment of learning needs, autonomous
functional application and ongoing evaluation.

Review of Literature

This literature review will explore the prevalence,
pathophysiology, characteristics and treatment of common
foot disorders in the elderly population. Additionally, in
acknowledgment of clearly alarming statistics indicating a
relationship between diabetes and lower extremity morbidity,
lack of requisite adherence by primary care providers to a
prescribed regimen of foot assessment and care is discussed.

£122

The outermost layer of skin, the epidermis, is
comprised of five sub—layers and is estimated to be 75
microns to 0.6mm thick, thinning as one ages. This organ's
surface layer, or ’horny’ stratum corneum, is subjected to

daily use and exposure to the environment. An acid mantle,

20

which retards certain bacterial and fungal proliferation,
provides a protective water—repellent covering (Alterescu &
Alterescu, 1988).

The innermost layer, the dermis, contains blood and
lymphatic vessels, nerves and cellular components such as
mast cells, leukocytes, macrophages, and fibroblasts
(Alterescu & Alterescu, 1988). The dermis decreases in
vascularity, elasticity and defensive ability as an
individual ages, leading to a loss of water content and
slowing of re—epithelialization.

Decreased circulation to the skin of the appendages
results in diminished oxygen and nutrients at the cellular
level. Reduced production of sebaceous and sweat glands
couples with decreased water storage to produce a rough,
scaly texture with decreased skin turgor. Diminished tactile
sensation is caused by neurosensory changes; pain or
friction to surface tissues may go unrecognized. The
aforementioned physiological functional changes categorize
the elderly foot as identifiable at high risk for impaired
skin integrity (Jaffe, 1991).

Research

No long term skin care studies have examined the
effects of patient education on foot care. A hands-on
teaching—learning approach was evaluated in a study (n=50)

by Kruger and Guthrie (1992) in a diabetic population over a

21

6 month period. Although the results were inconclusive,
positive minimal changes were reported in self-care
practices; daily inspection and washing of feet, and
trimming toenails related to skin and foot care.

A medically oriented classification tier has been
reported by Strauss, Hart, and Wiant (1998) which assigns a
grading system, I—IV level, for the evaluation for foot,
nail and skin problems. Specified interventions for both
physician and patient exist at each grading level. Grade I
indicates a moist and well-lubricated skin condition. No
interventions are necessary and patients are encouraged to
continue good skin care. Grade II shows mild to moderate
scaling and dryness. Daily and consistent skin care is
stressed. Grade III reveals marked scaling and dryness and
office care is begun. A three—step skin care program is
initiated with incorporated self-care teaching. Grade IV is
characterized by crusts, plaques, and debris. In-office
whirlpool, debridement, inception of skin care program, and
patient teaching are begun. This documentation has proven to
be both reimbursable and practical in preventing further
lower extremity and foot complications.

Hyperkeratoses

 

Structural changes occur simultaneously; the loss of
subcutaneous plantar fat pads allows for less tissue

insulation and vessel support (Jaffe, 1991). Calluses, or

22

diffuse areas of thickened skin, may form on bony
prominences or any area where soft tissue is exposed to
prolonged unrelieved pressure, friction or shear (Kelechi &
Lukacs, 1997). Tensile stress may also be a factor in callus
formation. Digital deformity, such as toe alignment can
cause the head of one phalanx to be compressed against the
base of an adjacent metatarsal—phalangeal articulation. The
continued pressure may create a hyperkeratotic lesion
(Helfand, 1989). The formation of additional layers of skin
reflects the body’s attempt at a protective mechanism.
Calluses may also form under weight bearing areas such as
the heel or metatarsal heads. Wearing slippers or ill-
fitting shoes that do not have a snug heel counter
predisposes an individual to thickened, dry, heel skin
(Kelechi & Lukacs, 1997).

'Pressure may intensify as the keratin layers build and
the cause of the callus is not identified and eradicated. A
central nucleus develops and a corn (heloma) is generated.
The pressure acts as a foreign body; inflammation is common,
and ulceration may occur (Helfand, 1989). Appropriate
documentation should be made upon assessment of callus, corn
or ulcerous conditions, noting the location, width and
estimated depth in centimeters, as well as surrounding
redness, dryness or bruising (Dorgan, Birke, Moretto,

Patout, & Rehm, 1995).

23

Advanced practice nurses, implementing standard skin
care protocols, debride hyperkeratotic foot lesions with a
pumice stone, foot file or rotary tool, followed by
application of an emollient. There is little data available
comparing the method of intervention, but general parameters
include thickness of callus, degree of expertise, and level
of associated patient discomfort (Kelechi & Lukacs, 1997).
Most calluses cannot be completely removed, but thinning may
bring about relief (Kelechi & Lukacs, 1997). A large foot
file may be applied in one direction until the skin is
smooth and even with the foot surface (Ruscin, Cunningham, &
Blaylock, 1993). It is not recommended that patients apply
commercial products to aid in corn removal, as the
concentrations of acid may produce a.second-degree chemical
burn (Helfand, 1989).

Insertion of a small foam pad or ring interdigitally
may serve to separate the web space occupied by a soft corn
and cushion surrounding tissues (Lian, 1992). Used
circumferentially, the corn pad will cushion areas of
friction and allow relief from direct pressure.

Dryness of the skin, decreased elasticity and keratotic
thickening may produce heel fissures, which can extend into
the dermis. Assessment of depth, size, drainage and
condition of surrounding tissues is imperative (Kelechi &

Lukacs, 1997). Recent documentation of acceptable

24

interventions includes the application of a solid sheet of
high—glycerin content hydrogel, which acts both as a
cushion, and possesses bacteriostatic and anti-fungal
qualities (Kelechi & Lukacs, 1997). Keratolytic compounds,
in an emollient cream or lotion base utilize concentrations
of urea, alpha-hydroxy acid, lactic acid and salicylic acid
to exfoliate (Kelechi & Lukacs, 1997). Application of any
petroleum—based barrier moisturizer to soften the skin
should be preceded by a moisture—containing product, and be
applied 2—4 times per day and after bathing (Kelechi &
Lukacs, 1997).

Maceration of the interdigital web spaces may develop
from the use of emollients between the toes, the inability
to dry feet completely, or friction from lateral pressure of
shoes or digital contractures (Kosinski & Ramcharitar,
1994). Lamb’s wool or cotton gauze is used to separate and
dry the interspace, but should not encircle the digit
(Kosinski & Ramcharitar, 1994; Kelechi, 1996; Kelechi &
Lukacs, 1996). Patients are to dry between the toes
completely, switch to shoes with a roomier toe box and are
encouraged not to soak feet (Lian, 1992).

Research

Through an extensive review of the literature, these

authors discovered a paucity of research based studies

related to hyperkeratoses. In 1995, the Department of

25

Veteran Affairs conducted a study involving 100 homeless
participants (Robbins, Roth, & Villanueva, 1996). The
national incidence and prevalence data were consistent; the
three most common conditions were nail pathology, corns and
calluses, and foot infections (fungal, skin, and warts).

Bony Deformities

 

Generalized musculoskeletal changes associated with
aging include loss of muscle fiber, strength and limitations
in mobility. Ligaments become stretched, resulting in joint
stiffness and reduced motion. Postural changes include a
shift from the hips as the center of gravity, to the chest
(Jaffe, 1991). In order to increase stability, the elderly
begin to walk with their feet directed outward, which does
not follow the design or last of most shoes (Helfand, 1989).
This alteration in gait elicits a foot—shoe incompatibility
that accentuates pressure points on the feet (Helfand,
1989).

Bunions are the result of a subluxation of the
metatarsal—phalangeal (MP) joint of the great toe, creating
a lateral angulation that produces pressure from two
distinct directions. The MP joint becomes enlarged, and may
be reddened and inflamed from friction with a toe—box or
instep. Bunions are-caused by an inherited joint weakness

and/or poorly fitting shoes.

26

A hammer toe may be caused by lateral derangement of
the second toe due to a bunion. This deformity is a
combination of extension at the MP joint and flexion at the
proximal inter—phalangeal (PIP) joint. Pain results as the
plantar muscles tear and soft tissue lesions form from
friction at the dorsal PIP joint, with corn development at
the tips of the toe and PIP joint (Lian, 1992). Conservative
treatment with hammer toe pads, designed to fit over the toe
and hold down the PIP joint may be used in conjunction with
a roomier, high toe—box shoe (Lian, 1992). The treatment
provides symptomatic relief and is not curative.

Research

The American Academy of Orthopaedic Surgeons & the
National Shoe Retailers Association (1995) found that women
are 9 times more likely than men to develop pain and
deformity in their feet; causative factors include poorly
fitting shoes, shoes that are too small for the foot, and
heels higher than 2 1/4 inches.

Additionally, a survey of 813 bunionectomies revealed
that 94% involved females (Conkling, 1994). Medical costs
and associated time off work are estimated at $3.5 billion
per year (American Academy of Orthopaedic Surgeons & the

National Shoe Retailers Association, 1995).

27

These authors did not find evidence of research based
Level 3 intervention studies. This finding supports the need
for future exploration.

Footwear and Self—Care Practices

 

Advance practice nurses should assess footwear for
signs of uneven wear, friction, pressure and poor fit. These
simple measures are basic to preventive foot care. All
footwear should be replaced when worn, and inspected
periodically for torn linings or rough edges. Padding may
restore neutral functions, and prevent repeated microtrauma
of the foot in—patients with degenerative changes (Helfand,
1989). Leather or canvas shoes allow moisture to evaporate,
and should be purchased in the afternoon, when the feet are
largest. Cotton or wool socks should be worn to absorb
moisture and wick it away from the foot. White socks are
preferable if lesions exist; entry of dyes into the wound is
eliminated (Ruscin et al. 1993). Patients should never go
barefoot, thus reducing the risk of penetrative or abrading
injury from foreign body (Helfand, 1989).

Feet should be inspected with a mirror every day and
twice daily, for patients at high risk for complications.
Nurses should assess blisters, sores or cracks in the skin,
changes in toenails, skin temperature and color (Ruscin et

al. 1993).

28

Research

Pelican, Barbieri, and Blair (1991) found that most
people, including nurses, had strong negative reaction to
contact with feet. This negative reaction was especially
noted with respect to cutting toenails.

Pock, Frankel, and Shiu (1995) identified that on
routine physical examination, the foot is the most neglected
part of the body. In fact, the Foundation for Accountability
of the Agency of Health Care Policy and Research had a
predominantly negative response when diabetic patients were
asked whether they recalled taking their shoes and socks off
during a recent office visit (FACCT, 1996).

At Risk Diabetic Populations

 

The diabetic mellitus population is a group at
heightened risk for impaired skin integrity and foot and
lower extremity trauma. ”Diabetes predisposes individuals to
amputation primarily because of the presence of peripheral
neuropathy and peripheral vascular disease" (Ahroni, 1993).
An estimated 1 in every 4 diabetic patients admitted to a
hospital has an infected foot lesion, with ”the age adjusted
rate of lower extremity amputation in the diabetic
population 15 times that on the non—diabetic population"
(Ahroni, 1993 p. 320). Although foot lesions can arise
anywhere that pressure or repeated friction occurs, common

hot spots are under plantar calluses, in the toe-nail bed or

29

in tandem with neuropathic ulcers (Garrison & Campbell,
1993). The sequela of minor trauma, ulceration and eventual
failure of a wound to heal occurred in 72% of lower
extremity amputations studied (Pecoraro, Reiber, & Burgess,
1990).

Neuropathic ulcers may present as red, warm, painless,
circular lesions, surrounded by callus, and located over
bony prominences. Deformity, muscle weakness, dry skin and
tight shoes have all been implicated as causative (Dorgan et
al. 1995).

Autonomic, sensory and motor neuropathies act together
to create foot ulceration (Ahroni, 1993). Diabetic
impairment of the autonomic nerves causes a reduction in
blood flow and glandular activity, resulting in drier skin
that is prone to fissures and infection (Garrison &
Campbell, 1993). Motor neuropathy leads to muscle weakness
and changes in the shape of the foot. ”Weaker intrinsic
muscles allow flexors to predominate, lesser toes become
hammered or clawed. Toe tips may ulcerate" (Ahroni, 1993).

Patients with sensory neuropathy experience progressive
insensitivity to pain, pressure and temperature. To test for
sensory loss, ”the APN applies a 5.07 (10-g) monofilament
perpendicular to the skin until it bends, to the count of 1-
second touch, l-second bend, and 1 second lift. Four areas

are screened, including the distal fat pad areas of the

30

great and fifth toes, and the metatarsal head areas below
these two toes” (Kelechi & Lukacs, 1996). Eyesight may be
impaired by diabetic retinopathy or macular degeneration to
the extent that it is not the protective sense of sight, but
the foul smell of an infected wound that prompts the patient
to seek attention (Garrison & Campbell, 1993).

Disruption of arterial flow from micro and macro
angiopathies and atherosclerosis occurs at a heightened rate
in the diabetic patient (Jaffe, 1991). Thickening of the
capillary walls, restricted blood flow to the site of
invading bacteria (typically polymicrobial) and impaired
oxygen perfusion at the cellular level combine to evidence
as pale, cool extremities with shiny skin and a weak or
absent pulse (Garrison & Campbell, 1993). Almost 20% of
diabetic patients with palpable pedal pulses have
significant small vessel disease (Kosinski & Ramcharitar,
1994). Thus, the APN should check each foot for the presence
of dorsalis pedis and posterior tibial pulses, with referral
to specialists for absence of pulses. Skin temperature
should be checked by feeling both feet simultaneously to
compare any ’hot—spots’ that may indicate problems. The
dorsal surfaces of the hands may be used, with detection of
any difference greater than 2 degrees Centigrade both
determinable and potentially significant (Dorgan et al.

1995).

31

Research

Studies indicate a defined need for focused assessment
of foot care in diabetics. Plummer and Albert (1996)
conducted a study of 308 elders to investigate the
prevalence and characteristics of foot problems in diabetic
versus non—diabetic populations. They identified 90% of the
sample as having inappropriate foot care practices, 47% of
non—diabetic participants wearing inappropriate shoes and
peripheral vascular diseases increasing with age,
irrespective of diabetes. Conclusions that all elderly are
at risk for foot-related disease and should be evaluated,
educated, and receive specific follow—up were echoed by
Evans (1991).

In 1995 Wylie—Rosett, Walker, Shamoon, Engel, Basch and
Zybert determined adherence to documented guidelines (CDC,
1995; ADA, 1996) for foot examinations of primary care
patients with diabetes in an inner city setting. There was
no documentation of foot examination or referral for 58% of
the elderly participants over a two—year period. Payne
(1989), based on a one—year review, identified that only
half of diabetic patients in a Denver clinic had a foot exam
by a primary care provider.

In a study of 6 nurse practitioners, Fain & Melkus
(1994) found documentation of foot exams in 23% of charts

reviewed. Despite lack of written adherence, in a 1989 NIH

32

survey, over 80% of primary care providers indicated
performance of foot, neurological and circulatory exam in
diabetic patients one or more times per year. Results of a
1990 study by Hempel suggest that use of a flow sheet in a
nurse—managed patient education clinic significantly
enhances compliance and documentation to standards in a
diabetic population.

Fungal Infections

 

It has been estimated that fungal (onychomycosis)
infections explain 50% of all nail diseases. ”There are four
major types of fungal nail infections: distal subungual
onychomycosis, white superficial onychomycosis, proximal
subungual onychomycosis, and Candida onychomycosis”
(Elewski, 1996, p. S6; Scher, 1983). Causative pathogen and
the method of fungal invasion into the nail plate
differentiate these types of fungal infections. The
literature supports that distal subungual onychomycosis is
the most common form of fungus (typically Tricholphyton
rubrum) invading the distal nail plate and hyponychium
(Scher, 1983; Berg, Cantwell, Heudebert, & Sebastian, 1993;
Hobday, 1995; Elewski, 1996; Tierney, McPhee & Papadakis,
1997). Dermatophytes, yeasts, and non—dermatophytes molds
are the three major groups of fungi that can cause

onychomycosis (Hobday, 1995; Elewski, 1996; Lukacs &

33

Kelechi, 1997). Of these three fungi, the dermatophytes
account for the most common pathogens.

Onychomycosis can be visible by changes in the texture,
structure, and presentation of one, several, or all nails of
the upper and lower extremities. Typically, the nail plate
becomes thick and discolored (onychauxis) and the damaged
nail becomes brittle, crumbly, and a subungual
hyperkeratosis is present with an uplifting of the nail
plate (onycholysis). A ’musty’ odor may also accompany these
findings. Occasionally, the surrounding skin, proximal nail
fold, near the fungal nail may be involved (Omura, 1985;
Stone, 1989; Hobday, 1995). The proximal nail fold and the
two lateral fold makeup the three borders the nail plate.
The raised portion of the proximal nail fold is the cuticle.
Paronychia is acute pain and swelling associated with a past
trauma to the nail, poor nail care, fungal infection
(onychomycosis) or an ’in—grown nail’ (onychocryptosis)
around the lateral nail fold (Berg et al. 1993).

Generally, subungual hyperkeratosis (onycholysis) may
be regarded as the most reliable sign of onychomycosis
(Scher, 1983). Trauma to nails plays an important role as a
precursor to onychomycosis.

Subungual hematoma can be defined as trauma resulting

in the collection of reddish—blue blood in the nail bed.

34

Increased pressure, under the nail plate, causes extreme
tenderness on palpation (Berg et al. 1993).

Grossly elongated nails (onychogryphosis) may be a
result of poor hygiene or neglect in foot care.
Onychogryphosis may result in extreme curvature with a
’hooked’ configuration (gryphos, meaning 'claw’) to the nail
(Omura & Rye, 1994).

Research

Summerbell, Kane, and Krajden (1989) reported that of
3000 nails studied, 91% of the fungal infections were caused
by dermatophytes. Elewski’s-(1996) study found nearly the
same results and reported 90% of the nail infections were
from dermatophytes.

Again, the literature is lacking in documented
intervention based studies. Anecdotally, topical Vick'sC)
application has been thought to inhibit growth of fungus in
toenails (Michigan State University Nurse Managed Foot Care
Clinic, East Lansing Michigan)

Summary of Literature Review

 

There is a dearth of medically based research
applicable to lower extremity and foot care. A thorough
literature review was conducted with specific findings
enumerated above. There is however, a new approach to foot
care, which finds its origins in the scope of nursing

practice.

35

Pelican, Barbieri and Blair (1991) report the inception
of a nurse managed well foot care clinic with the
development of an assessment tool, instructional videotape
and informational brochure. Kelechi and Lukacs (1996), both
Master’s prepared nurses, recognize foot care as an
”integral part of the promotion and maintenance of health”
(p. 722). They have implemented a comprehensive lower
extremity assessment protocol with nursing interventions,
which focus on problems associated with toenails and skin.
Patient and caregiver education is complemented by
identification of complications that need to be referred to
a primary care provider or specialist.u

Many nurses possess limited assessment skills and
minimal clinical expertise in dealing with lower extremity
and foot care. Many are unaware that foot care is within the
scope of nursing practice. Some expressed that this type of
care was aesthetically unpleasing. ”Nurses typically adopt
the attitude that this procedure is not considered part of
nursing practice" (p. 6—7).

These authors believe nursing care is delivered with
the premise of providing holistic care; foot care which
includes lower extremity assessment, skin care, and toenail
care is an essential component of nursing care. Indeed, the
identification of real or potential risk for lower extremity

complications, detection of problems followed by initiation

36

of appropriate care and ongoing client education is integral
with nursing and the promotion of health. -

The use of standardized documentation provides an
avenue for consistent assessment, identifies and tracks
patient complications and self—care practices, and allows
for follow-up of patient education. ”Medical records suggest
that even health—care workers do not typically consider the
feet as a priority. Edema is often the only consistent
documentation." (Pelican, Barbieri, & Blair, 1991, p. 6).

Improved patient outcomes were reported in an
intervention study (Hempel, 1990) as a result of utilizing
standardized flow sheets for provider documentation of foot
care, education, and appropriate referrals.

It is the purpose of this project to develop an
Enhanced Lower Extremity and Foot Assessment Tool for APNs
in order to improve patient outcomes using the methodology
of a standardized tool specific to nursing. Coupled with
this intervention, a self—directed teaching-learning module
was created; accessed via web site or traditional written
material.

Teaching-Learning Project Development
Overview

Acceptance of student autonomy and the creation of

educational Opportunities, in which metaconceptual inquiry

and drive induces learner—generated import of knowledge,

37

represents significant contextual pedagogic reform. Although
APNs share considerable cognitive commonalities, their
contextual differences may include level of scientific
expertise, differing communities of learners or scope of
personal practice, and a divergent research focus.

Implementation of the principles of constructivist
teaching allows for anchors of grounded instruction,
followed by a focus on the nature of reasoning to enable the
learner to construct a new conceptual perspective.
Consistency and generalizability of the information
presented acknowledges the individual learner's level of
adaptation, and the incorporation of viability and
independent judgment; producing a fruitful conceptual
balance.

Learning is framed in this project as an active,
continuous process, which invites application and review.
Respect for competency in the Advanced Practice role,
coupled with an expectation of vital experience and sense of
direction affords a valid and relevant participation in the
teaching—learning module.

The teaching format should yield a multivariate impact,
interfacing with the learner's experience. Text, embedded
with imagery, solicits participant involvement. Content
scanning ability constructively focuses on direct

implications for practice. A generative model, richly

38

complex, yet explicit in communicative outline is made
possible by transforming educative input into an
interactive, computerized translation through use of the
World Wide Web (WWW).

Computer Assisted Instruction

 

Teaching on a web site entails the design of the site,
writing of the code (content) in the source language, and
loading and executing of the program. The vertical framework
in this project maps each topic in a subsystem that first
specifies overview, and then examines relevant conditions,
with assessment technique or intervention in table format
encompassing graphic and discussive review. This process of
cueing and probing is mirrored by the horizontal shared
borders of the web site, through which one may interface
with any number of related foot care aspects. The ultimate
goal of this generative module is to energize the learner
through the initial capture of overview, one component of
the overall process, and facilitate movement through the
additional units until each has been internalized.

The use of computer assisted instruction (CAI) as a
curricular adjunct has been documented in epidemiological
and community health nursing in a baccalaureate population
(Russell & Miller, 1994). Conceptual content, calculations
and simulations were programmed, allowing students to work

at their own pace, repeating full or partial modules as

29

necessary. Development of CAI in planning and decision
making affecting nursing administration found secondary gain
in enhanced participant motivation in the search for
knowledge via computerized sources (Carmagnani & Cunha,
1995). Computerized modules for uniform nursing
documentation of patient education in a diabetic population
allowed for measurement of specific educational outcomes
(Farris, Stoupa, Mendendall, & Mazzuca, 1994). Proposal of a
computerized database through the University of Nebraska
Medical Center goes beyond the standardized educational
series to include tools for assessing knowledge and self-
care behaviors for multiple chronic diseases.

Creation of the Web Site

 

Enhanced Foot Assessment was developed as a web site to
educate nurses in the standardized assessment and delivery
of foot care. The site includes text and graphics, is
complemented by an assessment tool, Enhanced Lower Extremity
and Foot Assessment, and illustrates a simulation of
standardized charting.

An International Business Machine (IBM) compatible
personal computer with Pentium processor and a factory

installed Windows 95 operating system was used to create the
site. Text was processed in MicrosofUO Word for WindowsC>

(7.0). Images were captured by a Sony 10x digital still

camera (Mavica MVC—FD7), with permission to photograph

40

obtained from all participants. Images were saved as a

graphics interchange format (gif) file, and imported into
the FrontPageC>98 document, along with the text. All images
retain participant anonymity.

The web site was developed using FrontPageC>98

software, which features FrontPage Editor, a tool for
creating and editing web pages. In addition, FrontPage

Explorer was used for viewing, modifying and administering
the site. One benefit of using FrontPageC>98 is that

automatic conversion into HTML is accomplished. The
assessment tool was scanned for inclusion on a Hewlett
Packard 7.0 scanner. Interactive hyperlinks were created,
allowing the user to link to additional pages in the web
site, as well as access related sites on the Internet.

Ipswitch WS_FTP allows for transference of digital
files through the use of a modem, from the personal computer
to a local Michnet server for access to Internet services at
Michigan State University (MSU). Exploration of the web site
may be accomplished by any server, such as Microsoft
Internet Explorer.

Michigan State University’s computer lab publishes MSU

PILOT Electronic Mail (Appendix A) to establish access to a

 

student, employee or customer account, as well as

configuring information in Using Terminal Emulation to Dial

 

in to the Internet (Appendix B). These author's student

 

41

PILOT account used a — Advanced features to access a — Fix
AFS public space (Andrew File System). This function will
create a directory called 'public’ and set the permissions
so anyone can read files there. All files, text and
graphics, were transferred to the newly created web site:
BEEP://pilot.meu.edu/~c1arkm10/ opening with a home page
titled Enhanced Foot Assessment. This location is reached on
the WWW via a browser of your choice. Vertical links are
provided to the following pages: Role of APN; Normal Foot
Structure with links to Supportive Footwear, Normal Nail and
Age Related Changes; Skin Integrity; Bony Deformities;
Dystrophic Nails; Effects of Diabetes; Foot Assessment with
links to Assessment Tool and Step—by—Step; and Related

Links.

Standardized Assessment for

 

Lower Extremity and Foot Care

 

The value of standardized protocol for lower extremity
assessment and care by nurses should not be minimized. Foot
care is an integral part of optimal health maintenance; and
historically a missed opportunity. The use of flow sheets
significantly improves the assessment and documentation of
foot care (Hempel, 1990). Through the use of standardized
assessment tools and consistent documentation, retrospective

research studies can provide nursing knowledge in the client

42

outcomes related to routine foot care and the reduction of

complications in high risk populations.

assessment should include:

I. Documentation flow sheets

Comprehensive

A. Demographic information and current health

Review of recent history, medications and

balance, falls and

Assessment of feet and lower extremities

history
1.
changes
2. Assessment of ADLs,
footwear
3.
a. Color
b. Temperature
c. Varicosities
d. Edema
e. Circulation
f. Capillary refill
g. Pain
h. Skin integrity
i. Bony deformities
4. Nail assessment

Shape
Color variations
Texture

Fungal changes

43

e. Macerated web space

f. Sensation

g. Skin changes

5. Interventions to include:

a. Soak feet

b. Inspect and dry between toes

c. Nails debrided with orange stick,
hyponychial border located, nails trimmed
and filed

d. File calluses and corns

e. Lotion massage to feet

H1

Apply treatment ointments, if applicable
g. Recommendations, education and referral
6. Completion of documentation form per protocol
7. Narrative note, if applicable
II. Teaching—Learning Module to include
A. World Wide Web site access of interactive teaching
material
1. Digital photographs of common foot and nail
conditions and bony deformities
2. E-mail feedback from on-line participants
C. On site orientation ( area future development)
1. Use of equipment
2. Routine care per visit

3. General guideline for referral

4. Client education at each visit
5. Documentation protocol

The review of the literature supports the components
identified in the Enhanced Lower Extremity and Foot
Assessment Tool. Foot examination should include review of
medications and past medical history, assessing circulation,
skin integrity and presence of hyperkeratotic lesions,
temperature, nail condition, pain, bony deformities, skin
color, edemah varicosities, neurological status, evaluation
of footwear, education, and the need for referral.

The importance of client history is imperative to
identify at risk populations. Lia van Rijswijk (1998)
described at risk populations as client's with a history of
diabetes mellitus, smoking, atherosclerosis, deep vein
thrombosis, increased age, signs of neuropathy (numbness of
pain), limited mobility, coronary artery disease, spinal
problems, impaired vision, decreased hand dexterity,
decreased hip flexion, obesity, and peripheral vascular
disease. These populations exhibit greater need for lower
extremity and foot care assessment. Also, through
identifying a change in activities of daily living (ADLs)
from one visit to another providers may predict actual or
potential risk factors (Kelechi, 1996). An Enhanced Lower
Extremity and Foot Assessment should include circulation

(color, temperature, and palpation of pedal pulses). Observe

45

for evidence of bony deformities (bunions, hammer toes, or
overlapping toes) as well as skin changes (edema, corns,
calluses, fissures, lesions, wounds, and maceration).
Included in this Enhanced Lower Extremity and Foot Care
Assessment Tool (Figure 3) are the examination of toenails
for thickness, length, condition, and hygiene. Protective
sensation is assessed using a special instrument such as a
monofilament (Kelechi, 1996; Kelechi & Lukas, 1997). Lastly,
footwear is assessed for appropriateness of fit, wear, and
style (North Carolina Medical Society, 1995).
Use of Enhanced Foot Assessment Tool

The following text has a detailed description of ’how
to’ use the Enhanced Lower Extremity and Foot Assessment
Tool. This tool is designed for ease of use; thus, the
format of circling or use of a check box format is
consistent. Rarely, when ’other’ is used, a written
description is required. This tool has been developed after
a thorough review of the literature relevant to content and
design. An example of current practice, which parallels our
tool, is reflected in the 1996 Iowa Intervention Project
Nursing Intervention Classification (NIC) with the taxonomy
1660 entitled Foot Care (Appendix C). It is these authors
intent that the Enhanced Lower Extremity and Foot Assessment

Tool will provide succinct documentation for research

46

analysis and comparative evaluation from visit—to—visit by

providing two assessments on one form.

Use of Front Page of Assessment Tool

 

The front page of the assessment tool (Appendix D)
begins with basic demographic information such as client
name, date of birth, primary care provider, podiatrist, and
a brief past medical history. In addition, a series of
questions are asked that focus on activities, which may or
may not change from one visit to the next. The questions,
simple yes or no, invoke possible changes in ADLs,
medications, mobility, purchase of new shoes, visits to
primary care provider or a podiatrist that would solicit
further investigation. Additionally, with each assessment,
current medications are reviewed.

Providers of foot care are generally positioned in
front of, and below the client. Typically, the provider sits
upon a stool, while the client is seated in a chair;
thereby, allowing the client’s feet to rest upon the
providers lap. With this positioning as a point of
reference, this tool has been designed to enhance
documentation by clearly labeling right or left, dorsal or
ventral, anterior or posterior lower extremity parameters.
This format will attempt to decrease the number of

documentation errors.

47

The lower extremities are assessed for color (pale,
pink, ruddy, brown, cyanotic, or other), temperature (warm,
cool, or other), presence or absence of varicosities
(superficial, palpable, tortuous, or other), edema (1+, 2+,
3+, 4+, or other), circulation including the dorsalis pedis
and the posterior tibial pulses (0, 1+, 2+, 3+) and
capillary refill after blanching, documented in seconds.
Presence or absence of pain, coupled with location, is
recorded utilizing the Numeric Pain Intensity Scale (0-10).
The inclusion of footwear (proper or improper) gives insight
as to wear patterns, foot support (orthotic or prosthetic),
and sole, fabric, and toe box dimensions. Skin integrity is
delineated on a diagram using the first initial of the
following descriptive words: moist(M), dry(D), flaky(F),
bruised(B), opened(O), scabbed(S), or other. Space has been
allocated for selected further documentation and provider
signature.

Use of Back Page of Assessment Tool

 

The back page of the assessment tool (Appendix E)
focuses on the foot assessment. The presence or absence (yes
or none) of bony deformities are differentiated as bunions,
hammer toes, overlapping digits, prominent metatarsal heads,
or amputations. If present, the provider will circle the
abbreviation for the appropriate digit. Nail shape

(incurvated, c-shaped, ingrown, flat, other), nail color

(white, yellow, brown, black, other), nail texture (thick,
thin, crumbly, brittle, split, separated nailbed, other),
nail fungus (yes or none), and macerated web space is
delineated in the same fashion. Sensation may be assessed
using a 5.09 monofilament according to the Lower Extremity
Amputation Prevention (LEAP) program protocol (Appendix E).
Location to be assessed is identified on the diagram by a
circle; presence of sensation is denoted by placement of the
+ symbol in the circle or a — symbol, if applicable. The
test consists of one—second landmark touch with a 5.09
monofilament, one second mdnofilament bend, and one second
release. Next, skin changes of the foot are added to the
plantar and dorsal diagrams using the first initial(s) of
the descriptors: corn(K), callus(C), pain(P), redness(R),
fissure(F), wound(W), scar(S), or wart(Wa). Interventions
(soak, trim, file, lotion, massage, other) are documented as
yes or no. Recommendations for education or referral include
daily hygiene and inspection, drying between the toes, and
the opportunity for other education. Space has been
allocated for additional comments, if needed. The provider
recommends the projected interval for return to clinic

visit. Lastly, the provider of care signs the form.

49

Evaluation of Project
Practice

The format of this scholarly project allows for the
establishment of an enhanced foot assessment protocol to be
utilized by nursing colleagues who have opportunities to
provide foot care. These authors recognize the importance of
establishing protocols and guidelines, which provide APNs
with standards of care for preventive lower extremity and
foot health. Hempel (1990) noted a significant increase in
lower extremity examinations (25%) when practitioners
utilized an assessment tool.

Education

 

The Enhanced Lower Extremity and Foot Assessment
Protocol includes: access to a self—paced teaching—learning
module via the WWW and a documentation tool for
practitioners. Through the use of the WWW many convenient
opportunities exist; feedback from site authors, ability to
hyperlink to related content, and exposure to a visual
representation of the variables assessed. Unique to the WWW
is the ability to track the numeric counts of visitors to
the site.

Research

The Lower Extremity and Enhanced Foot Assessment Tool

allows the user to establish a client baseline and monitor

any deviations in a consistent manner. Omission of any

50

variable during documentation on the assessment tool is not
likely. The assessment tool requires a response in all
categories; including ’not assessed’ or ’none'. Each
categorical variable has a discreet value. Research tools
designed in this fashion have fewer data entry errors and
require less data cleaning.

In any observational encounter a degree of discrepancy
may exist; as two raters or observers, operating
independently, assign relative value to the attribute being
evaluated. Measures employed by this project to enhance
interrater reliability include: comparative visits aligned
on one form, encouraged use of lower extremity and foot
photographs, and an opportunity to access visually
interpreted variables via the world wide web.

Future Implications

 

A logical outcome of this teaching—learning protocol is
application to applied research; the study of finding a
solution to immediate and practical problems. A
quantitative, longitudinal, prospective research design
would be appropriate. Many Level II questions involving the
relationship between or among variables would be possible. A
correlational design will explore the relationship between
nail thickness and presence of fungus. A comparative design
supports or rejects a hypothesis, for example, does the

combined use of the teaching-learning module and

51

documentation tool lead to increased referrals and (or)
decreased complications.

These authors challenge advanced practice nurses to
reevaluate and analyze their learning needs related to lower
extremity and foot assessment. Refinement of assessment
skills, nursing knowledge, and past clinical experience
strongly suggests a greater probability of selecting

interventions, which improve client outcomes.

52

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American Academy of Orthopaedic Surgeons & the National
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it. In North American Medical Society Health Watch. North

 

Carolina Medical Journal, 56(12), 619—622.

 

 

American Diabetes Association (1996). Clinical practice
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Barrows, H. (1985) How to design a problem based

 

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Christensen M., Lee C., & Bugg, P. (1979). Professional
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Research, 28, 51—56.

 

Clark, R. (1987). The Teaching—Learning Event: a

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Conkling, W. (1994). Are your feet killing you? American

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Creedy, D., Hand, B., & Horsfall, J. (1992). Problem—
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Cross, K. (1976). Accent on learning. San Francisco:

 

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K. (1995). Performing foot screening for diabetic patients.
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Evans 8., Nixon B., & Lee, I. (1991). The prevalence and
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Fain, J., & Melkus, G. (1994). Nurse practitioner
practice patterns based on standards of medical care for

patients with diabetes. Diabetes Care, 17(8), 879—881.

 

Farris, N., Stoupa, R., Mendenhall, J., & Mazzuca, K.
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documenting patient outcomes. Computers in Nursing, 12(6),

 

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diabetes. The Diabetes Educator, 19(6), 522—531.

 

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Goldrick, B., Gruendemann, B., & Larson, E. (1993).
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teaching. ed. New York: Macmillan.

 

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Hempel, R. (1990). Physician documentation of diabetes
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Advanced practice nursing: Changing roles and clinical

 

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Highfield, M. (1988). Learning styles. Nurse Educator,

 

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56

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McCloskey, J., & Bulechek, G. (Eds.), Nursing interventions

 

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Jacono, B., & Jacono, J. (1995). A holistic approach to

teaching responsibility and acceptability. Nurse Educator,

 

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Texas: Skidmore—Roth.
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60

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61

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primary foot care clinics. Arch Family Medicine, 4, 46—50.

 

63

Appendix A
Quickstart Guide to Pilot Electronic Mail Page 1' of 3

MSU Computing Information Center Publication

Quickstart guide to PILOT Electronic
Mail

 

 

PILOT users can exchange email with other email users on the worldwide Internet. Every MSU
student and employee has an account on the PILOT email system This document describes how to
activate and use a PILOT account. Some terms you'll need to know:

CIC: Computing Information Center, 305 Computer Center. Phone 432-6200. The CIC has copies of
all the documents and software mentioned here.

MSU identification number: Students use PID. MSU employees use employee ID (ssn). For newly
admitted students, your PID was included in your admissions letter. For others, this number is
assigned when your applican'on for a PILOT account is processed.

PIN: Students use PAN. (Admissions gives PAN s to newly admitted students, usually on a form

included with this document). Employees use PIN. Others are assigned a PIN when their PILOT
application is processed. If you lost your PIN or PAN , contact the CIC.

MSUnet ID and password: Your network ID and password. These are created when you activate

your PILOT account. They are your authorization keys to many network functions, including PILOT
email. You can also use PILOT to change your MSUnet password.

What You Need

You need communications software and a computer connected to the Internet. The software must be
able to do vthO terminal emulation. Your Internet connection can be either by modern and phone line
or by direct connection. To begin using your account, you also need to activate it. See Aggya ting vour
account on the page below.

Connecting

In short, connect your computer to the Internet and then telnet to the address pilatmsu.edu
There are two ways to connect to the Internet. Either a dial-in connection or a direct connection.
Dial-in Connection

Within Michigan, the Internet and PILOT can be accessed by a loc lc ll Mi hN t
the document WWW

If you access the lntemet through a commercial service provider such as America Online, contact that
provider for help on telnetting to the Internet address pilot.msu.edu

http://www.msu.edu/user/cic/pilot/quickstart.hunl 9/21/98
64

Quickstart Guide to Pilot Electronic Mail Page 2 of 3

Direct Con nection
From an off-campus site connected to the Internet

0 Telnet to the lntemet address: pilotmsuedu (MSU students and employees)
or
Telnet to the lntemet address: msualummsuedu (Alumni)

From PC on MSU's Campus Ethernet

. Using DOS and PC/I‘CP software:
1. At the C:/> prompt. enter: tn pilotmsuedu (MSU students and employees)
or
At the C:/> prompt, enter: tn msualummsuedu (Alumni)

Using Windows 95:

1. Run the telnet application.
2. Pull down the Connect menu and select Remote System.
3. Enter one of , these host names:

pilot.msu.edu (MSU students and employees)

or

msualummsuedu (Alumni)

From Micro Lab PC

1. Use the HD menu to select PILOT (MSU Email System). If necessary, reset the PC to display
the HD Menu.
2. Enter one of these host names:
pilot.msu.edu (MSU students and employees)
or
msualummsuedu (Alumni)

From Micro Lab Mac or Mac on the Campus Etheth

1. Open (double click) the NCSA Telnet application. In the microlabs, NCSA Telnet is on the
server in the Communications folder.
2. Pull down the File menu. Select Open Connection.
3. Enter one of these host names:
pilotmsuedu (MSU students and employees)
or
msualummsuedu (Alumni)

Activating your Account

Before using PILOT you must activate your MSUnet ID and choose a password. To do this you need
to identify yourself to PILOT by your MSU identification number and your secret PIN (see definitions

http://www.msu.edu/user/cic/pilot/quickstart.hmtl 9/21/98

65

Quickstart Guide to Pilot Electronic Mail Page 3 of 3

above).

1. Connect to PILOT. When the login: prompt displays, enter pilot. When asked for a password,
press Return (Enter).

2. Read the screens carefully. Enter your MSU identification number and PIN when asked. .

3. Enter a secure passtrd when asked. An MSUnet ID will be created. On future logins use this
ID and password to enter PILOT.

4. The last activation screen will show your MSUnet ID. Remember your ID and the password
you entered in step 3. Your lntemet email address using PILOT is one of the following:
yourMSUnetID@pilot.msu.edu (student or employee account) .
yourMSUnetID@msualummsuedu (alumni account)

Using PILOT

Getting On-screen Help
‘ The bottom of most PILOT screens describes how to get on-line help.
Create and Send Mail

1. From the MAIN MENU press m

2. From the MAILBOX screen press m '

3. Enter the email address of the person you are emailing. To send to another PILOT user simply
enter their MSUnet ID. (Do ID searches from the MAIN MENU).

Enter the subject of yom' message. ,
Type the body of your message.
When done, press the esc key, then I, then s.

I

9‘9.“

Read Mail

1. From the MAIN MENU press m.
2. Use the arrow keys to select a message you want to read then press Enter.

Disconnect

Quit PILOT

Always exit via the MAIN MENU. From the MAIN MENU press q .

 

Revised: I 7 Feb, 1997 Feedback wglcgtml

 

CIC Home Page I I MSLJ Computer Store I l MSU Microlabs

 

http://www.msu.edu/user/cic/pilot/quickstart.html 9/21/98

66

Appendix B

Using Terminal Software to Dial in to MichNet / MSU http://www.msuedu/user/cic/net—diaI/terminalhunl

lof2

MSU Computing Information Center Publication

Using Terminal Software to Dial in to
- MichNet / MSU

This document provides general information on how to use terminal emulation sofiware and a mode- to
connect to MichNet (within Michigan). For information about access from outside of Michigan, see the
section Out 91 State. Popular emulation software is HyperTerm (Windows 95), Z-terrn (Mac), and
Kermit (all platforms).

 

What you need

You nwd a computer, modem, phone line, and commrmications software capable of vthO terminal
emulation. A number of capable commercial and shareware programs are available. Kermit
communications soflware works well and is available free from the Computing Information Center
(CIC). See More Help.

Configuring your modem and communications software

You may need to consult your modem and software documentation for instructions on how to make the
following settings. Kermit, as provided by the CIC, is preconfigured and does not require additional set
“P - . , .

[Macon or software setting [Value you should use

 

 

 

 

 

 

 

 

 

 

 

 

 

    

 

 

 

 

 

 

[Modern (DCE) speed .. [14.4 Kbps or higFest spwd supported
[Computer (DTE) speed [57. 6 Kbps or highest speed supported
[Error correction [On
[Type of error correction 42, ifV. 42 isn’t supported, use MNP4
[Fats compression
[Type of data compression t:j__hi.s;_ifV.42bis_isB't supported, use W§:n M” f _ i m
Wow control or handshalcing. Ifnot supported, use
Flow control , X,ON/XOFF but be aware that enabling XON/XOFF may interfere with
lainary file transfers).
"—- -__.___.__ : nnect whm rs dropped fl 4
TR clearing
[F ac. Ignore DTR
[Darabits _-l§__..... _ -- -- . fl -
[Stop bits [1
lW‘. chl‘iiifln.-. _.- 111199- _ - -.--.,- __
[Othersettflings " . . [Default settings H __

 

 

East Lansing MichNet dial-in numbers
The East Lansing MichNet dial-in numbers are:

e 517/318-2500 (ISDN, 56K) (Note: not listed with Michnet)
o 517/353-3500 (33.6k speed)

10/27/98 8:49 AM

67

Using Terminal Software to Dial in to MichNet / MSU http://www.msu.edu/user/cic/net-dial/terminal.hmrl

A comprehensive list of dial-in numbers is available from any of the following:

o The printed document MichNet Dial-in Access Numbers

0 Connect to any MichNet number and search the on-line phone list by entering help at the host:
prompt.

. Using the World Wide Web:
hm;://www.merit.edu/mjchnet/how.to.get.connected/michnet.nos

Connecting

1. Use your modem and communications software to dial the selected phone number.
2. At the host: prompt, enter the domain name address of the computer you want to connect to.
Examples:

Thom: pilot.msu.edu [PILOT email

[hostz stuinfo.msu.edu . Student information system em) _ _ -1 _. _._.

: , . Gateway to MSU IBM hosts. Use this address to go 16 magic, enroll,
[[host rbmgatemsuedu ibm. cl. msu. edu, and ais3270 . ‘

 

4.»mg.~-~-~ ~ -

-vw H7 -V, L i A ,

 

 

 

.m .- - Vr—A’” -4.

 

 

3. When prompted for your network ID and password, enter your MSUnet ID (same as your PILOT
ID) followed by @1911. edu Then enter your PILOT password. Login example

' ogm: smithjan@msu. edu '

. password (your PILOT password, it won‘t display) 1

.—-—.—-..~‘

you haven't yet activated your PILOT account, enter guest@msu.edu and press Return (Enter).
Then follow the instructions on Activating Your Account in the MSU PILOT Electronic Mail
handout. Login example:

 

 

 

 

 

 

login: guestZQtnsdetht (to? people without an active PILOT ID.
assword: (no password required)

 

 

Out of State

Outside of Michigan, a dial-in connection to the Internet can be made using the Mgr/MSU Wide
Am Dial-in (for fee) Services or through many different Internet service providers (ISPs). An
extensive list of ISPs is available at the web site:

b ://www. ahoo.com/Bus' es an /Co ' t et ervices/Intemet Access

More help

Consulting is available by email at consult@msu.edu or fiom the Computing Information Center
(CIC), 305 Computer Center, 432-6200. The CIC also distributes preconfigured versions of Mac
and MS Kermit free of charge.

 

Revised: 7May, I998 FMbgk welgme!

1 W ‘ k (31; masterly"511cm WuterStorel—‘IOMSU Miciblabsh

 

2 of 2 10/27/98 8:49 AM

68

Appendix C

Foot Care (1660)
DEFINITION: Cleansing and inspecting the feet for the

purposes of relaxation, cleanliness, and healthy skin

ACTIVITIES:

0 Inspect skin for irritation, cracking, lesions, corns,

calluses, deformities, or edema
0 Inspect patient’s shoes for proper fit
0 .Administer foot soaks, as needed
0 Dry carefully between toes
0 .Apply lotion
0 Clean nails
0 .Apply moisture—absorbing powder, as indicated
0 Discuss with patient usual foot care routine
0 Instruct patient/family on the importance of foot care
0 Offer positive feedback about self—care foot activities
0 IMonitor patient’s gait and weight disturbance on feet

0 IMonitor cleanliness and general condition of shoes and

stockings

0 Instruct patient to inspect inside of shoes for rough

areas
0 IMonitor hydration level of feet

0 ZMonitor for arterial insufficiency in lower legs

69

0 Monitor legs and feet for edema

0 Instruct patient to monitor temperature of feet using the

back of the hand

0 Instruct patient in the importance of inspection,

especially when sensation is diminished

0 Cut normal thickness toenails when soft, using a toenail

clipper and using the curve of the toe as a guide

0 Refer to podiatrist for trimming of thickened nails, as

appropriate

Iowa Intervention Project (1996).

70

Appendix D

WEI-n10 1

Enhanced Lower Extremity and Foot Assessment Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Since yolrhstvkit haveyon (yonr).... Medientions Medic-no- Clio-1N...
Date Date

medicationsclnnged?YesD NoCl YesCl Not] nut-am

changedyourADLs? YesD NoCl YesEl NOE] magnum

falkn? YesElNoCl YesElNoEl .

pmehsednewshoes?YesD NOD YesD NoEl Podiatrist

seenaPCP/podiatristflostl NOD YesD NOD mm

Cil'eloalfilt‘liflhfl'dhu,”

chm-mamma- "

Lower-Extremity

lit-m M W J

Color Right-PalePhKRuddy,&wn,Cynnotic,ahc-r Right-PakPhrLRuddy,Blwn,Cyl1aic,odter
un-nnmhamnmammqumeamr un-nmmhanmquhmacnmauue

Temperature Right-WmCooLothc m-wmmm
ud-Wmnaflmma un-wmnmnidu-

Variedtioo Right- WWTMM - Right- WhlpobleTmother
NoneE] Noel]
Iefi- Wanner-Mame Lon- WWTmm
NoneD bit-3:0

Eon-n Right 1+, 2+, 3+, 4+ other Lott t+,2+,3+,4+ otha Right 1+, 2+, 3+, 4+ orbs tar t+,2+,3+,4+ one
Naretl NmeCl NoneD Nanci]

CM RightDP 0,I+,2+,3+ LeItDP 0,I+,2+,3+ RightDP 0,I+,2+,3+ LeftDP 0,I+,2+,3+
RightP'l‘ 0,I+,2+,3+ LefiPT 0,I+,2+,3+ RightPT 0,I+,2+,3+ LefiPT 0,I+,2+,3+

ogggnmt ’1 Same on Same 5gp Same um Samm‘

mine-don N00 YesEl ifyeo,doocriho N00 YesD ifyadeou'ihe

SeoIoO-lo

«uneven; egg &fle

Footwear Shoot Proan Improan Shoes Propel] lmpropeD
Socks Props D Improper D Socks Proper El 1mm [J
Orthodco NoDYesCl RightEl Lead 01m NoDYesD 11131110 Leno

Prosthesis NoDYesU 0&0 use W NoEIYesD 411110 Lean

Shhintogrity NoneCl

M-Moist

1'5ka

B-Bruisod

0-0pa1

S-Scohhod

otherdeoerihe

Additional

Comments:

Nunel’rovidor

 

 

 

 

 

 

Wemamawmxmmw 10-3-98

71

Bunions
l-lammer toes

Prom inent met held

lnwrvated
C

Flat

White
Brawn
Black

MRI-g-
Minty-es

Sena-mas.”
WM
thoOwith+ a'—t‘w

K-oon(s)
C-enl‘cs)
P-ph
R-rodn.
F-h'oo)
w-w—eo)
s-oenrm
Wa-Ms)
’methediaumto
m
Sedation ”elation.
mother
Recommendation.

Additimal Cornrnmts

nmuuwunuhn

Figure 3. Enhanced Lower Extremity and Foot Assessment Tool

 

(Clark—Ehnis,

Appendix E

R4 Rl'
R5 R4 R3 R2 RI
R2

R4

R4
R3
RS R4
R5
YesD Nate 0

R50 R40 R30 R20 1201.30 UCLSD

MFG-0 2
Yes

M
R4 R3 R1
R4 R3 R2 R1
RI

R5R4R3R2RI
R5R4R3R2Rl
R4 R2
R4R3 RI
R4 R2Rl

RI

Yeo0
R4
R50 R40 R30 R20 120 L30 “01.50

NmeU

Daily hygiene. dry

 

 

 

ChileyAMhlnvisod l0-3-98

1998)

72

Appendix F

Enhanced Foot Assessment http://pilotmsu.edu/~clarkm‘

Role of the APN
Normal Foot Structure.

 

 

 

 

Skin Integrity Welcome to our Web Site!

Bony Deformities

Dystrophic Nails This site was developed by Margherita P. Clark RN and Wendy A. Ehnis RN. We
Effects of Diabetes welcome inquiries or suggestions. Please feel free to contact us at either

Foot Assessment, clarkm10@pilot.msu.fiu or ehniswen@ i1 su.

 

Related Links
Introduction

A key component in maintaining physical independence is the promotion of
regular foot care and the prevention of potentially debilitating foot injury or loss of
function. Early detection and management effect a difference between
limb-threatening complications and a return to full potential. Healthy feet are a
prerequisite for balance and stable ambulation. Immobility can be considered a
strong risk factor in predicting systemic diminution of physical and psychological

health.
HEALTHY FEET ARE HAPPY FEET!

This page has been accessed times as of 2/26/99

73

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‘ Relate :1 Links 7;;
Discussion

Foot care is an integral part of optimal health maintenance; and historically a missed opportunity.
Many nurses possess limited assessment skills and minimal clinical expertise in dealing with lower
extremity care. Many are unaware that foot care is within the scope of nursing practice. indeed. the
ability to differentiate normal changes from pathological threat and deteCLion of problems followed by
initiation of appropriate care and ongoing patient education is integral with nursing and the promotion
of health.

The value of the advanced practice nurse (APN) in providing expert knowledge. coupled with
strong decision making skills. enables the APN to function in a number of roles. As a facilitator, the
A PN may coordinate teaching-learning opportunities that enhance reciprocal learning. The role of the
advanced practice nurse in primary care is multidimensional. The American Nurses‘ Association‘s
(ANA) former Council of Nurses in Advanced Practice defines the APN as (cited in Hickey. Ouimette,
& Venegoni): . ’ .

Nurses in advanced clinical practice have a graduate degree in nursing. They
conduct comprehensive health assessments. demonstrate a high level of
autonomy and expert skill in the diagnosis and treatment of complex
responses of individuals, families. and communities to actual or potential
health problems. They formulate clinical decision to manage acute and
chronic illness and promote wellness. Nurses in advanced practice integrate
education. research, management, leadership, and consultation into their
clinical role and function in collegial relationships with nursing peers,
physicians and others who influence thc health environment (p.22). This
definition clearly illustrates the multidimensional nature of the APN.

Clcarl y. the val no of a standardized protocol for lower extremity assessment and care by nurses
should not be minimized. in a study of 6 nurse practitioners. Fain & Melkus if 1994) found
documentation of foot exams in 23% of charts reviewed. Despite lack of written adherence, in a 1989
NIH survey, over 80% of primary care providers indicated performance of foot, neurological and
circulatory exam in diabetic patients one or more times per year. Results of a 1990 study by Hempel
suggest that use of a flow sheet and nurse-managed patient education clinic significantly enhances
compliance and documentation to standards in a diabetic population.

Pelican et al. ( 1991 )rcports in the Journal of Gerontological Nursing, the inception of a nurse run
well foot care clinic, with the development of an assessment tool. instructional videotape and
informational brochure. Kelechi and Lukacs (1996). both Master’s prepared nurses, recognizing foot
care as an "integral part of the promotion and maintenance of health" (p. 722) have devised
"comprehensive lower extremity assessment, hygiene and nursing interventions that address problems
associated with toenails and skin. it also includes patient and/or caregiver education and the
identification of complications that need to be referred to a physician or specialist." It is the purpose of
this project to develop for practitioners an assessment and documentation protocol, along with a
self-directed teaching—learning module to deliver foot care in a geriatric non-traditional setting.

74

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Supportive Footwear
Normal Nail

Age Relatfl Qhanges

 

 

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Discussion

Each foot is made up of 28 bones, 33 joints, and a complex web of greater than
100 tendons, muscles, and ligaments (Conkling, 1994). Acting as a shock absorber
for the leg and spine, the plantar arch of the foot contacts the ground at only the
heel and ball. Skeletal muscles further shape the foot, holding the bones in position
and serving as attachments for tendons. Cord-like tendons are held in place by
broad ligaments to allow foot and ankle flexion and extension.

The average American walks 4-5 miles per day. 70,000 miles lifetime, with the
feet supporting accumulative pressure of several 100 tons. It is estimated that l in
6 Americans (43.1 million) suffer from foot discomfort or disease. Women are 9
times more likely than men to develop pain and deformity; causative factors include
poorly fitting shoes, shoes that are too small for the foot, and heels higher than 2%
inches (North Carolina Medical Society, 1995). A survey of 813 bunionectomies
revealed that 94% involved females (Conkling, 1994). Medical costs and
associated time off of work are estimated at $3.5 billion per year (North Carolina
Medical Society. 1995).

The femoral artery supplies the majority of blood to the legs. One of its
branches descends down the top of the foot forming the dorsalis pedis artery. Its
pulse can be palpated on the medial dorsal foot (great toe side). The posterior
branch is the posterior tibial artery, palpated behind the medial malleolus of the
ankle. These vessels supply the foot with blood.

Venous circulation is a low pressure system. The blood from the leg and foot
must flow upward to the heart with the help of one-way valves, muscular
contraction. and a pressure gradient. Venous return is impeded and stasis results
with impairment of the aforementioned sturctures (tortuous and dialated veins, lack
of muscular activity. and prolonged sitting, standing, or lying).

75

Supportive Footwear htth/pllot.msu.odu/~clarkm10/newpages.htm

 

 

. HOW ' 3 3:33 I. UP ’ .. ._ _ if; SUPPOIHVE Footwefl ‘:;:j . . NW, ,..1I.‘1.ail_._i§}
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Ass Relates Changes?

0 O
Discussron

The average American walks 4-5 miles per day, 70,000 miles lifetime, with the feet supporting a
cumulative pressure of several hundred tons. Each road warrior is made up of 28 bones, 33 joints and a
complex web of greater than 100 tendons, muscles and ligaments (Conkling. 1994).

Careful assessment of footwear by the APN for signs of uneven wear, friction, pressure and poor fit is
basic to preventive foot care. All footwear should be replaced when wom, and inspected periodically for
torn linings or rough edges. Padding may restore neutral functions, and prevent repeated microtrauma of
the foot in patients with degenerative changes (Helfand, 1989).

Leather 0r canvas shoes allow moisture to evaporate, and should be purchased in the afternoon. when
the feet are largest. Cotton or wool socks should be worn. instead of nylon, to absorb moisture and wick it
away from the foot. White socks are preferable if lesions exist. entry of dyes into the wound is eliminated
(Ruscin et al, 1993). Patients should never go barefoot, thus reducing the risk of penetrative or abrading
injury from foreign body (Helfand, .1989).

Desirable shoe features include padded tongue and ankle collar, a flexible curved sole. arch support.
comfortable well-fitted insole, a well cushioned heel with a firm heel counter and a padded Achilles'
tendon collar.

The client's shoe should fit their lifestyle. Standing for several hours a day or walking on hard surfaces
requires a shoe with a thick sole and soft upper.

When buying shoes consider these points:

[3. have both feet measured: full weight bearing on measured foot.

r; stand on one foot at a time; wiggle toes; stand on tip toes; make sure. foot and shoe bend at the
same place.

5 don't buy with the idea of breaking a shoe in; your foot may alter in an uncomfortable shoe, but the
shoe will not

I? allow 112 inch of space between end of big toe and shoe.

‘9 widest part of the foot should fit comfortably in the widest part of the shoe.

shoe shop in the middle of a normal day, not early in the morning, since feet swell as the day

progresses: wear the type of socks or stockings you intend to wear with the shoes.

F when considering a shoe style. trace your foot on paper and place the particular shoe over the

' tracing if your foot extends beyond the. borders ofthe shoe...it's not for you!

as;

 

    

 

 

i'l’his is an example of supportive footwear.

 

 

76

Normal Nail

http://pilot.msu.odu/~clarkm10lnormalt .l‘

HDmE . g _ Up _ h ., SupportiveFootw'ear Normal Nail J

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"MvM.~,~;,x?tha“,w-_”fittwmw ”’wa'l warm,..,,,W,”~MMW.M,.~,m~wp.cw W's-WWW, , . "““ ’ nu W‘

Discussion

The primary function of the toenail is to provide protection for the soft tissue of the toe. The nail.
normally measures l/l6 of an inch in thickness and is comprised of three layers; a dorsal thin
covering, a thicker middle layer, and a deep inner layer derived from the nail bed. The nail bed is
made up of epithelium, a rough surface of longitudinal waves which interface with grooves on the
underside of the nail plate, facilitating adherence of the plate to the bed. The hyponychium smoothly
seals the boarder between the distal end of the nail and the bed. Normal nail color is translucent with
a pink tinge reflecting the highly vascular matrix. As the nail grows. extending beyond the matrix, the
translucent color is lost and becomes white.

77

Age Related Changes http://pilot.msu.edu/~clarkm10/newpage1.r-i

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Age Related Changes ;

 

Discussion

The process of normal aging inherently involves adaptation to change. Physical challenges are
observed in every organ during the lifespan continuum. The epidermis of the skin thins, and the dermis
decreases in elasticity and vascularity. Nails become brittle, with a 30~50% slower growth rate.
Slowed cell reproduction and repair, coupled with a diminished immune response sets the stage for
delayed healing of trauma or ulceration. The pumping ability of the heart slows and venous return is
delayed. Increased systolic blood pressure interfaces with added vascular resistance at the cellular
level, precipitating foot edema, impaired sensation, and a diminished response to pedal insult.

Bony landmarks become more prominent as subcutaneous fat decreases in the periphery. Joints rest
in greater degree of flexion, develop increased potential for stiffness, deformity, inflammation and
pain. Muscular changes create slowed movement, tendon shrink and harden, and reflexes diminish.

Neurologically, decreased proprioception and impaired balance may result in gait disturbances or
imbalance. Healthy, older individuals exhibits a reduction in stride length and velocity. Women
develop a narrow-based, waddling gait, while men increase the flexion of their posture and widen the
base of support. Sensory changes may include an altered perception of pain due to neuropathey, as
well as decreased visual acuity and peripheral vision. Minor, unattended trauma may result in
progressive ulceration as the result of lack of protective senory input. Potential implications exist for
impaired mobility, loss of function. injury from falls and concurrent decreased independence.

78

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Discussion

The outermost layer of skin. the epidermis. is comprised of 5 sub-layers and is estimated to be 75
microns to 0.6mm thick. thinning as one ages. This organ‘s surface layer, or "homy" stratum comeum. is
subjected to daily use and exposure to the environment. it is protected by an acid mantle. which retards
certain bacterial and fungal proliferations, a protective water-repellent covering (Alterescu & Alterescu,
1988).

. The innermost layer, the dermis, contains blood and lymphatic vessels, nerves and cellular components
such as mast cells, leukocytes, macrophages, and fibroblasts (Alterescu & Alterescu, 1988). The dermis
decreases in vascularity. elasticity and defensive ability as an individual ages, leading to a loss of water
content and slowing of rc-epithelialization.

Decreased circulation to the skin of the appendages results in diminished oxygen and nutrients at the
cellular level. Reduced production of sebaceous and sweat glands couples with decreased water storage
to produce a rough, scaly texture with decreased skin turgor. Diminished tactile sensation is caused by
neurosensory changes; pain or friction to surface tissues may go unrecognized. Structural changes occur
simultaneously; the loss of subcutaneous plantar fat pads allows for less tissue insulation and vessel
support (Jaffe, 1991). The aforementioned physiological functional changes categorize the elderly foot
as identifiable at high risk for impaired skin integrity (Jaffe, 1991).

 

Calluses. or diffuse areas of thickened skin, may fonn on bony
prominences. or any area where soft tissue is exposed to
prolonged unrelieved pressure. friction or shear (Lukacs,
1997). Tensile stress may also be a factor in callus formation.
Digital deformity. such as toe alignment can cause the head of
one phalanx to be compressed against the base of an adjacent
metatarsal-phalangeal articulation. The continued pressure
may create a hyperkeratotic lesion (Helfand, 1989) The
fonnation of additional layers of skin reflects the body‘s
attempt at a protective mechanism. Calluses may also form
under weight bearing areas such as the heel or metatarsal
heads. Wearing slippers or ill-fitting shoes that do not have a
:snug hccl counter predisposes an individual to thickened, dry
ihecl skin (Lukacs. 1997).

 

 

 

 

 

1f the cause of the callus is not identified and eradicated,
pressure may intensify as the keratin layers build. A central
nucleus develops and a corn (heloma) is generated. The
pressure acts as a foreign body. inflammation is common, and
ulceration may occur (Helfand, 1989). Appropriate
documentation should be made upon assessment of callus, corn
or ulcerous conditions, noting the location. width and estimated
depth in centimeters. as well as surrounding redness, dryness
or bruising (Dorgan et al. 1995 ).

 

 

 

 

 

 

 

79

Skin Integrity himzllpllot.mau.odul~elanun10Isldn.htm

Skin care may be accomplished by the advanced practice
nurse to debride the hyperkeratotic lesion with a pumice stone.
foot file or rotary tool, followed by application of an emollient.
There is little data available comparing the method of
intervention. but general parameters include thickness of callus,
degree of expertise. and level of associated patient discomfort
(Lukacs, 1997). Most calluses cannot be completely removed,
but thinning may bring about relief (Lukacs, 1997). A large
foot file may be applied in one direction until the skin is
smooth and even with the foot surface (Ruscin et al. 1993l.lt is
not recommended that patients apply commercial products to
aid in corn removal, as the concentrations of acid may produce
a second degree chemical burn (Helfand, 1989').

 

 

 

 

Insertion of a small foam pad or ring interdigitally may serve to
separate the web space occupied by a soft corn and cushion

{ Picture not available surrounding tissues (Lian. W92). Used circumferentially. the
corn pad will cushion areas of friction and allow relief from
direct pressure.

 

 

 

Dryness of the skin, decreased elasticity and keratotic
thickening may produce fissures which can extend into the
dermis. Assessment of depth. size, drainage and condition of
surrounding tissues is imperative (Lukacs, l997) Recent
documentation of acceptable interventions includes the
application of a solid sheet of hi gh—gl ycerin content hydrogel,
which acts both as a cushion. and possesses bacteriostatic and
anti-fungal qualities (Lukacs, 1997). Keratolytic compounds, in
an emollient cream or lotion base utilize concentrations of urea,
alphashydroxy acid, lactic acid and salicylic acid to exfoliate
(Lukacs. 1997). Application of any petroleum-based barrier
moisturizer to soften the skin should be preceded by a
moisture-containing product. and be applied 2-4 times per day
and after bathing (Lukacs. I997).

 

 

 

. l
5Maceration of the interdigital web spaces may develop from
the use of emollients between the toes, the inability of the
elderly to dry their feet completely. or arise due to friction from
lateral pressure of shoes or digital contractures (Kosinski &
Ramcharitar, 1994). Lamb’s wool or cotton gauze is used to
separate and dry the interspace, but does not encircle the digit.
(Kosinski & Ramcharitar. I994). The patient is encouraged not
to soak their feet, to dry between the toes completely, and
switch to shoes with a roomier toe box (Lian. 1992).

 

 

 

 

 

 

 

80

Home 1.1} Role ofthe APN Nomalf‘oot Structure Skinlntegrity fr

 

 

 

 

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A V Felated Links

Discussion

The average American walks 4-5 miles per day, 70,000 miles lifetime, with the feet supporting a
cumulative pressure of several hundred tons. Each road warrior is made up of 28 bones, 33 joints and a
complex web of greater than 100 tendons, muscles and ligaments (Conkling, 1994). It is estimated that
1 in 6 Americans (43.1 million) suffer from foot discomfort or disease. Women are 9 times more likely
than men to develop pain and deformity; causative factors include poorly fitting shoes, shoes that are
too small for the foot. and heels higher than 2 1/4 inches (North Carolina Medical Society, 1995). A
survey of 813 bunionectomies revealed that 94% involved females (Conkling, 1994). Medical costs and
associated time off work are estimated at $3.5 billion per year (North Carolina Medical Society, 1995).

Generalized musculoskeletal changes associated with. aging include loss of muscle fiber, strength and
limitations in mobility. Ligaments become stretched. resulting in joint stiffness and reduced motion.
Postural changes include a shift from the hips as the center of gravity, to the chest (Jaffe. 1991 ). In
order to increase stability, the elderly begin to walk with their feet directed outward, which does not
follow the design or last of most shoes (Helfand, 1989). This alteration in gait elicits a foot-shoe
incompatibility that accentuates pressure points on the feet (Helfand, 1989).

81

Bony Deformities http://pilot.msu.edu/~clarkm10/bonyJ‘

 

Bunions are the result of a subluxation of the
metatarsal-phalangeal (MP) joint of the great toe, creating a
lateral angulation that produces pressure from two distinct
directions. The MP joint becomes enlarged, and may be
reddened and inflamed from friction with a toe-box or instep.
Either an inherited joint weakness or poorly fitting shoe-s may be
culpable.

The top photo demostrates a bunion on the 1 st digit and a
hammer toe on the 2nd digit. There is evidence of a corn on the
2nd digit.

 

 

A hammertoe may be caused by lateral derangement of the
second toe due to a bunion. This deformity is a combination of
extension at the MP joint and flexion at the proximal
inter-phalangeal (PIP) joint. Pain results as the plantar muscles
tear and soft tissue lesions form from friction at the dorsal PIP
joint. with corn development at the tips of the toe (Lian, 1992).
Conservative treatment with hammertoe pads, designed to fit
over the toe and hold down the PIP joint may be used in
conjunction with a roomier, high toe-box shoe (Lian. 1992). The
treatment provides symptomatic relief and is not curative.

 

 

 

 

 

Hammer toe

 

 

 

Client Education

Careful assessment of footwear for signs of uneven wear, friction, pressure and poor fit is basic to
preventive foot care. All footwear should be replaced when worn. and inspected periodically for torn
linings or rough edges. Padding may restore neutral functions, and prevent repeated microtrauma of the
foot in patients with degenerative changes (Helfand, 1989). Leather or canvas shoes allow moisture to
evaporate, and should be purchased in the afternoon, when the feet are largest. Cotton or wool socks
should be worn, instead of nylon, to absorb moisture and wick it away from the foot. White socks are
preferable if lesions exist, entry of dyes into the wound is eliminated (Ruscin et al. 1. 993). Patients
should never go barefoot, thus reducing the risk of penetrative or abrading injury from foreign body
(Helfand, 1989).

Daily inspection of the feet should be encouraged, twice daily for patients at high risk for

complications. using a mirror to enhance visualization. if needed. Assessment should include blisters,
sores or cracks in the skin, changes in toenails, skin temperature and color (Ruscin et al, 1993).

82

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Discussion

Onychomycosis represents 50% of all nail disease (Elewski, 1996) and the most difficult to treat of
all skin mycoses. Fungal infections of the toenails are almost always caused by a dermatophyte fungi,
with distal and lateral subungual onychomycosis being the most common (Roberts, 1993). These
molds, and occasionally yeast, infect an already diseased or traumatized nail. Arterial circulatory
disorders, peripheral nerve disease, disturbances of the venous and lymphatic drainage systems, as well
as chronic paronychia are common predisposing factors (Haneke, 1991). Onychomycosis may cause
disturbances in nail growth with loosening or separation of all or part of the nail plate from the nail bed
at the free edge (Helfand, 1989). Anti-fungal drug treatments remain difficult to enact because
predisposing factors are usually not amenable to therapy. Patience combined with optimal patient
compliance are mediators. A high recurrence rate is estimated at 80 - 90% (Haneke, I991).

83

uysrropmc Nails http://pilot.msu.edu/~clarkm10ldystroph.

 

It has been estimated, that fungal (onychomycosis) infections
explain 50% of all nail diseases. Types of fungal infections are
differentiated by causative pathogen and the method of fungal
invasion into the nail plate. The literature supports that distal
subungual onychomycosis is the most common form of fungus
(typically Tricholphyton rubrum) invading the distal nail plate and
hyponychium (Elewski, 1996;Scher, 1983; Hobday, 1995; Tierney,
McPhee & Papadakis, 1997; Berg, Cantwell, Heudebert, &
Sebastian, 1993). Trauma to nails plays an important role as a
precursor to onychomycosis. Dermatophytes, yeasts, and
non-dermatophytes molds are the three major groups of fungi that
can cause onychomycosis (Hobday, 1995; Elewski, 1996).

 

 

IOnychomycosis can be visible by changes in the texture, structure,
and presentation of one, several, or all nails of the upper and lower
extremities. Typically, the nail plate becomes thick and discolored
(onychauxis) and the damaged nail becomes brittle, crumbly, and a
subungual hyperkeratosis is present with an uplifting of the nail
plate (onycholysis). Generally, subungual hyperkeratosis
(onycholysis) may be regarded as the most reliable sign of
onychomycosis (Scher, 1983). A ‘musty’ odor may also accompany
these findings.

 

 

 

Occasionally, the surrounding skin, proximal nail fold, near the
fungal nail may be involved (Hobday, 1995). The proximal nail fold
and the two lateral fold makeup the three borders the nail plate. The
raised portion of the proximal nail fold is the cuticle. Paronychia is
acute pain and swelling associated with a past trauma to the nail,
poor nail care, fungal infection (onychomycosis) or an ‘in—grown
nail’ (onychocryptosis) around the lateral nail fold (Berg,
Cantwell, Heudebert, & Sebastian, 1993).

 

 

 

 

 

 

 

Grossly elongated nails (onychogryphosis) may be a result of poor
hygiene or neglect in foot care. Onychogryphosis may result in
extreme curvature with a ‘hooked’ configuration (gryphos, meaning
"claw") to the nail (Omura & Rye, 1994).

Subungual hematoma can be defined as trauma resulting in the
collection of reddish-blue blood in the nail bed. Increased pressure,
under the nail plate. causes extreme tenderness on palpation (Berg,
Cantwell, Heudebert, & Sebastian, 1993).

no picture at this time

 

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Discussion

One group at heightened risk for foot and lower extremity trauma and impaired skin integrity is the
diabetic population. Accelerated atherosclerosis of the diabetic cardio-vascular system, diabetic
retinOpathy and sensory polyneuropathy all contribute to a higher risk of poor tissue perfusion, trauma,
ulceration, gangrene and lower extremity amputation for the diabetic patient. The prevalence of
diabetes in the United States was estimated by the National Institutes of Health in 1995 at 16 million
individuals. Diabetes mellitus, complications notwithstanding, ranks as the 7th most common principal
diagnosis requiring a patient to be seen by their primary care provider (Ostergaard & Schmittling,
1997).

Alarming statistics for lower extremity amputations reveal that 50 - 70% of all non-traumatic lower
extremity amputations involve diabetic patients (Ahroni, 1993); the Centers for Disease Control (CDC)
reports 54,000 such procedures are performed yearly (1995). Through early detection and treatment. it
has been estimated by the CDC that half of these lower extremity amputations are preventable.
Recommendations by both The American Diabetes Association (ADA) and the CDC include an
examination of the feet of diabetic patients by the primary care provider at every visit (1991).

Disruption of arterial flow from micro and macro angiopathies and atherosclerosis occurs at a
heightened rate in the diabetic patient (J affe, .1991). Thickening of the capillary walls, restricted blood
flow to the site of invading bacteria (typically polymicrobial) and impaired oxygen perfusion at the
cellular level combine to evidence as pale, cool extremities with shiny skin and a weak or absent pulse
(Garrison & Campbell, 1993'). Almost 20% of diabetic patients with palpable pedal pulses do have
significant small vessel disease (Kosinski & Ramcharitar, 1994).

 

85

Effects of Diabetes http://pilot.msu.edu/~clarkm10leffects.h

Although foot lesions can arise anywhere pressure or repeated
friction occurs, common hot—spots are under plantar calluses, in the
toe-nail bed or in tandem with neuropathic ulcers (Garrison &
Campbell. 1993). The sequela of minor trauma, ulceration and
eventual failure of a wound to heal occurred in 72% of lower
extremity amputations studied (Pecoraro).

 

 

Neuropathic ulcers may present as red, warm, painless, circular
lesions. surrounded by callus, and located over bony prominences.
Deformity, muscle weakness, dry skin and tight shoes have all

, been implicated as causative (Dorgan et a1, 1995).

 

Autonomic, sensory and motor neuropathies act together to create
foot ulceration (Ahroni, 1993). Diabetic impairment of the
autonomic nerves causes a reduction in blood flow and glandular
activity, resulting in drier skin that is prone to fissures and
infection (Garrison & Campbell, 1993). Motor neuropathy leads to
muscle weakness and changes in the shape of the foot. "Weaker
intrinsic muscles allow flexors to predominate, lesser toes become
hammered or clawed. Toe tips may ulcerate" (Ahroni, 1993).

 

 

 

 

86

Effects of Diabetes http://pilot.msu.edu/~clarkm10/effectsJ'

Sensory neuropathy allows patients to experience a progressive
insensitivity to pain. pressure and temperature. To test for sensory
loss, "the APN applies a 5.07 (IO—g) monofilament perpendicular
to the skin until it bends, to the count of l—second touch, l-second
bend. and I second lift. Four areas are screened, including the
distal fat pad areas of the great and fifth toes, and the metatarsal
head areas below these two toes" (Kelechi & Lukacs, 1996).
Eyesight may be impaired by diabetic retinopathy or macular
degeneration to the extent that; it is not the protective sense of
sight, but the foul smell of an infected wound that prompts the
patient to seek attention (Garrison & Campbell, 1993).

 

 

 

 

 

 

 

87

Effects of Diabetes

 

 

 

 

 

Posterior tibial pulse

http://pilot.msu.edu/~clarkm10leffectsJ

Thus, the APN should check each foot for the presence of dorsalis
pedis and posterior tibial pulses. with referral to specialists for
absence of pulses. Skin temperature should be checked by feeling
both feet simultaneously to compare any "hot-spots" that may
indicate problems. The dorsal surfaces of the hands may be used.
with detection of any difference greater than 2 degrees Centigrade
both determinable and potentially significant (Dorgan et al, 1995).
Capillary refill is measured in seconds after blanched pressure to
the nail bed. Less than 3 seconds is consistent with a normal
finding.

 

 

 

 

Capillary nail bed pressure

 

 

 

 

 

 

 

88

Hour: 1 V I :1 Bole minesr’tt Nominal Foot Structure __ ~ '3’};er Integrity

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£5.51 Bony Deformities 1*than 11“: “3115 Eff-3'35 Cf Difll‘fiiéig Foot Assessment i

 

.s. ""wwm v'i¢t.-.~ .-.'~J-.\Ig~ m aw..." ,“v"./.v.~a r». a, ,fiIqu New 6* in“ w." ‘W‘ ! w ”v ‘M .

Related Links [jig

m-‘vufllmm “‘H~o..-..,MVN,#-n—

Assessment Tml Lower Extremity and F not Care
- - t The value of standardized protocol for lower extremity assessment and care by nurses
should not be minimized. Foot care is an integral part of optimal health maintenance; and
historically a missed opportunity. The use of flow sheets significantly improves the
assessment and documentation of foot care (Hempel. 1990). Through the use of
standardized assessment tools and consistent documentation, retrospective research studies
can provide nursing knowledge in the client outcomes related to routine foot care and the
reduction of complications in high risk populations. Comprehenswe assessment should
include:
1. Documentation flow sheets
A. Demographic information and current health history
,1 .Review of recent history. medications and changes
2.Assessment of ADLs, gait. balancefalls and footwear
3.Assessment of feet and lower extremities

a.Color

b.Temperature

c.Varicosities

d.Edema

c.Circulation

f.Capillary refill

g.Pain

h.Skin integrity

89

Foot Assessment http://pilot.msu.edu/~clarkm10/protocol.htm

i.Bony deformities
4Nail assessment

a.Shape

b.Color variations

c.Texture

d.Fungal changes

c.Maccrated web space

[Sensation

g.Sl<in changes
5.]ntervcnti0ns to include:

a.Soak feet

b.1nspect and dry between toes

c.Nails debrided with orange stick, hyponychial
border located. nails trimmed and filed

d.File calluses and corns
e.l-,otion massage to feet
llApply treatment ointments, if applicable
g.Recommendations. education and referral
6.Completi0n of documentation form per protocol
7.Narrative note. if applicable
ll. Teaching-Learning Module to include
A.World Wide Web site access of interactive teaching material

1.Digital photographs of common foot and nail conditions
and bony deformities

2.E~mail feedback from on—line participants

B.On site orientation (area future development)

2 of 3 4/8/99 2:37 AM

90

Foot Assessment

Sofa

http://pilot.msu.edu/~clarkm10lprotocolhtm

1.Use of equipment

2.Routine care per visit
3.Gcncral guideline for referral
4.Client education at each visit
5.Documentation protocol

The review of the literature supports the components identified in the Enhanced Foot
Assessment Tool. Lower extremity and foot examination should include review of
medications and past medical history, assessing circulation, skin integrity and presence of
hyperkeratotic lesions. temperature, nail condition. pain. bony deformities. skin color,
edema. varicosities. neurological status. evaluation of footwear. education, and the need
for referral.

The importance of client history is imperative to identify at risk populations. Rijswijk
(1998) described at risk populations as client's with a history of diabetes mellitus.
smoking, atherosclerosis. deep vein thrombosis, increased age. signs of neuropathy
(numbness of pain). limited mobility, coronary artery disease. spinal problems. impaired
vision. decreased hand dexterity, decreased hip flexion. obesity. and peripheral vascular
disease are in greater need for foot care and lower extremity assessment. Also, the need for
identifying a change in activities of daily living (ADLs) from one visit to another(_Kclechi,
1996). An Enhanced Lower Extremity and Foot Assessment should include
circulation (color. temperature, and palpation of pedal pulses). Also. observe for evidence
of bony deformities (bunions. hammer toes, or overlapping toes) as well as skin changes
(edema. coms, calluses, fissures. lesions, wounds. and maceration). included in this
enhanced foot care assessment are toenails for thickness. length. condition. and hygiene.
Protective sensation is assessed using a special instrument such as a monofilament
(Kelechi, 1996; Kelechi & Lukas. 1997). Lastly, footwear is assessed for appropriateness
of fit. wear, and style (North Carolina Medical Society, 1995).

4/8/99 2:37 AM

91

How to use the Tool http://pilot.msu.edu/~clarkm10lhowtousehtm

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Use of Enhanced Lower Extremity and Foot Assessment Tool

-. ,. 1 - : ~ .. .1 a- -: an- r 5‘ I .
LL"; C.,-(Te ”LOWE. L:_' Cull-CT. 1.55 a 001.63. LCM. C1:::SCT.LpL.l-t.21‘; 01' HOW to 1.180

9’
ch Enia ‘.1 ed Lower Extremity and Foot Assessment Tool. This too; 1:
dessigrzoc for ease of us); thws, rue forna: oi CircLing or use of a
check box format is consistene. Rarely, when ’other’ 18 used, a
vaLeen descr1o;‘on is requ11ed. TLLS too ‘as b in deveiopeo aite:
a rhu‘oug: IfiVlfw of the "iteratero reinvent to content and design.
L L * ‘? ide'sucoan“

.‘ C—,_ .s— "' +—" — - a a .- ‘h‘ ‘ ‘5'-

Tno L on. page or the eSSwSmment 1-. wzsn has.c
‘ -‘L.’ : . ,L- -1‘ _b- ‘ '1 1 ' . -
demogzaphLC tormetL 3 auto as, CLlene date 0: Dlrtt, o1 perv

care prov:der,aodia:115t, and a brief 3 . L *1ca1 h13tor'. In
fl . . . .

  

addition, a series of buertloas are as~ focus on activzti s
which car or may not change from no V“ - next. go“
questions, simple yes or no, invoke pos:7.1. changes in at.s,
medicati as, mobil'2y, purchase of new shoes, visits to primary car a
provisior or a poiiatrist that would solicit further investigation.
Add"; L Lonally, with each assessmenz, current medigations are

reviewed.

-4, ‘ C .C ....'_. .. .. .. .' . 1 ' .—_- L- I: — '3
ProvLoers oL LOU. care a1e gene1.Lly p'31tLoneo n fLonc :L, GHQ
oeLow tne CLa‘Lg. Typ1~ :eLLy, the pzovLoer SLLS u to
‘ 1 HA“- L.‘ ~' .. ‘ ‘- . -—-- ‘ ‘- . i Z» i - -'-« . ~—
13 seL on Ln a on L1, enoreoy, aLtovLLo toe cl one a Luce

to rest upon the arov1oers lap. With :215 pos1tlon1ng as a po1n: o:
1‘t2:-;~:»:r«:-2:1<:r32, tins :ooi nae; moon des‘Lqrzod to enriamce a<u<.1..ror.ta.-io 1:2};

_ . a . .— . ..
I

Lisarty Laoe11ng 1191: or Lezt, dorsaL or v nt1aL, anterior or
posLeLio: Layer extremLLy pa1amet are. Tan format leL at.ea.t to
decrease toe 3 “bet oi transoriot1on errors.

Lower Extremity Assessment

Th“ L‘wcr ex:-o“1tLe are assessed for coLor “pa 8, pink, ruody,
temperature (ware, oiol, or other ,,
' L, pale z‘L,
) and -doma (1+, 2n, 3+, 4+, or Cher),
cireuLatioL 1ncluding the d 11.1111r peris and the posterior tib1al
‘ e {0, 1+, “+, 3+) and capilLar‘ refilL after bia.ca1ro,
ends. Presence or absenoo of pain, coupled wit.n
'ed utiL121nj the N“ 1“ Pain =n'crw1tv Scale

u (.
Con of foo:woar proper or imoropor) gives insight

h

10f2 4/8/992:46AM

92

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93

Using the Tool

‘—

 

Assessment Tool I if S-tep»-by-5t2p ‘

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an»... _ _ . .l we”; um-.. e. .mmv... Aw 1' ‘

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right Fl” 0.1+. 2+. 34 Lefl FT 0. iv. 2*. 3'

Right" 0.1+.2r.3+ nan 0, 1+,», 3.

 

 

 

 

 

 

 

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Mimosa No .3 Yeast; ifycsAcsmhe Not Yum if yes. dumb:

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(O'Nooeflo-tgi) Seek _ Sale

Features: Shoes Proper I.) lmpmpa in; Shoes Propa' 1,2 Improper L3
Soda Proper :3 improper :3 Socks Proper 3 moroper 0
Onhm‘es N04; Yes ;3 my“ :3 L6! L2 Onholies Nazi} You; Right (.3 Len {3
Prosthesis N03”, Yesf. Right L; lcfl J: Prosthesis No.2» Yes!) Right 1! Left If!

SUI integrity Antenor None I; Postma Anterior None ~.; Posh-rim

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Additional ___ .....

Cousteau:

 

 

 

None Provider

 

 

 

 

WMWMP.CM&WMAEW. human! 10488

W Foo: W Farm 0 1
Enhanced Foot Assessment Form
Since your text visit have you (your).... Mitotic” Medium cum Nun
Date Date
medications changed? Yes 3;} No {.3 Yes I} No Z; one at Birth
changed your ADLs? Yes No Li‘s . Yes 53 No Li Prhn-qum
fallen? YesE} No i’.’ Yes :1:- No
purekmsednewsfnes‘.’YesU Noi: Yes?! No.) PM
seen a PCP/podiatristi’Yes '3 No :3 Yes C: No L:- PM}!
Circle all that apply. If other. describe
‘ M and to: W (locum-union
Lower Extremitl
Assam! Date ! Date
Color ngm. Pm. Punk. Rudd). Blown. Cymohc. om: mam- Pale. Punk. Ruddy. Brown. cymom. other
Lea - Pate. Pink. Ruddy. Brown. Cymuie, other Lefi - Plk. Pink. Ruddy. Brown. We. «be
Tmmz Right - Warm. Cool. other § Right - Warm. Cool. other
Let! - Warm. C001, and ‘ Lei! - Warm, Cool. abet
Varkmiuu Right - Supaficiai. Palmble. Tortuous aha Right . Superficial. Palpable, Tonuous, other
None (5 None L;
1:“ - Suwfwial. Pflpabk. Tamas. other Left - Supetficial. Polo-hie. Tm other
\‘mc “I 5"" ‘5 '
Ellen. Ruth! “.2‘~.3*.“'01h¢flkfl |°.2*.3*,4‘ other Rxght i+.2*,3o,t¢ gamut! “153544-th
None LE None .3 None 2 None 2“,
Cimhlio. RingP 0.|+.2+.3+ Lefi DP 0.!!.2¥.3' RingP O, l+.2r.3‘ LeflDP 0.l§.2‘*.3+

 

94

 

 

 

WMWMO 2

 

 

 

Foot Wot Date Date
Bony Deter-amt: Yes D Nam: 21." Yes 1“,; None Cl
Bunions RV; R11! Hf, 1.59 None '3 R55 RI: LID LSC None 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hammer toes K5 R4 R3 R2 R1 LI [.2 [.3 L4 l.5 None R5 R4 K1 R2 RI L1 L2 L3 U3 L5 Nfl [.1
Overlappmg digits R5 R4 m R2 RI Ll L2 L3 L4 L5 None :3 R5 R4 R3 R2 R1 LI L2 L3 L4 15 Nme n
Prommenl met head K“ R4 R3 R2 R! L! L2 L3 L4 1.5 None LL R5 R4 R] R2 R1 L1 L2 L3 L4 [.5 None U
Amputation: R5 R4 R3 R2 R1 Ll L2 L3 LA LS None R5 R4 R3 R2 R1 Ll 1.21.3 L4 L5 None D
N." Slug:
loam/med R5 R4 R3 R2 R1 L112 L31AL5 Monet} R5 R4 R3 R2 RI Ll L2 1.3 123 L5 chC
(:43!an R5 K4R3R2Rl Ll L21.3MLS None” R5124 R3R2Rl LI 1.21.3121 L5 NoneL.’
Ingrown K‘ R4 R3 R2 RI Ll L2 L3 1.41-5 None U R5 R4 R3 R2 RI 1.] 1.2L] L4 L5 Nanci?
Flat R5 R4R3R2Rl Ll L2 L3 [241.5 NuncU MR4 R3R2Rl LIL2L3L4L§ NoncD
Other RSRQ R3 R2 R1 LlL2L3 L415 R5514 R3R2R| LlLlLJL‘ LSNGICU
NIH C930:
White R5 R4 R3 R2 R! LI 1.21.3 L4 L5 None!) R5R4RJR2RI L1L2L3L4L5NmeC
Yeilow K5 R4 R3 R2 R1 [.1 L2L3 1.41-5 Nanci; R5 R4 R3 R2 RI Ll L213 L4 1.5 None f‘;
Brown R5 R4 R3 R2 RI LI 1.21.3 L4 1.5 None .1 R5 R4 R3 R2 R! L1 L2 L3 L4 L5 None C3
Buck R5 R4 R3R2 R} LI L2L3L4L5N0t1c13 R5R4 K3 R2511 LI [.2 L3 L4 [.5 None?)
Other R5 R4 R3R2R! 1.!L2L3L4L5 FUR-1R3 RlRl LIL? [JMLS
Nail Texture
Thick R5 R4 K3R2Rl Ll 2L3LALS Nanci; R5514 R3R2Rl Ll L213 L4L5None£3
Thin RSV.“ R3R2Rl Ll 1.2L31AL5 Nonci. R5 R4 R3 RZRI LI L214} [A L5 ch3
Cmmbiy R5 K4 R3 R2 [(1 LI L213 [211-5 None; R5 R4 K3 R2 R1 Ll 1.21.3 U4 L5 chLI
Brit"! ' RS R4R3R2Rl Lt L2 L3L-1 LS Nonel} ”R4 RJRZRI LIL2L3L44LSNWC
Spit! R5 R4 K3 R3 R1 LI [.2 L3 [A [.5 chi.) K5 R4 R3 R2 R1 1.! L2L31A [.5 NoneLJ

 

Separated nail bed

R5R4R3K2Rl

L! L213 LALS None?!

R5R<1R3R2 RI

L! 1.21.3111 LSNoneii

 

 

 

 

 

 

 

 

 

 

 

Educat'im o Referral

ether

other

Other RSRJRJRIRI LIL2L3L4LS R5R4R3R2Rt LIL2LJLALS

Nail Poop. Yes U None U Yes £13 None 1']
RSRJRJRZRI LILZLBLALS RSRARJRJRI LlLlLJlALS

Mmrotedwebspoce R5;.;R4L1R3ERR2(; ULJUUMULSC R53 R40 ‘6'.) R211 12121.3!) MLLSJ
None *3 None 13

Sensation use a 5.09 fight I 0 Right ‘ Left

monofilament; «wk ~ , ~4

theOwith+u~for 000 0° 0‘ *0

sensation not assessed C.‘

K - cor-(s) Right Right ‘ None [3 Left

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Souk. trim. file. lotion.

Wt. WW other, describe othet. describe

Recount-4100.1. Daily hygiene. dry between toes. feat inspectitm, Daily hygiene. dry Mum toes. foot inspection,

 

Additional Comments

 

Return to Clinic

 

 

W
Nam Provider

 

 

 

 

UnetopedhyWiu RCMtWel-dykfilufigblnm 10-3-98

 

95

 

 

Step-by-Step

 

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http://pilot.msu.edu/~clarkm1 Olstep-by-.

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Provider wears protective gear; gloves and eye shield

Client seated in a comfortable chair with supporting arm rests

Provider seated on a stool in front of client

Remove stockings and shoes, if applicable

Assess lower extremities and feet prior to soaking

Begin assessment with lower extremities and progress to the feet *scc Using the Tool for assessment
inclusion criteria

Soak feet in tepid water (95 degrees F) for 5 minutes using mild foot soap. *placc soap powder in
basin first. then add water

Remove one foot at a time for foot care

First, dry foot with special attention to dry between the toes (may use 2 x 2 gauze to remove excess
debris)

Inspect between toes and top and bottom of foot

File, in one direction, corns and/ or calluses using a large foot file

Remove debris under the nail using a beveled wooden stick (orange wood stick)

The above step identifies the hyponychium borders under the nail

Compress and secure base of nail to be trimmed

Hold nail nippcrs with the flat edge of nippcr against nail

Trim nails to the contour of the. toe, taking small nips in the nail as you progress across the nail
File nails in a downward direction

Apply lotion: avoid toe web spaces

Massage feet and lower legs, if not contraindicated

Begin the above procedure on the second foot

Client teaching threaded throughout encounter

Referrals to specialists, if applicable

Contract with client for follow-up appointment and return to clinic ('RTC')

Assist. client with putting on socks (clean) and shoes

 

96

Home , ;. I Role om APN

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The ftfllowing links access sites of relevance to podiatric medicine.

Leap Proggam site with use of monofilament

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