it has been said, "When your feer hurt, you hurt all over." The American Podiatry Association estimates that 80% of people over 50 years of age suffer from at least one foot condition. The most common local chronic foot problems were associated with the toes, skin, and structural changes in the bone. Dry skin is a major cause of discomfort and secondary foot complications.1
Spoor' states that dry skin is the result of oil deficiencies due to: 1) natural oil loss from soap, detergent, and water; 2) aging changes in the skin or lack of oil replacement by sebaceous glands; 3) allergie-dermatologie entities; and 4) "dry" skin dermatoses.
Dry skin problems are a universal complaint and are present regardless of the environment or temperature.3 Many dollars are invested in creams, lotions, and oils to correct dry skin when the primary problem is lack of water in the skin, not the lack of oil. The stratum corneum, the outermost layer of skin, can be hydrated or rehydrated by high humidity.3
A problem concurrent with dry skin of the feet is the potential for injury to the insensitive feet of the elderly from poorlv-fitted or inappropriate footwear. Nursing assessment and intervention must be directed at providing adequate shoes for long-term care residents. The majority of residents were found to wear slippers and poorly-fitted shoes. These types of footwear do not provide protection for the feet and increase the chances of falls.
Foot problems, even when not severe, can limit people's ability to move about, care for themselves, and remain active.® Since foot problems can have such devastating effects on the elderly, early recognition is of great importance. Nurses Can play a key role in foot assessments. Accurate and systematic assessments are necessary for foot care needs to be identified and care initiated early.
The Foot Assessment Guide
A guide to nursing assessments of the feet is included. (See Figure.) The top portion of the form includes space for the patient's name, room number, age, sex, and date. The left hand margin contains information about the patient's mobility, problems with the feet including podiatric care, and any known allergy to mineral oil. The guide includes drawings of the feet from the top, bottom, and sides and can be used to record areas of particular problems for the patient.
The bottom portion allows the nurse to rate each portion of the foot and assign a score to the area. The rating scale ranges from 1 (oily skin) to 7 (very dry and scaly skin).6 For example, if the dorsal toes are dry and have a few white scales, they would receive a score of "4." Each area should be rated in this manner and the total recorded in the right hand margin. A total of 7 is the lowest possible score, and would indicate a person with oily skin, not requiring any special foot care. Fortynine is the highest possible score and indicates a person with extremely dry skin with many thick yellowareas. This person would require foot care to prevent such areas from cracking open and allowing infections to begin. When the total score is 21 or greater, foot care with soaks and mineral oil should be started.
Patients who had open, draining wounds or recent podiatric surgery, or who were receiving podiatric therapy were not selected for this project. The demonstration protocol below was first developed by Anderson7 and was implemented by her in at least one urban long-term care facility.
The Foot Soaks Procedure
1. Wash hands between patients.
2. Place the patient's feet in a basin of warm water (temperature of 90° to 100° F) for ten minutes.
3. Wash feet per routine without soap.
4. Blot dry with a bath towel, leaving the surfaces of the feet moist. Dry completely between the toes.
BLACK & GASPAR FOOT ASSESSMENT TOOL
5. Massage feet with mineral oil and wipe off any excess.
Skin condition has been noted to improve after a ten-minute foot soak in warm water,7 this is the basis for the tenminute length of soaks. Mineral oil was chosen for its economy and ability to hold water on the surface of the skin, allowing the water to be absorbed.3
There are some precautions that must be taken by the nursing staff using this procedure. Patients who are confused must not be left unattended during the foot soak. They can forget and wander off with wet, bare feet. Mineral oil is slippery and should not be left in the patient's room. Any spilled mineral oil should be wiped up from the floor immediately because of the potential for causing falls. Individual bottles of mineral oil and foot soak pans should be labeled and used for only one patient in order to help prevent the possibility of fungae contamination.
Thirty-one residents of a Nebraska nursing home were evaluated with the foot assessment guide. The highest score for any one patient before treatment was 46. After two weeks of foot treatments three times per week, this patient's score dropped to 34. When the Wilcoxon signed-rank statistical test was applied to the results on all patients, the probability of these results happening by chance alone were less than one in 100. It was concluded from this demonstration that the ten-minute foot soaks and application of mineral oil three times per week for two weeks improved the condition of the skin of feet in the elderly.
The elderly have increased potential for problems with the feet.
Care of the feet begins with a thorough assessment.
The nursing staff implementing this project found it helpful for supervision of residents and reduction of nursing time to group the residents together in one large room for foot soaks. This arrangement also provided group socialization for the residents.
The Introduction of the Change
Active participation is essential to any project involving a change. Developing human resources through participation will facilitate the continued use of innovations after the trial period. The managerial staff should become involved first, since any change withou managerial support is not likely to succeed.8 The nurses' participation was enhanced by involving them in the choice of those residents who could benefit from foot care and those who could cooperate with the procedure. A program to teach the assessment and the procedure was conducted for aH nursing staff, members to assure continuity of care. Emphasis was placed on the technical procedure, including demonstration of the technique.
The feet are soaked in warm tap water, blotted dry with a towel, and massaged with mineral oil.
Some resistance was expressed concerning the amount of time needed to do the foot soaks. This was seen as an example of restraining forces to change that oppose and resist the change process. Driving forces to assist change must be increased to overcome the opposing forces.9 In this setting, the driving force emphasized was the need for beneficial foot care by the residents. It was pointed out that the time spent in preventive measures often is less than that used in restoring skin integri ty after a problem begins. The project went on through completion without problem. In fact, as the staff began to see the beneficial effects of the foot soaks, resistance to the time factor diminished greatly. The nursing staff was committed to quality nursing care and commitment increased during the trial demonstration period.
The residents also were reluctant to change their schedules at the beginning of the project. Again, the benefits of foot care were emphasized and it was stressed that, since involvement was voluntary, the resident could discontinue the treatments at any time. After the first week, the residents expressed enjoyment and looked forward to the foot soaks. At the end of two weeks, they were disappointed that the project was over, since they were noticing improvement in the condition of their skin as well as softening of their nails, callouses, and corns. Many of the residents capable of self care wanted to continue the foot soaks and mineral oil application for themselvess..
A four-month, follow-up study was conducted with the staff. Due to state regulations, the procedure could not be implemented without a physician's order but it was believed that the project was successful in improvingskin condition and would be implemented in the future for those residents with problems of dry skin of the feet.
- 1. King P: Foot assessment of the elderly. Journal of Gerontological Nursing 34:67-70, 1978.
- 2. Spoor H: Measurement and maintenance of natural skin oil. NY State J Med 58:3292-3299. 1958.
- 3. Weiner E, Beiser S, Guidice R, et al: Treating the dry skin syndrome. / Am Podiatry Assoc 63:571-58!, 1973.
- 4. Hampton G: Therapeutic footwear for the insensitive foot. Phys Ther 59:23-29, 1979.
- 5. Helfand A: Podiatric services for the aged. / Am Podiatry Assoc 63:368-373, 1973.
- 6. Hopp RA, Sundberg S: The effects of soaking and lotion on dryness in the feet of elderly patients. J Am Podiatry Assoc 64:749-760, 1974.
- 7. Anderson J K: Prevention and treatment of dry skin in the feet of the elderly. Unpublished manuscript, University of Nebraska College of Nursing, 1975.
- 8. Pierce S, Thompson D: Changing practice: By choice rather than chance. J Afurs Admin 6:33-39, 1979.
- 9. Lewin K: Field Theory in Social Science. New York, Harper and Row, 1951.
- Blank I: Factors which influence the water content of the stratum corneum. ] Invest Dermatol 18:433-439. 1952.
- Conrad D: Foot education and screening programs for the elderly. Journal of Gerontological Nursing 3:13-15, 1977.
- Gaul E, Underwood G: Relation of dewpoint and barometric pressure to chapping of normal skin. J Invest Dermatol 19:9-18, 1952.
- Gilchrist A: Common foot problems in the elderly. Geriatrics 34:67-70. 1979,
- Helfand A: Podiatry in a total geriatric program: Common foot problems of the aged. J Am Geriatr Soc 15:593, 1967.
- McGregor R: Geriatric foot care. Nuts Clin North Am 3:687-695, 1968.
- Schank M: A survey of the well-elderly: Their foot problems, practices, and needs. Journal of Gerontological Nursing 3:1014. 1977.
- Tarara E, Spittel J: Clues to systemic disease from examination of the foot in geriatric patients. J Am Podiatry Assoc 68:424-430, 1978