Foot disorders present a challenge for nurses. Almost 80% of the population over age 50 will be afflicted at some time with at least one significant foot problem.1 According to Haviland and Garlinghouse, the performance of regular nursing foot care, including assessment for early detection of abnormalities, management of minor conditions, patient education to prevent foot problems, and prompt referral for specialty care, are services that lie within the domain of nursing practice.2 This article will review aging changes, clinical skills related to foot care, and patient education parameters to enable nurses to enhance the overall comfort and well-being of their patients.
Age-related changes in the foot include the following:
* The skin tends to become dry, inelastic, and cool;
* Subcutaneous tissue on dorsum and sides of foot thins;
* Plantar fat pads shrink and degenerate;
* Toenails become brittle and thicken with decreased resistance to fungal infections;
* Degenerative joint diseases diminish range of motion;
* Complications of vascular insufficiency arise due to circulatory impairments.
An understanding of these changes enables the nurse to distinguish normal changes from pa
GOALAND OUTCOME STANDARD
Provide routine nursing foot care for patients who are unable to perform independent foot care.
The patient will have a decrease in nail thickness and length, improved foot hygiene, and knowledge of proper self-care for the feet.
FOOT CARE ASSESSMENT
The authors adapted the foot care assessment from foot care articles found in the nursing literature (Table I).3-5 It was originally designed for use in a nursing foot care clinic and has been further condensed into a handy pocket reference.
Adequate space is included for documentation of interventions and the plan for future care, as well as the need for a follow-up nursing foot clinic visit and whether a referral was made to a physician, podiatrist, or other specialist.
Equipment to perform foot care can be purchased for approximately $1 20. An asterisk denotes those supplies needing to be replenished atan estimated cost of $10 per month, depending on the number of foot care recipients.
The authors recommend the purchase of square basins for soaking; plastic garbage bags* (optional onetime use liners for basins); one pair of barrel spring, chrome-plated nail nippers, size 41,? or 51A; orange wood sticks* for debris removal and cuticle care; emery boards* for smoothing nails; nail file boards* for surface filing of thick and brittle nails; lotion or skin softening product* such as Carri ngton Foot and Body Cream or vegetable shortening (a cost-effective alternative) for massage; gloves*; stepstools; white towels and washclothes; 2 x 2 or 4 X 4 cotton gauze pads* for foot hygiene; soap* (liquid or bottle); soft brush for debris removal (the type used for cleaning fingernails); large foot file for callus removal; protective masks* (the type used for painting and sanding); and protective eye goggles.
Optional equipment may include a basket for carrying supplies, adhesive bandages, antibiotic ointment (requires physician order to use), magnifying glass, institution strength cleaner, and stainless steel bowls for cleaning equipment. A motorized tool (Dremel) can be used for filing nails only after the nurse has received in-depth instruction from a knowledgeable specialist. Reusable equipment and supplies should be cleaned and stored according to institution policies. Most equipment can be purchased at drug, hardware, beauty supply, or discount/variety stores (Figure).
FOOT CARE PROCEDURE
1. Observe patient ambulate and remove footwear if possible. Explain procedure.
FOOT CARE ASSESSMENT
2. Place protective pad or towel under a basin of warm water (1 1 00F) and soak feet for 5 to 1 0 minutes to soften nails. Wash feet with soap, rinse, gently remove any debris over nails with soft brush, and pat dry.
3. Face patient in comfortable position while seated on a stepstool; elevate patient's leg by placing it on another stepstool or in your lap.
4. Perform the assessment using the assessment card.
5. Provide foot hygiene while the foot is still damp by first separating toes. Fold a gauze pad or washcloth in half and gently move it back and forth between each toe to loosen or remove any accumulated debris. Use a large foot file with gentle but firm strokes in one direction to loosen and remove dry skin patches on plantar and heel surfaces.
6. Trim nails using nail nippers. Carefully nip nail tips by trimming straight across or in the direction of the toe edge contour. Be careful not to catch underlying tissues and do not cut deep into nail margins. The nail tip may peel or crumble. At this point, begin to smooth the nail with an emery or nail file board. Do not cut or file nails too short and always begin at the distal end of the mid nail. If nails are extremely thick and brittle, the nail file board may be used to gently file the top surface of the nail. Remember, intact tissue remains underneath. Also, it may take several weeks to get the nails down to the appropriate length using this procedure. Use an orange wood stick to remove any remaining debris around nail surfaces and under nail tips.
Figure: Examples of selected foot care supplies: 4'/2-in nail nippers; 5i/2-in nail nippers; orange wood stick; emery board; nail file board; large foot ftle, son brushes; 2x2 cotton guaze; skin softening product; basket; goggles; mask.
EDUCATIONAL GUIDELINES CHECKLIST
7. Buff corns and calluses with large foot file, filing in one direction until the area is smooth and even with skin surfaces, being careful not to file intact skin. Do not completely remove corns or calluses as they protect the foot.
8. Massage the foot using lotion if foot is free of lesions and underlying pathology. Do not massage calves or place lotion between toes. Do not use powder. Use the palmar surface of your hands and knuckles to massage with strokes and circles until the skin is smooth and supple. One hand may be required to steady the foot (a good reference on massage technique by Downing6 is recommended). Remove excess lotion with a towel.
9. Assist client with replacing footwear.
10. Soak equipment in cleaner for 15 to 20 minutes, rinse, dry, and store in dry place.
The sequence of performing foot care can be altered depending on the amount of time and energy required. For example, we do not always soak feet or provide foot hygiene for persons whose nails are thin or who have clean feet, although foot soaks are highly recommended for comfort and relaxation benefits.
Patient education, an essential component of foot care, may be done while foot care is being performed. Examples of appropriate footwear, stockings, and other props are helpful, as are written booklets and materials if the patient is literate. Patient education materials are available from a variety of sources.7 The educational guidelines checklist can be individualized to provide appropriate patient education about feet (Table 2).
The need for gaining an abundance of hands-on experience is important, especially when confronted with the aging foot. Unfortunately, there are not significant numbers of nursing programs that provide clinical instruction in the provision of foot care. Obtaining additional training is strongly recommended before engaging in the provision of foot care, especially for persons with complications. Nurses are encouraged to consult with other nurses who have expertise in foot care, such as clinical nurse specialists, certified diabetic educators, and enterostomal therapists. Other resources for learning about foot care may also be available in the community from podiatrists, orthopedists and orthopedic surgeons, and dermatologists. The single most important step, however, is to incorporate foot care into the daily nursing routine.
- The authors acknowledge Dr Faith Holoch for reviewing this column.
- 1. Evanski P. The geriatric foot In: Jahss MH (EdX Disorders of the Feet. Philadelphia: WB Saunders; 1982.
- 2. Haviland S, Garlinghouse C. Nursing foot clinics fulfill a great need. Geriatr Nurs. 1985;6:338-341.
- 3. Drury D, Reynolds B. Foot care for the highrisk patient. RN. 1982; 46-49.
- 4. King PA. Foot assessment of the elderly. Journal of Gerontological Nursing. 1978; 4:47-52.
- 5. Christensen M, Funnell M, Ehrlich M, Fellows E, Floyd J. How to care for die diabetic foot. Am J Nurs. 1 99 1 ; 9 1 (3):50-58.
- 6. Downing G. The Massage Book. New York: Random House-The Bookworks; 1972.
- 7. Ford RD. Patient Teaching Manuals / and 2. Springhouse Pa: Springhouse; 1987.
FOOT CARE ASSESSMENT
EDUCATIONAL GUIDELINES CHECKLIST