Journal of Gerontological Nursing

Geropharmacology 

Managing Common Foot Problems in Older Adults

Jane Anderson, MSN, RN, GCNS-BC; Kathleen G. White; Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN

Abstract

Foot problems related to aging or disease processes such as nail fungus or arthritis often go unrecognized and untreated, and can lead to considerable dysfunction. Multiple contributing factors, such as repetitive stress and structural changes in the foot, further compromise function. Effective topical management approaches for xerosis, fissures, hyperkeratotic lesions, and fungal infections can lessen the severity of symptoms. However, when recalcitrant, such as long-standing onychomycosis, prescription medications may be warranted. These medications are not without serious side effects and should be used with caution in older adults. New methods that pose fewer risks, such as film-forming solutions and photodynamic therapy, are emerging to treat skin and toenail infections. Several nonpharmacological and pharmacological treatment approaches are presented in this article.

Abstract

Foot problems related to aging or disease processes such as nail fungus or arthritis often go unrecognized and untreated, and can lead to considerable dysfunction. Multiple contributing factors, such as repetitive stress and structural changes in the foot, further compromise function. Effective topical management approaches for xerosis, fissures, hyperkeratotic lesions, and fungal infections can lessen the severity of symptoms. However, when recalcitrant, such as long-standing onychomycosis, prescription medications may be warranted. These medications are not without serious side effects and should be used with caution in older adults. New methods that pose fewer risks, such as film-forming solutions and photodynamic therapy, are emerging to treat skin and toenail infections. Several nonpharmacological and pharmacological treatment approaches are presented in this article.

Ms. Anderson is Instructor, Ms. White is a BSN nursing student, and Dr. Kelechi is Associate Professor, Medical University of South Carolina, College of Nursing, Charleston, South Carolina.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN, Associate Professor, Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas Street, Charleston, SC 29425-1600; e-mail: kelechtj@musc.edu.

Posted Online: September 22, 2010

Although many older adults lead physically active lives well into their 80s and 90s, they are often plagued by foot problems. When coupled with aging changes, foot problems can have a negative impact on functional ability, mobility, and quality of life. Approximately 90% of adults 65 and older exhibit some form of altered foot integrity (Helfand, 2009) such as skin and nail fungus, dry skin, and corns and calluses, which are often cosmetically unsightly. These problems frequently go unrecognized and untreated, leading to considerable dysfunction (Pattillo, 2004).

Excessively dry skin and increased thickening of skin can cause pain and cracking. Structural changes in the foot such as bunions and hammertoes increase the pressure on bony prominences, increasing the risk of corns and calluses (Figure 1). When toenails are too long and thick, they are at risk for being traumatized causing a nailbed wound. In addition, long toenails can affect one’s ability to wear properly fitted shoes, thus increasing the risk of falls and susceptibility to infection. A plethora of over-the-counter (OTC) and prescription medications, as well as therapies, are available to treat foot conditions. The goal of managing common foot problems in older adults is to promote mobility, independence, safety, and comfort.

Hammertoes and Painful Corn on the Fifth Toe.Photo Credit: Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN.

Figure 1. Hammertoes and Painful Corn on the Fifth Toe.Photo Credit: Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN.

Contributing Factors

Multiple factors have an effect on the foot, including aging changes, repetitive stress, structural changes, and chronic diseases. Age-related alterations in the skin include thinning of the dermal layer, decrease in the surface contact between the dermal and epidermal layers, as well as decreases in dermal cells, blood vessels, nerve endings, and collagen. These changes increase the risk of skin trauma, altered sensation, and transepidermal moisture loss. As the sweat and oil glands atrophy, the skin becomes dry (xerosis) (Figure 2), and keratin dysfunction causes hypertrophy and thickening of the skin. Hyperkeratotic lesions, also known as corns and calluses, are more prevalent when skin is exposed to repetitive mechanical stress, for example, from ill-fitting footwear. Dry, scaly, or hardened skin can easily crack, leaving fissures that are painful and difficult to heal. These changes in skin integrity affect the skin’s immune abilities, setting the stage for increased susceptibility to fungal infections (Yaar & Gilchrest, 2007).

Severe Xerosis (dryness).Photo Credit: Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN.

Figure 2. Severe Xerosis (dryness).Photo Credit: Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN.

No less affected is the structure of the foot, in which aging changes cause a laxity of ligaments, tightening of tendons, settling of arches, and thinning of subcutaneous padding. In turn, the foot becomes wider, bony prominences become less padded, hammertoes can develop, and pressure on these points can cause skin thickening and the development of painful corns and calluses (Helfand, 2009). Chronic disorders such as vascular insufficiency, diabetes, and neuropathy further worsen pre-existing aging changes. In the presence of foot problems, these disorders can lead to devastating consequences including foot amputations. Arthritis or stroke can stiffen toes, reducing toe movement and airflow between them, thus setting up an environment conducive to bacterial and fungal growth. Many of these problems can be managed or ameliorated with proper hygiene and OTC products. However, chronic dry skin, corns and calluses, and nail and skin infections that are resistant to conservative treatment warrant more aggressive therapies to prevent negative outcomes such as wounds.

Management Approaches

Xerosis and Fissures

Dry, scaly, and cracking skin, especially on the heels, can often lead to painful fissures and increase the risk of infection. Treatment begins with daily foot hygiene using a mild soap to remove dirt, sweat, and dead skin, followed by careful drying and the application of an emollient-based product. These products may contain moisturizers, humectants, lipids, and/or keratolytic agents. Emollients aid in smoothing and rehydrating the skin by reducing the epidermal water loss and replacing natural skin lipids. Products that contain lipids (e.g., lanolin, petroleum) and humectants (e.g., glycerol, propylene glycol) should be selected. However, many individuals are sensitive to lanolin-containing products and thus should use caution (Proksch, 2008).

Emollients are available as lotions, creams, or ointments. The difference in these formulations is the lipid content, with lotions containing the least and ointments the most. A formulation that best addresses the level of dryness present should be selected (Nazarko, 2009). Emollient products should be applied twice daily but not between the toes, as this increases the risk for fungal and/or bacterial infections, especially when moisture is present. Products containing perfumes or dyes should be avoided. Products such as Eucerin® Plus Intensive Repair Foot Creme or Lubriderm® Intensive Skin Repair Ointment are beneficial. A comparison of OTC and prescription products appears in the Table.

Over-The-Counter (OTC) and Prescription Recommendations for Common Foot Conditions in Older Adults

Table: Over-The-Counter (OTC) and Prescription Recommendations for Common Foot Conditions in Older Adults

If hyperkeratosis exists, a product containing urea or ammonium lactate and other alpha hydroxy acid (AHA) formulations such as LacHydrin® should be applied to the area. The urea softens hyperkeratotic skin by dissolving the intracellular matrix, resulting in the loosening of the horny layer of the skin. The AHAs have kerotolytic properties that decrease the adhesion of keratinocytes, increasing the turnover of the outer skin layer, thus leaving the skin smoother (Kockaert & Neumann, 2003). These products should be used one to two times daily for up to 3 weeks, then tapered to 1 to 3 days per week, then 1 to 2 days each week.

When fissures are present, deep cracks furrow into the dermis and are considered wounds. While the goal is to close the fissure and promote healing, this is often difficult due to the excessively thick, hyperkeratotic, and dry skin that surrounds the fissure. To treat the thick and dry skin, the area should be thoroughly cleansed with mild soap and water, then patted dry. A keratolytic product such as Kerasal® can be applied to reduce skin thickness. Prescription-strength keratolytic agents such as Carmol® 40% or Keralac® 50% that contain higher concentrations of urea can be used for stubborn skin thickness. Products should be applied once or twice daily to the affected area until the thickened skin is removed. In addition, treatment is often accompanied by mechanical debridement of the area with a somewhat course file of 100 grit so the agent can penetrate the thickened skin. Filing the skin frequently with minimal pressure can remove much of the thickened skin, but this takes time. After the thickened skin is removed, the fissure should be treated with an application of skin adhesives or sealants. Some of these OTC products include Nu Skin® or BAND-AID® Single Step Liquid Bandage over which cloth tape or even Steri-Strips® can be applied to keep the fissure closed. Prescription-strength skin adhesives such as Dermabond® can be applied to fill the fissure. For very deep, bleeding, or infected fissures, a health care provider should be consulted.

Hyperkeratotic Lesions

The best practice to manage corns and calluses is to pad and protect the affected areas. OTC medicated products such as salicylic-based “plasters” are often the first approach to remove the thickened skin, but when used on older skin, or on individuals with disorders such as diabetes or vascular insufficiency, these occlusive products can be dangerous. These kinds of products should be used with extreme caution, as their chemical action can macerate and significantly traumatize intact surrounding skin. Unmedicated products that are made of silicon or glycerin provide padding and comfort and should be the approach of choice, especially for corns on the tops of toes. Calluses tend to occur under bony prominences and can be managed with mechanical debridement (filing) and padding. Cream keratolytic agents are also helpful in reducing the thickness associated with hyperkeratotic tissue (Borelli, Bielfeldt, Borelli, Schaller, & Korting, 2010). Prescription-strength products, used under the direction of a health care provider, should be considered when the thickened area is resistant to OTC creams and padding.

Fungal Infections

Fungal infections of the feet frequently target the nails (onychomycosis), can be difficult to treat, and can cause functional impairment when shoes or slippers rub against thickened and loosened toenails. No less important are fungal infections of the skin (tinea pedis, or athlete’s foot). However, skin infection is more sensitive to topical treatment than onychomycosis due to the penetrable nature of the skin.

Onychomycosis. Onychomycosis is prevalent in almost 15% of the U.S. population and is thought to be much higher in older adults. It is the most common nail disorder; 80% of all cases affect the feet compared with the fingers (Jacobson & Zajac, 2008). The toenail is susceptible to fungus due to its constant bombardment of moisture and exposure to unclean environments. The fungus causes mild to severe dystrophic changes in nail color (brown, yellow, white specks), texture (thick, brittle, flaky, crumbly), and integrity (loosened from the nail bed) (Figure 3). In addition to aging, other risk factors include immunocompromised status, trauma to the nail, diabetes, and skin problems such as psoriasis. Smoking and the presence of tinea pedis have been associated with onychomycosis. Rarely does the infection cause pain, except when the nail is extremely thick, long, and rubs against a shoe or sheet. Dermatophytes such as Trichophyton rubrum are the most common culprits, whereas yeasts and molds are the least.

Onychomycosis, Nail Fungus that Causes Changes in Nail Color, Texture, and Integrity.Photo Credit: Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN.

Figure 3. Onychomycosis, Nail Fungus that Causes Changes in Nail Color, Texture, and Integrity.Photo Credit: Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN.

Topical approaches to treat onychomycosis depend on numerous factors such as severity, age of the patient, and concomitant illnesses. Cost of the medications and whether the aim of treatment is to eradicate the fungus or improve nail appearance all influence treatment approaches. Eradicating the fungus and preventing its return require longer treatment commitments and full patient adherence to therapy. An important consideration to make when choosing between treatment options (topical, systemic, or both) is the potential for adverse events. Severe events are extremely rare with topical treatments, but they can produce rash, redness, burning, or itching sensations of the skin.

Many older adults are unable to tolerate or afford oral medications and therefore many turn to OTC products. For example, tea tree oil has been advanced as a treatment for nail infection. However, limited evidence supports its use for curing onychomycosis or tinea pedis. Findings from one small clinical trial found it was ineffective (Satchell, Saurajen, Bell, & Barnetson, 2002). Unfortunately, many of these OTC products have a low efficacy profile, and patients should be advised to use caution when applying any kind of OTC treatment.

The limited body of research for topical prescription medications indicates mixed results in cure rates. For the best outcomes, topical treatments such as creams, gels, and lacquers should be applied to nails where only the nail plate is involved, not the matrix. The matrix is the area of tissue located distal to and under the bottom of the nail plate where the cells “grow” the nail plate. Treating the matrix topically is difficult because most products cannot penetrate to the depth needed to reach the cells. It is also important to use topical agents in early distal nail disease and when there are few nails involved (Baran, Hay, & Garduno, 2008a).

While prescription topical agents have better efficacy than OTC preparations, monotherapy—the use of one kind of topical agent by itself—has a suboptimal cure rate. Recent evidence shows that a common topical monotherapy delivered through a transungual drug delivery system (TDDS), or colorless nail lacquer, is a step forward from previous ineffective topical agents (Baran et al., 2008b). Two common TDDS are ciclopirox olamine 8% (Penlac®) and amorolfine 5% (Loceryl®). Ciclopirox is applied to the nail daily, each layer on top of the other, without removal. The layers are removed every 7 days with nail polish remover or alcohol, and the daily regimen is continued until the nail is clear of infection, usually 6 to 9 months. Unfortunately, cure rates after approximately 1 year are estimated between 30% and 40%.

There is general consensus that topical monotherapy should be used where less than 50% of the nail surface is affected, without matrix involvement. In cases where the nail is so affected that the topical treatment cannot penetrate the nail, such as a loosened and extremely thick nail, chemical or mechanical thinning or removal of the nail should be considered. The most efficacious approach to treating onychomycosis is using both oral and topical therapies when there is greater than 50% of the nail plate involved.

It is important to advise older patients who are using topical agents to avoid discontinuing the treatment as soon as the nails look normal. The fungal infection tends to rapidly reoccur into a full-blown infection. Patients should be reminded to continue the treatment as prescribed, as it is important for the drug to remain in the nail tissue for some time after resolution of symptoms.

Tinea Pedis. Fungal infections of pedal skin tend to target the skin where there is contact with the shoe or between the toes. Interdigit infections involve the toe web spaces, appear whitish, and can have cracks and peel. Pedal skin infections can mimic dry flaky skin; however, there is often an element of peeling and redness. Sometimes a splotchy, rash-like appearance and severe itching are present. Inflammation and open draining areas are the most severe form. Topical treatments vary widely. Topical therapy to treat tinea pedis has a much better outcome compared with topical treatment for onychomycosis (Korting, Kiencke, Nelles, & Rychlik, 2007). The risk factors for developing tinea pedis, in addition to those noted for onychomycosis, include chronic exposure to damp, moist environments such as shoes or communal areas such as showers. The best approach to managing tinea pedis lies in its prevention by reducing dampness and exposure to communal environments. Wearing socks that wick moisture from the skin, frequently changing shoes, and limited application of moisturizers to the areas between the toes are helpful.

In the presence of tinea pedis, topical therapies can be effective in reducing peeling skin, redness, itchiness, and in severe cases, split, cracked and bleeding skin or severely macerated toe web spaces. A recent meta-analysis of randomized clinical trials (Crawford & Hollis, 2007) suggests that the best results for the treatment of tinea pedis were observed with the use of allylamines such as terbinafine (Lamisil®), naftifine (Naftin®), and butenafine (Mentax®) for 1 week. Azoles such as miconazole (Lotrimin®) and econazole (Spectazole®) are also very effective but should be applied to the skin for 4 weeks. For interdigit tinea, the application of ciclopirox 0.77% gel, applied once or twice daily, is effective and safe (Gupta, Skinner, & Cooper, 2003).

Mounting evidence supports the application of a single-dose film-forming solution to infected skin (de Chauvin, Viguié-Vallanet, Kienzler, & Larnier, 2008). For example, terbinafine 1% has been found to be highly effective and remains in the skin for up to 13 days (Schäfer-Korting, Schoellmann, & Korting, 2008). This novel approach is a significant advancement that enhances adherence and is convenient.

Topical therapies for skin infections are readily available, generally easy to apply, and have low adverse event profiles. Proper hygiene, keeping feet dry, and wearing socks that wick moisture (synthetic fabrics) are important adjuvants when working with older adults. When adults’ backs do not bend as easily and eyesight is failing, it is often difficult for them to reach between the toes and visually inspect the skin for infection. Thus, infections often go unnoticed. Older patients should be advised to seek treatment early when symptoms first appear rather than waiting for a full-blown skin infection, which can be harder to resolve with topical therapy.

Upcoming Therapies

A very promising treatment, photodynamic therapy (PDT), may eventually eliminate the need for topical therapy. Near infrared, dual-wavelength optical energy is pulsed on the skin or nails using special equipment, without the production of heat. While the technology is well established in other dermatological conditions, the science is emerging to suggest cure rates of 60% to 100% in a small body of studies (Qiao, Li, Ding, & Fang, 2010). The use of PDT for superficial fungal infections of the skin and nails requires further study to evaluate its efficacy.

Conclusion

Pharmacological approaches to manage common skin and nail disorders include both OTC and prescription products. Topical treatment is the cornerstone of treatment strategies for dry skin, corns and calluses, and mild to moderate nail and skin fungal infections. There is a need to understand which agents are best suited for older adults, promote adherence, and are safe. The goal is to prevent unnecessary complications that could result in decreased function, mobility, and quality of life.

References

  • Baran, R., Hay, R.J. & Garduno, J.I. (2008a). Review of antifungal therapy and the severity index for assessing onychomycosis: Part I. Journal of Dermatological Treatment, 19, 72–81. doi:10.1080/09546630701243418 [CrossRef]
  • Baran, R., Hay, R.J. & Garduno, J.I. (2008b). Review of antifungal therapy, part II. Treatment rationale, including specific patient populations. Journal of Dermatological Treatment, 19, 168–175. doi:10.1080/09546630701657187 [CrossRef]
  • Borelli, C., Bielfeldt, S., Borelli, S., Schaller, M. & Korting, H.C. (2010). Cream or foam in pedal skin care: Towards the ideal vehicle for urea used against dry skin. International Journal of Cosmetic Science. Advance online publication. doi: 10.1111/j.1468-2494.2010.00576.x doi:10.1111/j.1468-2494.2010.00576.x [CrossRef]
  • Crawford, F. & Hollis, S. (2007). Topical treatments for fungal infections of the skin and nails of the foot (Article No. CD001434). Cochrane Database of Systematic Reviews, Issue 3.
  • de Chauvin, M.F., Viguié-Vallanet, C., Kienzler, J.L. & Larnier, C. (2008). Novel, single-dose, topical treatment of tinea pedis using terbinafine: Results of a dose-finding clinical trial. Mycoses, 51, 1–6.
  • Gupta, A.K., Skinner, A.R. & Cooper, E.A. (2003). Intergidital tinea pedis (dermatophytosis simplex and complex) and treatment with ciclopirox 0.77% gel. International Journal of Dermatology, 42(Suppl. 1), 23–27. doi:10.1046/j.1365-4362.42.s1.1.x [CrossRef]
  • Helfand, A.E. (2009). Primary considerations in managing the older patient with foot problems. In Halter, J.B., Ouslander, J.G., Tinetti, M.E., Studenski, S., High, K.P. & Asthana, S. (Eds.), Hazzard’s geriatric medicine and gerontology (6th ed., pp. 1479–1489). New York: McGraw-Hill.
  • Jacobson, A. & Zajac, L. (2008, November10). Four nail disorders every clinician should know. The Clinical Advisor. Retrieved from http://www.clinicaladvisor.com/four-nail-disorders-every-clinician-should-know/article/120660/#
  • Kockaert, M. & Neumann, M. (2003). Systemic and topical drugs for aging skin. Journal of Drugs in Dermatology, 2, 435–441.
  • Korting, H.C., Kiencke, P., Nelles, S. & Rychlik, R. (2007). Comparable efficacy and safety of various topical formulations of terbinafine in tinea pedis irrespective of treatment regimen: Results of a meta-analysis. American Journal of Clinical Dermatology, 8, 357–361. doi:10.2165/00128071-200708060-00005 [CrossRef]
  • Nazarko, L. (2009). Caring for older skin: Preventing and treating dryness. Nursing and Residential Care, 11, 333–336.
  • Pattillo, M.M. (2004). Therapeutic and healing foot care: A healthy feet clinic for older adults. Journal of Gerontological Nursing, 30(12), 25–32.
  • Proksch, E. (2008). The role of emollients in the management of diseases with chronic dry skin. Skin Pharmacology and Physiology, 21, 75–80. doi:10.1159/000112957 [CrossRef]
  • Qiao, J., Li, R., Ding, Y. & Fang, H. (2010). Photodynamic therapy in the treatment of superficial mycoses: An evidence-based evaluation. Mycopathologia. Advance online publication. doi:10.1007/s11046-010-9325-2 doi:10.1007/s11046-010-9325-2 [CrossRef]
  • Satchell, A.C., Saurajen, A., Bell, C. & Barnetson, R.S. (2002). Treatment of interdigital tinea pedis with 25% and 50% tea tree oil solution: A randomized, placebo-controlled, blinded study. The Australasian Journal of Dermatology, 43, 175–178. doi:10.1046/j.1440-0960.2002.00590.x [CrossRef]
  • Schäfer-Korting, M., Schoellmann, C. & Korting, H.C. (2008). Fungicidal activity plus reservoir effect allow short treatment courses with terbinafine in tinea pedis. Skin Pharmacology and Physiology, 21, 203–210. doi:10.1159/000135636 [CrossRef]
  • Yaar, M. & Gilchrest, B.A. (2007). Aging of skin. In Wolff, K., Goldsmith, L.A., Katz, S.I., Gilchrest, B., Paller, A.S. & Leffell, D.J. (Eds.), Fitzpatrick’s dermatology in general medicine (7th ed.). New York: McGraw-Hill.

Over-The-Counter (OTC) and Prescription Recommendations for Common Foot Conditions in Older Adults

ConditionOTC RecommendationsPrescription Recommendations
Dry skin (xerosis) and fissures

Select products containing lipids such as petroleum and humectants such as glycerol and propylene glycol (e.g., Aquaphor®)

Avoid products containing perfumes or dyes.

For hyperkeratosis, choose a lotion or cream containing urea, ammonium lactate, or alpha hydroxy acid (e.g., Cetaphil®, LacHydrin®, Eucerin® Plus Intensive Repair Foot Creme, or Lubriderm® Intensive Skin Repair Ointment).

To keep fissures closed, use skin adhesives or sealants, Nu Skin® or BAND-AID® Single Step™ Liquid Bandage, adding cloth tape or Steri-Strips®.

For very deep, bleeding, or infected fissures, a health care provider should be consulted.

Use prescription-strength skin adhesives such as Dermabond® to fill the fissure.

Use prescription-strength moisturizers such as AmLactin® or products from PEDiNOL® (http://www.pedinol.com).

For in-depth information on moisturizers, visit http://emedicine.medscape.com/article/1067211-overview

Corns/calluses (hyperkeratotic lesions)

Salicylic-based “plasters” should be used with extreme caution and avoided if possible.

Use unmedicated products that are made of silicon or glycerin (e.g., Pedifix® Visco-GEL corn protectors); a variety of products available from Southwest Technologies, Inc. (http://www.elastogel.com) provide padding.

Mechanical debridement (filing) and padding can help thin the skin.

Keratolytic products (e.g., Kerasal®, Dr. Scholl’s® Intensive Heel Repair) may be useful.

Prescription-strength products should be considered when the thickened area is resistant to OTC creams and padding.

Keratolytic agents (e.g., Carmol® 40%, Keralac® 50%) are helpful in reducing the thickness associated with corns and calluses.

Onychomycosis

Several OTC nail lacquers (e.g., Fungi-Nail®) are available that are applied with a brush to the nail daily or per package directions.

Nail lacquers such as ciclopirox olamine 8% (Penlac®) and amorolfine 5% (Loceryl®) are available and are to be used daily for several weeks to months.

Tinea pedis (athlete’s foot)

Allylamines such as terbinafine (Lamisil®) or naftifine (Naftin®) may be applied for 1 week or per package directions.

Azoles such as miconazole (Lotrimin®) may be applied for 4 weeks or per package directions.

Powders such as Zeasorb-AF® may be sprinkled on the skin and between the toes to help absorb moisture.

Ciclopirox 0.77% gel may be applied once or twice daily for interdigit tinea.

Allylamines such as terbinafine, naftifine, and butenafine (Mentax®) may be applied for 1 week.

Azoles such as miconazole and econazole (Spectazole®) may be applied for 4 weeks.

Authors

Ms. Anderson is Instructor, Ms. White is a BSN nursing student, and Dr. Kelechi is Associate Professor, Medical University of South Carolina, College of Nursing, Charleston, South Carolina.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Teresa J. Kelechi, PhD, RN, GCNS-BC, CWCN, Associate Professor, Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas Street, Charleston, SC 29425-1600; e-mail: .kelechtj@musc.edu

10.3928/00989134-20100831-03

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