Foot Care
Podiatric Definitions for Identifying Residents With Foot Care Needs
Onychomycosis of Toe Nails Causing Pain – Onychomycosis is a fungal infection of the nail plate. It is observed as thickened brittle, yellowish or darkened areas of discoloration of the nail. Pain from the nail plate is either from shoes or footgear pressing on the nail causing pain into the soft tissue or from direct pressure by pushing on the nail plate downward. Pain or limited ambulation may also be documented about the patient that walks or propels in the wheelchair.
Callus/Corns (hyperkeratosis) – Corns and Callus are areas of thickened skin that occur in areas of pressure. Corns appear as a horny thickening of the skin on the toes. This thickening appears as a cone shaped mass pointing down into the skin. Hard corns are usually located on the outer surface of the little toe or on the upper surface of the other toes, but can occur between the toes. A soft corn occurs between the toes and is kept soft by the moisture in this area. A callus is more diffused area of thickening and does not have the focal point of the corn.
Preulceration – This is any area that is subject to pressure and/or friction, that might breakdown as a result of either. A bony prominence like a hammer toe might be at risk for preulceration on the dorsal aspect of the toe, if it rubs against the shoe or even the bed sheet, for any length of time.
Ingrown Toe Nail (onychocryptosis) – An ingrown toenail occurs when part of the nail penetrates the skin, which can often result in an infection. The ingrown nail can also apply pressure in the nail fold area without penetrating the skin – this is not technically an ingrown toenail, but can also be painful (a corn/callus is also common down the side of the nail and is a reaction to this pressure, rather than the nail actually penetrating the skin).
Diabetes (or more correctly, diabetes mellitus) – Insulin is a hormone that helps the body deal with sugar (glucose) in the diet. When diabetes is present, either the body produces less or no insulin (Type 1) or the body tissues are resistant to the effects of diabetes (Type 2). This results in higher levels of glucose in the blood, which can damage a range of body tissues and organs.
The foot is especially affected by diabetes. It may get damaged and the resident will not realize it. Due to peripheral neuropathy, they may not feel a sore on their foot. Due to poor circulation, it may not heal well. In diabetic residents, foot ulcers are common and infections can spread.
Foot ulcers are a common complication of the diabetic foot. They allow a portal for infection to occur. Ulcers are caused by too much pressure on an area and the skin just “breaks down”. They can occur under corns and calluses.
Peripheral Vascular Disease (PVD) – PVD is the medical name given to a group of problems that cause poor circulation to the feet and legs. The most common cause of this is arteriosclerosis (hardening of the arteries) in which there is a gradual hardening of the walls of the arteries. The most common cause of PVD is diabetes.
Symptoms of PVD include numbness or tingling in the foot or toes, changes in the color of the skin, changes in skin temperature, skin breakdowns, infections and sores that do not heal as well as they should.
Peripheral Neuropathy – This is a relatively common neurological disorder that results from damage to the peripheral nerves. Diabetes is, by far, one of the most common causes of peripheral neuropathy.
Diabetic neuropathy deserves special mention as it is the most common type. It can lead to serious complications in those with diabetes. Diabetic peripheral neuropathy can cause numbness (loss of feeling) or painful tingling in parts of the body.
Peripheral Vascular Disease (“PVD”)
PVD is the clinical name for a group of medical problems that cause poor circulation to the toes, feet and legs. One of the major contributing diseases in this category is arteriosclerosis. We commonly refer to this as hardening of the arteries. This condition causes a loss of elasticity in the blood vessels that bring blood from the heart to the feet and legs.
Diabetes is a major cause of PVD and creates serious foot problems, if diagnosis and treatment is not provided in an effective and timely manner.
Factors Contributing to PVD
- Heart disease
- High blood pressure
- Smoking
- Family history of vascular disease
- Obesity
- Elevated cholesterol levels
- Obstructions in the wall of the arteries
Identifying PVD Problems
- The patients feet are cold or numb
- Excessive pain in the calf or thigh, if the patient is ambulatory
- Sores & wounds that do not heal in the toes or feet
- Black or blue marks on the feet and toes
- Muscle cramps at rest or during periods of sleep
- Discolored and infected toenails
Managing PVD Related Foot Problems
- Conduct a comprehensive foot care evaluation on a periodic basis
- Train professional caregivers to assess & identify PVD symptoms
- Schedule comprehensive exams that are clinically documented
- Retain licensed personnel to provide the necessary clinical services
- Maintain consistent foot care assessment and treatment programs
- Keep clinically accurate and well-documented records
- Refer high-risk patients to the appropriate health care professionals
Diabetic Foot Care Protocols
The American Podiatric Medicine Association and the American Diabetes Association jointly issued a clinical care guideline for patients with diabetes. The guidelines were intended primarily for health care professionals that are engaged in the diagnosis, evaluation and treatment of patients with Type I & II diabetes.
The APMA and ADA have recommended a series of foot care assessments and examination protocols that will help caregivers manage these patients, with the stated goal of minimizing surgical treatment and possibly amputation.
Visual Foot Inspection
- Identify & document obvious foot problems
- Determine the need for comprehensive exams
- Schedule the necessary follow-up care and referrals
Professional Inspection
- Foot evaluations should be conducted by a physician, nurse or other professionally credentialed personnel
- Inspect the feet for injury, calluses, blisters, fissures, ulcers and any unusual conditions
- Patients should be designated Low-Risk, Moderate or High-Risk, based upon the comprehensive inspection
Frequency of Inspection & Examinations
- Annual exams for patients rated as Low-Risk: no obvious wounds or abnormalities
- Twice per year for patients with Moderate Risk: ulcers, fungal infections, calluses and blisters
- As often as needed for High-Risk patients with wound care problems, neuropathy, Peripheral Vascular Disease, amputations, progressive deformity & related conditions
Examination Protocols
- Musculoskeletal deformities: hammer & claw toe, bunions & plantar joint
- Pedal Pulses: Posterior tibial and doraslis pedis in both feet
- Sensory exam: Use a prescribed device to determine risk for ulcers
- Assessment & treating of infections in and between the toes & nails