Foot care isn’t glamorous by any means. But I’ve seen way too many toe, foot and leg amputations that may have been avoided with consistent nursing care.
Yes, I know, feet can be grotesque looking with those thick curled nails and hard calluses. And yes, they can have quite an odor.
One of the first questions I have for a patient, if I don’t already know, is: “are you a diabetic?”. Diabetes plays havoc with the circulation and neurologic condition of diabetic feet. Therefore, you should recommend a podiatrist and take care that no trauma to the skin occurs on your watch.
A nursing skill you can perform on non-diabetic patients is to clip or file toenails. This is not something you do for diabetics. One little nick of the skin from the clippers can turn into a raging infection in no time.
And since the sensation to the feet of diabetics can diminish to the point of not feeling pain, injuries can go unnoticed for long periods of time. So the foot needs to be assessed regularly.
Teach the diabetic patient to LOOK at his or her feet daily to see if any new traumas have occurred. Have them look between toes as well.
Your job is to get those tootsies in the best condition possible. It is also up to you to teach your patient the importance of good foot care. Remember that instruction to the patient is also a nursing skill.
Let’s start with some really basic foot care.
Many times you will come across common foot ailments.
Generally seen in diabetic patients, it is an obvious malformation of the foot. It is now considered to be due to chronic inflammation secondary to underlying neuropathy, trauma, and disturbance of bone metabolism.
What you see is a midfoot collapse also called a “rocker-bottom” foot. Obviously specially made custom shoes are required. Again, part of this nursing skill is to instruct your patient to make an appointment with a podiatrist if they don’t have one.
Named because of its prevalence in athletes, this is a fungal infection. It is easily caught in warm moist places like group shower situations such as the gym. It is a rashy, burning, itchy infection that can be difficult to cure.
Fungus, or yeast generally likes warm, moist, dark places which is exactly what is between the toes.
There are many OTC (over the counter) medications in powder, cream and aerosol which can be used. A physician may also order antifungal cream to be used. Nursing skill: Instruct your patient that the creams must be massaged into the skin.
The order is usually for twice a day (but read the prescription to be sure) and the area must be kept clean and dry (difficult to do with toes that are in socks and shoes most of the day.
Also instruct the patient to use white cotton socks and to change whenever the socks or feet become moist during the day as part of this nursing skill.
Lots of people get callus formation on their feet. Due to pressure and friction from shoes, it is hyperkeratosis of the skin. This is a protective response to chronic irritation. Obviously, better fitting shoes would be ideal.
With diabetics, a callus can harbor more than in non–diabetic patients. Sometimes what looks like a callus can be hiding a developing ulcer underneath, so during foot care, it is an important nursing skill to assess these areas carefully. This is why most podiatrists will scrape away callus on diabetic feet.
One important sign that a callus is becoming pre-ulcerative is seeing speckles of blood within the callus. Instruct your patient about this.
Seems to be the curse of old folks. The nails get thick and yellow, sometimes lifting off the foot bed. They become difficult or impossible for the individual to clip the nails. This adds the problem of greatly overgrown toenails.
The fungal infection is hard to eradicate because the fungus has gotten under the nail where it is tough to apply medication. I recall one podiatrist mentioning that the surface of the nail needs to be scrapped to break the shiny “seal” of the nail to allow absorption of medication.
This difficulty is probably why an oral medication is used many times to cure the infection. It systemically can get to the root of the problem.
If you see nails like this, it is time to recommend that the patient set up an appointment with a podiatrist. No, your nursing skill does NOT include clipping their nails. Besides, you’d probably need a dremel tool to get through them. Seriously.
Podiatrists are one of the few doctors that still, for the most part, will do home visits to trim nails monthly. This is a good thing for homebound patients.
Some toenails of the second through fifth toes will grow so closely to the skin and wrap around the end of the toe, you may not initially realize the length of the nail.
There are several types of gangrene:
Podiatrist: (how to pronounce) a person qualified to diagnose and treat foot disorders. Practice is restricted to the area from the knee to the toes. The initials after the individual’s name is DPM (Doctor of Podiatric Medicine)
Charcot: (how to pronounce) malformation of the foot usually in diabetics
Fungus: A single-celled or multi-celled organism without chlorophyll that reproduces by spores and lives by absorbing nutrients from organic matter. NOT a bacteria, NOT a virus.
Hyperkeratosis: (how to pronounce) a thickening of the horny layer of the skin or cornea of the eye. Hyper = excessive. Keratosis = any horny growth
Neuropathy: (how to pronounce) a disturbance in the peripheral nervous system. It can be sensory, motor, autonomic, and mixed. It is common in diabetics; the most common is a chronic pain or reduced sensation in the the nerves of the lower limbs (less common in the upper limbs).
Peripheral: (how to pronounce) outer boundary, furthest from the core of the body. Hands and feet are the furthest from the central part of the body. Therefore, peripheral circulation would be circulation in the limbs, peripheral neuropathy would be nerve damage to the hands, feet, limbs.