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Foot Assessment

Lower Extremity and Foot Care

The value of standardized protocol for lower extremity assessment and care by nurses should not be minimized. Foot care is an integral part of optimal health maintenance; and historically a missed opportunity. The use of flow sheets significantly improves the assessment and documentation of foot care (Hempel, 1990). Through the use of standardized assessment tools and consistent documentation, retrospective research studies can provide nursing knowledge in the client outcomes related to routine foot care and the reduction of complications in high risk populations. Comprehensive assessment should include:

  1. Documentation flow sheets
    1. Demographic information and current health history
  2. Review of recent history, medications and changes
  3. Assessment of ADLs, gait, balance,falls and footwear
  4. Assessment of feet and lower extremities
    1. Color
    2. Temperature
    3. Varicosities
    4. Edema
    5. Circulation
    6. Capillary refill
    7. Pain
    8. Skin integrity
    9. Bony deformities
  5. Nail assessment
    1. Shape
    2. Color variations
    3. Texture
    4. Fungal changes
    5. Macerated web space
    6. Sensation
    7. Skin changes
  6. Interventions to include:
    1. Soak feet
    2. Inspect and dry between toes
    3. Nails debrided with orange stick, hyponychial border located, nails trimmed and filed
    4. File calluses and corns
    5. Lotion massage to feet
    6. Apply treatment ointments, if applicable
    7. Recommendations, education and referral
  7. Completion of documentation form per protocol
  8. Narrative note, if applicable
  9. Teaching-Learning Module to include
    1. World Wide Web site access of interactive teaching material
      1. Digital photographs  of common foot and nail conditions and bony deformities
      2. E-mail feedback from on-line participants
    2. On site orientation (area future development)
      1. Use of equipment
      2. Routine care per visit
      3. General guideline for referral
      4. Client education at each visit
      5. Documentation protocol

The review of the literature supports the components identified in the Enhanced Foot Assessment Tool. Lower extremity and foot examination should include review of medications and past medical history, assessing circulation, skin integrity and presence of hyperkeratotic lesions, temperature, nail condition, pain, bony deformities, skin color, edema, varicosities, neurological status, evaluation of footwear, education, and the need for referral.

The importance of client history is imperative to identify at risk populations. Rijswijk (1998) described at risk populations as client's with a history of diabetes mellitus, smoking, atherosclerosis, deep vein thrombosis, increased age, signs of neuropathy (numbness of pain), limited mobility, coronary artery disease, spinal problems, impaired vision, decreased hand dexterity, decreased hip flexion, obesity, and peripheral vascular disease are in greater need for foot care and lower extremity assessment. Also, the need for identifying a change in activities of daily living (ADLs) from one visit to another (Kelechi, 1996). An Enhanced Lower Extremity and Foot Assessment should include circulation (color, temperature, and palpation of pedal pulses). Also, observe for evidence of bony deformities (bunions, hammer toes, or overlapping toes) as well as skin changes (edema, corns, calluses, fissures, lesions, wounds, and maceration). Included in this enhanced foot care assessment are toenails for thickness, length, condition, and hygiene. Protective sensation is assessed using a special instrument such as a monofilament (Kelechi, 1996; Kelechi & Lukas, 1997). Lastly, footwear is assessed for appropriateness of fit, wear, and style (North Carolina Medical Society, 1995).

How to use the PDF file Assessment Tool

Use of Enhanced Lower Extremity and Foot Assessment Tool

In the following text is a detailed description of 'how to' use the Enhanced Lower Extremity and Foot Assessment Tool. This PDF file assessment tool is designed for ease of use; thus, the format of circling or use of a check box format is consistent. Rarely, when 'other' is used, a written description is required. This tool has been developed after a thorough review of the literature relevant to content and design. It is these authors intent that this tool will provide succinct documentation for research analysis and comparative evaluation from visit-to-visit by providing two assessments on one form.

Use of the Front Page of the Assessment Tool

The front page of the PDF file assessment tool begins with basic demographic information such as, client name, date of birth, primary care provider, podiatrist, and a brief past medical history. In addition, a series of questions are asked, which focus on activities which may or may not change from one visit to the next. The questions, simple yes or no, invoke possible changes in ADLs, medications, mobility, purchase of new shoes, visits to primary care provider or a podiatrist that would solicit further investigation. Additionally, with each assessment, current medications are reviewed.

Provider Positioning

Providers of foot care are generally positioned in front of, and below the client. Typically, the provider sits upon a stool, while the client is seated in a chair; thereby, allowing the client's feet to rest upon the providers lap. With this positioning as a point of reference, this tool has been designed to enhance documentation by clearly labeling right or left, dorsal or ventral, anterior or posterior lower extremity parameters. This format will attempt to decrease the number of transcription errors.

Lower Extremity Assessment

The lower extremities are assessed for color (pale, pink, ruddy, brown, cyanotic, or other), temperature (warm, cool, or other), presence or absence of varicosities (superficial, palpable, tortuous, or other) and edema (1+, 2+, 3+, 4+, or other), circulation including the dorsalis pedis and the posterior tibial pulses (0, 1+, 2+, 3+) and capillary refill after blanching, documented in seconds. Presence or absence of pain, coupled with location, is recorded utilizing the Numeric Pain Intensity Scale (0-10). The inclusion of footwear (proper or improper) gives insight as to wear patterns, foot support (orthotic or prosthetic), and sole, fabric, and toe box dimensions. Skin integrity is delineated on a diagram using the first initial of the following descriptive words: moist, dry, flaky, bruised, opened, scabbed, or other. Space has been allocated for selected further documentation and provider signature.

Use of the Back Page of the Assessment Tool Foot Assessment

The back page of the assessment tool focuses on the foot assessment. The presence or absence (yes or none) of bony deformities are differentiated as bunions, hammer toes, overlapping digits, prominent metatarsal heads, or amputations. If present, the provider will circle the abbreviation for the appropriate digit. Nail shape (incurvated, c-shaped, ingrown, flat, other), nail color (white, yellow, brown, black, other), nail texture (thick, thin, crumbly, brittle, split, separated nailbed, other), nail fungus (yes or none), and macerated web space is delineated in the same fashion. Sensation is assessed using a 5.09 monofilament according to the Lower Extremity Amputation Prevention (LEAP) program protocol. Location to be assessed is identified on the diagram by a circle; presence of sensation is denoted by placement of the + symbol in the circle or a - symbol, if applicable. The test consists of one second landmark touch with a 5.09 monofilament, one second monofilament bend, and one second release. Next, skin changes of the foot are added to the plantar and dorsal diagrams using the first initial(s) of the descriptors: corn (K), callus, pain, redness, fissure, wound, scar, or wart (Wa). Interventions (soak, trim, file, lotion, massage, other) are documented as yes or no. Recommendation for education or referral include daily hygiene and inspection, drying between the toes, and the opportunity for other education. Space has been again allocated for additional comments, if needed. The provider recommends the projected interval for return to clinic visit. Lastly, the provider of care signs the form.

Step by Step

Provider wears protective gear; gloves and eye shield

Client seated in a comfortable chair with supporting arm rests

Provider seated on a stool in front of client

Remove stockings and shoes, if applicable

Assess lower extremities and feet prior to soaking

Begin assessment with lower extremities and progress to the feet *see Using the Tool for assessment inclusion criteria

Soak feet in tepid water (95 degrees F) for 5 minutes using mild foot soap. *place soap powder in basin first, then add water

Remove one foot at a time for foot care

First, dry foot with special attention to dry between the toes (may use 2 x 2 gauze to remove excess debris)

Inspect between toes and top and bottom of foot

File, in one direction, corns and/ or calluses using a large foot file

Remove debris under the nail using a beveled wooden stick (orange wood stick)

The above step identifies the hyponychium borders under the nail

Compress and secure base of nail to be trimmed

Hold nail nippers with the flat edge of nipper against nail

Trim nails to the contour of the toe, taking small nips in the nail as you progress across the nail

File nails in a downward direction

Apply lotion; avoid toe web spaces

Massage feet and lower legs, if not contraindicated

Begin the above procedure on the second foot

Client teaching threaded throughout encounter

Referrals to specialists, if applicable

Contract with client for follow-up appointment and return to clinic (RTC)

Assist client with putting on socks (clean) and shoes

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