Common Observations for Nurses while Performing Foot Care

Often patients take their feet for granted until problems such as blisters, calluses, and ulcers form. It's very important for nurses to promote good foot care practices, especially in people who are susceptible to foot wounds and neuropathy. The elderly are especially susceptible to a foot injury and often have a hard time performing foot care. For this reason, we often see elderly patients coming into community foot clinics. It is estimated that 80% of older people have foot problems. It's important to address this issue with this group of patients as they are often unable to bend down to cut their toenails, apply lotion, and check for breakdown. These patients often do not have a good sense of pain or feeling. In this paper, we will look at the assessment nurses should look for before and while performing foot care, some common observations we may see in elderly clients, and what type of teaching regarding foot care, we should give our patients.

There are a huge variety of people seen at community foot clinics. They vary in age and condition. It does not matter what the person's age or the condition of their feet; there are a few questions a nurse should always ask. It is essential to ask the patient if they are diabetic. Diabetes affects the blood flow and can cause diabetic neuropathy, and loss of feeling in the feet, which can lead to wounds and ulcers as well as impaired healing. For that reason, it's often recommended these patients see a podiatrist or a specialist. If they are diabetic, it is often a good idea to look carefully at the bottom of their feet, in between toes, and on bony prominences for any breakdown or wounds. As a nurse, we should recommend wearing foot protection such as slippers, shoes, or socks while ambulating to avoid any injury to the feet. We can also teach these patients about looking carefully at their feet daily to be alerted to any wounds before they become worse and give them information on when to notify their doctors.

It's also important for the nurse to ask if the patient is on any blood thinners. If the patient is on blood thinners and the skin is nicked, they may have an increased risk of prolonged bleeding. The geriatric population has the highest prevalence of blood thinner usage due to high rates of CHF and other preexisting conditions. Nurses should also ask if the patient has any other conditions, such as osteoporosis, CHF, impaired immune system, or a history of chronic wounds. Knowing the patient's history can be essential in preventing any complications and may indicate some future teaching.

The nurse should always observe the skin and the feet, even before treating or caring for the patient. The first questions should be in regard to the patient's shoes and socks. The nurse should not if the patient wears compression stockings, if these stockings constrict the toes, and if their shoes fit appropriately or leave marks on the skin. After removing the shoes and socks, the nurse should note the skin on the legs and feet, specifically noting the color and integrity. The nurse should observe and note any lesions on the feet or calves. If there are lesions, the patient should be referred to a specialist, a primary care provider, or a wound clinic. The nurse should feel the patient's calve and ask if they experience any pain. If the patient reports pain, they should be referred to a specialist or their primary care provider, as this may indicate some extensive problems. Next, the nurse should observe the toenails. The elderly population often have thick, overgrown toenails. The nurse should note if the toenails are cracked, discolored, or ingrown. Observation of these symptoms in the big toes is most common. Lastly, we can check the dorsal pulses on the feet and note the temperature of the skin. If there are significant variations in assessment data, it's always a good idea to tell the patient to go to their primary care provider for a checkup.

There is a wide variety of changes that occur to the body as it ages. Specifically, with feet, we see a few common changes. The first pertains to the skin. Aging skin tends to become dry and inelastic. There is a loss of the underlying fatty tissue that is important for protecting bone and soft tissue, and as a result, painful calluses are more likely to form. Dryness of the skin, often due to reduced blood flow, may cause the skin to split, leading to painful fissures. In some cases, these may become infected and result in significant wounds. In addition to skin, we also see a difference in the toenails. Toenails can thicken and become hard and brittle with age, making it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes. Toenails also may become ingrown due to overgrowth, injury, and tight or poorly fitting shoes. The foot itself may also be deformed. Foot width and length often both increase with age; in addition, the feet may swell with edema during the day (Woodrow et al., 2005). Arthritis inherited deformities, and previous trauma can also cause feet to change shape. Bunions and misshapen toes can lead to pressure sites where corns and calluses develop (Society of Chiropodists and Podiatrists, 2010). A bunion is a bony deformity of the joint at the base of the big toe and can lead to the big toe pointing inwards. Corns and calluses are areas of hard skin on the feet caused by excessive pressure or shoe rubbing. Corns are usually small and circular. Hard corns tend to develop on the bumpiest parts of the foot, and soft corns develop between the toes, where sweat keeps them moist. Calluses are wider and less well-defined and often develop in areas that take the most weight, such as the ball of the foot.

Proper Foot Care

It's important to teach patients how to take care of their feet at home to prevent future problems. Instructing the patient to check their feet daily is essential. Look and feel the bottom of the feet, in between the toes and on the heels, for breakdown, redness, dryness, and open wounds. Wash feet daily with soap and warm water, making sure to completely rinse off the soap and dry the foot completely, especially between the toes. If the patient chooses to apply lotion, remind them not to apply it between the toes. This can cause a build-up of moisture in between the toes and cause a breakdown or fungal/ bacterial infections. The patient should be instructed to cut or trim toenails straight across the toe and not to cut them too short. Patients should not cut or dig at the corners of the toenail. If the patient has corns or calluses, instruct the patient not to cut, shave or use over-the-counter treatments to resolve them; instead, inform them that they should see a podiatrist. This is especially important if the patient is diabetic or has an increased risk of infections or wounds on the feet. Make sure to remind the patient to wear clean socks and change them at a minimum daily to avoid athlete's foot. To ensure the feet are properly protected, ensure well-fitting shoes with non-slip soles, with orthopedics or padded socks if needed. It's important to teach our patients self-care techniques to prevent any complications on their feet.

The elderly population is at the highest risk for skin breakdown, which includes a breakdown of the feet. This breakdown may appear as redness or itchiness or be as severe as open wounds. It's for that reason we perform foot clinics for the community. During these clinics, not only is it important to perform care on the feet, but we also should be teaching the patient how to care for themselves year-round to avoid any future foot problems. As a nurse, we should also be assessing the patient's risk for skin breakdown and their ability to take care of themselves. As the patient ages, it gets harder to perform foot care. In these cases, we should be referring them to foot clinics or podiatrists to continue foot care year-round. Feet are often overlooked as an essential part of taking care of the patient's health; however, by taking care of patients' feet, we can avoid wounds that may eventually lead to infections.

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