Chronic wounds of the lower extremities impose an increasing burden on health care providers and systems, and they can have a devastating impact on patients and their families. These wounds include diabetic ulcers, venous ulcers, arterial ulcers, and pressure injuries. The estimated...
By Diana L. Gallagher MS, RN, CWOCN, CFCN
I recently had the honor of participating in a meeting of the Wound Ostomy Continence Nursing Certification Board (WOCNCB®). My role was to assist the Foot Care Committee with the evolution of the exam for certification in foot care nursing. All WOCNCB exams are expanding to a larger format based on the recommendations of the testing industry. The committee worked diligently to assure that item inclusion matched the test blueprint which in turn matched the job analysis that had been completed earlier this year. There is SO MUCH work that goes on behind the scenes to maintain examinations that are worthy of the WOCNCB's "Gold Standard." Participating in this meeting was truly an honor. As one of the members of the original committee for foot care nursing, I could not have been prouder of the progress that has been made in the past decade.
In 2004, the WOCNCB answered an increasing demand for a certification in foot care nursing. With the popularity of the certification in wound care and the growing pandemic of diabetes, it was both a timely and logical move. A committee was established and the research and work began in earnest. In January 2005 the first credentials were awarded to those nurses who had completed the didactic and clinical requirements and successfully passed the certification exam. The development of this new exam supported the board's ongoing commitment to assuring patient safety by providing the structure for nurses to become certified.
The Benefits of Foot Care Certification
The Certified Foot Care Nurse (CFCN®) credential was yet another clear illustration of WOCNCB's long-standing commitment to leading the industry. At the initial meeting of the original committee in 2004, there were very few published resources designed for nurses. Yet, there was growing evidence that clearly identified the need for early assessment and intervention for patients who were at risk of foot care complications. A number of studies confirmed that neuropathy assessment was a first line tool in preventing amputations; however, neuropathy assessment was done less than 30% of the time.
With the foundation established by the WOCNCB, the initial elite group of dedicated foot care nurses has grown more than ten-fold. These pioneers have helped change the lives and save the limbs of countless patients.
Foot care certification helps document the knowledge and expertise of nurses who choose to specialize, however, every nurse should incorporate basic foot care into their daily practice. Leonardo Da Vinci is quoted as saying, "The human foot is a masterpiece of engineering and a work of art." This quote illustrates the complexity of the foot and foot care and recognizes that the delivery of foot health care is an ongoing study of both form and function.
The changes that have occurred over the first decade since the CFCN credential was initially offered are monumental. Prior to the first in-person meeting, each committee member was tasked with bringing any reference material that they could share. When the assignment was made, it seemed fairly straight-forward. I had several trips planned in the months before the meeting. In every major city I visited, I went to bookstores. There were two medical bookstores, three campus bookstores and six large bookstores for the general public. I love books and bought a lot of them, but was disappointed that I could not find a nursing reference focused on foot care. I found a few podiatry texts that exceeded the scope of practice I was looking for. Sadly, the most comprehensive text that I found was a soft covered textbook intended for salon professionals. I bought it, read it from cover to cover, but was embarrassed to bring it to that initial meeting even though it was the only reference material that I had found. Apparently, my efforts were not unlike my other committee members. There were six members on the initial committee and there were four copies of the same text. Ten years later, nursing resources on foot care provide a solid foundation to learn from. As the number of references has grown, so has the number of dedicated nurses who have worked to earn their certification in foot care.
Making Patient-Centered Care a Nursing Priority
I will admit that not every nurse is fascinated by foot care; not every nurse will want to seek certification in foot care nursing. Nursing is a diverse profession with essentially countless opportunities. It allows us to practice and specialize in the areas that we like best. We all have those areas of health care that we love, others that intrigue us, and a few that simply make us cringe. Regardless of area that we choose to practice in, there are common parameters that are inherent to good nursing. We have a responsibility to care for the whole patient; our focus should extend beyond the part that is currently an issue. If we fail to provide comprehensive patient-centered care, we fail ourselves, our profession, and the patient we are trying to help.
We all appreciate the criticality of doing routine skin assessments. Not doing so might fail to identify an at-risk patient. This could lead to that patient developing a pressure ulcer. A quality assessment addresses the patient from head to toe. Foot care and nail care are one component of that care. A comprehensive foot assessment will provide the nurse with a wealth of information critically important in developing a plan that addresses prevention, early intervention, and treatment. You do not need certification in foot care to be comfortable performing a basic foot exam. The eyes may be the windows into the soul but the feet may open the door to our health history.
Basic nursing assessment of the feet should be done with the initial assessment of every patient and repeated based on a patient's personal risk. It should include gait, skin condition, skin integrity, temperature, nail condition, pulses, and neuropathies. The clues to systemic diseases, past medical compromises, nutritional impairments, psychosocial issues, and so much more may stem from a simple foot and nail assessment. Just like any other assessment, correctly identifying a problem can prompt education, early intervention, and improve a patient's overall quality of life.
By watching a patient walk, you are able to discern valuable information on their gait and stability. As you assist a patient in removing their shoes and socks, you will be able to determine if the shoe is appropriate, with normal wear patterns and free of any irregularities that could contribute to trauma. Skin assessment should always include the feet. The spaces between toes should be examined for any evidence of maceration, bacterial, or fungal infections. The skin surface should be assessed for abnormal callous or corn formation. For patients who are lying supine, heels must be carefully monitored and elevated off the surface of the bed to prevent pressure ulcers. Because of the anatomy of the foot, the heel is the second most common site for pressure ulcer formation and prevention is always one of our responsibilities.
The Different Types of Neuropathy
Polyneuropathy is associated with a number of diseases but one of the most common conditions is diabetes. Neuropathy is classically seen with both Type 1 and Type 2 diabetes. It is not reversible but early detection can help patients prevent its worsening. Diabetes affects at least 20 million people in the United States, and that number grows with every newly released publication. Nearly 60% of all people with diabetes suffer from neuropathy. There are three common types of neuropathy and patients may have one or all three present on assessment.
Sensory neuropathy is the inability to correctly identify sensation. This is easily and quickly tested using a 5.07 Semmes-Weinstein monofilament. With their eyes closed, patients should be able to accurately identify where you are touching their foot with the flexible wire of the monofilament. Inability to detect the pressure of the flexed monofilament wire constitutes a loss of sensation.
Another type of neuropathy is motor neuropathy. It is shown with changes in the tendons and ligaments of the foot. As motor neuropathy develops, the shape of the foot, and especially toes will change shape. Toes may draw up resulting in hammer or claw toes. This change is significant and places additional pressure on the metatarsal heads. This change will require shoes with a deeper, wider toe box to avoid pressure.
The final type of neuropathy is autonomic. It results in excessive dryness that may in turn create painful cracks or fissures in the skin. These breaks can be a painful irritation but in a higher risk patient may pose a real threat if bacteria are able to enter and set up an infection.
Nail care is an important component of taking care of a patient's feet. Trimming healthy nails is something we all can do. Healthy nails can be trimmed with clippers following the nail's natural curve. To avoid the risk of additional trauma to the nail or surrounding tissue, it is best to do this by clipping the nail back in smaller segments as opposed to one large piece. Unfortunately, not all nails are beautiful, healthy nails. With age, nail morphology may include any number of nail abnormalities.
Onychomycosis, a fungal nail infection, is one of the most commonly seen nail disorders, characterized by yellow, thickened, crumbling nails. Excessive thickness can affect how well a shoe fits, and a poor fit may leave the patient with pain and difficulty with simple ambulation. Although there are prescription options available to treat onychomycosis, Vick's VaporRub and tea tree oil have been proven to be effective. Teaching must be done to help patients understand that the toenails grow very slowly and it may take up to 18 months for the nail to grow out healthy. Another common nail complication is paronychia or infection of the fold of skin along the sides of the nail. This can be exquisitely painful. Warm compresses will help until more definitive treatment can be arranged.
Nurses interested in foot and nail care are encouraged to learn more. The resources are readily available. This expanded skill set will serve the nurse, the patients and the institution very well. As they learn more, those who may want to seek this coveted certification are to be commended for advancing their education and expertise. Information on preparing for certification can be found at wocncb.org. Upon successful completion of the requirements and the exam, candidates will be awarded with their CFCN credential (Certified Foot Care Nurse) which will be good for five years. This exam is one of several options offered by the WOCNCB.
Nurses who do not have an overwhelming interest in foot and nail care are challenged to incorporate basic foot care skills into their daily routines. As nurses, we have a responsibility to our patients. That includes appropriate education, referrals to necessary resources such as a CFCN or podiatrist, and prevention and interventions that are matched to the patient's needs. If your patient has a foot, they deserve a nurse who is knowledgeable about foot and nail care.
About the Author
Diana Gallagher has over 30 years of nursing experience with a strong focus in wound, ostomy, continence, and foot care nursing. As one of the early leaders driving certification in foot care nursing, she embraces a holistic nursing model. A comprehensive, head to toe assessment is key in developing an individualized plan of care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.