Foot/Nail Care Assessment & Care for the Assisted Living Resident Melissa Bowen, RN, BSN, Janice Chramosta, RN, BSN, Tracey Pelchat, RN, BSN, & Simone Vampola, RN, BSN

Katherine Kaiser, RN, PhD, APRN-CNS Faculty Advisor College of Nursing , University of Nebraska Medical Center, Omaha, NE 68198

According to the 2009 U.S Census statistics, people 65 years of age and older

account for 13.4% of Nebraska’s population.

According to the 2009 U.S Census statistics, people 65 years of age and older

account for 13.4% of Nebraska’s population.

Health Promotion Model

Foot/Nail Care Policy for Assisted Living Residents

• Individuals who participated in a comprehensive self-management and education training program showed clinical benefit compared to a group that received usual routine foot care every 3 months (Waxman et al., 2003)

Level of Evidence: II•Educational interventions that increase knowledge of foot and nail care for nurses improve elderly foot care and reduce foot pain (Stolt et al., 2011)

Level of Evidence: III•Individualized foot care educational interventions enhance patient knowledge and self-efficacy (Corbett, 2003)

Level of Evidence: IV• Diabetic-specific exercise and self-care management practices are a necessity to promote foot care and health promotion (Bowman, 2008)

Level of Evidence: IV• Type 2 Diabetics do not receive education on physical activity and the relationship in maintaining healthy feet (Bowman, 2008)

Level of Evidence: IV• Diabetic nurse educators identified foot/nail care behavior as most important for elders to participate in daily (Martinez & Tripp-Reimer, 2005)

Level of Evidence: IVStrength of Evidence: B mb, jc, tp, sv

Screening Tool

References

Problem

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Review of the Literature According to the 2009 U.S Census, people 65 years of age and older account for over 13% of

Nebraska’s population. In Lancaster County, this represents nearly 11% of the population. The elderly population can be considered vulnerable due to their reduced ability to care for themselves which makes them dependent on health care providers and family involvement. Other health care disparities in this population include poverty, physical or mental impairments, lack of transportation and limited access to health care.

•In high risk populations such as patients with neuropathy, 80% of foot problems are related to inadequate footwear (Corbett, 2003) •Nearly 40% of elderly have at least one foot ailment (Stolt et al., 2011)•Diabetics have a 20-40% chance of acquiring either neuropathy or peripheral vascular disease. Foot ulcers account for approximately 5% in this group (http://www.nice.org.uk/CG10) 

Section: General Developed/Revised by: Clinical Team

Effective date: 6/2011

Review date: Next review date 6/2014

Mission Statement Lincoln Feet provides quality health care to the elderly regardless of age, race or ability to provide payment.

Purpose•Create a collaborative, evidence-based methodology toward foot care management of the elderly •Provide a preventive foot care program to educate and motivate residents to maintain healthy feet

•Provide comprehensive baseline and on-going foot and nail care assessments for each resident

•Initiate treatment in an timely manner

•Develop an appropriate individualized plan of care for residents with actual and/or potential foot care needs

•Provide education and training to residents and family members to expand their knowledge of foot and nail care

Collaborative Agreement•Signed collaborative agreement on-site between the APRN executing the clinic and collaborating physician; contract renewed yearly•APRN maintains current licensure requirements

Developing accessible care for this vulnerable elderly population is a key healthcare initiative. Lincoln Feet, through a collaborative multidisciplinary team approach lead by an Advanced Practice Registered Nurse (APRN), promotes health maintenance and disease prevention to the elderly in regards to foot and nail care. The service is provided on site at the Lancaster County Assisted Living facility to promote access to health care.

Dorothea Orem’s Self-Care Framework model focuses on the individual’s ability to perform self-care activities. Lincoln Feet utilizes this model to promote residents in taking ownership of their own health care needs, and provides an innovative program focusing on self-care foot maintenance. The goal is to have appropriate resources available for each resident to become competent in independent foot care, each to his or her own ability.

Clinical Staff Responsibilities•Foot sensation tested by trained staff using 10 g monofilament on admission and for existing residents

•Weekly foot and nail assessments completed on all residents with loss of sensation monofilament test results

•All patients with risk factors: diabetes, renal failure, peripheral vascular disease, peripheral neuropathy, previous amputation, history of foot ulcers, visual impairments, and tobacco abuse referred to foot care clinic

•Refer residents to weekly foot clinic based on assessment

•Assess availability for family to assist in cares

•Provide residents with DVD and written instructions on foot and nail care and use of provided foot mirror upon admission

•Plan monthly education sessions on foot and nail care for residents and family members to attend

•Educate residents on a self management nail and foot care program

•Offer residents a sign to place in their bathrooms “Maintain Healthy Feet, Check them Daily”

•Notify APRN if any resident assessment changes and requires follow-up before the weekly clinical visit

Clinical Staff Education Development •Complete a foot care management program upon hire to facility•Annual competency validation on foot care management

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Clinical Staff Responsibilities•Foot sensation tested by trained staff using 10 g monofilament on admission and for existing residents

•Weekly foot and nail assessments completed on all residents with loss of sensation monofilament test results

•All patients with risk factors: diabetes, renal failure, peripheral vascular disease, peripheral neuropathy, previous amputation, history of foot ulcers, visual impairments, and tobacco abuse referred to foot care clinic

•Refer residents to weekly foot clinic based on assessment

•Assess availability for family to assist in cares

•Provide residents with DVD and written instructions on foot and nail care and use of provided foot mirror upon admission

•Plan monthly education sessions on foot and nail care for residents and family members to attend

•Educate residents on a self management nail and foot care program

•Offer residents a sign to place in their bathrooms “Maintain Healthy Feet, Check them Daily”

•Notify APRN if any resident assessment changes and requires follow-up before the weekly clinical visit

Clinical Staff Education Development •Complete a foot care management program upon hire to facility•Annual competency validation on foot care management

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Economic Analysis•All residents will be seen regardless of economic or insurance status•Public (CMS) and private pay insurance reimburse for nurse-provided and physician-supervised education and foot care (Pinzur et al., 2001)•Lincoln Lancaster County Health Department community resources available: Pier1 or Health 360 program

Transportation Needs •Clinic will be available on site to avoid transportation conflicts

Cultural Considerations•Obtain interpreter as needed•Russian heritage goal is to maintain warmth, may be reluctant to apply ice to feet if ordered•Muslim women value modesty, keeping the body covered, may be reluctant to have their feet assessed by the health care provider. Also, may refuse to remove clothing for physical assessment and hygiene, and require female health care provider.•Chinese descendants may feel uncomfortable touching their own bodies. Assess comfort level to participate in self foot care.

Resident Responsibilities•Attend a self care foot and nail care management programwithin one month of admission to the assisted living•Perform foot and nail care to ability

Referrals•High risk patient referred on an annual basis to podiatrist •Expert foot wear specialist available on site at weekly clinic

Economic Analysis•All residents will be seen regardless of economic or insurance status•Public (CMS) and private pay insurance reimburse for nurse-provided and physician-supervised education and foot care (Pinzur et al., 2001)•Lincoln Lancaster County Health Department community resources available: Pier1 or Health 360 program

Transportation Needs •Clinic will be available on site to avoid transportation conflicts

Cultural Considerations•Obtain interpreter as needed•Russian heritage goal is to maintain warmth, may be reluctant to apply ice to feet if ordered•Muslim women value modesty, keeping the body covered, may be reluctant to have their feet assessed by the health care provider. Also, may refuse to remove clothing for physical assessment and hygiene, and require female health care provider.•Chinese descendants may feel uncomfortable touching their own bodies. Assess comfort level to participate in self foot care.

Resident Responsibilities•Attend a self care foot and nail care management programwithin one month of admission to the assisted living•Perform foot and nail care to ability

Referrals•High risk patient referred on an annual basis to podiatrist •Expert foot wear specialist available on site at weekly clinic

APRN Clinical Responsibilities •Perform a weekly foot care clinic on-site•Complete screening tool and non-invasive diagnostic exam on each resident attending•Focused physical assessment to include: •Assess all areas/surfaces of toes, feet, and nails •Assess personal hygiene •Review foot wear/appropriateness of shoes •Assess color, temperature and capillary refill of toes, nails and feet •Observe characteristics of pulses •Identify if home therapies utilized •Assess pain level and characteristics •Observe gait•Assess self-care management abilities, i.e. visual acuity, mobility•Identify availability of support systems•Assess risk factors •Perform necessary treatments •Provide written instructions to resident on treatment plan•Refer residents to foot wear or other specialist •Establish follow up appointment at clinic

Education Material •Education plan reviewed and written material provided to resident at the end of the session•Large print education material available

Post Clinical Conference•APRN will conduct a post clinical conference with staff to discuss clinic findings, make referrals•APRN and staff will formulate individualized plans of care based on clinic findings•Perform educational session if knowledge deficit identified

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APRN Clinical Responsibilities •Perform a weekly foot care clinic on-site•Complete screening tool and non-invasive diagnostic exam on each resident attending•Focused physical assessment to include: •Assess all areas/surfaces of toes, feet, and nails •Assess personal hygiene •Review foot wear/appropriateness of shoes •Assess color, temperature and capillary refill of toes, nails and feet •Observe characteristics of pulses •Identify if home therapies utilized •Assess pain level and characteristics •Observe gait•Assess self-care management abilities, i.e. visual acuity, mobility•Identify availability of support systems•Assess risk factors •Perform necessary treatments •Provide written instructions to resident on treatment plan•Refer residents to foot wear or other specialist •Establish follow up appointment at clinic

Education Material •Education plan reviewed and written material provided to resident at the end of the session•Large print education material available

Post Clinical Conference•APRN will conduct a post clinical conference with staff to discuss clinic findings, make referrals•APRN and staff will formulate individualized plans of care based on clinic findings•Perform educational session if knowledge deficit identified

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Project Goal

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American Diabetes Association (2011). Standards of medical care in diabetes-2011, Diabetes Care, 34(1). Retrieved from http://care.diabetesjournals.org/content/34/Supplement_1/S11.full.pdf+htmlBowman, A.M. (2008) Promoting safe exercise and foot care for clients with type 2 diabetes. Canadian Nurse, 2, 23-28.Corbett, C.F. (2003). A randomized pilot study of improving foot care in home health patients with diabetes. The Diabetes Educator, 29, 273-282.Pender, N., Murdaugh, C., & Parsons, M.K. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc. Pinzur, M., Kernan-Schroeder, D., Emanuele, N. & Emanuel, M. (2001). Development of a nurse-provided health system strategy for diabetic foot care. Foot & Ankle International, 22(9), 744-746.Pundell, L. D. (2009). Guide to culturally competent health care (2nd ed.). Philadelphia, PA: F. A. Davis Company. Stolt, M., Routasalo, P., Suhonen, R., & Leino-Kilpi, H. (2011). Effect of an educational intervention on nurses’ knowledge of foot care and on the foot health of older residents. Journal of the American Podiatric Medical Association, 101(2), 159-166.Martinez, N.C. & Tripp-Reimer, T. (2005). Diabetes nurse educators’ prioritized elder foot care behaviors. Diabetes Educator, 31, 858-868. National Institute for Health & Clinical Evidence (2011). Type 2 diabetes: Prevention and management of foot problems. Retrieved from http://www.nice.org.uk/CG10U.S. Census Bureau (2011). State & county facts. Retrieved from http://quickfacts.census.gov/qfd/states/31/31109.htmlWaxman, R., Woodburn, H., Powell, M., Woodburn, J., Blackburn, S., & Helliwell, P. (2003). FOOTSTEP: A randomized controlled trial investigating the clinical and cost effectiveness of a patient self-management program for basic foot care in the elderly. Journal of Clinical Epidemiology, 56(11), 1092-1099.