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Journal of Wound, Ostomy & Continence Nursing:
doi: 10.1097/WON.0b013e318223183c
Foot Care Literature Review

Foot Care Literature Review 2010

Section Editor(s): Burdette-Taylor, Michele (Shelly) R. PhD, RN-BC, CWCN, CFCN;

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Foot and Nail Care

F1. Clinical Guidelines for the Recognition of Melanoma of the Foot and Nail Unit

Bristow IR, AR de Berker D, Acland KM, Turner RJ, Bowling J. Journal of Foot and Ankle Research. 2010;3:25.

Article Type: Integrative review

Description/Results:

* Malignant melanoma is a life-threatening skin tumor which may arise on the foot and under the nail.

* The prognosis is good when lesions are diagnosed and treated early, unfortunately, on the foot and under the nail conditions are often difficult to diagnose leading to delays in diagnosis with a poorer prognosis.

* Guidelines have been drafted specific to the foot and nail assessment the ABCDE acronym, modified ABCDE of nail melanoma, CUBED acronym, and understanding specific differences in nail unit melanonychia (NUM) versus subungal hematoma in causes, features, signs, and syndromes.

What does this mean for me and my practice?

Foot care nurses need to understand, educate, and refer their patients about the risk factors, signs, symptoms, various presentations, assessment, and treatment guidelines for this potentially life-threatening cancer.

The prognosis of melanoma corresponds to the histological (Breslow) thickness of the excised tumor which corresponds directly with the length of time the lesion was undiagnosed and left to grow. Many misdiagnoses are made in favor of a more benign condition such as ingrowing toe nail, foot ulcer, wart/verrucae, tinea pedis/onychomycosis, bruising, foreign body, or subungal hematoma. Simple rules are: check the skin of the feet, between the toes, plantar and dorsal aspect—if suspicious refer, check the nails—if the pigment arises solely within the nail bed with normal matrix and nail folds not likely to be a melanoma, if not be suspicious—if with treatment the lesion deteriorates or fails to heal—be suspicious—refer.

F2. Transitional Off-loading: An Evidence-Based Approach to Pressure Redistribution in the Diabetic Foot

McGuire J. Advances in Skin and Wound Care. 2010;23(4):175–190.

Article Type: Integrative review

Description/Results:

* Pressure redistribution is used to describe the mechanical attempts of clinicians to reduce the forces on the patients' plantar surface of the foot that is high risk or actually has an ulcer.

* 6 “W” Approach—Who—What—When—Where—Why—& the “Way” the patient walks is an attempt to be more inclusive in their evaluation.

* Options for off-loading include total contact cast, removable cast walker, molded ankle foot orthosis, charcot restraint orthopedic walker, modified healing sandal, felted foam technique, and football dressing.

* Ambulatory aides should be prescribed to enhance the effectiveness of the device.

* Follow-up with podiatrists, pedorthists, and orthotists may be essential for prevention of initial injury and recurrence of an ulcer.

What does this mean for me and my practice?

Foot and nail care nurses must have a basic understanding not only of the importance of off-loading/pressure redistribution but also of the options, disciplines involved as specialists, and needs in different phases of healing and prevention of injury. Understanding of therapeutic off-loading can minimize injuries leading to wounds and amputations, and facilitates the promotion of comfort. Foot care nurses are responsible for recommending ambulatory aides and making referrals for use of those aides as needed. Musculoskeletal deformities are common of people with diabetes and the older population which often necessitate a special molded shoe. A thorough understanding of the Medicare Therapeutic Shoe Bill is also an expectation of Foot and Nail Care Nurse with appropriate education and referral for our population meeting the criteria.

F3. Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients With Diabetes

Snyder RJ, Kirsner RS, Warriner RA, Lavery LA, Hanft JR, Sheehan P. Supplement in Wounds. April 2010:1–23.

Article Type: Integrative review

Description/Results:

* The world's population with diabetes will increase from 171 million to 366 million by 2025. Diabetic foot ulcers and amputations are a costly problem to the tune of $30 billion in 2007.

* Providers must not work in isolation when dealing with people with diabetes specific to preventing a foot ulcer that may lead to amputation.

* Assessment of the lower extremity should consist of 10-gram monofilament and 128-Hz tuning fork tests for sensory neuropathy.

* Lack of pulses is a good sign that there is poor blood flow but presence of pulses is not a good sign that there is sufficient blood flow to the feet.

* Doppler testing of pulses, conducting an ABI, may not be sufficient with PWD—a Toe Pressure is much more accurate when calcified vessels may be present and prompt referral for follow-up.

* Off-loading and therapeutic footwear is essential to prevention.

What does this mean for me and my practice?

Foot and nail care nursing is a specific approach for early intervention for this high-risk patient population. Appropriate education, referral, and intervention are essential for people with diabetes to successfully ward off a neuropathic injury that leads to infection and amputation. Assessment of the lower extremity is the largest didactic component for the foot and nail care nurse curriculum because with objective information that can be communicated the foot and nail care nurse is likely to make an impact as an advocate for that patient and family. Continued surveillance using evidence-based practice ideas, concepts, and recommendations is the best approach for preventing injuries that lead to amputation.

Copyright © 2011 by the Wound, Ostomy and Continence Nurses Society

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