Every nurse appreciates the value of a comprehensive nursing assessment. It confirms the information that the patient may have shared directly, as well as a wealth of findings the patient may not have shared or recognized as significant. A comprehensive assessment also provides the structure for the development of individualized plans of care. Failure to assess the feet is as serious an omission as overlooking any other body part or organ system. If the eyes are indeed the windows into the soul, then the feet are the doors that open into a wealth of patient information. No system works in isolation and each system impacts the body as a whole. Identification of abnormalities in the feet can reveal problems with the heart, liver, and kidneys, deficits in self-care, nutritional disorders, systemic diseases, infectious processes, and so much more.
Although a problem-focused assessment may yield some information, it does not provide the critical information that can be obtained when the patient is completely examined. While not every nurse is able to recognize subtle changes in heart or lung sounds, most readily recognize abnormalities with the feet. Whether the condition is a change in the nails or the structure of the foot itself, these changes are readily identifiable. A sign, an objective physical nail finding such as abnormal nail shape or color, may be combined with symptoms that are subjective indications of disease, pathology, or injury. The presence of signs and symptoms in the nail gives valuable clues that direct further workup to determine the precise diagnosis of the pathologic process.1 Recognizing these conditions and what they indicate provides critical information about the patient's overall well-being.
Although structural changes may be obvious, the successful candidate seeking the WOCNCB's certification in foot care will understand the significance and implications of those changes as well as the appropriate terminology. Foot care is complex; critical components include knowledge about anatomy, function, range of motion, vascular status, neuropathies, skin integrity, footwear, and management. A complete content outline to guide Certified Foot Care Nurse (CFCN) exam preparation can be found at www.wocncb.org.
The role of the CFCN is complex and often misunderstood. The nurse who has earned a CFCN credential is not a salon professional offering nail care. Instead, this person is a professional registered nurse who has obtained additional knowledge and clinical experience needed to perform comprehensive foot care, make referrals as indicated, reduce foot pain and improve mobility, and deliver education designed to improve limb salvage, improve fall prevention, and health-related quality of life.
Nurses who earn the CFCN credential appreciate the relationship between foot care and multiple other specialty practice nurses and physicians specializing in dermatology, occupational health, infectious disease management, and others. Assessment by a CFCN can identify changes in foot and nail structure that are associated with nutritional deficiencies, psychiatric disorders, cancers, localized trauma, infection, acute health crises, and chronic systemic conditions. For example, onycholysis is associated with hyperthyroidism, while onychomycosis is more commonly linked to lower limb ischemia.2
Successful candidates for foot care certification will blend a strong base of nursing knowledge with specialized didactic and clinical preparation as they journey along a path toward becoming a CFCN. This credential opens countless opportunities in a wide variety of settings and provides another venue for nurses to truly make a difference and improve lives.
The following questions are representative of the types of questions included on the exam for the CFCN credential.
- When observing patients ambulate, you notice an abnormal gait and that they are using furniture to assist with their balance. When questioned, they admit that they are always clumsy. This is most likely related to which of the following?
- Inner ear infection
- Motor neuropathy
- Autonomic neuropathy
- Disturbed proprioception
- A patient presents with a 10-year history of diabetes mellitus and a firm, rounded bulge on the mid-plantar surface of his or her foot. This is most likely which of the following?
- Charcot foot deformity
- Hallux valgus
- Tailor's bunion
- Gouty arthritis
- The dermatophyte fungi routinely lead to which common nail disorder affecting up to 13% of the general population?
Foot Care Certification: How and Where to Utilize CFCN Knowledge?
The Certified Foot Care Nurse (CFCN) can function in many care areas. These specialists and their knowledge of risk assessment can benefit patients or residents in acute care, outpatient settings, long-term care, and home health care, to name a few settings. My own journey toward certification began in home health care.
On my initial visits to home health care patients, I saw that functional limitations including poor mobility and self-care deficit were common nursing problems. Nursing interventions and goals were established to empower patients to regain their independence. I saw that providing foot care in addition to skilled assessments and medication teaching was easy as long as the patients remained homebound and had a skilled need that qualified them for ongoing home visits. But I was concerned about what would happen once the patients achieved the goals pertaining to their health conditions and the skilled need for home care was resolved. Perhaps the patients could manage their disease process and shower independently, but what about those who had difficulty reaching their feet and could not safely trim their toenails?
My observations identified a community need for foot care, and a plan was developed to provide foot care services on a private pay, outpatient basis. The initial focus of this service was trimming of toenails, but interventions to reduce calluses and debride thick toenails were also included. Each session with a foot care client became an opportunity for a nurse to assess self-care as reflected by observation of skin condition, personal hygiene, and mobility. This was clearly an avenue where the CFCN had a unique advantage and an opportunity to meet the needs of clients in the community and facilitate the diversification of services offered.
The CFCN can also function as an adjunct to the role of the Certified Wound Care Nurse (CWCN). Patients with lower extremity wounds typically have a difficult time caring for their wounds as well as their feet. A nurse trained to assess the condition of the skin, toenail dystrophy, and problems with footwear can greatly benefit these patients. While foot care and wound care have components that overlap, each specialty requires a different knowledge base and skills; the CFCN focuses on wound prevention, whereas the focus of the CWCN is wound care.
Long-term care is another venue where the CFCN can serve a vital purpose. As the body ages, the nails can thicken and become more difficult to care for. Those thick nails can be intimidating for nursing assistants and nurses alike. A CFCN, specifically trained and certified to provide care in these situations, can be an added benefit to these residents.
These are just a few examples of how the role of the CFCN can lead to a better quality of life for the patients or residents they serve. Of course, because the Nurse Practice Act, which defines the role of the registered nurse, varies from state to state, each nurse must determine if the care provided by the CFCN falls within that framework.
If you are interested in becoming a CFCN, begin by going to the Exam Handbook found at www.wocncb.org and review the Content Outline to learn what will be covered by the exam. The WOCNCB also has an online link, where you can buy a Self-Assessment Exam with practice questions to help you prepare prior to the exam. For more information or assistance, you can reach the WOCNCB staff at firstname.lastname@example.org.
Question 1: The correct answer to this application-level question is option d. Although diabetic patients could have abnormal gait secondary to sensory neuropathy, that option is not one of the choices presented. Other patients may have conditions that contribute to the inability to recognize position and placement such as fractures and other sources of nerve impairment. Motor neuropathy would lead to changes in foot anatomy but not a change in gait. Autonomic neuropathy is tied to excessive dryness and fissures but would not affect balance. Dizziness may be related to an inner ear infection and a change in balance, but the duration would be short-term and would not last long enough for a patient to feel that they were always clumsy.
Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. 4thed. St Louis, MO: Mosby Inc; 2010:254.
Content outline location: 1-B-8
Question 2: The correct answer to this question is option a. Charcot foot deformity is an increasingly common deformity affecting patients who have had diabetes for years and resulting sensory neuropathy. Among other signs, it is commonly identified by bony changes resulting in changes in the shape of the foot. Understanding common terminology and foot morphology is critical to success. A hallux valgus deformity is incorrect because, by definition, it involves the first metatarsophalangeal joint. Likewise, gouty arthritis involves the same joint and may affect the ankle and/or knee. A tailor's bunion is also identified by location and involves the fifth metatarsal joint.
Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Mosby Inc; 2010:229.
Content outline placement: 1B7
Question 3: The correct answer to this recall-level question is option c, onychomycosis, which is a common nail disorder directly caused by a nail fungi. Understanding terminology related to nail disorders is a critical component to preparing for the foot care exam. All nail terminology begins with “onycho,” which makes a careful reading key to selecting the correct answer. As with most terminology, sometimes keys can be gleaned from the word. For example, onycholysis is a lifting of the nail plate. Onycholysis breaks down to onycho meaning nail and lysis meaning lifting. Onychocryptosis is an ingrown toenail. It is sometimes triggered by oral antifungals but is not caused by a fungal infection. Onychogryphosis has similar features to an advanced fungal infection with thickened, deformed nails, but the hallmark is a significant curve that will extend without treatment to an actual curl and is commonly called “Rams Horn Nail.” The question is asking for a common nail disorder and onychogryphosis is not as common as onychomycosis. A careful reading of the question and determining what the question is asking are essential for success with all tests.
Menz H. Foot Problems in Older People: Assessment and Management. Edinburgh; New York: Churchill Livingstone; 2008:100.
Content outline placement: 1B10