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Update on Eligibility for the Foot Care Examination

Ellefson, Laurie L.; Thompson, Jeannine L.; Trelease, Jill

Journal of Wound, Ostomy and Continence Nursing: January/February 2016 - Volume 43 - Issue 1 - p 88–90
doi: 10.1097/WON.0000000000000199
GETTING READY FOR CERTIFICATION
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Correspondence: Laurie L. Ellefson (info@wocncb.org).

The Foot Care Certification credential was established by the Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) in 2005.1 Nurses who are certified in foot care provide a valuable service to patients with chronic diseases, demonstrating a positive impact on patient outcomes.2 Fujiwara and colleagues3 demonstrated a reduction in diabetic foot wounds with the implementation of a nurse-based foot care program. Beverley Meaney, a hemodialysis nurse, recognized the importance of foot care when developing a diabetes program. She argued that the clinical relevance afforded foot care in persons with diabetes mellitus and renal problems is underestimated, particularly given its role in avoiding complications such as diabetic foot ulcers and infections leading to amputation.4 Nurses who are certified in foot care are engaging in a leadership role through comprehensive patient assessment, direct patient care, staff education, and protocol creation/management.

When this certification was first introduced, a minimum of an associate's degree was required for eligibility to take the examination; however, health care and populations are changing, as are the roles of specialty practice nurses. United States Census data from 20105 list 18.5% of the population as aged 65 years and older. According to the American Diabetes Association,6,7 the prevalence of diabetes in 2012 was 9.3% or 29.1 million people, with 73,000 diabetic adults experiencing lower limb amputations. This translates to a global rate of approximately 1 amputation every 20 seconds. The increase in the aging population and the number of individuals affected by comorbidities such as diabetes will produce more patients seeking specialized care. The Certified Foot Care Nurse (CFCN) has evolved into an integration of multiple roles: content expert, consultant, and quality improvement in addition to direct patient care. The Institute of Medicine in the 2010 Future of Nursing Report: Focus on Education8 recommends that nurses “achieve higher levels of education ... that better prepare to meet the needs of the population.” These changes in the role of the CFCN led to the change in eligibility from an associate's degree to a bachelor's degree for the foot care examination.

Common concerns regarding this change involve the content of the exam. Content changes have been reflected in the new content outline found on the WOCNCB Web site at https://www.wocncb.org/certification/exam-preparation/exam-content-outlines. The new content outline is divided into 3 domains. They are Assessment and Care Planning, Intervention and Treatment, and Education and Referral. Each domain is subdivided into a series of tasks delineated by 2 categories: “knowledge of” and “skill in.” The knowledge category details the foundation of knowledge the certificant should have in that category. For example domain I/task 2 focuses on knowledge of anatomy and physiology of the lower extremities while performing a focused lower extremity assessment. The skill category describes how a task is performed; domain 1/task 2 specifies that the certificant should be able to identify the appropriate pulses to palpate when performing a focused lower extremity assessment.

Consider the second practice question in this Getting Ready for Certification feature article; what would a foot care nurse implement first for a 60-year-old diabetic patient with hyperkeratotic lesions over the second metatarsal head. The examination outline is designed to help you prepare for this question; specifically, it is broken down into what is known and what is done. Essential knowledge needed to answer this question includes how diabetes mellitus impacts the foot, what is a hyperkeratotic lesion, and the location of the second metatarsal head. The certificant must have an understanding of pedal anatomy and pathophysiology as well as resulting symptoms. Essential skills focus on how to address these symptoms. This is where the change in the examination material is most pronounced; it is a reflection of nursing practice that is elevated and consistent with a higher level of education. Nursing is a field that embraces change, a continuous dynamic process. Embracing these changes allows the certificant to be better prepared to provide safe care leading to positive patient outcomes.

1. Wound, Ostomy and Continence Nursing Certification Board. Foot care certification. https://www.wocncb.org/certification/foot-care-certification. Accessed June 28, 2015.

2. Bliss D, Westra W, Savik K, Yuefeng H. Effectiveness of wound, ostomy, and continence-certified nurses on individual patient outcomes in home health care. J Wound Ostomy Continence Nurs. 2014;32(1):135–142.

3. Fujiwara Y, Kishida K, Terao M, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs. 2011:67(9):1952–1962.

4. Meaney B. Diabetic foot care: prevention is better than cure. J Renal Care. 2012;38(suppl 1):90–98.

5. Administration on Aging. U.S. population by age: July, 2010. http://www.aoa.gov/Aging_Statistics/Cenus_Population/census2010/Index.aspx. Published 2010. Accessed June 26, 2015.

6. American Diabetes Association. Statistics about diabetes. http://www.diabetes.org/diabetes-basics/statistics. June 2014. Accessed June 26, 2015.

7. International Working Group on the Diabetic Foot. http://iwgdf.org. Published 2015. Accessed June 27, 2015.

8. Institute of Medicine. The future of nursing: focus on education. https://www.iom.edu/∼/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Education%202010%20Brief.pdf. Accessed June 26, 2015.

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Practice Questions

  • 1. What are 2 major contributing factors that lead to lower limb amputation?
    1. Chronic kidney disease and heart failure
    2. Obesity and advanced age
    3. Depression and osteomyelitis
    4. Diabetes complications and peripheral artery disease
    • Content outline: Domain 1/Task 1/Knowledge b
    • Cognitive level: Knowledge

Answer D: To correctly answer this question, 2 major contributing factors related to lower limb amputation must be identified. The correct answer identifies diabetes complications and peripheral artery disease. Both of these choices reflect impaired circulation, with diabetes as a microvascular disease and peripheral artery disease affecting both large and small vessels. Impaired circulation can lead to tissue injury and necrosis that can result in a lower limb amputation. Chronic kidney disease and heart failure are 2 disorders in which edema may be a common symptom. Edema does not usually precipitate necrosis. Obesity and advanced age certainly are contributing risk factors, but on their own do not lead to amputation. Depression would be an expectation after an amputation but not a precipitating risk factor for amputation. Osteomyelitis (infection) can be a complication of diabetes and peripheral artery disease but when combined with depression in this option would make this answer incorrect.

1. Limb Loss Task Force/Amputee Coalition. Roadmap for Preventing Limb Loss in America: Recommendation From the 2012 Limb Loss Task Force. Knoxville, TN: Amputee Coalition; 2012.

2. Bryant R, Nix D. Acute and Chronic Wounds. Kindle ed. Elsevier Health Sciences; 2006. Kindle Locations 12998-13001.

  • 2. A 60-year-old man is admitted with poorly controlled diabetes mellitus. Nursing assessment reveals bilateral cold feet and moderate loss of sensation. There are hyperkeratotic lesions over the second metatarsal head of each foot. What should the foot care nurse implement first?
    1. Protective footwear to pad the hyperkeratotic lesions
    2. Remove hyperkeratotic lesions using a #15 blade
    3. Apply antifungal ointment to the hyperkeratotic lesions
    4. Apply a total contact cast to reduce the hyperkeratotic lesions
    • Content outline: Domain 1/Task 2/Knowledge g
    • Cognitive level: Application

Answer A: The stem describes a patient with impaired circulation and loss of protective sensation. The first priority would be focused on relieving pressure over a lesion/callous and protecting an insensate foot. Nurses must follow their state's nurse practice act, with not all State Boards of Nursing allowing debridement to be done by nurses. An antifungal ointment would not be indicated because the only lesions identified in the stem were hyperkeratotic, which does not indicate the presence of a fungal infection. Total contact casting is contraindicated because the patient assessment indicates the presence of ischemia and complaints of sensation loss. The stem describes hyperkeratotic lesions but does not state there is an open ulcer. Total contact casting is an indication for a hyperkeratotic lesion. If an ulcer were present, further testing would be required to ensure adequate blood flow prior to casting.

1. Howes-Trammel S, Bryant R, Nix D. Foot and nail care. In: Bryant R, Nix D, eds. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Mosby; 2012:261.

2. Wu S, Armstong D. In: Armstong D, Lavery L, eds. Clinical Care of the Diabetic Foot. 2nd ed. Kindle ed. American Diabetes Association; 2010. Kindle Locations 648-650.

  • 3. An elderly gentleman presents for foot care. Nursing assessment of his left foot reveals a bunion with the second toe overlapping the great toe; the toenails are yellowish-brown, long, and thick. The nail of the third toe curves medially into a pincher. The skin of the toes and foot are dry and flaky but intact. Which of the following should the foot care nurse complete first?
    1. Trim and debride the toenails
    2. Refer patient to a pedorthist.
    3. Off-load toes with foam toe sleeve
    4. Refer patient to primary care provider
    • Content outline: Domain II/Task 4/Skill F
    • Cognitive level: Application

Answer A: The first priority of the foot care nurse is to trim the length and reduce the thickness of the nails. Long, thick toenails can be a risk factor for ulceration of the other toes and can lead to pain in the forefoot. Additional care would include moisturizing the skin and pressure prevention for prone areas. A subsequent plan of care would include referral to a pedorthist to assure appropriate footwear with extra depth and a wide forefoot. Off-loading the second toe with a foam toe sleeve may add to the height of the toes and forefoot making the shoe with the extra depth even more important. Use of a toe sleeve would not be the most effective method to reduce the pressure risk from the second toe overlapping the great toe. The involvement of the primary care provider is important to assure the patient receives adequate medical care and any appropriate referrals.

1. Howes-Trammel S, Bryant R, Nix D. Foot and nail care. In: Byrant R, Nix D, eds. Acute & Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Mosby; 2012:258, 263, 265.

2. Menz H. Foot Problems in Older People: Assessment and Management. Philadelphia, PA: Elsevier; 2008:107–108, 154.

© 2016 by the Wound, Ostomy and Continence Nurses Society.