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Wound Versus Foot Care: Is There a Difference?

Ellefson, Laurie; Wilson, Francis; Hoffman, Kathleen; Wells, Belinda

Journal of Wound, Ostomy and Continence Nursing: March/April 2017 - Volume 44 - Issue 2 - p E2–E4
doi: 10.1097/WON.0000000000000315
Getting Ready for Certification
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The WOCNCB® is acutely aware of the increased demands on our certified nurses in all practice settings and the need for wound care specialists at all levels of nursing education, licensure, and scope of practice. This need is best illustrated when considering the aging U.S. population and the need to promote additional bedside collaborative team support for the WOCNCB® certified nurse. To help meet the increased demands for certified wound treatment nurses, the WOCNCB® has created a psychometrically sound and legally defensible certification exam for those completing the WOCN sponsored Wound Treatment Associate (WTA) program. The WTA-C® exam validates basic wound care knowledge, and principles underlying the clinical skills needed to support safe, quality, patient/family-centered care. The certification is voluntary and confirms that the non-baccalaureate prepared nurse under the guidance of a CWOCN, or a CWOCN-AP has adequate knowledge to implement effective wound treatments and pressure ulcer prevention strategies. Development of the WTA-C® represents a critical stage in the evolution of nursing-based wound care delivery. The valuable addition of this WTA-C role continues the tradition of improving outcomes at the bedside, the community and with whom all WOCNCB certified nurses touch - one patient at a time.

Laurie Ellefson, BSN, RN, CWOCN, CFCN, Wound, Ostomy, and Continence Certification Board.

Francis Wilson, CNS, MSN, CWOCN, CFCN, Wound, Ostomy, and Continence Certification Board.

Kathleen Hoffman, MSN, RN, CWOCN, CFCN, Wound, Ostomy, and Continence Certification Board.

Belinda Wells, BSN, RN, CWOCN, CFCN, Wound, Ostomy, and Continence Certification Board.

Correspondence: WOCNCB, 555 E. Wells St., Suite 1100 Milwaukee, WI 53202 (info@wocncb.org).

The authors declare no conflicts of interest.

For more than 30 years, the WOCNCB has been the certification of choice for over 7600 professional nurses as a way to validate their specialized skills, knowledge, and considerable expertise in the areas of wound, ostomy, and continence nursing. Recognizing the growth and sophistication of the specialty, the WOCNCB expanded the tricertification to include a subspecialty certification in Foot Care Nursing in 2005 (Box). The foot care certification recognizes the expert care of nurses offering foot care in multiple care settings, ranging from hospitals and podiatry offices to patient homes, and it provides verification of this specialized knowledge. Many health care providers and patients have asked about the difference between the certified wound care nurse (CWCN) and the certified foot care nurse (CFCN) (Table). They both provide specialized care to the feet!

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BOX. Requirement for WOCNCB Foot Care Examination Cited Here...

  • Initial (first-time) candidates must have a current RN license and hold a bachelor's degree (or higher).
  • Complete BOTH of the following: Accumulate a minimum of 24 CE/CME credits (contact hours) specific to foot care and accumulate 40 clinical hours under the direct supervision of an expert in foot care. Both the CE/CME credits (contact hours) and specialty experience must be specific to foot care and must be completed within the previous 5 y from the date of the application while functioning as an RN and post-bachelor's degree.
  • The WOCNCB will initiate changes in January 2017 that will provide guidance to aid foot care candidates to meet the eligibility requirements. Of the 24 required CEs, 8 CEs may be related to basic skin and wound care. The remaining 16 CEs need to be specific to foot care. To further support the overlap of wound care and foot care, a CWCN may provide the direct supervision of up to 12 h of the specialty experience for the future foot care nurse. The experience would relate to basic skin and wound care. The remaining 28 h of specialty experience need to be performed under the direct supervision of a foot care expert. The candidate is expected to only submit the specialty experience completed under the direct supervision of the foot care expert; additional hours above 40 may not be accepted.

Abbreviation: CWCN, certified wound care nurse.

TABLE. C

TABLE. C

The need for specialized foot and nail care by nurses became evident in the 1990s. In 1997, the Louisiana State Board of Nursing published a “Declaratory Statement on the Role and Scope of Practice of the Registered Nurse in Performing Foot Care Interventions,”1 in which it defined basic, intermediate, and advanced foot care. After considerable deliberation, the WOCNCB moved forward on a food care certification using this document. As is the practice of the WOCNCB, the foot care examination blueprint has been recently updated to reflect the current practice of foot care nurses as defined by a job analysis. In addition, the revised outline incorporates recognition of the evolution of professional nursing as defined by the Institute of Medicine in the Future of Nursing Report to require as entry level the baccalaureate prepared nurse.2 The updated CFCN Content Outline expanded topics related to skin and wound care. The examples of examination questions that appear at the end of this article are specific to the foot exam, but similar topics may appear on the wound care examination.

A distinctive characteristic of WOCNCB certified nurses is their ability to provide comprehensive holistic care. Both the CWCN and the CFCN perform an in-depth assessment of the skin and surrounding structures that includes taking inventory of any factors that may impact skin health and the ability to heal. Questions related to skin assessment are found on both examinations. The nurse seeking certification in either specialty will benefit from a review of anatomy and physiology of the skin, foot and nails, the presentation of venous versus arterial insufficiency, neuropathy (motor, autonomic, or peripheral), screening the at-risk foot, characteristics of wounds, and nail pathologies.

While wound care and foot care have similar assessments, it is the focus and specificity of knowledge that make them unique. The foot is a complex structure that includes 26 bones, 33 joints, 107 ligaments, and 19 muscles. The certified foot care nurse uses in-depth knowledge about the foot to properly assess skin and perfusion, foot structure and bony deformities, protective sensation, nails, and nail pathology. The foot care nurse plays a vital role in promoting overall health by focusing on mobility, monitoring pain, preventing wounds and amputations, and reducing the risk for falls. As noted by Burdette-Taylor and Fong,3 the knowledgeable foot care nurse can reduce complications and costs for individuals with diabetes mellitus and lower extremity neuropathic disease or lower extremity arterial disease by preventing injuries and wounds, assuring appropriate footwear, providing education, and initiating prompt and appropriate referrals. A CFCN can tailor a plan of care that can reduce the burden of the symptoms and complications for those in their care.

Is there a difference between the wound care nurse and the foot care nurse? An obvious difference is the focus placed on the lower extremities and feet. The CFCN embraces multiple foci such as prevention, planning, and implementing interventions that facilitate improved ambulation and reduce the risk for limb amputations. The incidence of diabetes in the United States is increasing, with a 2014 estimate of more than 29 million individuals.4 The US Centers for Disease Control and Prevention notes that “people with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet, or legs, or premature death.”4 Nurses certified in foot care are well versed in the complexity of symptoms and the complications that occur as a direct result of this chronic disease. The CFCN has a unique skill set that can positively impact a patient's overall quality of life by identifying problem areas and assuring safe, evidence-based, patient-centered care.

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REFERENCES

1. Louisiana State Board of Nursing. https://http://www.lsbn.state.la.us/Portals/1/Documents/DeclaratoryStatements/declarat4.pdf. Published 1997. Accessed June 16, 2016.

2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.

3. Burdette-Taylor S, Fong L. Foot and nail care. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wound Ostomy Continence Nurses Society; 2016:531–532.

4. Centers for Disease Control and Prevention. Diabetes latest. http://http://www.cdc.gov/features/diabetesfactsheet. Published 2014. Accessed July 2, 2016.

5. Wound Ostomy Continence Nursing Certification Board. http://http://www.wocncb.org/certification/exam-preparation/exam-content-outlines. Accessed June 15, 2016.

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PRACTICE QUESTIONS

  • 1. A patient has a history of anhidrosis associated with autonomic neuropathy. Which of the following findings would the foot care nurse expect?
    1. Chilblain
    2. Heloma durum
    3. Fissures
    4. Verrucae plantaris

Content outline: Foot Care/Domain 1, Task 2: 010207

Cognitive level: Recall

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Answer: C

In this question, the candidate is being asked to identify the common characteristics observed in a patient with autonomic neuropathy. Anhidrosis results from the loss of autonomic control of the sweat glands, commonly manifests as severely dry skin, and may result in partial-thickness or full-thickness fissures. The severely dry skin cracks and fissures permit the invasion of pathogens that can cause serious soft-tissue infections.1 The other options may be seen by the foot care nurse but are not characteristic of autonomic neuropathy. A heloma durum, or a hard corn, is notable for its dry, horny appearance, is found most commonly over the interphalangeal joints, and is the result of mechanical trauma to the skin culminating in hyperplasia of the epidermis. Chilblains are a seasonal vasospastic condition that may be mistaken for an unusual callus or blister. Chilblains are the painful inflammation of small blood vessels in the skin that occur in response to repeated exposure to cold but not freezing air.3 Verrucae plantaris, also known as a wart, is a small growth on the skin that develops when the skin is infected by a virus. Warts can develop anywhere on the foot, but typically they appear on the bottom (plantar side) of the foot.4

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REFERENCES

1. Varnado M. Lower extremity neuropathic disease. In: Doughty DB, McNichol LL. eds. Wound, Ostomy and Continence Nurses Society Wound Management Core Curriculum. Philadelphia, PA: Wolters Kluwer; 2016:471.

2. Hogan DJ, Basile AL. Corns. In: Elston DM, ed. Medscape. http://emedicine.medscape.com/article/1089807-overview. Published 2014. Accessed July 26, 2016.

3. Mayo Clinic. Chilblains. http://http://www.mayoclinic.org/diseases-conditions/chilblains/home/ovc-20165478. Published 2015. Accessed July 26, 2016.

4. American College of Foot and Ankle Surgeons. Plantar wart (verruca plantaris). http://http://www.acfas.org/footankleinfo/Plantar_Wart.htm. Accessed July 26, 2016.

  • 2. A patient has bilateral nonpalpable dorsalis pedis and the posterior tibialis pulses. Which of the following would be the BEST initial recommendation?
    1. Urgent referral to a vascular surgeon
    2. Ankle Brachial Index (ABI) testing
    3. Digital subtraction angiography
    4. Intermittent pneumatic compression therapy

Content outline: Foot Care/Domain 1, Task 3: 010303

Cognitive level: Analysis

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Answer: B

This question requires the candidate to formulate a recommendation based on assessment findings. Diminished or absent pulses cannot be used as sole measure of arterial insufficiency. Some individuals with normal perfusion lack one or both pedal pulses. ABI is recommended as a first-line, noninvasive test to establish a diagnosis in individuals at high risk or suspected of having lower extremity arterial disease. Invasive tests, such as digital subtraction angiography, are associated with risks of bleeding, infection, and contrast nephropathy and are reserved for patients who require surgery. An urgent referral to a vascular surgeon for the absence of pulses with no other assessment findings would not be indicated. Intermittent pneumatic compression therapy may benefit patients with severe intermittent claudication or those with critical limb ischemia who are not surgical candidates; it is not a first-line intervention.

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REFERENCE

1. Bonham P. Assessment and management of patients with wounds due to lower-extremity arterial disease (LEAD). In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Wound Management Core Curriculum. Philadelphia, PA: Wolters Kluwer; 2016:429–430, 435, 449.
    © 2017 by the Wound, Ostomy and Continence Nurses Society.