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Getting Ready for Foot Care Certification

Foot Care Basics

Collins, Clay

Journal of Wound Ostomy & Continence Nursing: May/June 2019 - Volume 46 - Issue 3 - p 248–250
doi: 10.1097/WON.0000000000000531
Getting Ready for Certification
Free

Clay Collins, MSN, APRN, FNP-BC, CWOCN, CFCN, United Regional Health Care System, Wichita Falls, Texas.

Correspondence: Clay Collins, MSN, APRN, FNP-BC, CWOCN, CFCN, United Regional Health Care System, 1600 11th Street, Wichita Falls, TX 76301 (ccollins@unitedregional.org).

The authors declare no conflicts of interest.

Since the introduction of the Wound, Ostomy and Continence Nursing Certification Board (WOCNCB) Certified Foot Care Nurse examination in 2005, this specialty area has continued to evolve and is more important than ever. With approximately 1100 certified foot care nurses (CFCNs) across the country, CFCNs are in a pivotal position to provide comprehensive preventive care and treatment for those with diseases affecting the feet and lower extremities. The role of a CFCN requires knowledge and competence in multiple areas. When preparing for the Certified Foot Care Examination, begin by reviewing the exam content outline (http://www.wocncb.org/certification/exam-preparation/exam-content-outlines) to direct your study efforts. The content outline is divided into 3 domains: Assessment and Care Planning, Intervention and Treatment, and Education and Referral. Within each of these domains are tasks that further delineate specific knowledge and skills that the nurse will be tested on in the examination. The far right column of the exam content outline details the number of items from each task. The exam has a 110 items; the number of questions in each domain was determined from a job task analysis based on frequency performed and criticality of the task to the role of a CFCN. For example, there are 40 items pertaining to domain 1 (Assessment and Care Planning). Out of these 40 items, 10 are specific to task 1 (Obtain focused patient health history ...), 11 to task 2 (Perform focused lower extremity physical assessment ...), 10 to task 3 (Develop an initial patient-centered plan of care ...), and 9 items are specific to task 4 (Perform ongoing evaluation and modification of the patient-centered plan). Domain 2 has 52 items that pertain to interventions and treatment of skin conditions, foot and nail pathologies, and common wounds found on the lower extremity. Domain 3, though no less important, comprises 18 items that test knowledge that patients need to care for their feet and when they should be referred for more complex problems. Under each task in the blueprint section, you will find detailed topics outlining the required knowledge and skills required to perform each task. When studying for the examination, refer to the specific topics listed under the “Knowledge of” and “Skill in” headings under each task. You may see questions pertaining to any of these specific knowledge or skill topics on the exam. Viewing the blueprint in this manner will help you to gain a better idea of how best to study for the exam based on your personal strengths and weaknesses.

1. A patient with type 2 diabetes mellitus and a history of prior ulceration presents for an initial foot care appointment. During the exam the Certified Foot Care Nurse finds the patient has a loss of protective sensation and a plantar surface callus. The patient would be considered at what risk level for the formation of a diabetic foot ulcer?

  1. No risk for ulceration
  2. Low risk for ulceration
  3. Moderate risk for ulceration
  4. High risk for ulceration

Outline location: Domain 1; Tasks 1 & 2, Skills 010104 (Task 1), 010213 (Task 2)

Cognitive level: Analysis

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ANSWER D:

This patient is at high risk for the formation of a diabetic foot ulcer. Loss of protective sensation (LOPS) is determined through monofilament testing with a Semmes-Weinstein 5.07 (10 g) monofilament at multiple locations on the foot. In the absence of pain, a patient can fail to recognize injuries and take corrective action, which can lead to ulceration with normal walking. The presence of a plantar surface callus may lead to as much as a 30% increase in pressure to the underlying tissue, further increasing the risk of ulceration. Lower extremity amputations are preceded by a foot ulcer in 85% of cases. The prior history of ulceration is the key clue to determining risk level for this patient. To answer this item the certified foot care nurse must be knowledgeable of the lower extremity amputation prevention risk classification system to determine the appropriate risk classification for this patient. The question stem provides critical information needed to determine risk for ulceration. This patient has type 2 diabetes mellitus with a loss of protective sensation, a plantar surface callus, and a history of previous ulceration—all of which characterize high risk for future ulceration. Patients with diabetes and no LOPS would be considered no risk. Patients with diabetes and LOPS would be considered low risk. Patients with diabetes, LOPS, and either high pressure areas due to callus formation or foot deformity are at moderate risk.

Crawford PE, Fields-Varnado M. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Mount Laurel, NJ: Wound Ostomy and Continence Nurses Society; 2012:98.

Driver VR, LeBretton LA, Nanjiin JP. Neuropathic wounds: the diabetic wound. In: Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:246.

HRSA. Lower Extremity Amputation Prevention (LEAP). https://www.hrsa.gov/hansens-disease/leap/index.html. Published 2017. Accessed January 27, 2019.

Varnado M. Lower extremity neuropathic disease. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:480.

2. A patient presents with thick, long-curved nails, commonly referred to as Ram's Horn nails. Which of the following terms best describe this condition?

  1. Onychomycosis
  2. Onychogryphosis
  3. Hallux valgus
  4. Hallux rigidus

Outline location: Domain 2; Task 4, Skill 020402

Cognitive level: Recall

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ANSWER B:

Onychogryphosis is a condition resulting from inadequate nail care. The nails may become thickened, discolored, and curved. A patient may be unable to physically perform nail care for a variety of reasons such as poor vision, poor dexterity, limited mobility, or even self-neglect as a result of mental illness. This condition is commonly referred to as Ram's Horn nails and is important to recognize in order to develop an adequate care plan to meet the patient's needs. Onychomycosis is the most common nail disorder in older adults and is a fungal infection that may result in thickened, discolored, and brittle nails. Hallux valgus is a foot deformity in which the first metatarsal deviates laterally causing the metatarsal head to protrude and form what is commonly referred to as a bunion. Hallux rigidus is a condition in which the first metatarsophalangeal joint becomes stiff and rigid resulting in decreased dorsiflexion of the first toe. To begin to determine the correct answer to this item, the certified foot care nurse must first differentiate between nail deformities and foot deformities. Knowledge of onychopathology is an essential skill for the certified foot care nurse. Nail deformities may indicate a self-care deficit or an infectious process. The ability to identify common nail pathologies aids the certified foot care nurse to determine appropriate intervention and treatment.

Burdette-Taylor M, Fong L. Foot and nail care. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:544.

Howes-Trammel S, Bryant RA. Foot and nail care. In: Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:279.

3. During a lower extremity assessment, the certified foot care nurse identifies that the patient's lower legs are edematous with dark reddish/brown pigmentation of the skin and large varicose veins. The certified foot care nurse recognizes that these assessment findings indicate chronic venous insufficiency. When recommending therapeutic compression for prevention of ulceration which of the following would be considered the most appropriate?

  1. 10-20 mm Hg at the ankle
  2. 20-30 mm Hg at the ankle
  3. 30-40 mm Hg at the ankle
  4. 40-50 mm Hg at the ankle

Outline location: Domain 2; Task 5, Skill 020508

Cognitive level: Recall

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ANSWER C:

Therapeutic compression for the treatment of chronic venous insufficiency (CVI) is considered to be 30-40 mm Hg at the ankle. Compression of 10-20 mm or 20-30 Hg at the ankle is classified as low and medium and would not be the most appropriate choice for managing CVI. Compression using 40-50 mm Hg at the ankle is considered high compression and is not recommended for the routine treatment of CVI. The certified foot care nurse should be able to identify and make treatment recommendations for prevention and management of common lower extremity disease processes (ie, venous, arterial, and neuropathic). Early identification and intervention can prevent further progression of the disease and ulceration. The cornerstone of treatment for CVI is therapeutic compression, which comes in many forms such as wraps, bandages, garments, and devices. Compression therapy is utilized to reduce hydrostatic pressures and to aid in venous return of blood from the lower extremity. As studies have shown, some compression is better than no compression for the management of CVI and for the patient who is unable to tolerate or independently apply a 30- to 40-mm Hg compression system, lower compression may be utilized. Prior to recommending therapeutic compression, absolute contraindications such as deep vein thrombosis of the lower extremity or uncompensated heart failure should be ruled out. Likewise, the presence of coexisting lower extremity arterial disease should be evaluated with an ankle brachial index. Knowledge of the indications and contraindications for therapeutic compression ensures appropriate therapy and safe patient care.

Carmel JE, Bryant RA. Venous ulcers. In: Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:215.

Johnson J, Yates SS, Burgess JJ. Venous insufficiency, venous ulcers, and lymphedema. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:390.

4. When selecting a wound dressing to promote moist wound healing, which wound characteristics are the most important?

  1. Wound etiology and duration
  2. Wound depth and amount of exudate
  3. Wound odor and amount of exudate
  4. Wound etiology and depth

Outline location: Domain 2; Task 5, Skill 020504

Cognitive level: Analysis

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ANSWER B:

Wound depth and exudate are the 2 most important factors to consider when selecting a wound dressing promoting moist wound healing. Dead space within a wound should be filled to prevent abscess formation, premature closure, and provide a therapeutic interface with the dressing enabling moist wound healing. The amount of exudate is another key characteristic that drives dressing selection, as a dry wound will require a dressing that donates sufficient moisture to maintain optimal tissue hydration and exudating wounds will require absorptive dressings designed to manage varying degrees of drainage to maintain an optimally moist wound environment. Determining wound etiology is a key component for determining interventions and treatment strategies. However, etiology is not one of the most important characteristics for dressing selection. Likewise, the duration of the wound, although important for differentiating acute and chronic wounds and prompting a reevaluation of factors that may impair wound healing, does drive appropriate dressing selection. Most wounds will have some odor and this can also be affected by the type of dressing, presence of necrotic tissue, or poor personal and wound-related hygiene. Wound odor can be a key factor in helping to determine the presence of infection but is not one of the most important factors to consider when selecting a dressing optimizing moist wound healing. Principles of basic wound care and moist wound healing are now included on the Certified Foot Care Nurse (CFCN) examination. The CFCN should be knowledgeable in basic wound management and dressing selection. Topical dressing selection is based on a variety of wound characteristics, which are identified during a comprehensive wound assessment.

Bryant RA, Nix DP. Principles of wound healing and topical management. In: Acute and Chronic Wounds: Current Management Concepts. 5th ed. St Louis, MO: Elsevier; 2016:319.

Jaszarowski KA, Murphree RW. Wound cleansing and dressing selection. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:135.

5. During a lower extremity assessment the Certified Foot Care Nurse notices a dark purple area of nonblanchable intact skin located on the posterior right heel. The patient reports a recent fall resulting in fracture of the right hip. According to the National Pressure Ulcer Advisory Panel (NPUAP) how would this injury be classified?

  1. Stage 1 pressure injury
  2. Stage 2 pressure injury
  3. Unstageable pressure injury
  4. Deep tissue pressure Injury

Outline location: Domain 2; Task 5, Skill 020502

Cognitive level: Analysis

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ANSWER D:

According to the National Pressure Ulcer Advisory Panel (NPUAP), a deep tissue pressure injury is an area of intact or nonintact skin with a localized area of persistent nonblanchable deep red, maroon, or purple discoloration. There may be epidermal separation revealing a dark wound bed or the injury may present as a blood filled blister. Based on the presentation of the injury described in the stem, option D (deep tissue pressure injury) best fits this definition. Answer A would not be an appropriate choice because a stage 1 pressure injury is defined as intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Although the stem of this item refers to an area of intact skin, which is nonblanchable, the dark purple coloration described rules out a stage 1 as a correct answer. Answer B would not be correct as a stage 2 pressure injury involves a partial-thickness loss of skin and the item specifically states that the skin is intact. An unstageable pressure injury involves a full-thickness wound in which the extent of the tissue damage is obscured by slough or eschar. The definition goes on to further state that once the slough or eschar is removed a stage 3 or stage 4 pressure injury will be revealed. For this reason, option C would not be correct. The Certified Foot Care Nurse (CFCN) should be knowledgeable of the National Pressure Ulcer Advisory Panel (NPUAP) pressure injury staging system. Hip fractures are a major risk factor for the development of pressure injuries on the heel due to immobility. Heels are one of the most common sites for the development of pressure injuries and the CFCN is in an important position to implement prevention and treatment interventions.

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REFERENCE

The National Pressure Ulcer Advisory Panel (NPUAP). NPUAP Pressure Injury Stages. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. Published 2016. Accessed January 27, 2019.
    © 2019 by the Wound, Ostomy and Continence Nurses Society.