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Foot care for vascular patients
By Janice D. Nunnelee,
RN, MSN,
CS Arterial ulcer of the first toe in a diabetic patient. The patient was unaware of the ulcer until drainage occurred. Notice the pale base.
ication
Address for correspondence: Janice D. Nunnelee, RN, MSN,CS 14377Woodlake, Suite 300 Chesterfield,MO63017
February 1996iVol.
1
No. 1
is
caused
ascular patients are at increased risk for infection, gangrene, limb loss, and death resulting from impaired perfusion of the leg. Nurses must instruct patients carefully and completely on how to care for their feet. Instruction should begin with the patient’s admission to the hospital, continue through the hospital stay, and be reinforced by home health care providers. To accomplish this task, the provider must be aware of the signs and symptoms of arterial vascular disease in the leg and the elements of foot care. This teaching column is designed for health care providers practicing in hospitals, clinics, or the home. The information is not intended to be all-inclusive, and it may be altered to fit individual nurses and patients. The teaching methods include the three basic types of learners: visual, auditory, and kinesthetic. These methods should be used to teach the health care learners and to provide assistance in teaching patients.
TYPES OF LEARNERS Visual This person learns by seeing or watching a demonstration; he or she likes description and imagines what a scene would be in real life. This learner employs intense concentration and a vivid imagination. He or she thinks in pictures and envisions details. Such a student observes carefully in new situations and is quieter than other learners. He or she organizes well with lists and deliberate planning with details. Illustrations, photographs, and demonstrations are the most effective means of teaching and testing this student.
Auditory Such a student learns well through verbal instructions. He or she enjoys dialogue, pays little attention to illustrations, and remembers by vocal repetition. Auditory learners talk out problems and discuss the pros and cons, along with alternate choices. Details are less important than the overall picture to this student. Detailed explanation, followed by reading of Home Care Provider
33
Practice Teaching
Nunnelee printed material and verbal review of instructions, work best for teaching and testing of these learners.
Kinesthetic In this category, the student learns by doing, with direct involvement. He or she remembers best what was done, not what was said or illustrations of facts. Such learners find it difficult to sit still for extended periods. They try to touch objects and physically manipulate a situation to get a physical sense of the teaching. These students gesture when speaking and listen best when there is associated movement. Teach with demonstrations. Allow the patient to touch his or her own foot or your foot. Have the patient practice examination skills. Move when an explanation must be verbal. Test through demonstration, not by written examination.
COMPONENTS OF A VASCULAR HISTORY OF THE LEG Assessment Information Vascular status can be assessed with the following history questions to determine the site and extent of disease. I. How far can the patient walk? How soon does claudication develop? Where does the claudication start-the hips, thighs, and calves; or in the reverse pattern? Rutionale: Claudication is replicable; it occurs at the same distance when the speed is the same. If claudication begins proximally, the stenosis site is above the inguinal ligament; if it begins distally, the stenosis is below the ligament. 2. How long must the patient stop and rest to relieve the discomfort? RatioMak,The longer it takes to recover from the discomfort, the more severe the stenosis and distal disease. 3. Is claudication worse when the patient walks up hills and up steps? Does claudication occur sooner when the patient walks faster? Raiiot&e: It takes more oxygen to 34 Home Care Provider
“work,” to lift the body weight up as well as over a distance. This indicates narrowing. 4. How long has claudication been present? Is it rapidly worsening? Was onset acute? Rationale: If the claudication is recent and rapidly getting worse, or if it had an acute onset, the person has had a severe reduction in blood flow. This usually occurs when bleeding
occurs in a plaque or total occlusion of the vessel occurs rapidly. 5. Is there a history of surgical or endovascular intervention in any site in the affected limb(s)? Ratimale: If disease and intervention are known to have occurred, the nurse must assess the patency of the intervention. In addition, the nurse can determine whether outflow (flow below the intervention) has worsened February 1996/Vol.
1
No. 1
Practice Teaching
Severely ischemic the digits atrophic. grenous
changes
Nunnelee
foot in a nondiabetic patient. The skin is dry and Fungal infection of the nails is present, and ganare visible
next to the nail on the first toe.
Ratiomh In venous disease the most common sign of venous thrombosis is acute, unilateral edema. 1 1. Does the patient have diabetes? If so, what are the typical blood sugar levels? How often are they checked? Who controls the diabetes? Ratiode: Poor control of diabetes slows healing and increases the athersclerotic process. 12. Is there a history of phlebitis, injury
from level indicated in the patient’s record. 6. Are sores, ulcers, cracks, or open areas present on the leg or foot? How long have they been present? Are they getting worse or better? What therapy has been tried? Ratio&e: The severity of chronic arterial occlusive disease may be measured by skin integrity and rate of healing. Therapy history may reveal interventions that do not work. 7. What type of shoe does the patient wear? Neurotrophic ulcer on a Charcot joint of a diabetic patient’s Rationnie: Shoes can cause foot. The joint is now weight bearing; lack of sensation and pressure ulcers of the feet. poorly fitting shoes resulted in an ulcer. Teaching may be necessary to preserve the foot. 8. Is there any pain in the feet at to either extremity, or casting of an extremity? night? When does this pain occur? Rationale: A previous thrombosis is What must the patient do to relieve the pain? How often does the pain a risk factor for the development of a occur? new thrombosis. During an injury or casting, the patient may have susRatio&e: Rest pain indicates that tained a thrombosis and not been severe chronic arterial occlusive disease is present and that the person aware of it. has a higher risk of ulcer formation. PHYSICAL ASSESSMENT 9. Does the foot feel better when AND TEACHING it hangs down or when it is elevated? Rationale: Again, the presence of To assess the foot, the examiner pain that decreases with dependency needs a good light source and a indicates severe arterial insufficiency. length of flexible plastic tubing or filament. The examination should be 10. Is there swelling in the extremity performed in a warm room after the with pain? February 1996Nol.
1 No. 1
patient has been comfortable for at least 10 minutes after coming in from a cold environment. Evaluate the following factors. 1. Shoes and socks. Are there tears or rough areas in the lining of the shoes or holes in the socks? If so, show them to the patient. Explain that the edges decrease circulation and exert pressure on a small area of the skin, resulting in the equivalent of a bedsore on the foot. 2. Sense of touch. Ask the patient to close his or her eyes and to indicate when he or she feels the touch of the plastic tube. Begin the examination at the lower leg, not the foot, to ensure that the patient will respond positively the first time. Also test the patient’s response when you are not touching the skin to ensure that every response is not positive. Both feet should be examined from the tips of the toes and the plantar surface of the foot to the anterior surface of the foot and the distal leg. If the patient has gangrene or severe diabetes, extensive sensory loss may be present. Chart the loss areas diagramatically. If there is evidence of loss of sensation, identify the areas visually to the patient or caregiver. Provide a mirror for the patient to view the locations if mobility is a problem. 3. Color. Color must be assessed with the patient in two positions. If the leg is in a dependent position, a ruddy purplish color known as dependent rubor may develop. Next, elevate the foot above the heart and notice whether the foot becomes pale. If the patient’s leg shows both rubor and pallor, arterial insufficiency may be present. In addition, veins may not remain full in the presence of arterial disease. 4. CircuEation. Palpation of the pulses may not be an adequate examination, but it is a beginning. Palpate the posterior tibia1 artery just posterior to the medial malleolus and the dorsalis pedis artery on the anterior surface of the foot, approximately at the crown of the arch even with the second and third toes. If the patient Home Care Provider
35
Nunnelee
PracticeTeaching has had a bypass graft, palpate the graft course, not the native artery. If pulses are found, demonstrate the technique to the patient or family member. If pulses are not found, the patient should undergo noninvasive blood flow studies. If the anklehrachial index (the ratio between the highest ankle pressure and the brachial blood pressure) is not greater than .6, severe arterial disease may be present. In the diabetic patient the ankle/brachial index may not be an adequate indicator. Calcification of the arteries in diabetes may falsely increase the ankle/brachial index. Circulation should also be assessedon the basis of capillary return. Presson the end of the toe with a finger hard enough to blanch the skin. In a normal foot, skin color should return in lessthan 3 seconds. 5. ~r~~~~oce~t~~~.The patient’s position sense should be checked to further determine whether the patient
36 Home Care Provider
is aware of the feet. Have the patient close his or her eyes, place the toes in a neutral position, and then move them up or down while asking the patient to identify position. Ask about change of position without moving the toes to establish that the patient is not just giving positive responses to please the tester. 6. Skin. All surfaces of the feet should be examined, including under and between all of the toes. Corns, calluses, ulcers, and cracks should be recorded on the evaluation form. Areas of redness, warmth, fluid accumulation, tenderness, or edema should be called to the attention of a health care provider; these signs may indicate cellulitis or other forms of infection. The patient should be asked to identify problem areas. If he or she does not indicate a certain area, do not immediately comment that one has been missed. Positive reinforcement for correct answers should be given first, along with reinforcement of the patient’s abilities of self-care. Asking the patient why he or she did not identify a certain area might elicit an interesting answer and provide a teaching opportunity. Visual indication of areas to look for, verbal instructions on examination techniques, and kinesthetic feedback such as moving the patient’s hands over the feet provide all types of learners with the information they need. At the end of the examination, have the patient demonstrate a complete foot examination. Provide immediate input for correct answers and assist
the patient in performing a correct examination. The foot examination is a perfect opportunity to teach skin care. Explain the need for skin lubrication, and tell the patient that only nonperfumed lotion is acceptable becaused perfumed lotions contain alcohol, which dries the feet. Areas of rough skin or those with early callus formation may not require treatment if the patient uses a pumice-impregnated soap (eg, Lava@) to scrub such areas daily. 7. Toenails. Ask the patient, “Who cuts your toenails?” If the answer is “me,” instruct the patient to contact his or her vascular surgeon, diabetologist, clinic physician, nurse practitioner, or other health care provider for a list of health care specialists who provide foot care. “Who cuts your toenails?” If the answer is “me,” instruct the patient to contact his or her vascular surgeon, diabetologist, clinic physician, nurse practitioner, or continues on page 54
February 1996/Vol. 1 No. 1
RN, MSN,
CS Arterial ulcer of the first toe in a diabetic patient. The patient was unaware of the ulcer until drainage occurred. Notice the pale base.
ication
Address for correspondence: Janice D. Nunnelee, RN, MSN,CS 14377Woodlake, Suite 300 Chesterfield,MO63017
February 1996iVol.
1
No. 1
is
caused
ascular patients are at increased risk for infection, gangrene, limb loss, and death resulting from impaired perfusion of the leg. Nurses must instruct patients carefully and completely on how to care for their feet. Instruction should begin with the patient’s admission to the hospital, continue through the hospital stay, and be reinforced by home health care providers. To accomplish this task, the provider must be aware of the signs and symptoms of arterial vascular disease in the leg and the elements of foot care. This teaching column is designed for health care providers practicing in hospitals, clinics, or the home. The information is not intended to be all-inclusive, and it may be altered to fit individual nurses and patients. The teaching methods include the three basic types of learners: visual, auditory, and kinesthetic. These methods should be used to teach the health care learners and to provide assistance in teaching patients.
TYPES OF LEARNERS Visual This person learns by seeing or watching a demonstration; he or she likes description and imagines what a scene would be in real life. This learner employs intense concentration and a vivid imagination. He or she thinks in pictures and envisions details. Such a student observes carefully in new situations and is quieter than other learners. He or she organizes well with lists and deliberate planning with details. Illustrations, photographs, and demonstrations are the most effective means of teaching and testing this student.
Auditory Such a student learns well through verbal instructions. He or she enjoys dialogue, pays little attention to illustrations, and remembers by vocal repetition. Auditory learners talk out problems and discuss the pros and cons, along with alternate choices. Details are less important than the overall picture to this student. Detailed explanation, followed by reading of Home Care Provider
33
Practice Teaching
Nunnelee printed material and verbal review of instructions, work best for teaching and testing of these learners.
Kinesthetic In this category, the student learns by doing, with direct involvement. He or she remembers best what was done, not what was said or illustrations of facts. Such learners find it difficult to sit still for extended periods. They try to touch objects and physically manipulate a situation to get a physical sense of the teaching. These students gesture when speaking and listen best when there is associated movement. Teach with demonstrations. Allow the patient to touch his or her own foot or your foot. Have the patient practice examination skills. Move when an explanation must be verbal. Test through demonstration, not by written examination.
COMPONENTS OF A VASCULAR HISTORY OF THE LEG Assessment Information Vascular status can be assessed with the following history questions to determine the site and extent of disease. I. How far can the patient walk? How soon does claudication develop? Where does the claudication start-the hips, thighs, and calves; or in the reverse pattern? Rutionale: Claudication is replicable; it occurs at the same distance when the speed is the same. If claudication begins proximally, the stenosis site is above the inguinal ligament; if it begins distally, the stenosis is below the ligament. 2. How long must the patient stop and rest to relieve the discomfort? RatioMak,The longer it takes to recover from the discomfort, the more severe the stenosis and distal disease. 3. Is claudication worse when the patient walks up hills and up steps? Does claudication occur sooner when the patient walks faster? Raiiot&e: It takes more oxygen to 34 Home Care Provider
“work,” to lift the body weight up as well as over a distance. This indicates narrowing. 4. How long has claudication been present? Is it rapidly worsening? Was onset acute? Rationale: If the claudication is recent and rapidly getting worse, or if it had an acute onset, the person has had a severe reduction in blood flow. This usually occurs when bleeding
occurs in a plaque or total occlusion of the vessel occurs rapidly. 5. Is there a history of surgical or endovascular intervention in any site in the affected limb(s)? Ratimale: If disease and intervention are known to have occurred, the nurse must assess the patency of the intervention. In addition, the nurse can determine whether outflow (flow below the intervention) has worsened February 1996/Vol.
1
No. 1
Practice Teaching
Severely ischemic the digits atrophic. grenous
changes
Nunnelee
foot in a nondiabetic patient. The skin is dry and Fungal infection of the nails is present, and ganare visible
next to the nail on the first toe.
Ratiomh In venous disease the most common sign of venous thrombosis is acute, unilateral edema. 1 1. Does the patient have diabetes? If so, what are the typical blood sugar levels? How often are they checked? Who controls the diabetes? Ratiode: Poor control of diabetes slows healing and increases the athersclerotic process. 12. Is there a history of phlebitis, injury
from level indicated in the patient’s record. 6. Are sores, ulcers, cracks, or open areas present on the leg or foot? How long have they been present? Are they getting worse or better? What therapy has been tried? Ratio&e: The severity of chronic arterial occlusive disease may be measured by skin integrity and rate of healing. Therapy history may reveal interventions that do not work. 7. What type of shoe does the patient wear? Neurotrophic ulcer on a Charcot joint of a diabetic patient’s Rationnie: Shoes can cause foot. The joint is now weight bearing; lack of sensation and pressure ulcers of the feet. poorly fitting shoes resulted in an ulcer. Teaching may be necessary to preserve the foot. 8. Is there any pain in the feet at to either extremity, or casting of an extremity? night? When does this pain occur? Rationale: A previous thrombosis is What must the patient do to relieve the pain? How often does the pain a risk factor for the development of a occur? new thrombosis. During an injury or casting, the patient may have susRatio&e: Rest pain indicates that tained a thrombosis and not been severe chronic arterial occlusive disease is present and that the person aware of it. has a higher risk of ulcer formation. PHYSICAL ASSESSMENT 9. Does the foot feel better when AND TEACHING it hangs down or when it is elevated? Rationale: Again, the presence of To assess the foot, the examiner pain that decreases with dependency needs a good light source and a indicates severe arterial insufficiency. length of flexible plastic tubing or filament. The examination should be 10. Is there swelling in the extremity performed in a warm room after the with pain? February 1996Nol.
1 No. 1
patient has been comfortable for at least 10 minutes after coming in from a cold environment. Evaluate the following factors. 1. Shoes and socks. Are there tears or rough areas in the lining of the shoes or holes in the socks? If so, show them to the patient. Explain that the edges decrease circulation and exert pressure on a small area of the skin, resulting in the equivalent of a bedsore on the foot. 2. Sense of touch. Ask the patient to close his or her eyes and to indicate when he or she feels the touch of the plastic tube. Begin the examination at the lower leg, not the foot, to ensure that the patient will respond positively the first time. Also test the patient’s response when you are not touching the skin to ensure that every response is not positive. Both feet should be examined from the tips of the toes and the plantar surface of the foot to the anterior surface of the foot and the distal leg. If the patient has gangrene or severe diabetes, extensive sensory loss may be present. Chart the loss areas diagramatically. If there is evidence of loss of sensation, identify the areas visually to the patient or caregiver. Provide a mirror for the patient to view the locations if mobility is a problem. 3. Color. Color must be assessed with the patient in two positions. If the leg is in a dependent position, a ruddy purplish color known as dependent rubor may develop. Next, elevate the foot above the heart and notice whether the foot becomes pale. If the patient’s leg shows both rubor and pallor, arterial insufficiency may be present. In addition, veins may not remain full in the presence of arterial disease. 4. CircuEation. Palpation of the pulses may not be an adequate examination, but it is a beginning. Palpate the posterior tibia1 artery just posterior to the medial malleolus and the dorsalis pedis artery on the anterior surface of the foot, approximately at the crown of the arch even with the second and third toes. If the patient Home Care Provider
35
Nunnelee
PracticeTeaching has had a bypass graft, palpate the graft course, not the native artery. If pulses are found, demonstrate the technique to the patient or family member. If pulses are not found, the patient should undergo noninvasive blood flow studies. If the anklehrachial index (the ratio between the highest ankle pressure and the brachial blood pressure) is not greater than .6, severe arterial disease may be present. In the diabetic patient the ankle/brachial index may not be an adequate indicator. Calcification of the arteries in diabetes may falsely increase the ankle/brachial index. Circulation should also be assessedon the basis of capillary return. Presson the end of the toe with a finger hard enough to blanch the skin. In a normal foot, skin color should return in lessthan 3 seconds. 5. ~r~~~~oce~t~~~.The patient’s position sense should be checked to further determine whether the patient
36 Home Care Provider
is aware of the feet. Have the patient close his or her eyes, place the toes in a neutral position, and then move them up or down while asking the patient to identify position. Ask about change of position without moving the toes to establish that the patient is not just giving positive responses to please the tester. 6. Skin. All surfaces of the feet should be examined, including under and between all of the toes. Corns, calluses, ulcers, and cracks should be recorded on the evaluation form. Areas of redness, warmth, fluid accumulation, tenderness, or edema should be called to the attention of a health care provider; these signs may indicate cellulitis or other forms of infection. The patient should be asked to identify problem areas. If he or she does not indicate a certain area, do not immediately comment that one has been missed. Positive reinforcement for correct answers should be given first, along with reinforcement of the patient’s abilities of self-care. Asking the patient why he or she did not identify a certain area might elicit an interesting answer and provide a teaching opportunity. Visual indication of areas to look for, verbal instructions on examination techniques, and kinesthetic feedback such as moving the patient’s hands over the feet provide all types of learners with the information they need. At the end of the examination, have the patient demonstrate a complete foot examination. Provide immediate input for correct answers and assist
the patient in performing a correct examination. The foot examination is a perfect opportunity to teach skin care. Explain the need for skin lubrication, and tell the patient that only nonperfumed lotion is acceptable becaused perfumed lotions contain alcohol, which dries the feet. Areas of rough skin or those with early callus formation may not require treatment if the patient uses a pumice-impregnated soap (eg, Lava@) to scrub such areas daily. 7. Toenails. Ask the patient, “Who cuts your toenails?” If the answer is “me,” instruct the patient to contact his or her vascular surgeon, diabetologist, clinic physician, nurse practitioner, or other health care provider for a list of health care specialists who provide foot care. “Who cuts your toenails?” If the answer is “me,” instruct the patient to contact his or her vascular surgeon, diabetologist, clinic physician, nurse practitioner, or continues on page 54
February 1996/Vol. 1 No. 1