By Aakilah Ade RN, AFCN, LNC, CEO of Intel Health Care Services Inc.

“And I came close to losing a part of my foot on two occasions. I hope I’m consistently lucky and that the next time I develop a blister or step on something sharp, that I don’t go as far as I did on those two times.” Mary Tyler Moore

Members of the population, who are developmentally or emotionally challenged, need the intervention of caregivers to remind, encourage, supervise, support and sometimes provide total care. The focus of this article is about maintaining foot health and the caregiver’s role in preventing foot complications.

Persons who are not independent with their own care are at a higher risk for diseases of the foot than persons who can meet their own care needs. The level of risk increases with each additional medical condition, with multiple medications, and with age. Complications include but are not limited to anatomical changes, pain and discomfort, alterations to gait, wounds, infections and amputation.

The observation and maintenance of general foot health begins with daily hygiene. Before bathing the care provider can look for problems such as open areas in the skin, peeling or flaky skin, excessive dryness, new lumps, bumps, bruising, odour, redness or excessive moisture. These are signs and warnings of problems and potential complications. Formal and informal providers of personal care must report these findings to someone who can implement a medical assessment, a medical intervention or a medical referral.

It is important to note changes in foot structure occur regardless of whether an individual is able to ambulate or not. Physical changes occur as a result of aging, poorly fitting shoes and as a result of internal changes such as impaired circulation, nerve damage and fallen arches. Physical changes are usually accompanied by pain and discomfort, so it is important to observe for limping, feet swelling, reluctance to walk, difficulty applying shoes and socks that use to go on easily.

With aging there is a loss of subcutaneous fat, and a reduction in production of oils that naturally lubricate the skin. Fat on the bottom of the foot evenly distributes pressure; loss of fat creates pressure points that break down the skin. Loss of lubrication from oil causes the skin to crack and open to bacterial invasion. Internal circulatory changes cause hammer toes, and ill-fitting shoes cause overlapping toes, so the caregiver must be mindful of separating each toe when washing to remove bacteria.

The best tool to use to wash feet is a soft thin washcloth that can slide between each toe and over the sole of the foot. A soft wash cloth reduces the chance of skin abrasions. Soap and water on the washcloth help to physically remove and reduce skin bacteria. The action washing the feet in warm water promotes blood circulation and reduces swelling. Warm water provides comfort to the individual, and prevents further drying of the skin.

After washing, rinsing aids in the removal of skin bacteria, and removal of residual soap that may irritate and dry the skin. Drying of the feet is repeated in the same way as the washing of the feet, and has the same effect on circulation. Drying has another important role, it removes excess moisture from the skin, moisture will contribute to skin breakdown if left between the toes or is trapped on the skin of the foot when wet/moist feet are placed in shoes or socks.

Tips:

• Use only warm water to wash feet, extreme temperatures damage skin
• Use petroleum free lotions on feet
• Avoid lotion between toes
• Use clean socks daily
• Advocate for individuals to have proper fitting shoes

Nail care is also important, keep the individual’s nails trimmed, use a nail clipper (not scissors), to keep the nail even with the tip of the toe. Clean under the toe nails with an orange stick. Have these items in stock, stored and labeled for each individual’s personal use; do not share with other individuals. If you are not comfortable in this role, advocate for a foot care nurse to assess and treat each individual on a regular basis. Foot care nurses, assess feet for actual and potential problems, and take care of nail issues, calluses and many other foot conditions.

The final step in basic foot care is the application of lotion to the feet. An appropriate lotion (example Lubriderm) will provide enough moisture to prevent cracks in the skin, but not cause saturation (maceration) and skin breakdown. Lubriderm and similar lotions are specific for diabetics; they do not contain petroleum and do not block skin pores. Petroleum free lotions are recommended for anyone at risk for foot complications. Another benefit of applying lotion is that the caregiver can palpate the skin; problems under the skin can be picked up by touch. Watch the individual’s facial expression for grimacing, feel for the individual pulling away when certain areas are touched. Feel for changes of texture under the skin. Any unusual findings or new signs must be reported to a supervisor or registered health care provider (nurse or GP).

Chiropodists, and nurses are professionals that provide advanced foot care, but these two groups do not have a monopoly on foot health. Family, caregivers, DSWs and any other frontline workers are integral in preventative foot health through basic foot care.

Tips:

• Use sharp nail clippers
• Do not share clippers between individuals
• Toe nails should not be cut past the tip of the toe
• Refer to foot care nurse if there are concerns
• Diluted vinegar and water is a natural therapy for foot fungus

References

Edelstein, Joan: Foot Care for the Aging, Journal of the American Physical Therapy Association, 1988, 68:1882-1886

Etnyre, Annette et al: The Role of Certified Foot and Nail Care Nurses in the Prevention of Lower Extremity Amputation, J WOCN May/June 2011

Canadian Diabetes Association: Foot Care: A Step Toward Good Health, Consumer Fact Sheet, 2008

College of Nurses of Ontario: Nursing Foot Care Standards, October 2000
Canada Communicable Disease Report – Supplement: Infection Control Guidelines Foot Care for Health Care providers, Vol. 23S8, December 1997