Nursing and long-term care concerns of foot care in the elderly

Clin Podiatr Med Surg

20 (2003) 383–394

Nursing and long-term care concerns

of foot care in the elderly

Ilene Warner, RNC, CWCN, MA, MLSP, NHAAlden Geriatric Consultants, 2 Dundee Mews, Media, PA 19063, USA

Long-term care can no longer be thought of simply in terms of nursing homes.

Rather, home health care, adult day care, and assisted living, in addition to

nursing homes, encompasses the full spectrum of the delivery of long-term care

services. Great variability is seen not only in the regulation of these industries but

in reimbursement of the service providers. The nursing assessment of the geriatric

foot, too, is dictated in some measure by the type of setting, the regulatory

requirements, and the standards of care for that health care setting. Foot care of

geriatric patients is examined in this chapter through the regulatory framework of

long-term care providers.

General nursing assessment of the foot

The nursing assessment of an older individual begins with a head-to-toe

physical assessment. The vascular status of the feet and lower extremities should

be assessed by noting the temperature of one foot compared with the other, the

pattern of hair distribution, a shiny, taut appearance, and the presence and degree

of edema. Assessing for edema is most frequently accomplished by applying

pressure at the instep then releasing. Pulses should be palpated at the femoral,

posterior tibial, and pedal sites.

The examination of the feet should include inspection of the toes and nails for

evidence of corns, calluses, and abrasions. Foot deformities are common in this

population, including hammer toes and bunions. Inspect between the toes for

evidence of fungal infections, which are more common in diabetic patients.

Observe for evidence of thickened toenails and decreased capillary refill in

the toes, which may be indicative of impaired peripheral circulation. Note also

the presence of foot deformities caused by autonomic neuropathy. Assess the

sensation of the foot and note any differences in the sensation between the feet.

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doi:10.1016/S0891-8422(03)00031-4

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Assessment and treatment of pressure ulcers

Pressure ulcers at any stage should be assessed for length, width, and depth

and measured serially according to facility or agency policy. Most commonly,

pressure ulcers are measured upon admission and again at weekly intervals.

Additional assessments may be done if rapid deterioration or improvement is

noted at any point in the treatment process. Pressure ulcers are staged from I to

IV; however, wounds that are covered with black eschar or yellow slough may be

unstageable if the wound bed cannot be fully assessed. Accepted staging of ulcers

is as follows:

1. Stage I—Nonblanchable erythema of intact skin. In darkly pigmented

individuals, this may be seen as warmth, edema, hardness, or a change in

hue of the skin.

2. Stage II—Partial thickness skin loss involving the epidermis, dermis, or

both. It is a superficial lesion presenting as an abrasion, blister, or

shallow ulcer.

3. Stage III—Full thickness skin loss involving damage to the subcutaneous

tissue that may extend down to the fascia. It presents as a crater.

4. Stage IV—Full thickness skin loss with destruction of tissue to the muscle,

bone, or supporting structures.

Pressure ulcers only are staged using the above criteria. It allows health

professionals to communicate the degree of tissue loss present in a wound. The

staging system is not used for the description of wound healing, however, because

a stage IV pressure ulcer will not become a stage II wound over time because of the

presence of dissimilar tissue (granulation) used in the process of healing stage III

and IV ulcers. The practice of down-staging wounds is akin to the way a fracture

would heal. If a patient sustained a compound fracture of the femur, the fracture

would not revert to a simple fracture, then a hairline fracture upon healing. It would,

in fact, be a healing compound fracture of the femur. Similarly, a stage III or IV

pressure ulcer that has undergone significant tissue destruction will not regenerate

muscle, fascia, or bone as healing occurs. For this reason, wounds are described as

in the process of healing until wound closure has been complete.

Additionally, the type of tissue in the wound bed should be assessed in terms of

percentage present such as epithelial, granulation, slough, or eschar. The amount

and character of drainage should be assessed, particularly in stage III and IV ulcers

where copious amounts of drainage may indicate the presence of infection. Any

odor should be detected, and the condition of the periwound should be assessed for

evidence on undermining, tunneling, erythema, warmth, or induration. The

presence and degree of edema should be noted because edema decreases the

body’s ability to supply oxygen-rich blood to the affected area. Measures to

decrease edema include elevating the legs, the use of diuretic therapy, and

compression boots after an assessment of thromboemboli has been established.

Emboli are more commonly seen in a patient who has unilateral edema.Maceration

I. Warner / Clin Podiatr Med Surg 20 (2003) 383–394384

I. Warner / Clin Podiatr Med Surg 20 (2003) 383–394 385

of the skin is commonly seen as white tissue around the periwound area. It is

commonly caused by the skin’s inability to absorb the moisture from excessive

exudation of the wound; however, maceration may also occur with the overuse of

topical dressings, such as enzymatic debridement agents and liquid hydrogels.

These agents should be applied sparingly with a cotton-tipped application unless

directed otherwise on the product’s label.

The relative risk for pressure ulceration should be performed using a standard

instrument, such as the Braden, Gosnell, and Norton Scales. The Braden Scale

assesses the combined impact of sensory perception, moisture, friction, activity,

mobility, and nutrition. The Gosnell Scale also includes the nutritional aspects of

the patient. The Norton Scale is limited to the evaluation of the physical condition,

mental status, activity, mobility, and incontinence. Whatever scale used, the patient

should be reassessed using the same tool serially, depending on the type of health

care facility or agency.

Pressure ulcers are particularly problematic in the older adult’s foot because of

the exertion of pressure from the bones of the foot against the surface of the bed

mattress. As unrelieved pressure increases, the small capillaries that supply blood

to the foot become squeezed, unable to deliver oxygen-rich nutrition to that area.

As a consequence, the patient may develop a reddened area of nonblanchable

tissue, particularly on the heel or the lateral foot. Pressure ulcers may also be seen

on the medial aspect of the foot in patients who are malpositioned in bed with one

foot resting upon the other foot or leg. These stage I pressure ulcers provide a

signal to nursing staff that the source of pressure must be removed and

redistributed. The most effective means of such delivery is to use a pillow under

the calf to completely suspend the heel and foot off of the bed. Other devices,

such as heel protectors, may not be as effective in reducing the pressure on a

dependent area. Heel protectors may cushion the area without providing any

means of eliminating the source of pressure exerted by the heel against the

surface of the bed.

Stage II pressure ulcers are commonly seen on the heels in the form of

blisters. Bed-bound patients and those who underwent recent orthopedic or

vascular surgeries affecting the lower extremities are particularly vulnerable.

Ulcerations affecting the epidermis and dermis are often seen on the foot as well.

Intact blisters are generally protected by alleviating pressure on the heel through

the use of pillows and positioning devices. Transparent film dressings may also

be used to facilitate the reabsorption of the blister contents. The use of boots and

splints to relieve pressure over the heels should also be used judiciously in the

elderly patient. These devices may be effective in relieving heel pressure but they

may also increase pressure over the Achilles tendon. The minimal amount of

subcutaneous padding over the Achilles can often result in rapid skin breakdown

in this area. Significant tendon exposure may require surgical closure of the area.

If these devices are used, a policy should be followed with regard to the number

of hours it should be used, the intervals at which the device is removed, and how

often the skin must be inspected under the splint or boot to ensure that pressure

ulceration does not begin in this area.


Caution should always be used before considering any type of debridement of

necrotic tissue from the feet. It is imperative to fully assess the patient’s peripheral

vascular status before the process of debridement to ensure that sufficient

circulation is present in the feet and legs to support healing once debridement

has taken place. In instances where circulation is significantly compromised, it may

be prudent to assess the heel for evidence of fluid or bogginess and any evidence of

systemic infection. In the absence of such symptoms, relieving the pressure and

using protective dressings may be more beneficial than the use of sharp, me-

chanical, or enzymatic debridement. Enzymatic agents may be of minimal value in

an ulcer that has thick, black leathery eschar covering the wound unless the eschar

is crosshatched using a scalpel. This process allows for the penetration of the

enzyme into the tissue.

Stage III pressure ulcers occur with the destruction of epidemis, dermis, and

subcutaneous tissue. Older persons are especially vulnerable to this type of ulcer

as a result of immobility, the use of pain medications or psychotropic agents that

alter cognitive functioning, or the underlying presence of disease. Ulcers may

rapidly progress from a stage II to a stage III as there is normally little

subcutaneous fat in the foot as compared with the trochanter and buttocks.

Osteomyelitis is a particular concern in patients who have stage IV pressure

ulcers. In many cases, the lesion will have significant depth in the wound and

the periwound area shows evidence of erythema, induration, warmth, and

odor. Intravenous antibiotics are used for 6- to 8-week courses in an attempt

at limb salvage.

Policies for the standardization of pressure ulcer treatment should be consid-

ered in any nursing setting after careful assessment has been completed. These

policies are generally based on the recommendations put forth in the US

Department of Health’s Agency for Health Care Quality (AHRQ) Guideline

no. 15: The Treatment of Pressure Ulcers. These recommendations include assess-

ment, pressure management, ulcer care, nutritional interventions, the manage-

ment and control of infection, operative interventions, and patient education. The

role of nutrition cannot be minimized in the care of patients who have pressure

ulcers. The use of treatments and pressure relief/reducing surfaces will be

ineffective if nutritional assessment and interventions are not provided simulta-

neously. The need for protein supplementation becomes even more vital in the

presence of wound with moderate to copious exudate as protein becomes lost in

the drainage. The evaluation of serial serum albumin or prealbumin levels is

necessary in ensuring adequate protein stores to support wound healing. The use

of vitamin C, zinc, and multiple vitamins has been shown to be beneficial in

wound healing.

Wound treatment should be based on the assessment of the wound. A pressure

ulcer with a clean, red wound base may be treated with solid or liquid hydrogels

to support the process of epithelialization. Open wounds with significant yellow

slough in the wound bed may be treated with enzymatic debridement agents or

hypertonic saline solution. Pressure ulcers with considerable necrotic debris may

require serial debridements or whirlpool treatments. Calcium alginate dressings


may be used for a wound that has at least moderate drainage to promote the

process of granulation. If there is only scant or minimal drainage, the use of these

dressings may cause dehydration of the wound bed.

If pressure ulcer healing does not occur despite the presence of an appropriate

dressing, maximizing nutrition and relieving/reducing pressure to the area, the

wound should be assessed for evidence of infection. The use of swab cultures

should be avoided because most of these wounds will have some colonization of

surface bacteria. Instead, a 2-week trial of a topical antibiotic can be used, such as

silver sulfadiazine or triple-antibiotic ointment, then returning to the previous

type of dressing if it is still appropriate for that type of wound. Systemic

antibiotics should only be used if the patient’s clinical picture is one of sepsis,

cellulitis, or osteomyelitis.

Assessment and treatment of diabetic ulcers

All diabetics should be assessed upon admission for peripheral circulation and

the presence of foot deformities, trauma, and ulcerations. The patient may be

unaware of any problems related to their feet because of the presence of diabetic

neuropathy. Diabetic ulcers are commonly seen on the lateral portion of the fifth

metatarsal head from shoe wear. More typical lesions are seen on the plantar

surface of the foot under the first metatarsal head.

Diabetic wounds are also staged but in a manner that is different from that of

pressure ulcers. A Wagner Scale is commonly used to assess and stage wounds

based on the depth of the wound and the presence of gangrenous changes. The

lesion scale ranges from grade 0 to 5.

Grade 0: Skin intact

Grade 1: Superficial ulcer

Grade 2: Ulcer extends to tendon or bone

Grade 3: Ulcer includes abscess or osteomyelitis

Grade 4: Gangrene present in forefoot

Grade 5: Gangrene extends to major portion of foot

Wound treatment should be tailored to the needs of the patient based on the

grade of the lesion. In nearly all cases of diabetic ulcers, an assessment of footwear

and the use of extra-deep shoes with or without inserts will be necessary to off-load

pressure from the site of the wound. The patient’s current shoes and socks should be

assessed for evidence of uneven wear, indicative of excessive pressure over a

particular surface of the foot. The toes should be examined for abrasions caused by

the position of a shoe of inadequate length. The use of shoe inserts should be

considered as a means of redistributing pressure and improving shock absorption,

although crepe sole shoes do provide some degree of pressure relief for this

purpose. Diabetic ulcers that are grades 1 to 3 may be treated with total-contact

casting (TCC) and antibiotics. TCCmay be effective by lowering the pressure over

the plantar surface of the wound while increasing weight bearing over the lower


leg. Patients who are casted require nursing assessment of the color, sensation, and

movement of the extremity. Using the patient’s own reports of pain as an indicator

of potential problems below the cast will likely be of little benefit in patients who

have diabetic neuropathy.

Care of the elderly foot in the nursing home

Since the implementation of the Omnibus Budget and Reconciliation Act

(OBRA-87) in 1991, regulatory oversight for nursing homes has significantly

shifted the focus toward resident-centered outcomes, residents’ rights, and

mandatory assessment tools that are used for interdisciplinary care planning.

As a result, nursing home employees have become increasingly focused on the

avoidance of patient falls and accidents, the prevention and treatment of

pressure ulcers, and the assessment and alleviation of pain. These issues cannot

be fully addressed without consideration of the physiological changes imposed

by age and the presence of disease processes, such as diabetes and peripheral

vascular disease.

The federal regulations for long-term care contained within 42 CFR x 483

provides a framework for understanding the rules governing nursing homes and

the clinical and administrative issues that arise in these settings.

Comprehensive assessments

All nursing homes which receive reimbursement from Medicaid or Medicare

assess residents with a tool known as the Minimum Data Set (MDS), which

gathers information regarding cognitive status, mood, behavior, functional

abilities, incontinence, medical diagnosis, falls, pain, pressure ulcers and other

skin impairments, weight loss or gain, the use of psychotropic medication, and

activity preferences. Based on the MDS, Resident Assessment Protocols (RAPs)

are triggered that prompt the interdisciplinary team to devise a care plan to meet

an individual’s needs. The focus of these tools is to provide a proactive

assessment of potential issues, such as falls prevention and the preservation of

ambulatory function. Staff are required to assess the resident’s skin integrity for

the presence of pressure and nonpressure lesions, to complete the staging process,

and to note the interventions (support surface, lotions, dressings) used in the

treatment of skin disorders. The resident is also assessed for the presence and

nature of pain and any current diagnoses. Information regarding the resident’s

nutritional status, weight changes, and the use of enteral feedings are also

contained in the form. The MDS is completed within 14 days of admission

and again every 90 days unless a significant improvement or deterioration in the

resident’s clinical picture occurs. The MDS provides a clinical snapshot of a

particular resident’s status and enables comparisons to be made from one MDS to

another over time.


Venous ulcers are also noted on the MDS form and it is therefore important for

nursing staff to understand the pathophysiology and healing of each type of

wound. Unlike pressure ulcers, venous stasis wounds are caused by underlying

venous insufficiency. These lesions are generally seen from the lower leg to the

medial malleolus and are accompanied by peripheral, dependent edema. These

wounds generally are not associated with pain, but they tend to be extremely

exudative, making it difficult for patients to manage their drainage. The lesions

are often superficial and irregularly shaped. The surrounding skin is often stained

brown from red blood cell debris.

Arterial ulcers are characterized by pain, particularly at night. Residents with

this type of lesion often feel the need to dangle their legs on the side of the bed to

relieve rest pain caused by the lack of gravity bringing blood to the feet. If side

rails or other types of restraints are used, the resident may be unable to change

position to relieve the pain. Because cognitively impaired residents may have

difficulty expressing the pain they are experiencing, the nursing staff will have to

interpret symptoms of restlessness, which may be pain.

Comprehensive care plans

Patient care should be coordinated using an interdisciplinary care plan, which

is used as tool for communicating with all departments the needs, goals, and

interventions to be provided to an individual resident. The MDS form triggers the

need to create a care plan for the potential of pressure ulcers based on the

following factors:

1. Previous history of pressure ulceration

2. Impaired tactile sensation

3. Significant impairment in bed mobility

4. Bedfast state

5. Hemiplegia or quadraplegia

6. Incontinence

7. Peripheral vascular disease (PVD)

8. Diabetes mellitus

9. Hip fracture

10. Restraints to the trunk or limb, or chair restraints used daily

11. Antipsychotic agents used daily

A care plan for potential or actual pressure ulcers identified by the MDS

should be created using an interdisciplinary rather than a multidisciplinary

approach. The interdisciplinary approach identifies an issue and provides

measurable interventions from all disciplines to address the needs and attain

the goals of wound prevention or wound healing. A multidisciplinary approach

focuses only on the identification and interventions by a particular discipline.

Obviously, an interdisciplinary approach will provide a more coordinated effort

in skin assessment and outcomes.

Pressure ulcers

Quality of care issues in long-term care facilities have focused on the

prevention of pressure ulcers. As such, federal regulations state that residents

entering the nursing home without existing lesions should not develop pressure

ulcers unless those ulcers were clinically unavoidable. The regulations also

require that residents who do have existing wounds be provided with the

necessary care and services to promote wound healing. It is expected that

the support surface, nutrition, and treatments be provided according to the need

of the resident, regardless of the reimbursement by the resident’s health insurance

plan. This is of particular importance when a resident is admitted through a

contract with a Medicare HMO, which may limit the amount and type of

reimbursement for these devices. The support surface includes a variety of

mattress overlays or bed replacements designed to either reduce or relieve the

pressure over boney prominences. It also includes the use of chair cushions to

reduce pressure over ischial tuberosities, a primary site of skin breakdown from

inadequate pressure redistribution. Foam or air pillow donuts, once considered a

therapeutic intervention, have been shown to increase pressure to the buttocks

and are no longer used for pressure ulcer prevention or treatment.

Two common misconceptions about pressure ulcers are that they are always

the result of poor or negligent nursing care and that they can always be prevented.

There are a number of conditions in which the development of pressure ulcers

may be unavoidable. The federal regulations governing nursing homes has

identified a number of factors that play a role in the pressure ulceration and that

may indicate that the ulcer was not secondary to negligent acts of the staff. These

factors include the following:

1. The presence of multiple disease states, such as diabetes, severe peripheral

vascular disease, chronic fecal incontinence, continuous urinary incon-

tinence, paraplegia, quadriplegia, sepsis, terminal cancer, end-stage cardiac,

hepatic or renal disease, immunosuppressed states (disease or drug in-

duced), or the presence of a full body cast.

2. The use of steroids, radiation therapy, chemotherapy, renal dialysis, or the

need to keep the bed in high fowlers position due to medical necessity, such

as the use of enteral feedings.

3. The presence of malnutrition as indicated by low serum albumin levels,

weight loss of 10% or more over 30 days, or a depressed hemoglobin.

The presence of one or more of these categories of primary risk factors does not

relieve the nursing home from providing preventive care for residents. Facilities are

mandated to perform risk assessments for skin breakdown serially, usually upon

admission and when quarterly MDS assessments are done. They are required to

devise care plans to address issues of potential or actual pressure ulceration.

A key question about pressure ulcer development in the nursing home setting

is whether the ulceration was as a consequence of a disease process or the result



of inadequate care. The answer will be found in the documentation of risk

assessment, the care planning, and the provision of care in accordance with the

care plan. Moreover, many facilities have used the Agency for Health Care

Quality Guideline #15 as the basis of their policies and procedures. To this end,

nursing homes have been able to incorporate accepted standards of practice for

wound assessment and treatment into their policies. This is particularly helpful in

attempting to standardize care according to the stage of the pressure ulcer as well

as including all the disciplines involved in pressure ulcer prevention and

treatment. At each stage, treatment, positioning, pressure relief/reduction, incon-

tinence care, and nutritional issues will need to be addressed. The use of these

policies is also beneficial when physician orders for care run contrary to generally

accepted practices of wound care, such as the use of wound cleansers or

treatments been found to be cytotoxic, including hydrogen peroxide, Dakin’s

solution, and povidine iodine.

State licensure and facility policy may allow the sharp debridement of necrotic

tissue to be performed by licensed physical therapists. Again, establishing a

baseline of the resident’s peripheral circulation will be necessary before sharp

debridement can begin. Other modalities, such as electrical stimulation of a

wound and the use of mechanical debridement through whirlpool treatments, may

be explored for residents with pressure ulcers of the feet and lower extremities

unless contraindicated. Clinical factors such as significant lower leg edema,

acute infection, impaired cardiopulmonary function (including congestive heart

failure), renal failure, thrombophlebitis, or the presence of dry gangrene are

considered contraindications to whirlpool therapy. The use of whirlpool treat-

ments should be avoided in any condition in which the softening of the tissues is

contraindicated, such as gangrene, callous formation in diabetics, and already

severely macerated skin.

Nonhealing wounds should be assessed for the presence of necrotic tissue that

may need to be debrided using enzymatic, mechanical, or autolytic means. The

presence of necrotic tissue can be a medium for bacteria, increasing the risk of

wound infection. Enzymatic agents such as collagenase and papain-urea may be

effective in removing yellow slough but cannot penetrate hard eschar unless

crosshatching has been performed. Film dressings can be used alone or in

combination with enzymatic agents for autolysis. If healing is still delayed

despite debridement and appropriate dressings, an assessment for wound infec-

tion should be completed. An evaluation of the nutritional status of the resident

should be performed in the absence of wound healing despite the maximization

of these other factors.

Nutrition

The role of nutrition in the prevention and treatment of pressure ulcers cannot

be underestimated. Pressure ulcers cannot be resolved in the presence of protein

malnutrition; therefore, the involvement of the dietitian is essential when a

resident is identified at high risk for skin breakdown as well as when an ulcer has


formed. Serial weight measurements allow for the quantification of nutritional

status and may need to be performed more frequently that the usual once-a-month

measurement commonly obtained in long-term care facilities. Weight loss of 5%

in 1 month, 7.5% in 3 months, and 10% over 6 months suggests the presence of

significant loss requiring nutritional interventions unless the resident had been

prescribed a weight loss diet or the loss can be directly attributed to the use of

diuretic therapy.

A baseline serum albumin level should be obtained to establish the protein

stores of the resident and the need for protein supplementation. Additional protein

can be provided through the use of liquid supplements, puddings, protein powder

sprinkled in food, and high-protein ‘‘supercereals.’’ Serial albumin levels should

be obtained to monitor protein status, particularly in individuals with moderate to

copious wound drainage. Accurate assessments of the resident’s oral intake of

fluid and food should be obtained by the certified nursing assistant and reviewed

by the interdisciplinary team.

Accidents

Federal regulations require that the nursing home be as free from envi-

ronmental risks and hazards as possible and that residents receive adequate

supervision and assistive devices to prevent accidents. Nursing homes are

prohibited from using physical or chemical restraints solely for the purpose of

convenience or discipline. As a consequence, most nursing homes have imple-

mented the use of a fall risk assessment tool and fall prevention strategies. Fall

risk assessments commonly examine the following:

1. Intrinsic factors—age-related changes to vision and balance, gait changes,

alterations of the muscular-skeletal system, acute diseases, vision disorders,

confusional states, and the use of specific medications (antihypertensive

agents, diuretics, antipsychotic agents, minor tranquilizers, laxatives, and

sleep-inducing medications).

2. Extrinsic factors—physical environment (glare, highly polished floors,

uneven carpet tread), the use of side rails on the bed, the inappropriate use

of canes, walkers, and other devices, and the use of improper footwear. It is

not uncommon for elderly women to prefer shoes that have a higher heel,

altering the base of support for ambulation and causing the resident to lean

forward when walking. Leather-soled shoes and wearing socks without

shoes should be discouraged because of the increased risk for slipping on

the surface of the floor.

The assessment for the risk of falls should include an examination of the

resident’s feet for evidence of corns, calluses, hammer toes, bunions, and other

deformities. It may be necessary to discuss cutting the toe box with the resident

and his or her family to decrease pain while ambulating.

Special needs—foot care

Nursing homes are required to provide podiatric care to residents of the

facility. Residents covered by Medicare HMOs may need referrals for podiatric

care in the facility to maintain compliance with regulations and maintain good

foot care. Residents and families should be given information regarding payment

issues for podiatry upon admission. The facility is required to enter into an

agreement with a podiatrist who is contracted with the HMO to provide services

to these residents.


Foot care and home health nursing

The focus of home health nursing differs from that of institutionalized care in

that patients are provided with the services and education to function indepen-

dently in the community. The assessment of foot disorders in the home setting

allows for the nurse to assess the techniques used by the patient or the family in

their own environment. Turning the hot water heater down to 110 degrees may

decrease the chances of scalding injuries in an elderly patient who has decreased

sensitivity to extremes of temperature.

In addition to assessment, the role of home care includes teaching the patient

and family how to manage foot-related disorders. Patients who have diabetic

ulcers should be instructed in the following areas:

1. Daily foot inspection using a magnifying glass or mirror if the patient has

adequate vision. Visually impaired patients may need the assistance of others

to examine for lesions between the toes and on the plantar surface of the foot.

Inspect for broken or infected toenails, callus formation, or any open lesions.

2. Nail care should be done only by a podiatrist. Make arrangements for a

podiatry visit at the office or home visits.

3. Routine foot care should be done daily using warm water and nondrying

soap. The foot should be towel dried and a skin moisturizer should be

applied to prevent the dehydration of the skin.

4. Foot care precautions include wearing shoes around the house and outside.

Extremely hot water and heating pads on the feet, even if the patient

complains of cold feet, should be avoided. Inspect the shoes for evidence of

an uneven wear pattern. Be sure that the shoes fit well and the toe box is

large enough to accommodate the toes. Select shoes that do not have

stitching directly over the forefoot of the shoe as this may increase the risk

of skin breakdown over the area.

Home care patients who have limited ambulatory status may be at increased

risk for the development of pressure ulcers. An assessment begins with an

evaluation of the patient’s bed mobility and the degree to which he or she can

independently change position in bed. Determine if the patient is in need of a


hospital bed with replacement surface. Instruct the patient/family in positioning

the heels off the bed and inspection of the foot for evidence of pressure.

Changes in the reimbursement of home health agencies by Medicare have

increased the pressure on health professionals to select longer-wearing dressings.

The use of saline wet to dry dressings every 8 hours are no longer practical in a

home health environment unless there is a willing and able caregiver in the home.

Extended-wear hydrogel and hydrocolloid dressings may provide protection of

the wound and absorption of drainage.

Summary

The elderly are particularly susceptible to foot problems caused by underlying

disease states, foot deformities, and alteration in the normal perfusion to the lower

leg and foot. As a consequence, mobility may be compromised and quality of life

threatened. Nurses, regardless of the setting in which they practice, are able to

provide assessment, treatment, and education to geriatric patients to promote the

care of the foot.

Further readings

Agency for Health Care Quality (AHRQ). Clinical practice guideline no. 15: pressure ulcer treatment.

Washington, DC: US Department of Health and Human Services, Public Health Service; 1994.

Maklebust J, Sieggreen M. Pressure ulcers: guidelines for prevention and nursing management.

2nd edition. Springhouse (PA): Springhouse Publisher; 1996.

Sussman C, Bates-Jensen BM. Wound care: a collaborative practice manual for physical therapists and

nurses. Gaithersburg, MD: Aspen Publishers; 1998.

Teasdall RD, Holman JA, Hodges JH, Stauffer DM. Common foot problems. In: Hazzard WR,

Blass JP, Ettinger WH, et al, editors. Principles of geriatric medicine and gerontology. 4th edition.

New York: McGraw Hill; 1999. p. 1553–64.

Tideiksaar R. Falls in older persons. 2nd edition. Baltimore, MD: Health Professions Press; 1998.

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Nursing and long-term care concerns of foot care in the elderly