What should a health care worker be looking for in foot care? A Comprehensive Guide

According to the American Diabetes Association, foot ulcers precede 85% of lower-extremity amputations in people with diabetes.

This highlights the critical importance of diligent foot care, and explains what a health care worker should be looking for in foot care to prevent complications in their patients.

Quick Summary

A health care worker should meticulously inspect a patient's feet for skin integrity issues like cuts, blisters, and ulcers, check for signs of infection such as redness or swelling, and assess for changes in nail health or foot deformities. They must also perform vascular and neurological assessments to identify potential circulation or sensation problems, especially in patients with diabetes.

Key Points

• Daily Visual Inspection: Regularly check for cuts, blisters, swelling, redness, and color changes on the top, bottom, and between a patient's toes.

• Assess Skin and Nails: Look for dry, cracked skin, calluses, fungal infections (thick, discolored nails), and ingrown toenails as part of the assessment.

• Evaluate Circulation and Sensation: Palpate foot pulses and ask about numbness or tingling to identify signs of poor blood flow or neuropathy.

• Educate for Prevention: Provide clear instructions to patients on daily self-checks, proper washing/moisturizing, and appropriate footwear choices.

• Recognize Urgent Signs: Immediately report any open ulcers, signs of infection (pus, odor), or new, persistent pain to a supervising clinician.

• Document All Findings: Maintain meticulous records of all foot care assessments to ensure continuity of care and track changes over time.

Why Foot Care is Crucial for Patient Well-being

For healthcare workers across various settings, from nursing homes to home care, routine foot inspection is more than just a task on a checklist; it is a vital component of a patient's overall health assessment. Early detection of foot problems can prevent serious complications, reduce hospital stays, and improve a patient’s quality of life. This is particularly true for individuals with chronic conditions like diabetes or peripheral vascular disease, where compromised circulation and neuropathy can lead to devastating consequences if foot issues are overlooked.

Performing a Visual Foot Assessment

A thorough foot assessment begins with a careful visual inspection of both feet. This should be done daily for high-risk patients. You must be systematic to avoid missing any potential red flags.

Skin Integrity and Appearance

Examine the skin on the top, bottom, and all sides of the foot. Don't forget to look between the toes. Critical indicators include:

• Cuts, sores, or ulcers: Open wounds, especially on the soles or heels, can be gateways for infection. A diabetic foot ulcer can be painless, making visual inspection the only way to detect it.
• Blisters and calluses: These can be a sign of poorly fitting footwear causing friction. In patients with neuropathy, they may not feel the discomfort and the problem can escalate.
• Color changes: Redness can signal inflammation or infection. Blue or dusky tones may indicate poor circulation. In darker skin tones, examine the soles and look for warmth or swelling.
• Dryness and cracks: Cracked, dry skin can lead to breaks in the skin barrier, allowing bacteria to enter. Conversely, macerated (overly moist) skin, particularly between the toes, suggests a fungal infection.
• Swelling (Edema): Unilateral or bilateral swelling can be a sign of many health problems, from localized infection to heart failure or kidney disease.

Nail Health

Inspect the toenails for several potential issues:

• Thickening or discoloration: Fungal infections (onychomycosis) often cause nails to become thick, brittle, and yellow or brown.
• Ingrown toenails: Redness, swelling, and pus around the nail edge can be a sign of infection. For high-risk patients, do not attempt to trim ingrown nails.
• Brittle nails: Can be a sign of malnutrition or circulatory issues.

Assessing for Potential Neuropathy

Neuropathy, particularly peripheral neuropathy, is a common complication of diabetes and other conditions. It can cause a loss of sensation, leaving patients unaware of injuries. Healthcare workers should screen for these signs:

1. Patient's report: Ask the patient about any tingling, numbness, burning, or pins-and-needles sensations in their feet.
2. Protective sensation: While a monofilament test is the gold standard, a quick check with a cotton ball or light touch can indicate a loss of protective sensation.
3. Foot shape changes: Neuropathy can lead to changes in foot structure, such as Charcot foot, a rare but serious complication that can cause the foot to become misshapen.

Examining Vascular Status

Poor circulation is a significant risk factor for foot complications. Assess blood flow by:

• Palpating pulses: Check for the dorsalis pedis pulse (on the top of the foot) and the posterior tibial pulse (behind the inner ankle bone). Absent or weak pulses can indicate arterial disease.
• Comparing skin temperature: A cool foot or differences in temperature between the feet can signal poor circulation.
• Hair growth: A lack of hair growth on the toes or legs is often a sign of inadequate blood flow to the extremities.

Comparison Table: Common vs. Urgent Findings

Understanding the severity of foot findings is key to prioritizing care. This table helps distinguish between issues that require ongoing monitoring and those that demand immediate attention.

Finding	Level of Urgency	Action Required
Dry, cracked skin	Ongoing monitoring	Apply moisturizer (avoiding between toes); educate on skin care.
Discolored, thickened nails	Ongoing monitoring	Recommend follow-up with a podiatrist for assessment.
Small, non-bleeding callus	Low to moderate	Advise on proper footwear; monitor for changes. Do not debride yourself.
Persistent redness or swelling	Moderate to high	Investigate cause; check for infection signs; notify supervising clinician.
Open wound, ulcer, or blister	High	Do not debride; clean gently; apply dressing; notify supervising clinician immediately.
Signs of infection (pus, warmth, odor)	Urgent	Notify supervising clinician immediately; prepare for wound care and potential systemic treatment.
New or severe pain	Urgent	Assess for fracture, sprain, or infection; elevate foot; notify clinician.
Loss of sensation or absent pulse	High	Notify supervising clinician immediately; assess for vascular or neurological issues.

Patient Education and Preventive Care

An integral part of a healthcare worker's role is empowering patients to participate in their own foot care. Educating patients and their families on proper techniques and preventive measures is essential.

Tips for Patient Education:

• Daily foot checks: Encourage patients to inspect their feet daily using a mirror or with help from a family member.
• Proper washing and drying: Instruct them to wash their feet daily with mild soap and warm (not hot) water, drying thoroughly, especially between the toes.
• Moisturize, but not between toes: Advise applying lotion to the tops and bottoms of the feet to prevent dryness, but emphasize avoiding the areas between toes to prevent fungal growth.
• Appropriate footwear: Stress the importance of wearing properly fitting shoes with sufficient arch support and a roomy toe box. Shoes should be inspected for foreign objects before wearing.
• Never go barefoot: Remind patients to wear shoes or slippers, even indoors, to prevent injury.
• Trim nails correctly: Teach them to trim nails straight across, not curved, to prevent ingrown toenails.
• When to seek help: Educate patients on the warning signs that require a prompt call to their healthcare provider.

For additional resources on diabetic foot care, refer patients to the American Diabetes Association's foot care guidelines.

Conclusion

For a health care worker, diligence in foot care can be a defining factor in preventing major health complications for patients, particularly those with compromised health statuses. A systematic approach that includes thorough visual inspection, assessment of vascular and neurological status, and targeted patient education is crucial. By being observant and proactive, health care workers can act as a critical line of defense, catching problems early and ensuring timely intervention. This proactive care not only prevents severe health issues but also contributes significantly to a patient's overall well-being and quality of life.

Frequently Asked Questions

How often should a health care worker perform a foot assessment?

For high-risk patients, especially those with diabetes, a foot assessment should be performed daily. For low-risk individuals, it can be done less frequently, but a visual check during routine care is always recommended.

What are the first signs of a serious foot problem in a patient with diabetes?

The first signs can include a loss of sensation, unexplained numbness or tingling, changes in foot shape, redness or swelling, and the development of sores or ulcers that may not be painful due to neuropathy.

Why is it important not to cut a diabetic patient's toenails?

Healthcare workers should not cut a diabetic patient's toenails unless they are specifically trained to do so. Improper technique can cause nicks and cuts that can quickly lead to serious infections in patients with poor circulation and sensation. It is best to refer them to a podiatrist.

What is Charcot foot and why should a health care worker look for it?

Charcot foot is a rare but severe complication of neuropathy, where the bones in the foot become weak and fracture, eventually leading to a misshapen foot. A healthcare worker should look for swelling, redness, and a new or altered foot shape, as prompt referral to a specialist is crucial to prevent further damage.

How can I check for poor circulation in a patient's feet?

You can check for poor circulation by palpating for the dorsalis pedis and posterior tibial pulses. Additionally, note if the feet feel cold to the touch or if there is a lack of hair growth on the toes and legs.

Is it safe to use moisturizer between a patient's toes?

No, it is not recommended to use moisturizer between a patient's toes. This can create a damp environment that promotes fungal growth. Always ensure the skin between the toes is thoroughly dry after washing.

When should a healthcare worker refer a patient to a podiatrist?

A healthcare worker should refer a patient to a podiatrist for any persistent pain, ingrown or fungal nails, hard-to-manage calluses or corns, open wounds, deformities, or if they have a condition like diabetes that requires specialized care.