Unit 5 - Assessment Flashcards
Survive this damned course.
Appropriate documentation practices related to nursing foot care
Approrpriate health information will ALWAYS include…
(health history interview components)
AABCCD GROAN
Advanced directives ADL functional assessment Biographical details (name, address, phone, DOB) Current acute or chronic conditions Current meds (incl herbal/natural) Doctor (family physician)
General health history of all body systems
resp, cardiac, digestion, endocrine, EENT, neuro, musc/skel, psych, surgery
Reasons for seeking foot care
Other members of the health care team
Allergies
Next of kin
Appropriate documentation practices related to nursing foot care
What is the purpose of the health history interview?
A BUG
Assess understanding of foot health, foot conditions and preventative care
Build a trusting relationship and rapport
Understand the client’s perspective
Gather data from client
Appropriate documentation practices related to nursing foot care
– demonstrate the ability to document a health history
Other important components of the health history to consider are:
PCCCHHH
Personal habits (smoking, alcohol intake)
Communication needs (language)
Cultural practices that might impact care of the foot
Current and past occupations
Health maintenance practices
History information source (client, family)
History of falls
Any symptoms the client brings forward should be further investigated.
PQRSTU mnemonic
P: Provocative/Palliative
- What brings it on? What makes it better?
Q: Quality/Quantity
- How does it feel or look? Describe the symptom.
R: Region/Radiation
- Where does it occur? Does it spread or move?
S: Severity
- Scale of 0-10; is it better, worse or is there no change?
T: Timing
- What was the onset? What is the duration? What is the frequency or occurrence?
U: Understand the Client’s Perception
- What do you think this symptom means?
The complete health history may involve a lengthy interview during the initial visit.
During subsequent visits?
the foot care nurse must set aside time to verify that the data previously collected and documented is still valid
a more focused assessment of the lower limb will occur
A comprehensive assessment of the lower limb includes the following components:
Observe (4)
Inspect (3)
Assess (2)
OBSERVE gait hygiene - cleanliness, odour, detritus footwear - style/appropriateness, fit, safety, stockings/socks
INSPECT
musculoskeletal function
circulatory function
neurological function
ASSESS ambulatory aide(s) - type, frequency/appropriate use integumentary
Gait can be divided into 2 phases:
stance and swing phase
Describe stance phase.
How much of the gait cycle occurs during the stance phase?
The stance phase can be subdivided into:
the weight bearing part of gait
Approximately 60% of the gait cycle occurs in the stance phase.
Heel strike
Foot flat mid stance
Heel off
Toe off
Describe swing phase.
How much of the gait cycle occurs during the swing phase?
The swing phase can be subdivided into:
one foot is swinging freely in preparation for heel strike
The remaining 40% of the gait cycle occurs in swing phase.
Toe off
Mid swing
Heel strike
Once heel strike occurs, the foot enters?
The foot will then flatten and begin to toe off.
At this point the foot will enter?
Supination - outward roll of the foot
heel inversion
adduction
plantar flexion
Pronation - the inward roll of the foot
heel eversion
abduction
dorsiflexion
A certain amount of supination and pronation are normal but excessive amounts will lead to pressure areas, callus build up and even leg or back pain.
The cycle begins with…
The cycle ends when…
one heel striking the ground
that same heel strikes the ground once again
There are 3 major tasks required in order for propulsion to occur. The client must be able to:
bear own body weight
bear weight on a single lower limb
swing the lower extremity forward
Describe gait Ax
How to do it.
What to observe.
CHAD SACS
Have the client walk 15 to 20 feet then turn and walk back.
Do with/without usual footwear.
Check it out from all angles.
OBSERVE
Cadence (smooth, even rhythm)
Head/shoulder movement (any dipping, are shoulders symmetrical)
arm swing (should be asymmetrical)
Discrepancies in leg length
Stability (potential for falls)
Ability to move around obstacles (agility)
Coordination of movements
Stride length (approximately 15 inches)
For the purposes of assessment, the nurse should ask the client to wear?
their usual choice of foot wear
With the shoe ON the client, describe how to assess the fit.
widest part of foot fits widest part of shoe
Heel
> fits snugly, no piston movements
> no gaping
Toebox
> toes not confined (person can wiggle)
> 1/2” between longest toe and end of toebox
Breaking/flexion point of shoe
> lines up with MTP articulation at ball of the foot
(an oblique crease that accommodates the foot movement during toeing off)
What is a simple method for assessing the fit of the shoe?
a pedograph
Have the client stand barefoot on a blank piece of paper. Trace around the foot with a pen. Have the client step off the paper. Place the client’s shoe on the outline. Trace the shoe in a different colour pen. The differences between the client’s foot and the chosen foot wear will be obvious.
With the shoe OFF the client, describe how to assess.
In general, excessive wear/tear?
Inspect soles for area of wear
May signify pressure areas and/or gait abnormalities
Put hand inside shoe.
Excessive wear? Tears? Rough seams?
Any areas in the shoe that show signs of excessive wear should be noted by the nurse as there may likely be a corresponding “trouble spot” to be found on the client’s foot.
The foot care nurse must assess the appropriateness (suited to client’s feet and/or gait) and safety of the shoe.
To provide stability during the heel strike, the shoe should have a broad, solid heel that is no more than 1” in height.
A shoe that is worn everyday should be a functional shoe – one that can be closed either with laces or Velcro.
The soles should be made of a skid resistant material.
A skid resistant sole that curls up and over the toebox can grip carpeted areas and lead to falls.
Socks are included in the assessment process.
Why should they be worn with shoes?
Clients with moist or diabetic feet should wear what materials to prevent maceration?
What materials retain moisture?
These should only be worn by?
Speak to natural fibres.
What material should not be worn?
Why?
to protect the foot from seams and friction
Polypropylene
acrylic
cotton and wool
clients that can change them daily or more
Natural fibers tend to breakdown quickly and may become abrasive to sensitive skin after numerous washes. They should be inspected and replaced regularly.
Nylon
it retains perspiration, leading to maceration, blisters and foot odour
Integument Ax Categories
CTTV TIME
Colour
Temperature
Texture
Vascularity
Thickness
Integrity
Moisture
Edema
Integument Ax
Colour
general pigmentation consistent with genetic hx
erythema may = inflammation
marked pallor may = arterial insufficiencies
cyanosis = lack of oxygenation
dusky red (dependent rubor) may = insufficient venous return
hemosidern staining
Integument Ax
Temperature
localized areas of hypothermia
- impaired peripheral circulation
- conditions such as Raynaud’s phenomenon
localized areas of hyperthermia
- trauma or infection
subjective complaints of burning feet
- neuropathy
Integument Ax
Texture
normally smooth and firm
palpate for any nodules or lumps
areas of roughness
- friction or excessive pressure
weather beaten, thick and deeply furrowed
- rays today, raisins tomorrow!
decreased turgor d/t decreased elasticity
- elderly
Integument Ax
Vascularity
bleeding or bruising
- ? the origin of bruises
absence of hair
- arterial insufficiency
decreased vascularity of dermis d/t aging
- skin appears paler/more opaque
- leakage of blood from capillaries causes purple patches to appear on the skin
Integument Ax
Thickness
uniform thickness
- plantar surfaces are thicker than dorsal surfaces
thin skin
- arterial insufficiency
- dorsal surface of feet becomes thinner with aging
Integument Ax
Integrity
corns (hard or soft) and calluses
- signify areas of pressure or friction
- assess further for source (ill-fitting shoes, biomechanical problems, structural deformities)
plantar’s warts
fissures
rashes
ulcerations, lesions
For any skin integrity impairment, the foot care nurse assesses and documents:
If wound is covered and you want to leave it, only need to ask:
ECHO
IF wound is uncovered or you are able to properly replace dressing, assess:
POWW’LESS
Etiology
Current wound care plan (eg Home Care daily)
Hx
Others following the client (Family Dr., Clinic, Specialist)
location
exudate characteristics
size (actual measurements, not “peasized”)
shape
periwound skin
odour
wound bed (if applicable)
wound edges
Integument Ax
Moisture
Ax dorsal/plantar surfaces and interdigitally
extremely dry skin
- anhidrosis
- fissures
moist skin
- bromidrosis
- areas of maceration
aging skin
- decreased sweat and sebaceous glands
- dry, rough and flaky
- itchiness
Integument Ax
Edema
How to Ax
pressing thumb firmly against the client’s anterior aspect of the shin
Integument Ax
Edema
Graded and documented based on the following subjective scale:
+1 mild
only a slight indentation noted
+2 moderate
indentation disappears rapidly
+3 deep pitting edema
indentation remains for a short period
+4 very deep pitting edema
indentation remains for a long period
