Key learning points:
– Primary care nurses can play a significant role in the identification of foot health problems that need further assessment and treatment by a podiatrist
– Good communication and liaison between primary care nurses and podiatrists are important to maintain high standards of care
– In people with diabetes it is essential to assess both feet at each visit and to refer and act fast if any problems are detected
Although our feet are essential for our balance, weight bearing and mobility, we have a tendency to take them for granted until something goes wrong. Problems with our feet will affect our general well-being, and in the elderly, can lead to falls,1 impaired mobility and loss of independence.2
Foot health problems can be minor (such as dry skin and/or long toenails) which can be cared for by nurses using basic techniques, or they can be more complicated (such as thickened toenails, corns and/or diabetic ulceration) that might need the care of a specialist (eg, podiatrist). This article aims to discuss some of the common foot health problems that primary care nurses might come across, how to identify these conditions and when a referral is needed.
Foot health problems
Foot health problems can be broadly classified as:
– Orthopaedic.
– Skin and nails.
– Systemic in origin.3
Orthopaedic deformities
The most often reported structural deformities are bunions (hallux valgus) and smaller toe deformities such as hammer toes.4 These lead to bony prominences at the joints that are very susceptible to pressure, particularly from shoes. To prevent or reduce the shoe pressure on these bony prominences, which can cause painful calluses and corns, advise the patient to wear sensible shoes that will hold their feet securely but still leave room for toes to move. If this does not help, refer to a podiatrist, who may recommend exercises, custom-made shoes or orthoses and ultimately refer for podiatric surgery to correct the deformity.5
Skin and nail problems
The most common podiatric skin problems that nurses will encounter are callus (hard skin) and corns. The formation of callus is a normal protective reaction to repeated pressure and friction. However, when the callus becomes too thick and painful it exceeds its protective function, causes increased pressure on the underlying tissues and may potentially lead to ulcers – so it has to be reduced.
Corns also develop as a result of pressure and friction but are usually found over bony prominences such as joints. They are almost always painful and can become infected. Over-the-counter remedies such as corn plasters are not recommended (especially if patients are elderly or diabetic) as they are ineffective and contain acids that can burn healthy skin.2
The removal of callus or corns should always be done by a registered podiatrist as it is a skilled treatment using a sharp blade. If carried out incorrectly, it can lead to further problems. Podiatrists can also apply padding and provide insoles to redistribute pressure for long-term relief.5
A foot skin problem more commonly seen in children, teenagers and young adults is verrucas. Verrucas are warts that commonly occur on the soles of the feet and the toes and are caused by the human papilloma virus (HPV). This virus is highly contagious and thrives in moist, damp environments such as swimming pools and communal shower areas. Verrucas appear as small cauliflower-type growths with tiny black dots, which can easily spread into a cluster of small warts. They can be distinguished from corns by pinching or squeezing, which elicits pain. Corns are painful when direct pressure is applied but not when they are pinched.
In children, verrucas often disappear on their own accord within six months as the body’s immune system fights the viral infection, but this can take up to two years for adults.5 If the verrucas are not painful, the advice is to cover them with a plaster and leave them alone, because some treatments can be painful, produce side-effects and can be difficult to administer to children. If the verrucas are painful or are spreading, there are self-treatments available from the pharmacist. However, as these often contain salicylic acid, which can damage healthy tissues, it is essential that the instructions are carefully followed. If the self-treatment is not working or problems arise, such as the surrounding area becoming red and inflamed, the treatment should be immediately stopped and a podiatrist should be seen.
Most importantly, if the patient has diabetes, poor circulation, is pregnant or has any other condition affecting their feet or immune system, they should never treat verrucas themselves. Refer to a podiatrist.5
A common nail condition representing approximately 20% of all nail disorders is onychomycosis, a fungal infection of the nails. The infected toenails tend to be thickened, white or brown-yellow and are often brittle, with brown-yellow ‘debris’ under the nail bed. This condition is almost always found in adults.3 To reduce thickened nails, a referral to a podiatrist is essential, particularly in patients with diabetes and neuropathy or patients with impaired vision, as incorrect nail cutting can lead to tissue loss and secondary infection.6
A nail condition more commonly found in younger people is ingrown toenails. In this condition, a toenail pierces the flesh of the toe, often due to poor nail cutting, leading to inflammation and, in more severe cases, infection. If an infection is present, referral to a GP for antibiotics is needed. This condition can be extremely painful and often affects the big toe, but not always. Don’t attempt to remove the ingrowing nail spike yourself, particularly if the patient has diabetes, is taking steroids or is using anticoagulants. Refer to a podiatrist for further assessment. If necessary, the podiatrist will remove the offending part of the nail under local anaesthetic.5
Arthritis and foot health
The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis is often called the ‘wear-and-tear’ arthritis. As the joint cartilage deteriorates (either from injury damage, infection, overuse or age), it leads to pain, swelling and stiffness (reduced range of motion) of the joint. Although any of the 33 joints in the feet can be affected, osteoarthritis most commonly affects the joints at the base of the big toes.2
Rheumatoid arthritis is not caused by wear and tear. It is a chronic inflammatory autoimmune condition affecting particularly the joints in the hands, feet, wrists, ankles and knees, leaving them swollen, painful and stiff. Additional symptoms include muscle aches, anaemia and flu-like symptoms.7 The smaller joints in the feet and hands are often the first to be affected by the disease, often leading to joint deformities. Due to the increase in pressure on the deformed joints in the feet, and a reduced ability to absorb shock during walking, further problems often develop such as painful corns, callus and even ulcers.5 Walking becomes increasingly difficult and painful.
For both types of arthritis, a podiatrist can make walking less painful by relieving the pressure and friction on the joints through custom-made orthoses, shoe advice and modification, and referral for podiatric surgery. They can also treat any secondary problems caused by the foot deformities such as ulcers and corns.5
Diabetes and foot health
Diabetes is one of the most chronic and prevalent conditions in the UK. It is estimated that by 2025 more than five million people in the UK alone will have diabetes and that, of those patients, as many as 10% will develop at least one foot ulcer in their lifetime. The most feared and costly consequence of foot ulceration is amputation, with diabetic foot ulcers preceding more than 80% of lower limb amputations in people with diabetes. The mortality rates following amputation due to diabetic foot ulceration are high, with approximately 70% of people dying within five years.8
The reasons for these high rates of diabetic foot ulcer development are that patients often suffer from peripheral neuropathy (loss of sensation in the feet) and peripheral vascular disease (poor blood supply to the feet).2 These patients will not be aware of an injury to their feet and the poor blood supply will mean the wound will be slow to heal (and any infection will spread quickly).
As a significant number of people with diabetes receive care in the community, primary care nurses are perfectly positioned to identify patients who have an increased risk of developing diabetes-related complications, to refer when required and to educate patients about foot care.9 Upon diagnosis, all people with diabetes should have had their feet thoroughly assessed and be referred for podiatry care, with low-risk patients receiving annual assessment by a podiatrist.8
However, as risk status can rapidly change as the disease progresses, it is important for nurses to assess patients’ feet at each visit. This assessment should consist of checking:
– The pulses and the sensation in the feet.
– The skin’s temperature, colour and integrity.
– Any signs of infection or inflammation.
– Nail changes or skin lesions, such as corns and callus and whether any foot deformities are present.
– The patient’s footwear to ensure that it does not cause any pressure on the feet.10
Refer immediately to acute services if there are any signs or suspicions of:
– Ulceration with fever or any signs of sepsis.
– Ulceration with limb ischaemia.
– A deep-seated soft tissue or bone infection or signs of gangrene.
For all other diabetic foot problems the patient should be referred to the foot protection service, which is led by a podiatrist specialised in diabetic foot problems.8
Conclusion
Primary care nurses play a major role in identifying foot health problems that might need further assessment and treatment by a podiatrist. Through early recognition and referral, nurses can greatly influence and improve their patients’ quality of life – and sometimes its length.
Resources
Arthritis Research UK –arthritisresearchuk.org/
National Institute for Health and Care Excellence guidelines (NG19) for diabetic foot problems: prevention and management –nice.org.uk/guidance/ng19
The College of Podiatry –scpod.org/#
References
1. Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: a prospective study. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2006;61:866-70.
2. Mitty E. Nursing Care of the Aging Foot. Geriatric Nursing 2009;30(5):350-354.
3. Helfand AE. Geriatric nursing review syllabus, 2nd ed. American Geriatrics Society; 2007.
4. Stolt M, Suhonen R, Voutilainen P, Leino-Kilpi H. Foot health in older people and the nurses’ role in foot health care-a review of the literature. Scandinavian Journal of Caring Sciences 2010;24:194-201.
5. The College of Podiatry. Common Foot Problems. scpod.org/foot-health/common-foot-problems/ (accessed 5 May 2016)
6. Bodman M. Current concepts in treating onychomycosis in patients with diabetes. Podiatry Today 2015;283:3.
7. Arthritis Research UK. Rheumatoid arthritis. Arthritis research UK; 2014.
8. NICE. Diabetic foot problems: prevention and management. NICE guideline (NG19). nice.org.uk/guidance/ng19 (accessed 6 May 2016)
9. Daly B, Arroll B, Sheridan N, Kenealy T, Stewart A, Scragg R. Foot examinations of diabetes patients by primary health care nurses in Auckland, New Zealand. Primary Care Diabetes 2014;8:139-146.
10. Burrow JG. Foot assessment: recognizing potential problems. Nursing and Residential Care 2004;6(2):68-71.
