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Foot Assessment Tutorial

It is not my style to knock the advice given by the American Diabetic Association, Podiatrists, the Lower Extremity Amputation Prevention Program or all of those other so-called experts who teach foot exams.  I certainly buy into their position that assessing feet is important for so many reasons but I find that their instructions are incomplete.  In response, Haydel Consulting Services, LLC has stepped up to the plate to provide you with the missing pieces for a complete foot exam.  Pay close attention.  The skills you learn could save a limb or a life.

  1. Start with a foot encased in a shoe and sock.  Take a look at the shoe to make sure it is appropriate for the patient and fits well.  High heels, flip flops and all the other really cool kinds of shoes are not appropriate for many of our elderly patients.  No matter how ugly the shoe is, do not criticize the patient’s choice of footwear if the shoes meet the above criteria.
  2. Untie the shoe.  This may add some time to your visit but it will definitely make it easier to complete the following steps.
  3. Gently ease the shoe off the foot.  Do not pull, tug or otherwise force the shoe off to prevent the foot from coming off with the shoe.
  4. Inch the sock down from the top towards the toes until the entire foot is visible.  DO NOT ATTEMPT STEP 4 UNTIL STEPS 1 – 3 ARE COMPLETE.
  5. Attentively assess the foot according to the incomplete guidelines published by above referenced agencies.  Notice how the nurse in this photo (Susie Soskin, RN) is at eye level with the foot.  If you cannot get down to eye level, find someone who can or get the patient to lay down in the bed.  If your knees are too old to bend down then chances are your vision is not good enough to assess feet from a distance.
  6. These are perfect feet.  I know this because they belong to my son.  I have bought hundreds of shoes for these size elevens.  At the cash register, I have often been a bit overwhelmed at the cost of keeping him in shoes.  After taking care of a few amputees, I am honored to have had the privilege to buy full pairs of shoes for him.  I hope when I am dead and gone, he still has to pay for a full pair.

A high resolution copy of the above tutorial is available by clicking here.  Please feel free to print it, share it or ignore it.  And yes, I know the vast majority of us do take shoes and socks off every visit and look at diabetic feet.  This is good but diabetics are not the only patients who benefit from foot assessments.  Patients with heart failure or take diuretics will show signs of fluid build up in their feet, compromised circulation from cardiovascular or other disease can result in discoloration or stasis ulcers and injuries to the feet can be overlooked by any patient with loss of sensation or callused skin.

So, if this helps you to remember, all is well.  If you don’t need reminding, kudos to you.  If you think that one of your nurses or coworkers is not taking the time to do a complete foot assessment, draw a happy face on the bottom of the foot and see what shows  up in the documentation:)

As always, questions and comments are welcome below or via email.  As so on…..

20 Comments Post a comment

  1. I understand why you posted this but it is kind of a slap in the face to the field nurse. Nurses know how to assess feet. A tutorial really is not necessary. I was expected some mysterious special knowledge from the podiatry field or something. You burst my bubble.

    February 17, 2012
    • Gail #

      Methinks thou doest protest too much.

      February 17, 2012
      • Gail #

        Oh, and what a cute (hilarious) way to remind us how important the foot exam is. I have a real horror story I could tell you regarding the foot exam (or the lack of foot exams) but I will spare y’all the upsetness y’all would probably experience.
        Good job, J!!! 🙂

        February 17, 2012

    • I respect your opinion cxg and I am sorry that you are offended. I do not know why it happens but I have seen pedal pulses and 1+ edema documented on amputees before. I have heard from a physician that he would never use home health again because one of his patients visited his office with maggots in her wound the very same day that a home health nurse saw her.

      There are a lot of people and organizations out there that know more than me and can offer academic and didactic information and training on how to perform a foot exam. I personally like the LEAP program linked in the first paragraph because it does not limit its research to the diabetic foot. I am a nurse and I am speaking about my nursing experiences and sharing what I have learned with other nurses. Different people respond to my posts differently but I do know that it is very hard to tell nurses that maybe some of them aren’t doing their job without offending someone.

      My opinion is that many nurses do not appreciate the value of a foot exam. Regardless of whether or not you find my post offensive, the truth is that there are some nurses who skip looking at feet when warranted. If my post brings home the importance of checking feet to nurses and a few more foot exams are actually performed and documented (step 6), I had a successful day.

      February 17, 2012
      • Gail #

        I really enjoyed the maggot story. It was almost as good as mine (which I still hesitate to tell because someone might recognize the story and I would get in some kind of trouble(. Maybe they were USP sterile maggots bred especially for debridement of stubborn wounds….just a thought. I also have seen nurses document pedal pulses and edema on amputees. When asked about it, they replied, “Just habit, I guess.” Not a good enough answer for me; it does make one wonder.

        February 21, 2012

        • Please tell us your story. You can mark it with a disclaimer.

          ‘just Habit’ gets nurses into trouble routinely. We are all guilty but making a conscious effort to be ‘present’ and attend to documentation goes a long way.

          By the way, I have two maggot stories but one was a direct admit to CCU. And apparently ants love tube feeding. What can I say? The south is a very hot and humid place. If you get a Patient in extremis, it is okay to get a heart rate and rhythm before checking for pedal edema. Sometimes situations arise that make the nurses sicker than the patients.

          Oh, and the one time I sort of understood drunk driving is when I went to insert a catheter on a patient only to learn he did not have a penis. Poor dear. I still don’t approve at all. I loved my brothers very much until they died in a drunk driving accident.

          February 21, 2012
          • Gail #

            OK. You lost me with the drunk driving analogy. Please elaborate. I am afraid I don’t get the connection to drunk driving and the guy without a penis.
            And did your real-life brothers really die in a drunk driving accident? That is so awful. Or did I miss something?
            I had to look up “extremis” by the way and I’m not embarrassed to tell you that. That is a good point now that I understand the terminology.

            February 24, 2012

            • So you really don’t get what maggots and men without members have in common? Sorry. It was just another in the list of stories that made me sort of grossed out. It is, in general hard to do. But when it comes to events that make the nurses sicker than the patients, that one is right up there. Perhaps it is one of those ‘had to have been there’ type of things.

              I like the phrase extremis. One of our docs used it a lot. It says it all in one word instead of droning on and on about the heart rate and rhythm, lack of respiratory effort, cyanosis, etc. or – since you are charting all that on the front of the chart, you could just write, ‘received patient in extremis’. No one expects you to see how oriented that patient is or if they follow commands. That whole ‘continue home meds’ order that wasn’t completed is fully explained by one word. I wish we had something like that in home health.

              I look up words all the time. I love the way my iPad Kindle app lets you touch a word to get the definition.

              February 25, 2012
    • Barbara Cleland #

      To exg175:
      I thought that it was a very good reminder, and I have been in Home Health for 29 years. I think you would be very surprised to know how many nurses do not know how to assess feet, simply because they do not do it !!! It is interesting to make a visit behind a field nurse and ask the patient if her nurse ever checks his/her feet…You may be surprised at the answer you get!

      February 17, 2012

  2. Another thing to remember is that our conscientiousness in checking on feet models the importance of it to patients and to caregivers.

    Thank you for making it an enjoyable (as in, not boring) read!

    February 17, 2012
  3. Anita #

    I have to agree that a reminder is necessary for some clinicians. These are the same folks who will document on a Start of Care OASIS that a surgical wound is known but can’t be assessed due to a non-removable dressing…then go on to say “patient had just changed dressing so wound wasn’t checked at this visit.”

    Unfortunately those few clinicians who short-change their patients won’t be the ones who would read this and “get” it.

    I also have to say I love the humor. Your photo guide presented in a comical way might be a nice intro to a general education session on diabetes care, wound care, etc. These are dry topics – anything to make things more interesting is great by me!

    February 17, 2012
  4. drobby #

    Useful reminders but find it the statement “so called experts” rather unprofessional

    February 21, 2012

    • Please try to put it in context. I have enormous respect for the Diabetes Association. It doesn’t matter where your patient is with their DM, you can find teaching guide materials on their site. If you want an entire guide to a healthy lifestyle or if you admitted a pt with another primary dx who needs to know about something new, you will find it there. Lots of recipes, etc. that can be given to family members who cook. The LEAP website is beyond terrific plus it is at Carville, LA. It is now a Hansens Disease research facility and for a while, it housed Federal Prisoners. It was also the oldest ‘leper colony’ in the country. That was shut down but many patients chose to stay. Talk about an interesting mix of people. Anyway, Hansen’s Disease is very nasty to the extremities. I had a patient once who got her finger stuck in a wheelchair spoke and didn’t know she had mostly removed until she noticed blood on her clothes. They have taken what they know and have applied it to all conditions that put extremities at risk.

      Here’s some interesting trivia. Armadillos and humans are the only species who can become infected with Hansen’s Disease. Similarly, only humans and armadillos can have identical twins. Armadillos do not hear and you can get very close to one if you approach it from the rear. Humans, on the other hand do hear.

      February 21, 2012
  5. Drhobby #

    To hcslic,
    I’m aware of all of your points and appreciate that you may be trying to enlighten the general public. Although I realize that this is only a conversational blog and comments are being posted without scientific or evidence basis. As a CWOCN, I believe that we must show enough respect to other professionals to not refer to them as “so called experts”…… Last time I checked, these ARE the experts..let’s keep this professional please and not belittle anyone else’s proven credentials….just sayin…..:-)

    February 22, 2012

    • I ran your comment by my editorial board who thought that I had made it abundantly clear that I had an enormous of respect for the experts.

      I appreciate how hard you have worked to obtain your wound ostomy credentials. I have absolutely no doubt that you could assess and treat a wound far better than myself. My point is that too many times, the feet are not examined. So, regardless of how much I respect the experts, nobody can do anything about a wound thats never been seen before.

      The only people who should be insulted are the ones who do not take off patients shoes and socks and look at feet. And someone wise pointed out, they probably don’t take the time to read this. On the other side are the other nurses who have read documentation or followed behind nurses who have failed to check feet and appreciated the fact that someone else shared their frustration.

      One thing I have learned over the years is that people respond differently to different people. We have different styles of learning and widely disparate senses of humor. It’s okay if you don’t share my sense of my humor or if you prefer to learn from more scholarly and academic models. You are perfectly free to interpret anything I write any way you like.

      What I write and how I write is ultimately my decision and my responsibility. You may choose to respect my right or not. I appreciate your feedback but beleaguering a point that’s been made, clarified and discussed will not get me to rewrite my blog according to your wishes. Just saying….

      February 23, 2012
      • Gail #

        I usually read your blog with “tongue-in-check” anyway, because it’s like a box of chocolates; you never know what you’re gonna get. It appears that some folks just take themselves entirely too seriously. My advice, “Lighten up before your head explodes” as my 12 year old granddaughter told her Poppy recently. (And she’s right too.)

        February 24, 2012

        • I love the ‘lighten up before your head explodes’. That is too funny. Also, the box of chocolates is one of the nicest things anyone has ever said about my blog. I like that.

          February 25, 2012
  6. ID, RN #

    I LOVED your post! I’m a nurse myself and I find it difficult to get the field nurses to actually do a thorough assessment. And it’s sad. Once again, there are plenty of nurses our there that are fantastic, and no one should take offense. What I loved about your post is that it is humorous, cracked me up, and reminded me how EASY it is to perform a foot exam. Sometimes all we need is a humorous post like this to remind us of the simplicity of the task and to make us more compliant. I will definitely use share it. Sometimes, funny things stick in our minds more than lectures.

    February 25, 2012
  7. Gail #

    “So, if this helps you to remember, all is well. If you don’t need reminding, kudos to you,” wrote Juliana Haydel in her most recent posting. This pretty much sums it up (to me) for all the positive commenters and the nay-sayers. I ran a quick review of posts from October-present and found that most posts had 7 or so responses, one had 14 (Medication Competency), a few had no responses, but none had as many as this one. So, if Ms. Haydel stirred it up a little and got us all to thinking about feet, then I believe the ultimate goal has been accomplished. How ’bout you?

    February 27, 2012

    • You are so good. Yes, that is an accomplishment even if some people took issue with it.

      Thank you so very much for reminding me of that. That was the point and while I regret that some people didn’t share my humor, it is so worth it if even one nurse is reminded of the importance of checking feet.

      February 28, 2012

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