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FOOT - Ax and Intervx > Unit 5 - Assessment > Flashcards

Unit 5 - Assessment Flashcards

Survive this damned course.

1
Q

Appropriate documentation practices related to nursing foot care

Approrpriate health information will ALWAYS include…

(health history interview components)

AABCCD GROAN

A 
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

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2
Q

Appropriate documentation practices related to nursing foot care

What is the purpose of the health history interview?

A BUG

A

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

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3
Q

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

A

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

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4
Q

Any symptoms the client brings forward should be further investigated.

PQRSTU mnemonic

A

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?

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5
Q

The complete health history may involve a lengthy interview during the initial visit.

During subsequent visits?

A

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

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6
Q

A comprehensive assessment of the lower limb includes the following components:

Observe (4)
Inspect (3)
Assess (2)

A 
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
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7
Q

Gait can be divided into 2 phases:

A

stance and swing phase

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8
Q

Describe stance phase.

How much of the gait cycle occurs during the stance phase?

The stance phase can be subdivided into:

A

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

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9
Q

Describe swing phase.

How much of the gait cycle occurs during the swing phase?

The swing phase can be subdivided into:

A

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

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10
Q

Once heel strike occurs, the foot enters?

The foot will then flatten and begin to toe off.
At this point the foot will enter?

A

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.

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11
Q

The cycle begins with…

The cycle ends when…

A

one heel striking the ground

that same heel strikes the ground once again

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12
Q

There are 3 major tasks required in order for propulsion to occur. The client must be able to:

A

bear own body weight

bear weight on a single lower limb

swing the lower extremity forward

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13
Q

Describe gait Ax

How to do it.
What to observe.

CHAD SACS

A

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)

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14
Q

For the purposes of assessment, the nurse should ask the client to wear?

A

their usual choice of foot wear

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15
Q

With the shoe ON the client, describe how to assess the fit.

A

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)

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16
Q

What is a simple method for assessing the fit of the shoe?

A

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.

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17
Q

With the shoe OFF the client, describe how to assess.

A

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.

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18
Q

The foot care nurse must assess the appropriateness (suited to client’s feet and/or gait) and safety of the shoe.

A

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.

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19
Q

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?

A

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

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20
Q

Integument Ax Categories

CTTV TIME

A

Colour
Temperature
Texture
Vascularity

Thickness
Integrity
Moisture
Edema

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21
Q

Integument Ax

Colour

A

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

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22
Q

Integument Ax

Temperature

A

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

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23
Q

Integument Ax

Texture

A

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

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24
Q

Integument Ax

Vascularity

A

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
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25
Integument Ax Thickness
uniform thickness - plantar surfaces are thicker than dorsal surfaces thin skin - arterial insufficiency - dorsal surface of feet becomes thinner with aging
26
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
27
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
28
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
29
Integument Ax Edema How to Ax
pressing thumb firmly against the client’s anterior aspect of the shin
30
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
31
Integument Ax Edema Unilateral may indicate? Bilateral? Describe skin if edema present. o is edema relieved with elevation?
a peripheral cause a more central cause, such heart failure turgor or mobility will be decreased
32
Toenail Ax Categories
cleanliness and condition colour shape
33
Toenail Ax cleanliness condition
should be smooth and clean jagged or dirty nails - deficits in self care abilities thick nails - pathology - injury - arterial insufficiency sulcus inflammation - onychocryptosis brittle nails lysis subungual ulceration
34
Toenail Ax colour
an even pink nail bed should be present beneath the nail plate small white markings may indicate trauma and are not usually cause for concern cyanotic nails - cardiovascular or respiratory problems discolored nails - trauma, infection or disease processes.
35
Toenail Ax shape
should be rounded and smooth should be firmly attached to nailbed assess for involuted nails
36
Assessment of the musculoskeletal system includes? Observations should be made when? Compare the feet?
gait assessment the client is standing and again when they are sitting bilaterally
37
Musculoskeletal Ax Categories
foot shape and structure | muscle strength and range of motion
38
Musculoskeletal Ax foot shape and structure Subjective (1) Shape (2) Joints (4) Toes (3) Other (2)
any tenderness in lower limb, feet or toes? broad VS narrow cavus (high arch) or planus (flat foot) symmetry mobility/rigidity swelling palpate IP and MTP joints, there should be no swelling or discomfort ``` lie flat and relatively straight structural deformities - claw, hammer, mallet - halux valgus, limitus, rigidus overlapping ``` heels for inversion or eversion any other bony prominences
39
Musculoskeletal Ax muscle strength and range of motion How to...
have client sustain dorsiflexion and then plantar flexion while nurse’s hand offers resistance
40
Musculoskeletal Ax Plantar flexion (ankle) Direction to client Expected findings
Point foot towards floor | 45 degrees
41
Musculoskeletal Ax Dorsiflexion (ankle) Direction to client Expected findings
Point foot towards head | 20 degrees
42
Musculoskeletal Ax Plantar flexion (hallux) Direction to client Expected findings
Point hallux towards floor | 40 degrees
43
Musculoskeletal Ax Dorsiflexion (hallux) Direction to client Expected findings
Point hallux towards head | 45-65 degrees
44
When assessing the peripheral vascular system, the foot care nurse must consider both?
venous and arterial flow
45
Assessing peripheral ARTERIAL circulation: Categories CHIMP CDT Monkeys on Central Daylight Time
``` cyanosis hair growth intermittent claudication more serious arterial blockage pulse ``` capillary refill dependent rubor temperature
46
Assessing peripheral ARTERIAL circulation: Cyanosis how to...
observe
47
Assessing peripheral ARTERIAL circulation: Hair growth how to? No hair indicates?
Observe for hair growth, if no hair is present ask client if they shave or use hair remover. Hairlessness can indicate decreased arterial circulation to area.
48
Assessing peripheral ARTERIAL circulation: Intermittent claudication how to? Cramping and pain might indicate?
Ask if they experience cramping/pain in the calf muscles after a brief activity such as walking. This might indicate insufficient arterial blood flow that cannot keep up to the muscle’s oxygen demands during exercise.
49
Assessing peripheral ARTERIAL circulation: More serious arterial blockage how to...
asking the client if they experience rest pain, such as cramps/pain in the calf, foot or toes when they are at rest
50
Assessing peripheral ARTERIAL circulation: How to...
palpate the pedal pulses (dorsalis pedis and posterior tibialalis)
51
Assessing peripheral ARTERIAL circulation: Pulse Where is dorsalis pedis? Remember this!
dorsum of the foot between the 1st and 2nd cuneiforms at the proximal end of the 1st metatarsal it requires light palpation as it may be easily obliterated
52
Assessing peripheral ARTERIAL circulation: Pulse Where is posterior tibialalis? Remember this!
just behind and slightly below the medial Malleolus it may be easier to detect when the foot is in dorsiflexion pedal pulses should be graded and documented as: recommended grading system for pulses – 0 = Absent + = Reduced ++ = Normal
53
Assessing peripheral ARTERIAL circulation: Pulse How should pedal pulses be graded and documented?
0 = Absent + = Reduced ++ = Normal
54
Assessing peripheral ARTERIAL circulation: Capillary refill how to...
Press toe until it blanches and then release. Observe how long it takes for the normal color to return. Circulation impairment may be indicated if color does not return within 2-3 seconds
55
Assessing peripheral ARTERIAL circulation: Dependent rubor how to...
observe
56
Assessing peripheral ARTERIAL circulation: Temperature how to... cool skin may indicate? Note what?
palpate arterial insufficiency any difference in temperature from one foot to the other
57
Assessing peripheral VENOUS circulation: Assess for...? EWe SUB VHc/o
edema weeping edema as excess fluid leaks from interstitial spaces stasis dermatitis ulceration blisters varicosities hemosiderin deposits (degraded red blood cells) as evidenced by a red-brown discoloration on skin c/o tired, aching legs
58
To assess the nervous system, the foot care nurse relies mainly on?
subjective data obtained from the client
59
What sensations can indicate impaired nerve function GPNL
generalized pain in feet parasthesias: burning, pins & needles or tingling numbness: having no feeling in area, feeling that foot is asleep or dead lancinating pain: sharp, stabbing pain; client may describe as “walking on glass”
60
Although subjective reports are of extreme value in a nervous system assessment, there are certain objective signs that could also be indicative of nerve impairment. (3)
dry, fissured skin that is flaking - sweat gland function r/t autonomic neuropathy cavus foot and claw toe deformities - motor nerve impairment contractures - nervous system dysfunction
61
The 10-gram monofilament test is a validated procedure that can be performed by the foot care nurse. The client’s responses will help to determine? This is important why?
if nerve damage has led to a loss of protective sensation in the foot to prevent or reduce the associated untoward effects
62
Monofilament testing should be done and recorded during the foot assessment. It should be done how often?
at least once on all clients/patients annually on all Diabetic clients if the result shows no loss of protective sensation
63
Once a client tested shows lack of protective sensation, then what? Why?
testing no longer needs to be done once neuropathy is detected it will not disappear
64
Symptoms of discomfort r/t neuropathy may abate, but?
that client should always be considered as at higher risk for foot complication
65
Primary function of the foot AAPS
Act as a flexible and adaptable unit during ground contact – provides a stable base Act as a rigid lever during propulsion Provide shock absorption – flexible and absorbs forces several times greater than weight of body that occur with walking, running, jumping Supports the entire weight of the body during walking/standing – steadiness/strength
66
Client education is an important part of nursing and is intended to...?
increase the client’s knowledge of basic foot health
67
It is important to remember that adult learners usually ...
expect to be actively involved in the learning process.
68
Adult learners learn best by?
building on previous experiences
69
Early in the teaching-learning process, the adult learner should be consulted about? Why?
topics they fell are most important to their foot health this greatly increases the likelihood that their educational and health care goals will be met
70
An assessment should begin with the foot care nurse identifying the clients learning needs. This can be done with?
open and closed ended questions regarding their current state of health
71
Adult learners...assess if the client Understands (3) Past VS Present Also
Implications of any foot health problems they may have Appropriate techniques for self foot care Implications of these practices past experience in relation to foot care current foot care practices current level of desire to learn more about foot health
72
The client's current level of desire to learn more about foot health will help...?
The nurse and the client decide how much the client may be willing and able to learn at each visit
73
Client education will encourage the client to?
take responsibility for their feet provide necessary knowledge of specific pathological conditions that may be affecting foot health ensure an understanding of nursing recommendations in order to maximize foot care effectiveness
74
The nurse must assess the individual’s ability to learn and perform proper foot care. Emphasis must be placed on?
the importance of proper nail cutting and foot health practices
75
What is critical to educate individuals with compromised feet ?
the importance of proper footwear and appropriate care of the feet

FOOT - Ax and Intervx (7 decks)

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