Educating Nursing Home Staff in Lower Extremity Assessment and Care A neglected area of care for the elderly in long-term care facilities is that of appropriate assessment and care of the lower extremities, particularly the feet. Two assessment guides one for the registered nurse and one for the nurs- ing assistant- are presented.

B Y P A T R I C I A A . K i N G / A L I C E J . L O N G M A N / J E S S I E V . P E R G R I N

N eglected area of care for the lderly is that of appropriate ssessment and care of the

lower extremities, particularly the feet. In view of the importance for the elderly to remain mobile, it is im- perative that recognition and atten- tion be given to maintaining their ambulatory status. Mobility may be limited because of painful and debil- itating conditions that can be reme- died by preventive care and appropri- ate treatment. This is especially true in long-term care facilities, where walking helps residents maintain their independence and control over their activities.

In long-term care facilities, 80% to 90% of the care of the residents is provided by nursing assistants. In- service programs that prepare nurs- ing assistants for tasks they provide

PATRICIA A. KING, MS, MA, RN, is a se- nior lecturer at the College of Nursing, AL- ICE J. LONGMAN, EdD, RN, FAAN, is a professor, College of Nursing, and JESSIE V. PERGRIN, PhD, RN, FAAN, is an associate ~rofessor emerita, College of Nursing, Uni- versity of Arizona, Tucson, Arizona. The ;tudy referred to in this article was part of a arger study funded by the Division of Nurs- ng, D.H.H.S.-P.H.S. titled Teaching Car- :givers: Patient Outcomes in Nursing Homes, ?,eference: 1 ROI NU/DE 00735-01, 1984. 14/1/34807

to the residents are impor tan t . Health care assessments and nursing care activities that should be done on a daily basis for the elderly resident include care of the lower extremities.

Impact on the Care o f the Lower Extremit ies

Changes that occur with normal aging affect the elderly's ability to give proper care and attention to the lower extremities. Because of im- paired vision and arthritic conditions that limit body and finger movement, older individuals have more trouble seeing and caring for their feet. They are often unable to manipulate nail clippers to cut toenails or see well enough to notice cuts or ulcerated ar- eas.

The mechanical stressors of con- stant pressure on the feet from poorly fitting shoes or improper walking habits often lead to the formation of corns, calluses, or ingrown toenails. 1 Changes in coordination and flexibil- ity and increasing stiffness of the lumbosacral spine tend to decrease an older person's length of stride and walking speed. 2 Arthritic changes of the spine and joints of the lower ex- tremities also may lead to gait distur- bances. Strokes, Parkinson's disease, and other neurologic disorders are

possible causes of gait disturbances that caregivers need to identify; ap- propriate interventions then need to be implemented to promote safe am- bulation. 2 Steinberg 2 reported that of the 400,000 stroke patients each year, about 60% survive the first month and about two thirds of them have a permanent disability. He urged early and effective rehabilita- tion as most important in keeping those so affected ambulatory and in- dependent.

There is probably significant vas- cular impairment of the feet of pa- tients past 65 years of age because of atherosclerosis)" With diminished circulation, slow healing and in- creased vulnerability to infection are present.

As an approach to improving pa- tient care in long-term care facilities, Pergrin et al. 4 conducted a study with the specific aims of increasing the knowledge and skills of nursing assistants in caring for the lower ex- tremities of elderly residents. There were 62 nursing assistants and 161 patients in the' study, which was con- ducted in five long-term care facili- ties over 1 year.

Two data collection forms were used in the study: (1) Research Tool: Assessment of the Lower Extremities of Patients and (2) Performance

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Evaluation: Assessment of the Lower Ext remi t ies of Pat ients . The Re- search Tool was used by two research assistants to assess the lower extrem- ities of patients at the beginning and end of the 7-week study period. In- t e r r a t e r re l iab i l i ty scores ranged from 85% to 90%. The Performance Evaluation Form was used by two re- search assistants and the nursing as- sistants three times during the study period. Interra ter reliability scores be tween the r e s e a r c h ass i s tan t s ranged from 85% to 90%.

To evaluate the lower extremities of residents, a series of classes was held for the nu r s ing ass i s tan t s . Taught by a medical-surgical nurse, the content included the importance of the lower extremities in maintain- ing ambulation, interventions used in the care of the legs and feet, and su- pervised clinical practice.

Using a performance evaluation form, the nursing assistants assessed the lower extremities of patients ac- cording to seven areas. Each area had a series of questions that could be answered "Yes" or "No ." There was a space for comments at the end of the form. This form was found to be too lengthy, cumbersome, and time consuming by th~ nursing assis- tants. The items were rearranged and simplified to enhance the guide's use- fulness. The final form, Assessment Gu ide of Lower E x t r e m i t i e s for Nursing Assistants, was developed as a result of this evaluation. Further study of the usefulness of this guide would be beneficial.

A d m i s s i o n A s s e s s m e n t b y Reg i s t e r ed Nurses

Registered nurses are responsible for the initial assessment of new res- idents admitted to long-term care fa- cilities. This assessment should in- clude the lower extremities. Once the initial assessment is made, the nurse has a guide for monitoring and eval- uating the resident's progress.

Specific areas have been identified as important for nurses in assessing residents' lower extremities. 5-s King 5 identified seven areas to be included in an assessment on admission to a long-term care facility: level of activ- ity and mobility, gait disturbance, footwear, skin lesiong, c i rcula tory status, s t ructural deformities, and

298 Geriatric Nursing November/December 1991

toenails. In assessing the level of ac- tivity and mobility, note: Is the resi- dent able to walk 10 feet without as- sistance? if not, does the resident walk with the help of equipment? T h e e q u i p m e n t c o u l d i n c l u d e crutches and /o r a cane. Additional information obtained would be that of noting whether the resident uses a wheelchair, does not walk, and/or is confined to bed.

The second area, gait disturbance,

ASSESSMENT GUIDE FOR LOWER EXTREMITIES FOR

NURSING ASSISTANTS

Directions: Please circle each letter or number that applies to each category. A. Gait disturbance B. Footwear

1. Type of footwear a. Tie shoes b. Slip-on covering feet c. Slippers d. Other (describe)

2. Condition of footwear a. Correct fit b. Free of crumbs, stones, nails c. Dry

C. Stocklng/socks 1. Constricting 2. Nonconstricting

D. Cleanliness of feet 1. Good 2. Fair 3. Poor

E. Toenails 1. Ingrown 2. Overgrown 3. Thickened 4. Black discoloration

F. Appearance of skin 1. Skin lesions

a. Cracked skin (1) Between toes (2) Heels

b. Scratches (1) Right leg/foot (2) Left leg/foot

c. Corns (1) Right foot (2) Left foot

d. Calluses (1) Right foot (2) teft foot

e. Other (describe) G. Circulation

1. Dry skin a. Right leg/foat b. left leg/foat

2. Edema a. Right foot/ left foot b. Right ankle/left ankle c. Right leg/left leg

3. Pain a. Right leg/foot b. Left leg/foot

is a key indicator of impending mo- bility problems and offers a more precise notation of the resident's am- bulatory status. The kind and condi- tion of the resident's footwear should also be noted (e.g., whether shoes are worn, whether the shoes are a correct fit, and whether the shoes are in good condition).

Inspection for skin lesions such as corns, calluses, and fissures is the fourth area.

The next area, circulatory status, is critical to note. It includes assess- ment for the pedal pulses, skin color, t e m p e r a t u r e , pain, d ryness , and edema. If circulatory impairment is present, manifestations can be seen in the feet, such as dry skin and thick toenails.

Additionally, structural deformi- ties should be noted because these problems may require the specialized services of a podiatrist. The last area is inspection of the toenails with no- tations made of their condition.

A d m i n i s t r a t i v e S u p p o r t

To institute a program in a long- term care faci l i ty, adminis t ra t ive support and staff in-service education are essential. To obtain support from the administration, it is necessary to stress the importance of such a pro- gram. For example, ingrown toenails, which have a potential for infection, can be prevented by properly cutting the nails; gait disturbances can be recognized early as risk factors for falls; and poorly fitting shoes can be replaced with shoes that provide the needed structural support for walk- ing, thereby keeping residents ambu- latory. In making the case it should be stressed" that the registered nurse is the pivotal figure between foot health and foot disability in the eld-

ADMISSION ASSESSMENT OF LOWER EXTREMITIES BY REGISTERED NURSE

Level of activity and mobility Gait disturbance Footwear Skin lesions Circulatory status Structural deformities Toenails

erly. By systematic assessment of the lower extremities, problems can be identified early and interventions can be planned for maintaining or restor- ing foot health.

After the initial assessment by the registered nurse, the nurse will note whether nail care can be delegated to the nursing assistant. In general , nursing assistants can give the care provided that they have been taught how to give nail care and the elderly resident does not have a high-risk condition, such as diabetes mellitus or severe circulatory impairment. 4 If any questionable problem exists, the registered nurse should provide the care or refer to the podiatrist.

Financial support should be ob-

BASIC SUPPLIES FOR FOOT CARE

Nail nippers Orange sticks Emery boards Alcohol, 70°,6 Emollient (water soluble) Betodine solution Cotton balls/cotton swabs Container for sterilization of nipper Sterilization solution (e.g., any germicide

concentrate) Towel

Courtesy of Raymond Petersen, DPM, Procticlng Podiatrist, TucsOn, Arizona.

tained for the proper equipment for care. The basic supplies for foot care as recommended by a podiatrist are shown. The most important instru- ment for t r imming toenails in the elderly is a large, 6 inch nail clipper. A fingernail cl ipper is not recom- mended because it can tear the nail. The foot ca re e q u i p m e n t can be placed in a special "ki t" for use by all nursing personnel. Supplies can be cleaned between patients by soaking in a sterilization solution obtained from a medical supply company.

In-Serv ice Education

An in-service program that is care- fully and creatively planned can gen- erate interest in care of the lower ex- tremities. Before the program, an- nouncements should be made about the program. For the presentation, a variety of teaching strategies can be used. For example, slides could be in-

INTERVENTION

FOOT DISABILITY,.,

Example of slide used in in-service education program.

cluded, some humorously calling at- tention to the feet and legs and others informatively showing common foot problems of the elderly.

During the program, the registered nurse needs to demonstrate the as- sessment of the lower extremities of an older person, preferably a resident of the facility. By listening to the res- iden t ' s c o m m e n t s and using the guide, needs of the lower extremities can be identified and recorded. A critical part of this program is the demonstration of nail care.

The equipment for nail care in- cludes a wash basin, nail nipper, or- ange sticks, emery boards, emollient, and soft towel. Soak the nails in warm water at 95 ° for 10 minutes or with cotton saturated with a com- mercial soaking agent. A podiatrist can be consulted for information on the type of soaking agent and nail nippers. Cut the nail by clipping straight across or with the contour of the toe. Begin in the center and clip to edges if it is difficult to catch the nail free of the cuticle. Do not cut into the nail groove. Remove embed- ded, loose material around the nail and between the toes with a soft towel. Apply one teaspoon of emol- lient to each foot and massage into the skin gently until absorbed. Re- move any excess.

At the end of the program, the fol- lowing instructions need to be rein- forced. • The best t ime for assessing the

lower extremities is before bathing the resident. Using the assessment guide, items A to D can be as- sessed, not ing the gait , type of footwear, stockings, and cleanli- ness of the feet . In the shower room before bathing items E to G can be assessed. Once the assess- ment is made, problems can be identified and reported to the reg- istered nurse. Nail care is best given af ter the bath. If the resident has had a cen- tury tub bath (combination bath and whirlpool therapy), the feet have been soaking during the bath- ing process and the nails can be t r immed immedia te ly a f te r the bath. If a shower has been given, the nails may need to be soaked in warm water for approximately 8 to 10 minutes.

Summary

Care of the lower extremities of residents in long-term care facilities is essential for mobil i ty. Because these residents have greater depen- dence on nursing assistants, it is im- perative that care of the lower ex- tremities be taught and included on the nursing care plan. The Assess- ment Guide can be used in this teach- ing and evaluation process. Thus the guide provides a method for docu- menting the effects of in-service pro- grams and, more importantly, an im- proved foot health status for resi- dents.

REFERENCES

I. Riccitelli ML. Foot problems of the aged and in- firm. J Geriatr Sac 1966;14:1058-65.

2. Steinberg FU. Rehabilitation medicine. In: Stein- berg FU, ed. Care of the geriatric patient. 6th cd. St. Louis: CV Mosby, 1983:537-8.

3. Jahss MH. Geriatric aspects of the foot and ankle. In: Rossman I, ed. Clinical geriatrics. 2nd ed. Philadelphia: JB Lippincott, 1979:638-50.

4. Pergrin JV, DeWalt E, Hinshaw AS, King P, Longman A. Teaching caregivers: patient out- comes in nursing homes. (Final Report) Division of Nursing-DHHS-PHS, Rockville, MD, 1984: Ref. No. 1 ROI NU/DE 00735-1, 1984.

5. King PA. Foot assessment of the elderly. J Ger- ontol Nuts 1978;4:47-52.

6. Chung S. Foot care: a health maintenance pro- gram. J Gerontol Nurs 1983;9:213-27.

7. Haviland S, Garlinghouse C. Nursing foot clinics fulfill a great need. Geriatr Nurs 1985;6:338-41.

8. Christensen MH, Funnell MM, Ehrlich MR, Fel- lows EP, Floyd JC. How to care for the diabetic foot. AJN 1991;91:50-6.

Guidelines for nail care and foot soaks can be obtained by writing the authors. A podiatrist can be consulted about the nail nipper.

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