Foot and Nail Care: Conditions of Nail Surface, Malformations, Skin and Soft Tissue Infections, Assessment and Intervention

Speaker A: 00:00:10

Okay, we're going to move ahead and we're going to talk about pathology involving the nail itself. And then, of course, we'll put it all together and start talking about nail care.

So we're going to talk about conditions of the nail surface, nail plate malformations, nail plate conditions, and then skin and soft tissue infections.

So we're going to introduce a lot of terms, and if you don't take the foot nail certification exam, you don't have to worry about all these terms so much.

But if you do decide to pursue foot and nail certification, you want to go back and you want to review all of these terms because you'll see a lot of them on the certification exam.

So there are some things that you're going to notice when you're taking care of toenails, and like, some of them are benign and some of them are significant, you need to be able to differentiate. So you have to know what you're looking at.

So one benign condition is parallel grooves that run from the base of the nail to the tip of the nail, and that's known as onycorexis. So you frequently see this in nails that are thin and ridged.

So when we talked about arterial disease, we said that the reduced perfusion to the nail bed frequently resulted in thin ridged nails. So you would have these narrow grooves or groove running from the base of the nail to the tip.

You can also see that in your much older patient, probably related to compromised perfusion. And sometimes you'll see it when there's been some damage to the nail matrix, but it's not pathologic, you don't have to do anything about it.

In contrast, if you see ridges and pitting in the nail, that's usually due to psoriasis. Again, nothing really to be done except just to be alert to the fact that they do have psoriatic changes affecting the nail.

Carefully assess the skin of the foot to see if you see any psoriatic changes there. Do they have any evidence of psoriatic arthritis?

In other words, do you need to send them back to the practitioner managing their psoriasis if it's just nail changes? No, you would not send them back. You would just provide nail care. Bose lines are different. Those are transverse lines running across the nail.

And it's very interesting because when you see Bose lines, you can ask the patient, so what's been going on in the last couple of years? Have you been sick? Have you been in the hospital? Because Bose lines represent periods of time when the nail stopped growing.

And it's usually during times of major systemic stress that just interrupt nail production.

So almost every time when I see Bose lines and I ask the patient, they're like, oh, yeah, six months ago, I had major surgery, and then I had all these complications, and I was in the hospital and I was septic, blah, blah, blah. I can see that in your nail, and then you can have nails that split at the distal end, and that's known as onikoskesia. So splitting nails.

So I always just think schizophrenia, split personality, onikosketsia, splitting of the nails, usually it's because of over hydration. Sometimes it's exposure to chemicals, sometimes it's age.

And again, not really significant, except that if I have splitting of the nail when I trim the nail, I usually want to provide mechanical support so that I don't make the splitting any worse.

Now, one of the most common pathologic conditions we encounter in providing foot and nail care is hypertrophy of the nail, where the nail becomes very thickened, and sometimes it's a brittle, sometimes it's discolored. The most common cause is fungal infection, and you're going to see a lot of fungal nail infections.

The big implication for us is that we need to thin the nail before we start to trim it, and we need to consider whether or not we should treat the underlying nail infection. You can see clubbing of the digits, so you can see clubbing of fingers, clubbing of toes.

So it's a rounded curvature of the nail, and it follows the underlying contour of the digit itself. And that's because of chronic hypoxia. I used to work with kids who had congenital heart disease, and this was a very common finding.

Again, nothing for you to do. Just follow the contours. Now, coelonychia, very interesting terms. That means spoon shaped nails.

So it means that the nail is very adherent to the underlying nail bed in the center, but at the edges, at the periphery, it kind of turns up and it looks very much like a spoon.

Again, age is a very common reason over hydration of the nails, sometimes seen in patients with anemia or in patients with underlying ischemic disease. Nothing to be done. Just follow the contours and just recognize this isn't pathological in terms of the way you manage the nails.

In contrast, when you see tile shaped nails, what we also call c shaped nails, or if you see trumpet or pincer nails, very, very significant. These are conditions that commonly result in ingrown nails. Ingrown nails commonly result in pain and in soft tissue trauma and infection.

So we'll just start at the top and go down, and we'll introduce these terms so you can see why tile shaped nails are also known as c shaped nails. That's what they look like. They look like a c shape. The problem is the nail curves down abnormally at the edges and digs into the underlying tissue.

Typically with your c shaped nails, your tile shaped nails is symmetrical. So usually you've got the potential for an ingrown nail, both medial and lateral.

Sometimes it's more significant, more pronounced on one side than the other, but usually relatively symmetrical. Now, what is a trumpet nail or a pincer nail?

This is the one you see in the middle, and it's when the distal nail, the nail, that is free floating, so you're past the free border. So the nail's acting pretty normally until it gets to that free border.

And then I it curls, curls under, and it can compress the underlying skin, and it can cause injury with nail trimming if we're not very careful.

So when we get to actual nail care, we'll talk over and over about how important it is to take your orange wood stick or your spatula, explore your free nail border so you can see exactly where it's safe to trim. So you have to know, how does this nail grow so that you don't inadvertently cut skin when you should be cutting nail? So just be careful.

And then the last one is plicatured or ingrown nails. So we typically use the term ingrown nails. That's what patients say. That's what most podiatrists say.

But the textbook term is plycratured nails, and it's usually due to some deformity of the underlying nail bed that causes the nail to curve down that c shaped nail curve down and compress the underlying tissue.

Now, sometimes it just compresses the tissue and doesn't cause a lot of symptoms, but many times what happens is that the tissue begins to grow over the nail. That's why it's called ingrown. So the nail is compressing the tissue, the skin starts to grow over the nail.

The nail acts as a foreign body, and you get an acute inflammatory response, sometimes infection.

So if you look at the nail on top, you'll see that that nail has been lifted and trimmed, and you'll see that there are little strips of an alcohol wipe that have been tucked between the nail and the underlying tissue to keep that nail from growing into the tissue. Pterygium, you don't really have to do anything about except just pay attention. It's abnormal here.

Adherence of the skin at either the proximal or distal edge of the nail. So that the nail and the skin are very difficult to separate. It's hard to find the free nail border.

So you have to be very patient and just work your way across. So you have to be very careful in trimming those nails.

And sometimes you'll get associated callus and you have to thin the callus before you can trim the nail.

And that's the second bullet point that you can get a callus at the distal end of the nail, especially if your shoes aren't fitted correctly and your toes are rubbing against your shoes all the time. Very common to get callus at the end of the third or fourth toe just from that constant rubbing.

And then the callus can actually obscure the free nail border. So sometimes you look and you're like, wow, I can't see. I don't even know where to start here.

So when you have a callus that's obscuring the free nail border, you always start by paring the callus. Then you can see the free nail border, then you can trim the nail. But the other take home message is, why are you getting callous?

I need to look at your footwear.

I need to talk to you about having your shoes professionally fitted so you don't continue to sustain trauma, splinter hemorrhages and subungual hematoma. You've probably all had this. So a splinter hemorrhage occurs with minor trauma, and it literally looks like a splinter.

You have bleeding between the nail plate and the underlying skin surface, the nail bed, and it looks like a blue or black splinter and it gradually grows out and you don't have to do anything. And it's usually asymptomatic. Subungual hematoma is a more significant accumulation of blood.

So this is when you kill your toe, you stub it so hard, or you drop something on it and you cause major injury and you get hematoma formation between the nail plate and the nail bed. And it hurts. But a lot of you know this.

What you can do is you can take a paper clip, you can flame the paperclip, and then you can hold the paperclip or touch the nail plate with the paperclip and it will create an opening in the nail plate that allows the blood to draw to drain out, and that stops the pain. Of course, you have to have the nerve to flame the paperclip and put it on that nail plate.

When it's hurting like crazy, but both of those just grow out. No further treatment required. Onychoma. Onycholysis, by now, you figured out oniko means nail.

So onychomedesis means that the nail plate is separating from the underlying nail bed and nail matrix. So it's at the proximal end of the nail, and it's caused by injury or illness. We don't see that very often.

Onycholysis, we see a lot, and this is separation of the nail plate from the nail bed at the distal end. And it's almost always due to fungal infection, and that's what you see on the bottom slide. So it can be alarming the first time you encounter this.

Cause you take your spatula, and you're following the free nail border and cleaning out any debris, and the nail just keeps lifting, keeps lifting, keeps lifting. You're like, what am I doing wrong? No, it's what the fungus has done.

The fungus has broken down the anchoring fibers between the nail plate and the nail bed. Onychomycosis, also known as tinea unguium, is fungal infection of the nail plate itself and the major risk factors.

We see it a lot in the elderly, especially if they have diabetes. We see a lot in people who are immunosuppressed.

A lot of patients will have some history of injury, but sometimes it's like, I don't know where this came from, but here's what you see. You see a lot of discoloration, and it ranges from yellow to brown to black, sometimes white. So the nail color is totally abnormal.

The nail plate is very thick. It may be crumbly or it may be brittle. You'll start to see separation from the underlying nail bed. We just talked about that.

And then there's a less commonly seen fungal infection, leukonychia. And that's where you get white discoloration.

It's from a very superficial fungal infection that typically grows out pretty easily and can be treated with some of your over the counter antifungal agents. So let's talk about treating onychomycosis. Such a common problem. And so clients come in, they're like, what can you do about this? I hate this.

Okay, so what kind of problems is it causing you? Well, not problems so much, except I can't really trim my nails because they're so thick and they're so hard. But they're so ugly.

So that's your take home message about onychomycosis. Does it cause some terrible pathology? No, but people hate the way they look, and it thickens the nail and it makes it very hard to trim.

So treatment is determined by the degree of distress it causes the patient, and the distress is primarily psychological. We hate the way they look. So you can do topical or systemic. Now, topical is much safer.

You can apply agents to the base of the nail, all around the cuticle, and all around the edge of the nail so that it penetrates right at the base of the nail, where you have the underlying nail matrix, the reproducing portion of the nail, so that you kill the fungus and the developing nail.

So I actually, when I first got interested in foot nail care, I read in an online group about using Vicks vaporub or some other kind of mentholated rub around the edge of the nail to treat fungal nails. And I thought, well, it can't hurt anything and it'll smell better than the fungus, so I'm going to try it.

And I saw that it made a difference and that the nail frequently grew out fungus free. But I did not know how it worked. I couldn't find any explanation of how it worked.

So some years later, I was doing a talk about evidence based practice, and I was using this as an example of a situation where we have very little evidence, but it's worth trying because there's no risk. So the risk benefit ratio says, yeah, go ahead, try it. You might not know how it works, but it can't hurt.

And so a podiatrist came up to me at the end of the talk, and he says, you know how it works. And I'm like, no, I really wish I knew how it worked. He's like, it's the menthol. The menthol penetrates at the cuticle and it kills fungus.

And so you can use anything with a menthol base. I'm like, okay, great to know. So you should know that you can use that. You can use tea tree oil, you can use clear nails.

All of those are topical antifungals. They require repetitive use during the entire growth cycle.

So twelve to 18 months until the fungal nail has grown out, but there's no adverse effects, so there's nothing you have to worry about. If they stop using it, nothing terrible is going to happen. They just won't get the benefit of the treatment.

In contrast, if you use systemic antifungals to treat onychomycosis, the benefit is that it's more consistently effective. Again, you need long term treatment, and almost always they have to monitor liver function because antifungals can affect liver function.

So, in a lot of centers, they primarily focus on topical treatment, but systemic measures are available. You want to be able to share that information with your clients.

If you're advanced practice, then you want to know the guidelines for ordering systemic agents. Now, less thing associated with ingrown nails is paronychia, and that's inflammation or infection of the nail folds due to trauma.

And the end result of trauma is bacterial or fungal invasion. Now, you can get this as a result of an ingrown nail. You can also get this as a result of cuticle damage.

People who bite their nails bite their cuticles. So those are the two common reasons. And this is what you see. It is a soft tissue infection. So it is going to be painful.

The patient will say, be really careful. I'm not sure I even want you to touch my toe, it hurts so badly.

So they have edema, they have erythema, they might have pockets of purulent drainage, and they definitely have pain. Some people have chronic ingrown nails or chronic cuticle damage, and they might say, it doesn't really hurt that much.

There might not be any purulent drainage. How do you manage?

So if you are advanced practice or if you're working with a podiatrist and somebody comes in with an acutely painful ingrown nail, like you see in the second and the third slideshow, then you would probably first do a nerve block to numb the whole toe, and then you could lift the nail out of the underlying tissue. So you take your nippers, you lift the nail, you trim the nail, you file the nail, and then you can put a little bit of packing.

So some people use cotton ball, little pieces of cotton ball.

We use little strips of alcohol wipes, and we tuck it between the nail down in the groove between the nail and the nail fold, and it acts as a spacer. So this is the nail, and this is my little bit of packing.

So when the nail tries to dig down into the tissue, it can't because it encounters the packing, and that can stay there for weeks. I always tell my patients, if I did a good job packing it in, it'll be there when you come back to clinic in three months, and I'll take it out.

If there is evidence of soft tissue infection, we typically also treat with a topical antibody. You have to use your judgment as to whether or not systemic antibiotic treatment is required. Now, what if I'm not advanced practice?

You come to my center, it's going to be days before I can get you in to see a podiatrist. I'm going to determine your level of tolerance. I'm going to say, I'm going to try to lift this corner out.

If you can't stand it, you tell me and I'll stop.

But if I can lift that corner out, and many times I can very gently lift out the most distal point, then a little bit more, then a little bit more, I will offload the underlying tissue. A lot of times I get a significant reduction in pain that helps them while they're awaiting their consult with the podiatrist.

So we've just been talking about ingrown nails. You'll notice that there's more than one term. So onychocryptosis is another term used for ingrown nails.

So you'll hear plycrotured nails, ingrown nails, onychocryptosis, we've talked about the fact it's caused by the pattern of nail growth. So you've got that c shaped nail that tends to dig down into the tissues.

And our goal is to prevent an acute infection, to prevent trauma to the underlying tissues, and most importantly, to prevent pain. So we are, we're going to lift, you'll see this in foot clinic. We're going to lift and trim out that corner of the nail.

We're going to do a little bit of packing to keep it from happening again. If they tend to develop recurrent ingrown nails, one option is to send them to the podiatrist and they'll do a wedge resection of the nail.

Or sometimes they'll remove the entire nail. If they have something called subungual keratoma, that's a callus under the nail. So sometimes you see that.

We talked about that very common on 2nd, third and fourth. We're just going to pair the callus very carefully and we'll show you how to do that during bridge week.

And then you can also get a subungual melanoma. It can present as a brown, black band in the nail or it can spread from the nail to the skin.

Remember, one characteristic of melanoma is it's enlarging, it is spreading. So you're very careful. You're monitoring.

If you see someone, you might take a magic marker, you might mark by the band and you say, if you see this expanding, you need to go see the podiatrist or the dermatologist, or you might just send them to rule out melanoma.

You do want to differentiate melanoma from evidence of a benign condition where you have a black bandaid in the nail that does not expand, that you can see in people with dark skin that's benign. No expansion, no intervention required.

So we've talked about pathologic conditions involving the nail surface, the nail plate and the soft tissue, and now we are going to move on to management.

So we're going to try to put it all together and we're going to go through the type of history you want to gather from someone who's coming to you for foot and nail care, the type of physical assessment that you want to do, vascular and sensory, motor, and then the interventions that you want to provide. So we talked about the systemic conditions that could impact on foot health and on nail health.

So you want to ask about any history of lower extremity arterial disease, lower extremity venous disease? Has anybody ever told you you have problems with your circulation? Has anybody ever told you you have trouble getting blood back to your heart?

Have you ever had problems with skin on your feet? Have you ever had problems with your nails before?

You're going to look at the lower extremity and the foot, specifically in terms of what happens when they walk. So you're going to look at me sitting. You're going to observe the contours of my foot. Do you see anything like flat foot or claw foot?

Then you're going to have me stand. Okay, what happens when I stand? Let's say I had normal arch sitting. What happens when I stand? Do I have excessive pronation?

You already know that you're going to need to do a referral for an insert for appropriate orthotics. Do they have ambulatory instability? So do they look very unstable when they're walking? Do they have abnormal gait?

Do we need to get them a cane, a walk, or a physical therapy referral? Do they complain of pain that gets worse the longer they walk? And what area does it involve?

So if they have lower extremity disease, they're probably going to say, it's really not my feet that hurt, it's my legs and it's in my calf. But if they have Morton's neuroma, it's probably going to be along the fourth and fifth toes. So first I ask them about systemic conditions.

Then I look at them sitting and I watch them walk, and I ask them about pain associated with walking. I'm going to assess any lesions. Do I see any lesions on your foot, on your lower legs? Are there any wounds? Are there any dermatologic conditions?

Because I either have to address those as a wound care nurse, or I have to refer you to make sure those conditions get managed. I'm going to look at your hygiene. I'm going to talk to you about how you take care of your feet. How do you wash your feet?

Well, I can't get in the shower anymore. I sure can't get in the tub. So I kind of. It's really hard to get to my feet. I kind of wipe them off the best I can. Do you have anyone to help you?

So I've got to find out what's going on because I have to put together a plan to address that. I want to ask you about medications. I specifically want to know about anticoagulants.

I want to know about chemotherapeutic agents that would compromise your ability to clot normally. I also want to know about anything that would affect your ability to heal. So are you on steroids? Are you on biologics, that kind of thing?

Okay, now I'm going to do my physical assessment. So we already talked about assessing gait and mobility and ambulatory stability.

Then I'm going to do that vascular assessment, which we've gone over several times. So I'm going to go through this pretty quickly. So I'm going to look at the skin. Does it look normal? Is there normal patterns of hair growth?

Do the nails look pretty normal or do I see thin, shiny skin, sparse or no hair, thin, ridged nails that would suggest arterial disease? Or do I see edema and hemocityrosis and dry, flaky skin that suggests venous disease? So I'm looking at skin, hair and nails. If I can.

If I can put you supine, I'll check both for dependent rubor and for elevational path. Otherwise, if you're sitting and I can't put you supine, I'll just check for dependent ruber. I'm going to check pulses.

I'm going to check capillary refill. If I can put you supine, I'll check venous filling time. If I can. If I can put you supine and I have the equipment, I'll do an Abi.

If I am unable to do an Abi because I can't put you supine or I do not have the equipment, but I see clear cut evidence of lower extremity or children's disease. If the person has thin, shiny skin, no hair, prolonged capillary refill, faint pulses.

Dependent Ruber, I'm going to initiate a vascular consult because I know you need further workup and edema. If it's pitting edema, you're going to further categorize it as one plus, two plus or three plus, which has to do with the amount of induration.

So when you press into the tissues, do you get 1 deformation, 2 mm or 3 mm? That's how you classify edema. So I've done my vascular assessment, now I'm going to do sensory motor assessment.

So I'm going to start with my monofilament. I definitely want to have monofilaments. If I'm doing foot and nail care, I have to have access to 5.07 monofilaments.

I'm going to explain to you what I'm going to do. I'm going to have you close your eyes. I'm going to put your foot either on a lap pad, in my lap or on the table.

I'm only going to touch your foot with the monofilament.

I'm going to test 1st, 3rd, 5th toe pads, 1st, 3rd, 5th met heads medial lateral at mid foot heel unless there's excessive callus and dorsum between the first and second toe. If there are areas where you fail to recognize that I've touched you with a monofilament, then you're beginning to lose protective sensation.

I'm going to incorporate that into my teaching accounts. If I have a tuning fork, then I'm going to use that to test for vibratory sense. So I'm going to strike it against my palm until it's vibrating.

I'm going to put it either at the base of your great nail or over your bunion bone. I'm going to see if you can sense the vibration and if you know when it stops.

If you do not have vibratory sense, I know that you're developing neuropathy. I have to talk to you about that. The importance of tight glycemic control position sense testing. How did I move your toe?

Do you know where your toe is in space? It has to do with your risk of fall. So if you do not know where your toe is, I have to talk to you about holding on.

When you're going downstairs watching when you're on irregular terrain, I'm going to then inspect your foot and your toes and your nails. And I'm going to look for corns or calluses or deformities. I'm going to look for any ulcers.

Very helpful to evaluate range of motion and muscle strength. So I might ask you to push against my hand and then pull up against my hand. Reflex testing is optional and frequently difficult to do.

So depends on your center, whether or not you do reflex testing. So I've evaluated vascular status, I've evaluated sensorimotor status. Now I'm going to look at your skin. Is your skin normally hydrated? Is it soft?

Is your skin very dry and flaky? Is it very thin and fragile? What about between the toes? Do I see maceration between the toes? Do I see fissures between the toes? Are there calluses?

Are there corns? What are your fat pads looking like? Are they normal? Are they thinning? Are they absent? And do I see evidence of fungal infection?

And then I'm going to look at the nails. So are they normal length, or are they excessively long? What are the contours? Are they growing down and around? Do I have a ram's horn nails?

Is there any evidence of an ingrown nail? Are they abnormally thick? Do they have that yellow brown discoloration? What about hygiene?

Okay, when I look at your feet, can I tell that your feet are being well managed, or are there issues there that I have to address in my education and counseling? What about the cuticles? Are they torn? You want to be very careful with cuticles. I'm very alert to indicators of fungal infections.

So the discoloration, that thickening, that change in the. Whether the nail is soft, crumbly, brittle, so it has abnormal turgor, and then do I see any evidence of infection?

I want to look at your footwear now, if I'm at all concerned about the size of your footwear, like, let's say I see that all of your toes are red, they look like they're bumping up against the end of the shoe. Then one thing I can do that's very simple to do, I don't have to have anything fancy.

I can have you stand on a piece of paper, I can trace your foot while you're standing, and then I can put your shoe on top of that foot tracing, and I should not see any of my mark. That mark should be totally encompassed by your shoe.

But if I see toes sticking out, sides of the foot sticking out, then I know that your shoes are not correctly fitted and that I need to send you to get appropriately fitted footwear. If I see corns on the tops of the toes, the toe box is too shallow. I already know that because I can see the end result.

I can look at the wear patterns on the bottom of your shoe and see, are they even, or does it look like you're getting excessive pronation and I should send you four insoles. If you have insoles, what's the condition? Do they need to be replaced? Are you wearing cotton socks or breathable hosiery, ideally without seams?

All of those things matter. And then we've already talked about talking to the patient. How do you wash your feet? Who helps you? Can you dry between your toes?

Do you use any kind of emollients to keep the skin soft? Who trims your nails? How often do you have a podiatrist?

Okay, so now we're going to talk about what you, the clinician, are going to do for the patient. So now you've done the assessment.

You know, if they're on anticoagulants and you need to be very careful, you know, if they're on chemo and you need to be very careful, you know, if they have evidence of arterial disease, if they have any kind of autoimmune condition. So you're now prepared to provide care. Very helpful to do a brief soak or to wash their feet.

So a lot of centers will do like a ten minute soak in warm, sudsy water or just warm water that's going to cleanse the skin, and it's also going to start to soften the nails and make it easier to trim the nails. You're going to take them out of the soak or the wash. You're going to dry their feet well, and now you're going to carry out your assessment.

So I'm going to do my vascular screening. I'm going to do my sensory motor screening. I'm going to look at the skin on the dorsal and the plantar surface and between the toes.

I'm going to assess the nails and I'm going to remember what medications they're on. Now, here are your priorities in providing nail care.

And all of us remember when we first started doing nail care, we were so nervous because even though we've been trimming our own nails, we hadn't done anything to anyone else's nails. And a lot of nurses have been taught, don't touch their nails. You can cause problems, just leave them alone.

And sometimes you see the results of that mindset because people in the hospital frequently have very long nails. Nobody's doing anything about them.

But if you take all of the principles that we've talked about and the things that we're going to show you during bridge week, you can provide nail care very, very safely. And here's the pathway you want to follow. First of all, if there's any callus that obstructs the free nail border.

You start there and we will show you how to pare. So you're going to pare down any callus affecting the free nail border.

If the nails are abnormally thick, then you're either going to use emery boards or a handheld drill to thin the nails before you try to clip them. You're going to trim them from side to side. You're going to follow the free nail border, and you're going to take little nips at a time.

Once you get the nails trimmed, then you're going to file the nails, and then you're going to buff or pare any corns or calluses. So if it's a very thin callus, you might just take your emery board and you might just buff in one direction.

But if it's a thick callus, you're either typically going to use the electric grinder with a sanding bit or you're going to use a scalpel. Depends on whether it's extensive or localized. And then finally, you want to address any c shaped or ingrown nails.

If there's evidence of infection, you're going to refer to a physician. Unless you're advanced practice, in which case you can manage it yourself. Again, you're going to thin any thickened nails.

So before I try to lift an ingrown nail, I'm going to thin it very hard to lift the nail when it's very thick. So thin it first you always thin before you trim, thin before you lift.

Once I've got the nail thinned out, then I can usually lift it with my nipper, slide my nipper under the edge to clip that corner that is compressing the underlying tissue. I'm going to repeat that until I get a free nail border, till I can slide my spatula down and around.

And then, if possible, I'm going to wedge a little strip of an alcohol wipe under that edge so it can't grow back down. Callus management if it's hard callus, we're going to pare it typically using a scalpel, holding the blade parallel to the skin. We'll show you that.

We'll practice that. If it's a soft callus, typically you hold your scalpel at right angles and you do a scraping approach.

You're just literally scraping off the soft callous one layer at a time. If you're buffing or sanding a callus, you buff it in one direction.

You don't go back and forth because that can cause friction damage in the underlying tissue. You're always going to.

Once you've done nail care, once you have managed corns and calluses, you're going to check your interdigital spaces to be sure that nothing's there. There's no little nail fragments there.

You're going to make sure that you didn't miss any fissures, that you don't see any evidence of a fungal infection. If there is evidence of a fungal infection, you're going to treat the inner digital spaces with an antifungal.

And then finally, you're going to apply emollients to the skin, but not between the toes. Now, managing specific problems. Again, we're going to show you this when you're on site. But hypertrophic nails, a very common issue.

So we said that you can either thin with a handheld drill, or some people would just use a very coarse emery board to thin thick nail. Now, if you are using a handheld drill, you want to be sure you wear a mask, because you can get fungal organisms aerosolized into the air.

So you want to be wearing a mask. The alternative?

In some centers, they elect nothing to use the handheld drill because they are concerned about the potential for aerosolizing fungal organisms, and they don't feel safe with just a mask. So if you choose not to thin, you can apply a product on this three way oil, and then you can literally trim or nip the nail from the top down.

So instead of just cutting across, you can cut top down. Now, we already talked about treating fungal nails that you could use any kind of menthol based product, like Vicks Vaporub or any menthol rub.

Or you could use other topical antifungals, or you could refer them to a podiatrist for systemic antifungals if they're very concerned about this. Now, you should be aware that the use of a handheld drill, the use of a dremel, is controversial due to the potential for creating fungal dust.

You absolutely have to wear a mask, or you can use an alternative approach. We really need a lot more data about this. We don't have a lot of data. So some clinicians elect not to use the handheld drill at all.

Others use the handheld drill, but are careful to use a mask and face shield. Okay, so we've taken care of the foot, we've taken care of the nails. Now we want to talk to the patient about their footwear.

We want to make sure that their shoes provide appropriate fit. So we're looking for any evidence that they need a deeper toe box. What's the evidence?

Corns on the tops of their toes, hammer toes, claw toes, mallet toes, overlapping toes. All of those people need deep toe box. We want to make sure there's adequate width and length.

So length you can check against the tracing width as well. You can also pinch on either side. So look at the shoe. Look at the widest point of the toe box and pinch right there.

And you should be feeling the bunion bone, and you should be right adjacent or right inferior to the fifth toe. That tells you that the widest point of the shoe is accommodating the widest part of the foot.

So look at the tracing, look at their toes, palpate at the widest point of the shoe and see if that's also the widest point of the foot. You want to make sure they have appropriate padding and insoles. How do you determine that? You look at the bottom of the foot.

Do you see callus formation? Do you see areas of previous ulceration or current ulceration?

Then you know that the insoles are not providing adequate protection for the plantar surface of the foot and that they need to be evaluated by an orthotist or a pajorthist.

If you have a patient who has limited range of motion who has a history of plantar surface ulcers, they should be in a fairly rigid shoe that has a rocker bottom type foot that limits their flexion and limits the amount of shear and friction that they get over the metatarsal heads.

If in doubt, you always want to send these people to a center where they have professionals who can measure the foot, fit the footwear, assess the insole, and make sure that their feet are appropriately protected until you can get them in to see a professional fitter. Athletic shoes in general are a good option. So as a temporizing measure, you might recommend athletic shoes and socks.

We've already said cotton or cotton synthetic blend. We have talked multiple times in this course about the importance of patient education. You're not going to be there every day.

You're not going to be there every week. You're probably not going to be there every month.

It's critical for you to educate the patient because they're the ones that will assume responsibility for foot care. So make sure that they have someone who can help them to provide hygienic care.

Make sure they know how important it is to provide emollients to the skin and to dry between the toes. Make sure they know how to use a pumice or an emery board to pare down recurrent calluse we've just talked about footwear.

So if you have a patient who has intact sensation, no major deformities, you just give them tips on assuring shoes that their shoes fit correctly. Pay attention to what your feet are telling you. Look at the tips of your toes, make sure they're not red. Make sure the tops of your toes are not red.

If you have a patient who has intact sensation but they have deformities, hammer toes, overlapping toes, mallet toes, any of those, you need to provide them with specific guidance in terms of what they're looking for in footwear. So if they have deformities involving the toes, hammer toes or claw toes or mallet toes or overlapping toes, they've got to have that deep toe box.

If they have a bunion, they've got to have a wide toe box. Very helpful in general, for people to have shoes with a conformable upper. In other words, those plastic shoes, those are terrible. Vinyl shoes.

Those are terrible. So leather in general is the best upper leather or fabric because it has gift.

And any patient who has reduced sensation, any patient with severe deformities needs to be referred to a professional fitter. We've already talked about educating the patients about injury prevention.

You do this for anyone with compromised sensation, anyone with compromised perfusion. Protective footwear at all times, shake them out. No sandals, no open toed shoes. That's not protective.

Breaking your shoes gradually, don't put them in and go marching around for four to 8 hours. Check your water temperature, never do bathroom surgery. Check your feet every day.

And if you have a skin thermometer, check the temperature of your feet every day and see a professional every three months. Many times the most important thing we do is we make appropriate referrals.

So if I have a patient with severe bony deformities and they'd like to get them corrected, you refer to a podiatrist. If they have ingrown nails, especially if they're recurrent, painful or infected, refer to a podiatrist.

Any kind of painful foot condition, they need to go to a podiatrist or if they have a suspicious lesion or significant infection, you're going to refer to a podiatrist. When should you refer to a podorthist or an orthotist?

Patients who have foot deformities and recurrent callus or they have excessive pronation and abnormal wear patterns. Who's going to fix that for them? The padorthus, the orthodox.

They're going to measure their foot, they're going to do an imprint with them walking and see what their gait is and what their weight bearing patterns are, and they're going to put them in appropriate footwear with an appropriate insult. You have concerns about arterial disease or venous disease. They go to vascular.

And if you're not in a position to provide wound care, you make sure they go to a wound center. Now, the last couple of things we want to talk about are just some professional practice issues related to foot and nail care.

So remember that for a long time, nail care was like, we don't do it. But now nail care is being recognized as a very valid specialty area and critical. And so now most states recognize foot and nail care certification.

You do want to check with your state board of nursing to determine what credentials are required for you to provide foot and nail care and what limitations there might be. We've already talked about the fact that if you're going to do foot in nail care, you definitely should be certified.

It gives you credibility and assures that client, that patient, that you're functioning within your scope of practice and knowledge. Infection control are critical issues. So you're going to use universal precautions.

If they have intact skin and you have intact skin, gloves are optional. If you have any breaks in your skin, if they have any breaks in their skin, gloves are essential.

You're going to use a face shield and a mask if you're using a handheld grinder and you're going to disinfect your equipment. So let's talk about disinfecting the equipment.

If you're using vinyl tubs to do brief soaks, you could either use disposable liners, which is best, or you can rinse them, dry them, spray them with Lysol until they're completely wet, and then allow them to air dry. But in general, disposable liners would be preferred.

Your stainless steel equipment, your nippers, your spatulas, your drill bits, you start out by washing them well to remove all particulates, rinsing them, drying them. Then you can either autoclave them or you can use a cold disinfection protocol. That is an accepted protocol. I'm trying to think of the right word.

So we happen to use CytX, which is a glutaraldehyde. But we follow the very specific guidance that our agency uses for cold disinfection. There's also guidance provided on the back of the container.

So whether you're using side x or another agent, make sure that you're adhering to the protocol for cold disinfection. Established by your agency. So this will be the same protocol that's used to clean scopes that are used for upper GI endoscopy, lower GI endoscopy.

It's a very well tested, well validated, evidence based protocol. Follow it. And finally, what about payment for foot and nail care?

Well, there's not a lot of, here's what we know currently about reimbursement guidelines. Third party reimbursement for foot and nail care is available only in outpatient and long term care facilities, not in the hospital.

You must be licensed as an advanced practice nurse to bill, or you have to be practicing under a physician or an advanced practice nurse and working in an outpatient facility. The patient has to meet the criteria. So you don't get payment for just anyone who needs foot and nail care.

They restrict payment to patients with arterial disease, rendering them high risk for infection and injury following any trauma. So it's usually not even enough to say they're diabetic.

You usually have to show that there's some evidence of this disease and that professional nail care is required. So talk with your, the billing specialist in your agency. Make sure that you have everything in place to bill appropriately.

But you should also be aware that even if you're not advanced practice, you can provide foot and nail care on a self pay basis. And there's many people who would be willing and happy to pay for foot and nail care from a professional.

Look at how many people go to nail salons in the mall. One thing to think about is this.

Even if I go to a podiatrist, if I do not meet the criteria for third party coverage, I'm going to pay the podiatrist out of pocket. So I could pay the podiatrist. I could pay you.

Many individuals would rather pay you because you'll come in, you'll do a full assessment, you'll provide gentle foot and nail care, hygienic care, education. So can you bill for your services? Yes. You do have to be sure that foot and nail care is considered to be within your scope of practice.

So goes back to checking with the state board of nursing. You definitely should have the patient sign a consent for treatment. And again, we highly recommend certification.

If you are going to provide foot and nail care, what equipment would you need if you were going to provide foot and nail care? Well, you can divide it into assessment, basic care and advanced care.

So for assessment, it's very helpful to have a doppler because what if I can't palpate pulses? I need to be able to see if I can hear them with a doppler. I need a tuning fork. I have to have monofilaments if I'm providing basic care.

I've got to have nippers and spatulas. I've got to have a pumice stone. I need disposable emery boards if I'm doing advanced care. If I'm managing thickened nails and ingrown nails.

I need a handheld drill with mask and goggles. I need disposable scalpels for pairing. And I need something for disinfection of my equipment.

I either need to be in a setting where I can do autoclave, or I need to have the equipment and the protocol for cold disinfection. So that is finally the end of foot and nail care.

I know it went on and on and on, but the critical things we want you to focus on are recognizing pathologic conditions and knowing what to do about them. Being able to do your vascular assessment, your sensory motor assessment, your skin and nail assessment.

Don't forget to check to see what medications they're on before you touch them. We've gone over major interventions. You're going to identify your free nail border. You're going to pair any obstructing callus.

You're going to thin thicken nails one way or another. So you're either going to thin with an electric grinder, thin with an emery board, use your three way and trim from the top down.

But somehow you've got to take down hypertrophic nails. Then you can trim. Then you can pair corns and calluses. You can manage ingrown nails and fungal infections.

You always incorporate patient education and referrals. So thanks for hanging in there. You're done with this.