Prior to beginning care for the foot care patient, the Certified Foot Care Nurse (CFCN) will want to obtain a thorough health history to ensure all areas of care impacting foot health are addressed. The CFCN should begin the health history by obtaining an assessment of the medications the patient is currently taking. Since early written history, there is documentation of medicinal products being used to treat a wide range of ailments and diseases. Prior to close governmental scrutiny of these products, almost anything could be used to treat an ailment.1 In 1938, Congress enacted the Food, Drug, and Cosmetic Act, which mandated that the manufactures of all new drugs would have to prove to the Food and Drug Administration (FDA) that these drugs were safe.2 With the heightened scrutiny of medications today, the public is far more protected than our ancestors. Previously we are assured that the prescription and over-the-counter medications available today are safe and will have the advertised and desired efficacy. All medications also have side effects. Many prescriptions and over-the-counter medications have side effects that can affect the feet and exacerbate chronic foot and ankle conditions. It is essential to ascertain from the foot care patient what medications they take so the CFCN may discuss potential side effects that may impact the feet. For example, neuropathy is the feeling of numbness, tingling, or burning. It is usually first experienced in the feet and lower extremities. Neuropathy is caused by nerve damage, resulting in this loss of normal sensation. While frequently the result of uncontrolled diabetes, many medications can also cause neuropathy in the feet including certain seizure medications, antibiotics, blood pressure medications, and chemotherapies.3 Many patients do not consider over-the-counter medications as well as herbals to be part of their medication list, so it is important to ask about these products specifically.

Next, the CFCN will need to assess any comorbidities the foot care patient may have, with the most important being diabetes mellitus. Due to vascular, structural, and neurological changes that can occur with diabetes, the diabetic foot patient is at a higher risk of developing wounds, which can lead to amputation if mismanaged. The CFCN will need to obtain a history of any prior issues such as ulcerations or other problems the diabetic patient has experienced as well as preventive measures implemented. Other comorbidities that may impact the feet are vascular disease, neuropathies, renal disease, autoimmune disease, and structural deformities caused by chronic conditions.4 The CFCN will need to obtain a thorough history of any of these conditions and whether they have impacted the foot health in any manner. Lastly, the CFCN will want to assess for habits that may have an ill effect on foot health such as smoking, diet, and activity level.4

As the CFCN is obtaining the health history, this is a good time to provide education as to how each of these areas can impact the foot health. Studies have indicated that education performed at the “teachable moment” provides more positive results by improving the adherence and absorption of the material.5

1. The CFCN is seeing a 73-year-old non-diabetic woman for routine nail care and a foot exam. The patient states her feet have felt like they are “on pins and needles.” The nurse administers the Semmes-Weinstein monofilament test and finds a significant loss of sensation. The nurse reviews the patient's medication list. Which medication is MOST likely contributing to these symptoms?

aspirin furosemide omeprazole metronidazole ANSWER D

Rationale: There is up to an 85% incidence of peripheral neuropathy with the chronic use of metronidazole.1 Taking a daily low dose aspirin can lower the risk of heart attack and stroke by reducing the chance the blood clots can form inside diseased arteries.2 Aspirin prevents blood clots by thinning the blood, so its main side effect is the increased risk of internal bleeding.2 However, side effects do not contribute to neuropathy. Furosemide is a diuretic and is used to help remove excess fluid (edema) from the body, which can be caused by a multitude of conditions such as heart failure, liver disease, and kidney disease.3 Removing excess fluid from the body can lessen symptoms such as shortness of breath and decrease the swelling in your arms, legs, and abdomen. Some of the serious side effects of this medication include electrolyte imbalance, hypokalemia, pancreatitis, and liver damage.3 Furosemide is not know to contribute to neuropathy. Omeprazole is in the class of drugs known as proton pump inhibitors.4 It is used to treat esophageal symptoms associated with gastric reflux as well as gastric ulcers.4 The most common side effects associated with omeprazole are abdominal pain and headache.4

There is no evidence Omeprazole contributes to neuropathy.

Content outline: Domain 1, Task 1, 010100 a

Cognitive level: Recall

2. The CFCN is obtaining a health history on a foot care clinic patient with no current foot wounds, who is not a diabetic. Although all these statements would indicate further follow-up and evaluation, which would be most important to address FIRST?

“My feet swell some in the afternoon and at night.” “I have been told that I need to wear inserts in my shoes.” “My feet are sometimes cold and pale.” “I get callus on the bottom of my big toe.” ANSWER C

Rationale: Poikilothermia or polar skin conditions (coldness) and pallor (paleness) can be indicative of arterial deficiency or critical limb ischemia which is limb threatening. Other symptoms, pain, paresthesia, paralysis, and pulselessness, comprise the 6 “Ps” of arterial deficiency or critical limb ischemia and always require immediate evaluation with Doppler, ankle-brachial index, and/or vascular studies.1 Peripheral edema can impact foot health, especially if footwear is too tight and causing pressure to the feet or if weeping is causing skin loss and wounds. As the swelling is not consistent, it is most likely not associated with an acute injury. Since there is no indication of wounds being present, this issue can be dealt with at a later visit. Many patients need to wear inserts for various reasons. It would be important to ascertain why the patient was told to wear inserts and for what condition. Most non-diabetic foot patients wear inserts due to biomechanical issues such as arch issues or plantar fasciitis.2 These issues will need to be addressed but can require the assistance of a podiatrist or orthotist for any specialized fitting. The formation of callus is an indication of pressure and should be addressed. Since the patient does not have any wounds, this should be addressed after the vascular issue as it can lead to pressure injuries.3 The patient will likely need an evaluation of footwear as well as gait to determine where and why the pressure is occurring as well as recommending the proper footwear and padding to prevent any issues.

Content outline: Domain 1, Task 1, 010101 b

Cognitive level: Analysis

3. The CFCN is conducting an exam of a 49-year-old female patient and observes bilateral edema of her ankles and feet. The patient has diabetes and is a nonsmoker. Which of the following is the most likely cause of this patient's lower extremity edema?

glipizide Premarin losartan hydrochlorothiazide ANSWER B

Rationale: Lower extremity edema increases the patient's risks for a multitude of health issues including infection, decreased blood flow, and skin breakdown leading to ulcerations. The edema can also adversely affect the patient's quality of life by making it difficult to ambulate and the stretching of the skin will often become painful and itchy. Many women are prescribed Premarin for treating the symptoms of menopause. One of the side effects of Premarin therapy is swelling in the extremities.1 Glipizide is used to treat type II diabetes. The most common side effects of glipizide are GI upset and a jittery feeling.2 Losartan is an ARB and is used to treat hypertension and for renal protection.3 Hydrochlorothiazide is a diuretic and is used to treat hypertension.4 Both losartan and hydrochlorothiazide will often cause dizziness.

Content outline: Domain 1, Task 1, 010102 c

Cognitive level: Recall

4. The CFCN is assessing a patient admitted to the acute care facility who has a pressure injury on the heel. The patient weighs 150 lbs and recently had hip surgery. Which of the following warrants attention FIRST?

HgA1C 5.7% weight loss from 160 lb in 180 days 2100 calorie per day diet receives 30 mg of protein supplements daily ANSWER D

Rationale: Although HgA1C is indicative of prediabetes, it is on the mildest end of the scale as prediabetes range is 5.7% to 6.4%. Although this issue would need to be monitored and discussed with the patient, it is not a major pressing issue at this point. The most concerning weight loss for this time frame would be a reduction of 10% or greater. This patient has lost 10 lb in the past 180 days, which is not 10%.1 Any weight loss should be investigated, especially if it is unintended weight loss. A 2100 calorie per day diet would be sufficient for this patient as the recommendation for caloric intake it 30 to 35 kcal/kg of body weight (150 lb/2.2 kg = 68 kg × 30 kcal = 2040).2 This diet would need to be evaluated by a dietician to ensure that the appropriate distribution of the calories and nutrients to enhance healing. The protein amount recommended for a pressure injury is 1.25 to 1.5 g protein/kg; 30 mg would not be sufficient to enhance healing.2 A dietician would need to assess the entire protein intake (supplements and dietary) as well as renal function to determine the correct amount of protein intake needed for healing this wound.

Content outline: Domain 1, Task 1, 010101 c

Cognitive level: Application