4. Toe Nails

1. Identify the structures (anatomy) of the nail unit
   
2. Identify and name toenail deformities from pictures
   eg. Onychomycosis, onychogryphosis (omega/rams horn), lytic nails
3. Identify changes to the nail from systemic disease from pictures
   eg, Clubbed nails, Beaus lines, Mees lines
4. List the categories of onychomycosis. eg distal subungual, proximal subungual
   
5. List the pathogens frequently isolated from onychomycotic toenails.
   eg, dermatophytes, t. mentagrophytes, t. rubrum
6. List topical and oral treatments for onychomycosis including:
   Methods of use, effectiveness, dangers/interactions of oral antifungal medications
7. List common injuries to toes and toenails, their cause and treatment options.
   eg subungual hematoma, fracture, ulcer, ingrown, blisters
8. Describe two different mechanisms that create ingrown toenails.
   eg, wide and thin nails lacerate lateral or medial nail fold, incorrect nail trimming leading to the
   lateral or medial distal nail edge cutting into tissue.
9. List common toenail procedures/surgeries and why you would refer a patient to have it performed.
   eg. Matrixectomy, avulsion, biopsy.

5. Dermatology

1. Identify the structures (anatomy) of the skin
   
2. Identify and name common skin conditions from pictures. eg hemosiderin, psoriasis, cellulitis
   
3. List common lower extremity skin conditions and their treatment options.
   eg, warts, tinea pedis, xerosis (dry skin), pressure marks/preulcerative skin changes
4. Discuss the cause (etiology) of various types of hyperkeratotic lesions (corns, calluses) on the foot
   
5. Discuss various treatment options for hyperkeratotic lesions on the foot.
   eg. Debridement (sanding/sharp,) exfoliation (urea or ammonium lactate creams),
   moleskin, felt pads, silicone pads, shoe/insert modification
6. Discuss various topic products and their uses.
   eg. Skin moisturizers (with humectants, emollients), barrier products for protection from
   moisture (petrolatum, zinc or dimethicone products), keratolytic/exfoliative products
   (urea creams, ammonium lactate creams)
7. Identify areas of high pressure (preulcerative lesions) caused by shoes, deformities, other pressure.
   

7. Care for iatrogenic lesions (cuts, scratches, etc. caused during foot care visit)

1. List various types of iatrogenic lesions that can occur during foot care.
   eg. Scratches with sander, cuts with scalpel or clippers
2. List different methods of bleeding control and their advantages.
   eg. Direct pressure, chemical cautery (silver nitrate sticks, Monsels, styptic, aluminum chloride)
3. List different ways to provide antimicrobial cleaning to the area.
   eg. Betadine, alcohols pads, chlorhexidine pads, antimicrobial sprays
4. List different choices for dressings and their advantages.
   eg. Bacitracin, polysporin, Bandaid, gauze/tape
5. List important issues to discuss with the patient/caregiver.
   
6. Discuss follow-up care options.
   
7. List charting requirements for iatrogenic lesions.
   

8. Shoes, socks, inserts/orthotics, pads/strapping/taping

1. Features of shoes which make them appropriate for diabetic/high risk feet
   
2. Features of socks which make them appropriate for diabetic/high risk feet
   
3. Features of inserts/orthotics which make them appropriate for diabetic/high risk feet
   
4. Methods of padding or taping that helps relieve problem areas on feet/toes
   
5. Adjustments to shoes and inserts that helps relieve problem areas on feet/toes

9. Infection Control

1. Steps to avoid cross contamination during patient care
   
2. Instruments -  appropriate cleaning methods, single use instruments
   
3. Techniques to avoid cross-contamination if using foot soaks
   
4. Procedure to avoid cross-contamination in the environment
   eg. Floor coverage, cleanup, dust management, personal protective equipment 

10. Patient Education

1. Check feet daily for… skin changes, nail changes
   
2. Skin care – cleanse, moisturize, Innerspace care, observe for problems
   
3. Shoes, socks, compression
   

Examination Objectives

1. Identify what Nursing Foot Care is and the role of the Nurse in Providing foot care treatment within the nurses’ scope of practice.
   
2. Describe presenting symptoms, potential causes, diagnostic methods, and treatment plans related to problems that may be present with feet.
3. Describe the role of the multidisciplinary team in referring clients with diabetic ulcers and amputation to wound care nurses or a specialist.
4. Describe strategies to prevent foot problems and complication including shoe gear, socks, pads, taping, cleansing and moisturizing.
5. Identify common foot and nail disorders of the diabetic and geriatric foot.
   
6. Identify common conditions of the feet such as corns, calluses, warts, ulcers, hallux valgus, tissue changes, and nail changes.
7. Describe and identify safe techniques of cutting the toe nails and removing hyperkeratotic lesions.
8. Identify techniques for proper use of nail nippers, curettes, stainless steel rasp or file, manual sanding files, powered rotary tool (sanders).
9. Identify the safe use of protective equipment when providing foot care treatment including; goggles, face masks, gloves, hand sanitizer, barrier towels, dust evacuators.
10. Describe the use of testing modalities such as the 5.07/9-gram Monofilament, tuning fork, Doppler.
11. Describe proper sterilization/disinfection protocols for instruments and equipment used in foot care.
12. Describe techniques and protocols which will prevent cross contamination of instruments, equipment, environment, patient exposure.
    
13. Describe potential chronic complications of diabetes in terms of pathology, associated risk factors, frequency, recommendations for screening, prevention, management, and foot care education.

Sample Questions

Which of the following are objective signs of venous disease?

1. Lower extremity edema
   
2. Hemosiderin discoloration
   
3. Varicosities
   
4. All of the above
   

Which of the following tests is performed to determine the patient’s ability to feel light touch or protective sensation?

1. 5.07 (10 g) monofilament
   
2. Deep tendon reflexes
   
3. Vibration testing
   
4. Proprioception testing
   

Which of the following refer to movement of the foot up and down?

1. Eversion and inversion
   
2. Dorsiflexion and plantarflexion
   

Which of the following skin changes might indicate the presence of arterial disease?

1. Atrophic skin
   
2. Dry, flaky skin
   
3. Thin, fragile skin
   
4. Decreased hair growth
   
5. 1 and 2 above
   
6. All of the above
   

Which of the following can be a contributing factor to the formation of bunions?

1. Pronation
   
2. Ligamentous laxity
   
3. Family history
   
4. All of the above
   

Which of the following are risk factors for developing a foot ulceration?

1. Bony deformity
   
2. Vascular insufficiency
   
3. Diabetes
   
4. All of the above
   

Macerated inner spaces/web spaces are areas of excess moisture between toes that can lead to an infection.

1. True
   
2. False
   

Which of the following is the most important treatment for ingrown toenails?

1. Prescription antibiotics
   
2. Removal of the ingrown portion of the toenail
   
3. Soaking the foot in Epson salts
   

What education would you provide to a patient with the following condition?
(picture of hammertoe with ulceration)

1. Even if the “corn” on the tip of their toe does not hurt, it is a serious finding because it can become ulcerated and infected
   
2. They should consult with their podiatrist or medical provider about the possibility of corrective surgery to straighten the toe
   
3. Inform them of beneficial shoe gear changes such as changing to extra depth shoes to allow more room for the toe deformities
   
4. All of the above
   

A patient who continues to develop ingrown great toenails should consider having which of the following procedures performed by a podiatrist, dermatologist or other practitioner?

1. Total matrixectomy of the nail.
   
2. Partial matrixectomy of the side of the nail, which becomes ingrown.
   
3. Topical medication to make the nail healthier
   
4. 1 or 2 above.
   
5. None of the above
   

What is the name of the skin condition/disorder shown in the picture below?  (picture of a red area over a bony prominence)

1. Plantar verruca
   
2. Tinea pedis
   
3. Pre-ulcerative skin changes
   
4. Cellulitis
   
5. Hemosiderin staining
   

What condition would you expect this patient has based on the picture below?  (picture of thin, atrophic, hairless skin on leg)

1. Psoriasis
   
2. Cellulitis
   
3. Arterial disease
   
4. Tinea pedis
   

Successful Completion of Examination

*  Complete the CFCS Competency Exam on-line with a passing score is 70% or better.

*  Testing failure: If you should fail your exam, you will have 1 additional opportunity to re-take and pass the Exam. 

*  The test is time limited and must be completed within 2 hours.

*  You will be able to immediately download your Certificate.

*  A Formal, numbered Certificate will be mailed to you.

*  You can immediately use the credentials CFCS after your name and other medical credentials such as RN.

*  CFCS certification is valid for five years.
    (see Re-certification Requirements for maintaining your certification thereafter.)