Skill 38 - 2

Performing Nail and Foot Care

Steps
1) Identify clients at risk for foot or nail problems:

Rationale
Certain conditions increase the likelihood of foot or nail problems.

A.

Older Adult

Poor vision, lack of coordination, or inability to bend over contributes to difficulty in performing foot and nail care. Normal physiological changes of aging also result in nail and foot problems.

B.

Diabetes mellitus

Vascular changes associated with diabetes mellitus reduce blood flow to peripheral tissues. Breaks in the skin integrity place a diabetic client at high risk for a ski infection. Meticulous foot assessment reduces the diabetic clients risk of debilitating foot problems.

C.

Heart failure or renal disease

Both conditions can increase tissue edema, particularly in dependent areas (e.g., feet). Edema reduces blood flow to neighbouring tissues.

D.

Cerebrovascular accident (stroke)

The presence of residual foot or leg weakness or paralysis results in altered walking patterns. An altered gait pattern increases friction and pressure on feet.

2)

Assess clients knowledge of foot and nail care practices.

Determines clients need for health teaching.

3)

Ask female client about whether they use nail polish and polish remover frequently. Assess clients ability to care for nails r feet: consider visual alterations, fatigue, and musculoskeletal weakness.

Chemicals in these products can cause excessive dryness. Demonstrates clients knowledge of proper foot care. Determines the amount of assistance and teaching required.

4)

5)

Assess the types of home remedies (e.g., aloe Vera, herbal preparations; that the client uses for existing foot problems: A. Over-the-counter liquid preparations to remove corns B. Cutting of corns or calluses with razor blade or scissors..

Microorganisms travel and grow in moisture.

Liquid preparations can cause burns and ulcerations. Cutting of corns or calluses may result in an infection caused by a break in skin integrity. The diabetic client or any client with decreased peripheral circulation has an increased risk for infection secondary to a break in skin integrity.

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C. Use of oval corn pads. Oval pads may exert pressure n the toes, thereby decreasing circulation to surrounding tissues. D. Application of adhesive tape. The skin of older adults is thin and delicate and prone to tearing when adhesive tape is removed. 6. Assess the type of foot wear worn by clients: Are socks worn? Are shoes tight or ill fitting? Are garters or knee-high nylons worn? Is footwear clean? Observe clients walking gait. Have the client walk down a hall r in a straight line (if able). 8. Assist an ambulatory client to sit in a bedside chair. Help a bedbound client to a supine position with head of the bed elevated. Place disposable bath mat on the floor under clients feet or place a towel on the mattress. 9. Obtain a physicians order for cutting nails if agency policy requires it. The clients skin may be accidently cut. Certain clients are more at risk for infection, depending on their medical condition. 10. Explain the procedure to the client, including fact that proper soaking requires several minutes. Client must be willing to place fingers and feet in basins for 10-20 minutes. Client may become anxious or fatigued. Types of shoes and footwear may predispose client to foot and nail problems (e.g., infection, areas of friction, ulcerations). These conditions decrease mobility and increase the risk for amputation in the diabetic client. 7. Structural as well as painful disorder of the feet can cause limping or an unnatural gait. Sitting in a chair facilitates immersing feet in basin. The bath mat protects feet from exposure to soil or debris.

Critical Decision Point: Clients with diabetes do not soak hands and feet. Soaking increases their risk of infection due to maceration of the skin. 11. Perform hand hygiene. Arrange equipment on an overbed table. 12. Fill wash basin with warm water. Test water temperature. Reduces transmission of microorganisms. Easy access to equipment prevents delays. Warm water softens nails and thickened epidermal cells, reduces inflammation of the skin, and promotes local circulation. Proper water temperature prevents burns. 13. Place basin n math mat or towel. Avoids spills; this maintains the safety of the care provider and the client. 14. Fill emesis basin with warm water, and place basin on paper towels on over bed table. 15. Pull curtain around the bed or close the room door (if desired). 16. Inspect all surfaces of the fingers, toes, feet, and nails. Pay particular attention to areas of dryness, inflammation, or cracking. Also inspect The integrity of feet and nails determines the frequency and level of hygiene required. Heels, soles, and sides of the feet are prone to Warm water softens nails and thickened epidermal cells. Maintaining the clients privacy reduces anxiety.

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the areas between toes, heels, and soles of feet. Critical Decision Point: Clients with peripheral vascular diseases or diabetes mellitus, older adults, and clients hose immune system is suppressed may require nail care from a specialist too reduce the risk of infection. 17. Assess the colour and temperature of toes, feet and fingers. Assess capillary refill. Palpate radial and ulnar pulses of each hand and dorsalis pedis pulses of feet. Assess the adequacy of blood flow to extremities. Peripheral vascular disease can contribute to poor wound healing. Immunocompromised and diabetic clients are at greater risk of developing infections. 18. Instruct client to place his or her fingers in the emesis basin and place arms in a comfortable position. Assist the client to place feet in basin. 19. Allow clients feet and fingernails to soak for 1020 minutes (unless the client has diabetes). Rewarm the water after 10 minutes. 20. Clean gently under the fingernails with an orange stick or the wooden end of a cottontipped swab while fingers are immersed. Remove fingers from the emesis basin, and dry thoroughly. 21. Using nail clippers, clip fingernails straight across and even with the tops of fingers. Using a file, shape the nails straight across. If client has circulatory problems, do not cut the nail; only file the nail. For infection-control purposes, use the clients own nail clippers. Cutting straight across prevents splitting of the nail margins and the formation of sharp nail spikes that can irritate lateral nail margins. Filing prevents cutting the nail to close to the nail bed. 22. Push cuticle back gently with the orange stick. Thoroughly dry the hands. Reduces incidence of inflamed cuticles. Thorough drying impedes fungal growth and prevents maceration of the tissues. 23. Move the overbed table away from the client. 24. Put on disposable gloves, and scrub callused areas of the feet with a wash cloth. 25. Clean gently under nails with an orange stick. Remove feet from basin, and dry them thoroughly. 26. Clean gently under nails with an orange stick. Remove feet from basin, and dry them thoroughly. 27. Apply lotion to feet and hands, and assist client For infection control purposes, use the clients own nail clippers. Shaping corners of toenails may damage tissues. Lotion lubricates dry skin by helping to retain Provides easier access to the feet. Gloves prevent the transmission of fungal infection. Friction removes dead skin layers. Removal of debris and excess moisture reduces chances of infection. Prolonged positioning can cause discomfort unless normal anatomical alignment is maintained. Clients with muscular weakness may have difficulty positioning their feet. Softening of corns, calluses, and cuticles ensures easy removal of dead cells and easy manipulation of cuticles. The orange stick removes debris under nails that harbour microorganisms through drying impedes fungal growth and prevents maceration of the tissues. irritation from ill-fitting shoes.

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back to bed and into a comfortable position. 28. Remove disposable gloves and place in a receptacle. Clean and return the equipment and supplies to the proper place. Dispose of soiled linen in a hamper. Perform hand hygiene. 29. Inspect the nails and surrounding skin surfaces after soaking and nail trimming. Determines the condition of skin and nails. Allows you to note any remaining rough nail edges. 30. Ask client to explain or demonstrate nail care. 31. Observe clients walk after toenail care. Evaluates clients level of learning techniques. Evaluates the level of comfort and mobility achieved. moisture. Reduces the transmission of infection.

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Unexpected Outcomes and Related Interventions

Inflammation and Tenderness of Cuticles and Surrounding Tissues Repeated soakings may be needed to relieve inflammation and loosen layers of cells from calluses or corns. Client with diabetes or peripheral vascular disease may require referral to a podiatrist. Antifungal cream may be needed.

Localized Areas of Tenderness on Feet, with Calluses or Corns at Points of Friction Change in footwear may be needed. Refer to a podiatrist.

Appearance of Ulcer between Toe or Other Pressure Areas in Foot Notify physician. Refer to a podiatrist. Increase frequency of foot assessment and hygiene.

Recording and Reporting

Document the procedure and any observations (e.g., breaks in the skin, inflammation, ulcerations) on the clients record sheets using the forms provided by your agency or facility. Report any breaks in the skin or ulcerations to the person i charge or the physician. These breaks are serious i clients with diabetes, peripheral vascular disease, and illnesses that impair circulation. Special foot care treatments may be needed.

Home Care Considerations

If the client has diabetes or decreased peripheral circulation, alternative therapies or foot soaking should only be done after consulting with a physician. An alternative therapy is moleskin applied to areas of the feet that are under friction- this is less likely to cause pressure than corn pads. Spot adhesive bandages can guard against friction, but they do not have padding to protect against pressure. If the client is ambulatory, instruct him or her to soak feet in a bathtub. If the clients mobility is limited, a large basin or pan can be used for soaking.