Skill 108 Providing Nail Care PDF

584 SKILL 108 ACTION RATIONALE the call bell and other nec- essary items are within easy reach. 16. Clean transfer aids per Proper cleaning of equipment facility policy, if not between patient use prevents indicated f...

584 SKILL 108 ACTION RATIONALE the call bell and other nec- essary items are within easy reach. 16. Clean transfer aids per Proper cleaning of equipment facility policy, if not between patient use prevents indicated for single the spread of microorgan- patient use. Remove isms. Removing PPE properly gloves or other PPE, if reduces the risk for infection used. Perform hand hygiene. transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. EVALUATION Patient is moved up in bed without injury and maintains proper body alignment. Patient is comfortable. Patient demonstrates intact skin without evidence of any breakdown. DOCUMENTATION Many facilities provide areas on the bedside flow sheet to docu- ment repositioning. Document the time the patient’s position was changed, use of supports, and any pertinent observations, including skin assessment. Document the patient’s tolerance of the position change. Document aids used to facilitate movement.  ͕͔͜      Care of the nails is important to prevent pain and infection. Long, rough- ened nails that have not been trimmed or filed may increase the occur- rence of traumatic nail injury, such as damage to the nail that may result in the nail plate being torn from the nail bed (Malkin & Berridge, 2009). Poor toenail care may lead to poor mobility. The nurse should document and report to the patient’s primary care provider any changes to nail color, such as discoloration of the entire nail or a dark streak under the nail; changes in nail shape, such as curled nails; thinning or thickening of the nails; separation of the nail from the surrounding skin; bleeding around the nails; and redness, swelling or pain around the nails (Mayo Foundation for Medical Education and Research, 2011c).  ƒ‹Žƒ”‡ǡ”‘˜‹†‹‰ 585 DELEGATION CONSIDERATIONS Depending on the organization’s policies and procedures, the care of a patient’s nails may be delegated to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP) after assessment by the registered nurse. The care of a patient’s nails may be delegated to licensed practical/ vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient’s needs and circumstances, as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. EQUIPMENT Nail file Towel Nail clipper Wash basin and skin cleanser, Cuticle scissors or commercially prepared Orangewood stick or cuticle bathing system stick Disposable gloves Emollient Additional PPE, if indicated Disposable waterproof pad ASSESSMENT Assess the patient’s nail care preferences: frequency, time of day, and type of products. Assess for any physical activity limitations. Assess for conditions that may put the patient at high risk for nail problems, such as diabetes and peripheral vascular disease. Assess the color and temperature of fingers and toes. Assess ade- quacy of pulses to area and capillary refill. Assess the skin of fingers and toes for dryness, cracking, or inflammation. Assess the nails and surrounding skin for changes in nail color, changes in nail shape, thinning or thickening of the nails, separation of the nail from the surrounding skin, bleeding around the nails, and redness, swelling, or pain around the nails. Nails should appear intact, smooth, firmly attached to nail bed, pink in color, with white crescent visible at the base. Dark streaks running lengthwise in nails are a normal variation for patients with darker skin tones. Assess the patient’s ability for self-care of nails or assist with the procedure. NURSING DIAGNOSIS Risk for Injury Bathing Self-Care Deficit Impaired Physical Mobility OUTCOME IDENTIFICATION AND PLANNING Nails are trimmed and clean with smooth edges and intact cuticles, without evidence of trauma to nails or surrounding skin. Patient verbalizes feelings of improved self-esteem. 586 SKILL 108 IMPLEMENTATION ACTION RATIONALE 1. Review health record for Identifying limitations prevents any limitations in physical patient discomfort and injury. In activity, or contraindications some settings, a medical order to the procedure. Confirm is required for nail care, particu- presence of medical order larly for a patient with certain for nail care, if required by health problems. facility policy. 2. Perform hand hygiene. Put Hand hygiene and PPE prevent on PPE, as indicated. the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify patient. Explain Identifying the patient ensures procedure to the the right patient receives the patient. intervention and helps prevent errors. Explanation facilitates cooperation. 4. Assemble equipment on Organization facilitates perfor- overbed table within reach. mance of task. 5. Close the curtains around the Provides for patient privacy. bed and close the door to the room, if possible. 6. Raise bed to a comfortable Proper bed height helps reduce working position, usually back strain while performing the elbow height of the caregiver procedure. Waterproof pad pro- (VISN 8 Patient Safety tects bed linens and surrounding Center, 2009). Lower side surfaces. rail. Place a towel or water- proof pad under the patient’s hand or foot. 7. Put on gloves. Wash patient’s Gloves prevent the spread hands or feet, depending on of microorganisms. Washing care to be given. removes surface dirt and softens nails and skin, making it easier to trim and care for cuticles (Mayo Foundation for Medical Education and Research, 2011c). 8. Gently clean under the nails Washing removes debris and dirt using the cuticle or orange- dislodged from under nails. wood stick. Wash hand or foot.  ƒ‹Žƒ”‡ǡ”‘˜‹†‹‰ ǦǦǦ 587 ACTION RATIONALE 9. Clip nail, if necessary. Avoid Cutting entire nail in one attempt cutting the whole nail in one may lead to splitting the nail. attempt. Use the tip of the nail Prevents injury to nail, cuticle, clipper and take small cuts and finger or toe and reduces (Malkin & Berridge, 2009). risk for in-growing nails (Mayo Cut the nail straight across. Foundation for Medical Educa- Do not trim so far down on tion and Research, 2011a; Mayo the sides that the skin and Foundation for Medical Educa- cuticle are injured. Only tion and Research, 2011c; file, do not cut, the nails of Malkin & Berridge, 2009). patients with diabetes or circulatory problems. 10. File the nail straight across, Smoothes the nail. Prevents then round the tips in a injury to nail, cuticle, and finger gentle curve, to shape the or toe and reduces risk for in- nail. Do not trim so far down growing nails (Mayo Founda- on the sides that the skin tion for Medical Education and and cuticle are injured. Only Research, 2011a; Mayo Founda- file, do not cut, the nails of tion for Medical Education and patients with diabetes or Research, 2011c; Malkin & circulatory problems. Berridge, 2009). 11. Remove hangnails, which Removes dead cuticle. Reduces are broken pieces of cuticle, hangnail formation. Tearing of by carefully trimming them hangnail can cause injury to live off with cuticle scissors. tissue. Avoid injury to tissue with the cuticle scissors. 12. Gently push cuticles back Keeps cuticles and nails neat and off the nail using the orange- prevents cracking and drying of wood stick, or towel. cuticles. 13. Dry hand or foot thoroughly, Thorough drying reduces risk of taking care to be sure to maceration, damage from overly dry between fingers or toes. and consistently wet skin. Mac- Apply an emollient to the eration increases risk for injury hand or foot, rubbing it into from rubbing or friction, and risk the nails and cuticles. Do not for fungal and bacterial infec- moisturize between the toes tions. Moisturizing between the of patients with peripheral toes of patients with peripheral artery disease. artery disease can encourage fungal growth (Mayo Founda- tion for Medical Education and Research, 2012). 14. Repeat Steps 7–13 for other extremity or extremities.