4.7 Nail Care
Providing hand, foot and nail care for a client provides an opportunity for HCAs to observe the health of their client’s skin, nails, and the strength of their hands and feet. It also provides a sense of comfort and promotes self-esteem for the client. While many clients may enjoy having their hands and feet cared for, take special care with clients who do not find this a pleasurable experience. Additionally, some clients have sensitive feet and may be ticklish. Health Care Assistants should always tell a client when they are going to touch their feet, and inform them of what they are doing, so that the client expects the touch.
HCAs may assist with hand and foot care tasks that are limited to the following list of tasks. However, the client must be assessed first by a regulated health professional (ie: registered nurse) before the HCA can participate in the tasks below.
- Observing for any changes and reporting to the supervisor
- Nail clipping for clients without chronic diseases like diabetes, without swollen feet, without compromised skin, and without compromised nail integrity.
- Soaking, massaging, and applying lotion to hands and feet as per the care plan.
Clients with chronic diseases or compromised skin/nail integrity require special care from a podiatrist or specially trained nurse. It is acceptable to wash and inspect these client’s hands and feet, but never clip their fingernails or toenails (Sorrentino, et al., 2019; McLain, et al., 2018). Chronic diseases and conditions that compromise skin and nail integrity and therefore make it unsafe for HCAs to provide nail care include:
- clients with diabetes or circulation problems
- clients whose hands or feet are swollen
- clients who are on medications that affect the blood clotting
- clients who have finger and/or toenails that are weak, brittle, thick or ingrown
- clients with infections, rashes or skin damage to their hands and feet
Make sure to follow directions from a supervisor and those written in the Care Plan for any nail care that is performed.
Hand and Nail Care
| STEP | ACTION | REASON/CONSIDERATIONS | |
|---|---|---|---|
| 1. | Gather information from the ADL, Care Plan, report, and team leader before beginning. | This helps ensure that you are aware of the clients need and changes to the client’s health status that may impact your ability to complete the task. | |
| 2. | Before entering the clients room, perform hand hygiene. | This reduces the spread of pathogens between client rooms. | |
| 3. | Identify the client and explain the procedure. Evaluate the client’s needs (ie: toileting, thirst, pain) | This ensures that the client is ready for the procedure. | |
| 4. | Observe the clients’ hands for rashes, open areas, skin color, temperature, swelling, excessive dryness and calluses. | If anything is different regarding the health and integrity of the skin or nails from the information you received from the nurse, ADL and care plan, if anything has changed from the last time you cut the nails, or if you have any concerns regarding the clients condition, report back to the nurse first.
Do not proceed with the nail cutting until the nurse has reassessed the client’s hands and fingernails and you have received confirmation that you can proceed. |
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| 5. | Perform Hand Hygiene.
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This can be done by washing your hands or using hand sanitizer, as per the infection prevention and control standards.
This procedure does not require gloves unless client’s hands are visibly soiled or there are isolation precautions in place. |
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| 6. | Gather all necessary equipment and place them on the over bed table. This includes:
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It is important to collect all the equipment prior to starting the task. This will allow you to save time and energy by decreasing the chance you will need to leave the client to collect forgotten equipment. | |
| 7. | Assist the client to sit on a chair and position the overbed table in front of the client. Ensure that the client is comfortable and place the call bell within reach. | Having the call bell within reach allows you or the client to call for assistance without getting up and moving all the supplies out of the way.
If necessary, this procedure can also be done while client is in bed, with a basin on top of a soaker pad or some absorbent cloth. |
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| 8. | Spread the paper towels on the over bed table. | You will need the paper towel later as part of the nail cleaning and clipping. | |
| 9. | Provide privacy. | This supports dignity and is part of DIPPS. | |
| 10. | Fill the basin half-way with warm water, which is about 40°C.
If you do not have a thermometer, check the temperature of the water with the inside of your wrist. Allow client to test the water for comfort.
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Water should feel warm, not hot, or cold or cool, as warm water is most comfortable for soaking.
Do not use your fingertips to test the water as they have little callouses and are therefore slightly less sensitive to heat. Be aware that clients who have circulation issues may not feel the water temperature appropriately. It is acceptable to warm up the water if needed, but ensure that it is not too hot, in order to avoid burning the client. |
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| 11. | Place the basin on the paper towels. | ||
| 12. | Have the client immerse their hands into water and soak for up to five minutes. | Soaking hands and fingernails in warm water helps to clean and soften the fingernails prior to cutting.
However, soaking for longer than 5 minutes causes the skin to swell which may cause issues with nail cutting because the swollen skin could get trapped more easily in the nail clipper. Consider how your skin looks like a prune after you have been swimming. These bumps in the skin make it more difficult to safely cut the nails. |
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| 13. | Remove the client’s hands from the basin and take the time to dry them thoroughly. | Do not cut nails instantly after soaking fingers as skin around the fingernails can be puffy and more prone to cuts when moistened. | |
| 14. | Gently clean under each fingernail using the wooden cuticle stick.
After cleaning each nail, wipe the nail debris on one of the paper towels. |
Cleaning under the nails allows the HCA to see how much of the nail can be carefully trimmed.
Be very careful not to dig too deep under the nails as this could cause pain or bleeding. Do not interact with the cuticles. Managing cuticles is outside of the HCA role. |
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| 15. | Dispose of the paper towel when done cleaning under the nails. | This maintains a clean working area. | |
| 16. | Carefully clip the client’s nails in a gentle curve using the nail clippers so that nails are even with or just below tips of the fingers.
Do not clip the sides. Instead use the nail file to shorten the sides/ sharp edges. |
Clipping the sides of the nail may cause you to accidentally cut the skin as visibility is poor and skin often gets trapped in the clippers along with the nail.
Also, take care not to clip the nail to short as this can cause injury and pain. If the client is accidently cut by the nail clippers, inform the nurse right away. |
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| 17. | After clipping, or if not clipping, use an emery board or a file to carefully shorten and smooth the nails.
Shape the client’s nails with the emery board or file. To maintain nail integrity, file in one direction instead of back and forth. |
Filing back and forth can create small tears and splits in the nail, leading to weakening nails and breaks.
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| 18. | Once you have completed clipping the client’s nails, dispose of the paper towel with the nail clippings. | This maintains a clean working area. | |
| 19. | Offer the client a hand massage using lotion. If the client has their own preferred lotion, use that lotion to respect their preference. If able, use a lotion where first few ingredients do not include alcohol. | Lotions with heavy alcohol content don’t act as an emollient and dry the skin instead. This is especially important with diabetic clients as dry skin tends to crack and may cause portals of entry for bacteria and wound formation. | |
| 20. | Gently massage the hands. | Most people like to receive massage and a gentle hand massage can provide comfort and relaxation to the client. | |
| 21. | Return the client to a comfortable position | ||
| 22. | Please ensure the call bell is within reach. | ||
| 23. | Clean the nail clippers with alcohol and clean and replace your equipment as per facility policy.
If you are using communal nail clippers, ensure proper medical asepsis and sterilization of the equipment as per facility policy. |
Unless sterilization procedures are in place at the facility, using communal (shared) nail clippers is not advised. | |
| 24. | Perform hand hygiene | ||
| 25. | Report and record your observations | ||
Foot and Nail Care
| STEP | ACTION | REASON/CONSIDERATIONS |
|---|---|---|
| 1. | Gather information from the ADL, Care Plan, report, and team leader before beginning. | This helps ensure that you are aware of the clients need and changes to the client’s health status that may impact your ability to complete the task.
Some facilities do not allow their staff to cut toenails and have a specialized footcare nurse visit on a regular basis. Ensure you know your facility’s policies regarding nail cutting. If you are not cutting toenails, you may still be able to soak feet and provide a massage. |
| 2. | Before entering the clients room, perform hand hygiene. | This reduces the spread of pathogens between client rooms. |
| 3. | Identify the client and explain the procedure. Evaluate the client’s needs (ie: toileting, thirst, pain) | This ensures that the client is ready for the procedure. |
| 4. | Gather all necessary equipment and place the equipment on the over bed table. This includes:
|
It is important to collect all the equipment prior to starting the task. This allows you to save time and energy by decreasing the chance that you will need to leave the client to collect forgotten equipment. |
| 5. | Assist the client to sit on a chair. Ensure that the client is comfortable and place the call bell within reach. | Having the call bell within reach allows you or the client to call for assistance without getting up and moving all the supplies out of the way. |
| 6. | Spread the paper towels on the over bed table. | You will need the paper towel later as part of the nail cleaning and clipping. |
| 7. | Provide privacy. | This support dignity and is part of DIPPS. |
| 8. | Apply the basin cover to the basin. | Disinfection and sterilization procedures will vary from facility to facility. In some facilities, a basin cover will not be used. Follow the disinfection and sterilization of equipment procedures as per your facility’s policy |
| 9. | Fill the basin half-way with warm water, which is about 40°C.
If you do not have a thermometer, check the temperature of the water with the inside of your wrist. Allow client to test the water for comfort.
|
Water should feel warm, not hot, or cold or cool, as warm water is most comfortable for soaking.
Do not use your fingertips to test the water as they have little callouses and are therefore slightly less sensitive to heat. Be aware that clients who have circulation issues may not feel the water temperature appropriately. It is acceptable to warm up the water if needed, but ensure that it is not too hot, in order to avoid burning the client. |
| 10. | Apply gloves and assist the client with the removal of their footwear | Footwear can be dirty. |
| 11. | Spread paper towels on the floor under the client’s feet so that the client’s feet are not touching the floor. | The floor is considered contaminated. |
| 12. | Inspect the client’s footwear for holes, foul odors, and the need for replacement. Give each shoe a quick shake to see if anything falls out of them. | Clients who have memory challenges and/or circulation issues, may put band-aids or cotton swabs in between their toes. These can fall off and stick at the top of the inside part of the shoe, and subsequently cause pressure and skin integrity problems for the client.
If the client walks barefoot often (ie: home support and assisting living settings) they may unknowingly pick up debris from the floor and transfer it into the shoe. |
| 13. | Change your gloves. | Footwear can be dirty, so change your gloves after removing the footwear before proceeding with foot care. |
| 14. | Place the wash basin on paper towels so that the basin is not touching the floor. | The floor is considered contaminated. |
| 15. | Help the client immerse their feet into the water. Soak the feet for up to five minutes | Soaking feet in warm water helps to clean and soften the toenails prior to cutting. However, soaking for longer than 5 minutes will cause the skin to swell cause issues with nail cutting because the swollen skin could get trapped more easily in the nail clipper.
Diabetic skin should be soaked for as little as possible as soaking will increase dryness of the skin and therefore increase the risks for skin cracks |
| 16. | Remove the client’s feet from the basin and take the time to dry them thoroughly, especially between the toes. | Taking time to dry thorough ensures that you are not cutting the nails right after soaking feet as the skin around the nails can be puffy and so more prone to cuts. |
| 17. | As you dry observe the feet for rashes, open areas, skin color, temperature, swelling, excessive dryness, calluses, or corns.
Inspect between the toes and check the toenail health and length. Use a white towel as white will show any discharge or blood |
If anything is different regarding from the information you received from the nurse, ADL and care plan, if anything has changed from the last time you cut the nails, or if you have any concerns regarding the client’s condition, report back to the nurse first.
Do not proceed with the nail cutting until the nurse has reassessed the client’s feet and toenails and you have received confirmation that you can proceed. |
| 18. | Gently clean under each toe using the wooden cuticle stick.
After cleaning each nail, wipe the nail debris on one of the paper towels. |
Cleaning under the nails allows the HCA to see how much of the nail can be carefully trimmed.
Be very careful not to dig too deep under the nails as this could cause pain or bleeding. Do not interact with the cuticles. Managing cuticles is outside of the HCA role. |
| 19. | Dispose of the paper towel when done cleaning under the toenails. | This maintains a clean working area. |
| 20. | Carefully clip the client’s toenails in a gentle curve using the large nail clippers so that nails are even with or just below tips of the toe.
Do not clip the sides. Instead use the nail file to shorten the sides/ sharp edges. |
Clipping the sides of the toe nail may cause you to accidentally cut the skin as visibility is poor and skin often gets trapped in the clippers along with the nail.
Also, take care not to clip the nail to short as this can cause injury and pain. If the client is accidently cut by the nail clippers, inform the nurse right away. |
| 21. | After clipping, or if not clipping, use an emery board or a file to carefully shorten and smooth the toe nails.
Shape the client’s nails with the emery board or file. To maintain nail integrity, file in one direction instead of back and forth. |
Filing back and forth can create small tears and splits in the nail, leading to weakening nails and breaks.
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| 22. | Once you have completed clipping the client’s nails, dispose of the paper towel with the nail clippings | This maintains a clean working area |
| 23. | Apply lotion and massage the client’s feet.
Using your thumbs, massage the top of the client’s foot, working from the ankle towards the toes and downwards towards the side of the feet. Next, massage the sole of the foot, working from the toes to the heel and from the middle to the sides. Ensure all lotion is absorbed, especially if any ends up between the toes. You can use the towel to wipe away excess lotion. |
Leaving excess lotion between the toes could increase the chances for bacterial growth in that area.
If the client has their own preferred lotion, use that lotion to respect their preference. However, if able, use a lotion where first few ingredients do not include alcohol as this dries the skin. |
| 24. | Re-apply the client’s socks and footwear | |
| 25. | Remove your gloves | |
| 26. | Perform hand hygiene | |
| 27. | Return the client to a comfortable position | |
| 28. | Ensure that the call bell is within reach | |
| 29. | Apply new gloves | |
| 30. | Clean the nail clippers with alcohol. If you are using communal nail clippers, ensure proper medical asepsis and sterilization of the equipment as per facility policy.
If using a basin cover, first dispose of the used water and then remove basin cover. Then clean and disinfect as per facility policy. |
Unless sterilization procedures are in place at the facility, using communal (shared) nail clippers is not advised. |
| 31. | Remove gloves | |
| 32. | Perform hand hygiene | |
| 33. | Report and record your observations | |
| 34. |
Watch the video:
How to Care for Nails, presented by the St. Elizabeth Foundation on YouTube CareChannel (2019). This video demonstrates the techniques for Personal Hygiene Care when you care for a client’s nails.
