CARE OF HANDS AND FEET
A client’s general condition and health habits affect the condition of his or her fingernails and toenails. Brittle, broken, or discolored nails may be caused by improper diet, illness, infection, or fever. Nail infections are fairly common. Some medical conditions cause ridges in the nails. In other cases, the nails become very thick, clubbed, or ingrown. Any unusual nail condition or complaint of pain in the hands or feet should be reported.
Caring for Fingernails
Emotional tension may cause fingernail or cuticle biting. Some occupations cause fingernails to be stained or broken. Water, strong soaps, and washing powders make nails and cuticles dry. Nails that are well cared for are pleasing to look at and are a health protection measure.
Conditions such as torn cuticles are an invitation to infection. Therefore, report reddened areas or breaks in the cuticles. Dirty nails can spread infection. If a client’s nails are torn or jagged, clip them with a sterile nail clipper and make them smooth. This helps prevent the nails from snagging on clothing or bed linens. (Scissors are not used because of the danger of accidentally nicking the skin. A metal nail file is not used because of its sharp point. This may be dangerous; it can damage the nail or the surrounding skin.)
The best time to complete fingernail care is after the client’s hands have been in water. Soap and water loosen dirt and temporarily soften cuticles. Cuticle oil or lotion applied to the nails and cuticles softens them as well. In Practice: Nursing Procedure 50-5 provides additional information about the care of nails.
Nursing Alert Never give equipment that has a sharp point or that is used for cutting to a client who has unsteady hands or who is confused, depressed, or at risk for selfinjury or injury to others. The client who is going to have surgery or who is experiencing respiratory distress usually is asked not to wear nail polish or artificial nails.
Key Concept Artificial nails are a health hazard because they can harbor pathogens and become infected.They may also spread infection to others. For this reason, most healthcare facilities do not allow persons giving direct client care to wear them.
In addition, the natural nails are usually "roughed up" so artificial nails will adhere betterThis can damage the natural nails and cause difficulty when artificial nails are removed and not replaced.
Clients who are to have surgery or other procedures or who have serious respiratory disorders are strongly encouraged not to wear artificial nails because they can interfere with the determination of oxygenation status.
Hand Massage
Massage of the hands and feet is a valuable tool in relaxing and calming clients. Circulation improves as blood vessels dilate from the warmth of friction. In addition, muscle tone improves. Massage helps to promote a feeling of calmness and vitality. A hand massage is soothing and is an example of therapeutic touch, providing a connection between the client and the nurse.
The nurse may perform hand massage, outlined in In Practice: Nursing Care Guidelines 50-4, but may also teach the client to perform self-massage. Remember that a nurse can perform a hand massage without a physician’s order, unless the client has an injury or has had recent hand or wrist surgery.
NCLEX Alert This topic highlights the importance of documentation of your observations as a means of communication with all members of the health care team. Documentation fosters continuity of care. Your understanding and awareness of this may impact your selection of nursing actions during the exam.
Caring for Toenails
Toenails need the same care as fingernails. Long toenails can scratch the client’s skin or catch on bedclothes and break. Soiled toenails can cause infection if they scratch the client’s skin. However, cutting a client’s toenails is an intervention that usually requires a provider’s order. Never cut a newborn’s toenails or those of a client with diabetes or hemophilia.
Nursing Alert Do not cut a client’s toenails if you have any question about the condition of the nails. Special orders are required before cutting the nails of clients with diabetes or hemophilia or those with very thickened nails to avoid accidental injury to soft tissues. Ingrown toenails must be reported. (In many facilities, nurses are not authorized to ever cut toenails of clients with diabetes or hemophilia.) Rationale: Wounds heal very slowly in clients with diabetes or hemophilia. Very thick nails often need to be cut by a specially trained person using special equipment and techniques.
When caring for toenails, follow the same procedure as for fingernails (see In Practice: Nursing Procedure 50-5), with some exceptions. If the toenails tend to grow into the skin at the corners, place a wisp of cotton under the nail to move the nail up and prevent growth into the surrounding skin (ingrown toenail). The cotton must be changed at least daily. (If cotton cannot be inserted or removed safely, a strand of waxed dental floss may be used.
IN PRACTICE :NURSING CARE GUIDELINES 50-4
PERFORMING HAND MASSAGE
SPECIAL NOTE: The nurse must take into consideration how the client might interpret a hand massage. In some cases, it might be construed as a form of inappropriate touching or harassment and may cause discomfort or embarrassment to the client.
• Take either of the client’s hands in both of the nurse’s hands.
• Warmed lotion may be used.
• Gently shake out the client’s hand. Rationale: Gentle shaking relieves tiredness and assists the client to relax.
• Rotate and twist each of the client’s fingers, bending each finger back and forth. Rationale: This motion redistributes synovial fluid around the finger joints and provides passive range of motion for the fingers.
• Massage the palm of the client’s hand with both thumbs, with fingers on top of the client’s hand. Rotate in a circular motion. Rationale: According to acupuncture theory, this motion relaxes the heart.
• Massage the back (dorsum) of the client’s hand with the thumbs, while the fingers are in the client’s palm. Rotate in a circular motion. Rationale: This action is soothing and relieves tension.
• Massage the webbed area between the client’s thumb and first finger Rationale: Pressure points for sinuses and intestines are located here. Massaging this area may also help to relieve headaches, constipation, or menstrual cramps.
• Massage between each of the client’s fingers. Massage each finger, from hand to tip. Rationale: This helps to encourage blood flow to the fingers.
• Massage the client’s wrist with an up-and-down stroke. Rationale: This helps to increase circulation to the hand.
• Gently pull on each finger and quietly place the hand on the table. Rationale: This helps to maintain the relaxed feeling when the massage is completed.
• Repeat the above steps on the client’s other hand.
• Teach steps to the client for self-massage. Rationale: The client can perform this massage whenever he or she feels stressed.
• Document the procedure on the client’s record. Rationale: Documentation provides communication and promotes continuity of care.
Tape the loose ends, to ensure that the floss will remain in place.) A notch cut in the center of the toenail also will cause nails to grow toward the center. This will pull in edges and corners. People who jog or walk a great deal often have thickened toenails, especially on their great toes. Thickened and raised nails can also be a sign of fungal infection. (A nail polishlike medication is available to treat fungal infections, as are creams and systemic medications.)
Nursing Alert Cutting into the corners or rounding the corners of toenails contributes to the development of ingrown toenails. This condition is painful and may become serious enough to require surgical removal.
FIGURE 50-2 • Observe the client’s toenails for abnormalities. Do not cut toenails if you have any concerns or questions.
While caring for toenails, observe whether corns or calluses are present on the client’s feet. If so, apply oil or lotion to soften them, but nothing else. If the client is distressed by corns, calluses, ingrown toenails, hammer toes, bunions, or other difficulties, report the condition (Fig. 50-2). Corns and calluses may become infected if the client tries to remove them by cutting them or by using corn removers that contain salicylic acid. Cover an infected area with a sterile dressing. Any additional treatment must be ordered by a physician. Also, observe for thickened, yellowed, or deformed toenails. Be sure to report and document any problems. See In Practice: Nursing Procedure 50-5.
Foot Soak
A foot soak is of particular importance to the client who has edema, tenderness, or some form of foot infection. Soak the foot in warm water or in a variety of commercially prepared salts (e.g., Epsom salts) and solutions as ordered. Dreft or another mild detergent is often used. Rationale: Warm water helps dilate blood vessels to promote improved circulation and relaxes the feet and legs. Salts and detergents contain medications or chemicals that the skin can absorb during soaking.
The length of time for a foot soak varies. In Practice: Nursing Procedure 50-6 lists the steps for giving a foot soak.
SHAVING
Most adult men shave daily. Clients who are unable to shave every day may feel or look untidy. Many healthcare facilities use electric razors because they are easier and safer to use than blade razors. If the client can shave without assistance, prepare the equipment, provide a mirror, and see that the room is well lighted. Allow as much privacy as possible for clients to carry out this part of their care.
If the client cannot shave without assistance, it is up to the nurse to provide needed assistance. Be sure to allow the client to do as much as possible for himself or herself. When using an electric razor, read the instructions carefully. Most healthcare facilities use a special shaver with a detachable head, to help prevent the spread of microorganisms. Each client uses his or her individual shaver head. Clean the shaver head and the razor after each use. Detach and mark the shaver head with the client’s name and keep in a safe place for the next use.
When shaving a client with a safety razor (blade razor), follow the facility’s recommended procedure. Be sure to follow Standard Precautions to reduce the risk of exposure to the client’s body fluids, particularly if the client’s face or neck could be nicked accidentally during shaving. Follow the steps in In Practice: Nursing Procedure 50-7 for shaving both men and women.
In some cases, the healthcare provider orders the client to be shaved before surgery or another procedure. This surgical scrub and shave is usually done in the Operating Room (OR) preparation area. If not, the nurse will require special instructions in the procedure.
Nursing Alert If your healthcare facility uses disposable blade razors, take extra precautions. Do not allow a client with unsteady hands or poor eyesight to shave with a blade razor. Also closely supervise clients who are depressed, suicidal, or assaultive. Use the sharps container for disposal of any shavers, detachable shaver heads, or blades.
Key Concept Some women have excessive facial hair (hirsutism) and may wish to shave.This may be embarrassing for them. Be sensitive to the client’s feelings.
HAIR CARE
Hair care is part of daily care, whether the client is in the hospital, the long-term care facility, or his or her own home. It helps keep the hair in good condition and makes the person feel better. Encourage clients to do as much of their own hair care as possible. This provides exercise and diversion, helps a client to achieve his or her desired hair style, and adds to the client’s self-esteem. Daily hair care varies with the type of hair.
Daily Hair Care
Some healthcare facilities, such as long-term care and rehabilitation facilities, have in-house beauty parlor and barber services. Although time is usually not available to provide elaborate hair styles for clients in the healthcare setting, try to style the hair as becomingly as possible in the time allotted. The client’s family will often assist in this process.
Some clients prefer to shave their heads, especially when in the hospital for some time. It is important for the person shaving the head to be very careful to prevent cutting or nicking the scalp. Some clients rub oil on their heads after they have been shaved to restore the natural oils of the scalp.
Some people have more oil on the shaft and ends of the hair than others. On the other hand, many people have very curly, dry hair. This includes hair that has been permed, relaxed, colored, or damaged in some other way. Some illnesses also contribute to dry or damaged hair. Very dry hair is more susceptible to breakage than oily hair. The curliness and texture of certain types of hair makes it difficult for the natural oils of the scalp to work their way to the ends of the hair. These types of hair are also more likely to tangle. In Practice: Nursing Care Guidelines 50-5 includes a number of procedures that are performed when caring for a client’s hair, as well as special considerations when caring for clients with oily, dry, or very curly hair.
Shampoo
A shampoo may be needed after lotions or other medications have been applied to the scalp; after an electroencephalogram for which a paste is used; or for cleanliness on admission or during a long-term illness. A shampoo may also be part of the treatment for lice (pediculosis) or dandruff (seborrheic dermatitis) or to remove foreign objects, such as glass or debris following a motor vehicle accident.
Giving a Shampoo to an Ambulatory Client
For the client who is ambulatory, the simplest method of shampooing is for the client to shampoo during a shower or bath. If a client cannot shampoo his or her own hair but can ambulate, he or she can have a shampoo in the bathroom, using the lavatory sink. Choose a chair at a level that allows the client’s head to rest comfortably on the bowl’s edge. Be sure to pad the edge of the bowl with towels. The person may prefer to sit facing the sink, resting the forehead on the edge and holding a folded towel over the eyes. If using a spray, adjust the water’s temperature before beginning. If the client feels light-headed or faint, stop the procedure, wrap the client’s head in a bath towel, and help him or her back to bed.
The client who can be moved on a wheeled stretcher can be moved to a convenient sink for a shampoo. The shampoo is done while the client lies on the stretcher with the head near the edge of the sink. Use a trough to funnel the water back into the sink.
Giving Hair Care After an Accident
A client may come into the healthcare facility after an accident with dirt, blood, or glass in the hair. If no scalp wounds are apparent, the client’s hair will usually be shampooed. An order from the primary healthcare provider for the first shampoo is required. If the client is able, a regular shampoo can be done in the shower or the bathroom basin. If the client cannot tolerate a regular shampoo, a product, such as the Shampoo Cap, is used (see Nursing Procedure 50-8).
The shampoo removes debris from the hair and makes the client more comfortable. Performing a shampoo also provides the nurse with the opportunity to examine the client’s hair and scalp further. Gloves must be worn until it is determined that no lesions, debris, or other conditions are present. Wear gloves if you have any question.
Comb the hair carefully first; this helps to remove larger pieces of debris. At the same time, inspect the scalp for any wounds. If wounds or lesions are discovered, check with the team leader or primary healthcare provider before continuing.
Nursing Alert It is important to document carefully any debris found in the hair, particularly in the case of an assault, an accident, or other insurance case. The physician or caregiver may instruct you to save any debris removed from the hair If in doubt, save the debris. Label any debris carefully and seal it in a plastic bag.
IN PRACTICE :NURSING CARE GUIDELINES 50-5
CARING FOR HAIR
General Procedures
• Ask each client about personal preferences. Rationale: The client can give you guidelines about how his or her hair should be cared for and styled.
• The nurse provides daily hair care as a part of routine personal hygiene. Rationale: This gives the nurse an opportunity to examine the client’s hair and scalp.
• Follow the direction of the client or the general guidelines for the type of hair as to the daily or routine care to be given. Rationale: It is important not to damage the hair.
• Short hair should receive the same care as long hair
• If the client has scalp lesions, pediculosis (lice), foreign objects in the hair (e.g., glass), or excessively dirty or matted hair, wear gloves. Rationale: This helps to prevent the transmission of pathogens and protects the nurse.
• Be sure your fingernails are short and clean. Rationale: It is important not to scratch the client or transmit pathogens.
• Wash the client’s comb, hair pick, or brush regularly, Rationale: This helps to keep the hair clean and prevents reinfection or reinfestation of the scalp in infectious conditions or pediculosis.
• Comb one lock of hair at a time, holding the lock firmly and leaving it slack between your hand and the client’s head. Rationale: This helps to avoid pulling.
• Avoid using hairpins or bobby pins. Rationale: They may be uncomfortable and may injure the client’s head while lying in bed. These items also may interfere with surgery and/or tests and treatments, such as electroconvulsive therapy (ECT), electroencephalograms (EEG), or magnetic resonance imaging (MRI).
• Report and document any adverse condition, such as excessive dandruff, loss of hair, split ends or other damage, breaking hair, lice, crusts, or any lumps or lesions. Rationale: Documentation and reporting provide communication and promote continuity of care.
Care of Long Hair
• Long hair is often braided. Rationale: This helps to prevent tangles when the client lies on the hair and moves about in bed.
• Start braids toward the front and keep them toward the side. Rationale: This helps the braids to be more comfortable when the client lies in bed. If they are started in the back of the head, the client must lie on them.
• Fasten braids with a "scrunchie” or ribbon instead of rubber bands. Rationale: Rubber bands can pull or break hairs. Also, clients may be allergic to latex (rubber bands).
Care of Oily or Semioily Hair
• Daily brushing is helpful. Rationale: This stimulates scalp circulation and distributes oil over the hair to give it sheen.
• The hair is often shampooed every day or two. Rationale: This helps remove excess oils.
• A male (or female) client with long hair may wish to have a ponytail. This may be held to one side. Rationale: This helps keep the hair
from tangling. Placing the ponytail on the side makes it more comfortable when lying in bed.
• A hat or scarf is usually not worn on the head. Rationale: This increases oiliness.
Care of Very Dry or Very Curly Hair
• Brushing is usually contraindicated. Use a wide-toothed comb, with teeth rounded on the ends and without seams. Rationale: The brush is likely to catch and break the hair. The specific comb (or hair pick) described here is least likely to damage the hair.
• For the client in bed, or when preparing to go to bed, section off and braid the hair, tie it back, or wrap it. A ponytail is usually not advised. Rationale: Braiding or wrapping helps avoid tangles; tangled hair is more likely to break. The ponytail adds weight and can cause damage to dry hair.
• Some clients wear woven braids or other hair styles in which the hair is twisted or braided in very tight, small braids close to the scalp. These hairstyles are relatively easy to maintain and are left in place for a number of days. However when these hairstyles are combed out and replaced, an effort should be made to vary the placement of braids. Rationale: This helps to avoid constant pulling on the same sections of hair.
• When in bed, the client may wish to wear a satin scarf, sleep cap, or to use a satin pillow case. Rationale: This allows the head to move about (by sliding) without catching, helping to avoid tangles and breakage.
• The client may wish to wear a hat, cap, scarf, or head wrap when out of bed. Rationale: This helps to retain oils.
• Wash the hair only about once a week or less often. Avoid alcohol-based products. Use little or no heat when drying the hair Rationale: It is important not to increase dryness of the hair.
• Use a specific hair grooming product, such as shea (pronounced: she) butter or jojoba oil, olive oil, or sunflower oil. Some sort of oil is usually added to the scalp regularly A daily moisturizer is often used. Woven braids, cornrows, and dreadlocks require regular oil application. Rationale: These products help moisturize the hair naturally and help to avoid breakage.
• Avoid using petrolatum (Vaseline) or mineral oil to groom the hair, if possible. Rationale: These products plug the pores of the scalp and restrict the release of natural oils.
• If the client is perspiring, rinse the salt out with water but do not use shampoo. Rationale: This will cleanse the hair of salt and add moisture, without drying the hair.
• Use leave-in conditioner with each shampoo. Use specific shampoo for dry hair Rationale: These products help retain moisture.
• Pat the hair dry; do not rub. Rationale: Rubbing encourages hair breakage.
• Massage the scalp daily Rationale: This encourages the release of oils.
Using the Shampoo Cap
A product called a Shampoo Cap is available and it is very handy for the client who cannot get out of bed for a shampoo. It is also very valuable when caring for a client who is uncooperative or who has severely matted or very dirty hair.
(In some cases, a shampoo must be forced, for health reasons. In this case, it is much easier to use a Shampoo Cap than to try to force a shampoo with water.) The cap is safe for all types of hair because it contains conditioner, as well as shampoo. Following an accident, if there is glass or other debris in the hair, the Shampoo Cap can be used as a fairly safe means to clean the hair and head. A provider’s order is required for this use, and the cap is left in place without the usual massage. In Practice: Nursing Procedure 50-8 describes the use of the Shampoo Cap.
Nursing Alert If there is any debris in the client’s hair do not massage the Shampoo Cap. Leave it in place for a longer time and then gently comb the hair to remove debris. Rationale: If glass, rocks, or other debris is in the hair, massaging may damage the scalp.
The Bed Shampoo
In most cases, the client who is immobile is given a shampoo using a product such as the Shampoo Cap or a dry shampoo that can be brushed out. In very rare cases, or in home care, the client may require a shampoo in bed. In Practice: Nursing Procedure 50-9 briefly describes the process of a bed shampoo. Consult the protocol of your facility if you are required to perform this procedure. Usually, a provider’s order is not required for a bed shampoo. Check if you are unsure.
