1. No category

PERSONAL TOE NAIL CARE ON THE
WARDS AT CHELTENHAM GENERAL
AND GLOUCESTERSHIRE ROYAL
HOSPITAL
ALL YOU NEED TO KNOW
Produced by
Gloucestershire Podiatry Services
Gloucestershire Care Services
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CONTENT:
Chapter 1: Introduction
Chapter 2: Podiatry
Chapter 3: Consent
Chapter 4 Foot Assessment
 Assessing the feet to determine the level of foot care required
 Foot Pathologies/Problems
 Diabetic Foot
 Contra indications and their relevance to foot care
 Inpatient Foot Care Pathway
 Inpatient Podiatry Service & Referral Form
Chapter 5: Personal Toe Nail Care
 Structure of a Toe Nail
 How to Cut Toe Nails
 How to File Toe Nails
Chapter 5: Infection Control
 Nail Care Instruments & CSSD
 Infection Control Procedures
 Hand Decontamination
Chapter 7: First Aid
Chapter 8: Manual Handling
Chapter 9: Record Keeping
Chapter 10: Foot Health Options Following Discharge
 Referring to Podiatry Department
 Referral Forms for Podiatry
 Personal Toe Nail Care Agency Fairford League of Friends
 Referral Forms for Personal Toe Nail Care Agency
Chapter 11: Foot Care Advice
 How to Look After Your Feet
 Advice on Hosiery
 Advice on Footwear & Shoe Fitting
 Footwear Fitting Referral Form
 Foot health Advice for Chair Bound Individuals
 Foot health Advice for Bed Bound Individuals
 Foot Exercises
Chapter 12: Contact Numbers
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CHAPTER 1: Introduction
Foot-Care For Healthcare Providers
As a Healthcare provider you will only be expected to provide personal toe nail care to the
feet of your patients. It is well known that the quality of life is improved if the feet are well
cared for.
The aims and objectives of this training package are:
To be able to assess an individual and determine the correct level of care required
and if necessary refer them to the Podiatry Service.
How to complete the Inpatient Podiatry referral form.
To carry out basic nail care safely and with confidence using best practice
To ensure the same level of Personal Nail Care is provided across GRH & CGH sites
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CHAPTER 2: What Is Podiatry?
Podiatry (pronounced PO-DIA-TREE) is the new name for Chiropody and Foot Health
Related Services.
NHS Chiropodists have also changed their name to Podiatrist.
Why The Change To Podiatry?
There are many reasons for the change:
All Podiatrists in the NHS have to graduate with a degree in Podiatry or Podiatric
Medicine. This degree allows them to become registered with the Health and Care
Professional Council (HCPC), a prerequisite for employment in the NHS.
In Gloucestershire foot-care services have changed dramatically over the last few years.
NHS foot-care provision is now based on medical and/or podiatry needs.
The traditional chiropody service role of just cutting peoples toenails no longer exists.
Every NHS Podiatrists is trained in advanced techniques such as use of local
anaesthesia, minor surgery, gait analysis, manufacture of insoles/orthoses, and
management of the ‘high risk’ foot e.g. Diabetes, Rheumatoid Arthritis.
What Does The Podiatry Service Specifically Offer?
Advice on all medically related foot health problems
Assessment of all medically related foot health problems
Courses of treatment with a Podiatrist registered with the HCPC.
treatment will be agreed with you in the form of a treatment plan.
Each course of
Treatments to keep chronic foot problems comfortable and patients mobile.
Full annual assessment, advice and treatment services for people deemed to be at ‘high
risk’ e.g. Diabetes, Rheumatoid Arthritis, Poor Circulation.
Minor surgical service specifically for the condition of ingrown toenails.
Podiatric Surgery
Gait analysis for those patients who experience pain in feet, legs, back brought on by a
biomechanical anomaly in their feet or gait.
A full orthotic service to support the gait analysis programme.
A fully comprehensive Foot Health Promotion Service
Footwear Advice & Fitting Service
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CHAPTER 3: Consent
Consent is the principle that a person must give their permission before they receive
any type of medical treatment.
Consent is required from a patient regardless of the type of treatment being given, from a
blood test to an organ donation.
The principle of consent is an important part of medical ethics and the international human
rights law.
Defining Consent
For consent to be valid, it must be voluntary and informed, and the person consenting must
have the capacity to make the decision. These terms are explained below.
Voluntary: the decision to consent or not consent to treatment must be made alone,
and must not be due to pressure by medical staff, friends or family.
Informed: the person must be given full information about what the treatment
involves, including the benefits and risks, whether there are reasonable alternative
treatments, and what will happen if treatment does not go ahead. Healthcare
professionals should not withhold information just because it may upset or unnerve
the person (see below).
Capacity: the person must be capable of giving consent, which means they
understand the information given to them and they can use it to make an informed
decision. Read about assessing the capacity to consent.
If the person has enough capacity and makes a voluntary and informed decision to refuse a
particular treatment, their decision must be respected. This is still true even if their decision
would result in their death, or the death of their unborn child.
How to Give Consent
Consent should be given to the healthcare professional directly responsible for the person's
current treatment, such as the nurse arranging a blood test, the GP prescribing new
medication, or the surgeon planning an operation.
It can be given:
verbally
non-verbally – e.g. raising a hand to indicate they are happy for a nurse to take a
blood sample
in writing – by signing a consent form
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If a person is going to have major medical intervention, such as an operation, their consent
should be obtained well in advance so they have plenty of time to study any information
about the procedure and ask questions.
Withholding Information
To consent to a treatment or procedure, the person needs to be fully informed about the
treatment and understand why it is considered necessary.
Healthcare professionals should not withhold information just because it may upset or
unnerve the person. Even if the person specifically requests not to be told about the extent
or likely outcome of their condition, the healthcare professional has a moral and legal
responsibility to provide them with at least:
a basic overview of their condition
the likely outcome of their condition
their treatment options
When Consent is Not Necessary
There are a few exceptions when treatment can go ahead without consent.
One main exception is if a person does not have the mental capacity (the ability to
understand and use information) to make a decision about their treatment. In this case, the
healthcare professionals can go ahead and give treatment if they believe it is in the person’s
best interests.
Further Reading
http://www.nhs.uk/conditions/Consent-to-treatment/Pages/Introduction.aspx
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CHAPTER 4: Foot Assessment
An assessment of the feet must be made to determine the level of foot care
required.
For a Foot Assessment:
1 Look at :Nails – e.g. long, short, thickened, infected, in-growing
Pathologies – e.g. corn, callous, ulcers, clawed toes
Circulation – e.g. oedema, ischemia
Skin – e.g. normal, dry, thin, shiny
2 Review Medication – e.g. anticoagulants, steroids,
immunosuppressant's
3 Review Medical History – e.g. Diabetes, Immunosuppessed, PVD
Assess each foot in its entirety noting any foot pathologies or abnormalities.
Dorsum (top) of Foot
Nails
Toes
and
Interdigitally
Heels
Plantar aspect (bottom) of foot
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FOOT PATHOLOGIES
1.
Corns and Callus (Hard Skin)
This is where the skin has become thickened due to excessive pressure or friction. It is
most often due to poorly fitting footwear/hosiery.
If these problems are present they can be eased by gently rubbing with a pumice stone or
file, and moisturising the feet regularly.
Never use corn plasters or liquids.
Check the fit of the shoe and hosiery.
If callus or corns become painful, or inflamed see a Podiatrist Registered with the Health
and Care Professional Council (HCPC).
2.
Fungal Infections of Skin and Nails
Fungal infections of the skin usually present as itchy, red and flaky areas commonly
between the toes.
Presentation in the nails can be variable but commonly causes
thickening and discolouration of the nail plate.
To treatment of fungal infections of the skin, the feet must be kept clean by washing at least
once a day and drying well. Antifungal creams and sprays can be purchased from
Pharmacy’s. Use as per manufacturers instructions.
Treatment of fungal infections of the nail – creams will not penetrate the nail plate so tablets
have to be taken for at least a three month period or lacquers can by used but this is a long
process that does not have any guarantees.
3.
Verrucae (Warts)
These are very uncommon in the older foot.
Verrucae occur by a virus entering the skin. For this to occur the skin needs to be in a
susceptible state. It is best not to treat but to let nature take its course and allow the bodies
own defences to fight the virus.
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4.
Bunions and Clawed Toes
Bunions are a hereditary condition that can be exacerbated by footwear. Toes claw due to
weakening of the foot muscles. Ill fitting footwear can increase problems related to bunions
and clawed toes.
5.
Cuts and Grazes
These must be washed with warm, salty water, dried with a clean tissue and covered with a
plaster. Plasters must be removed after a maximum of three days.
6.
Fissures (Skin Cracks)
These can appear especially around the heels when the skin is very dry.
To ease the discomfort; gently use a file or pumice to remove any roughness, moisturize the
skin twice a day and try to prevent pressure on heels when sitting down, or lying in bed.
7.
Chilblains
These are best avoided by keeping the legs and feet warm by wearing extra layers of
clothing. It is better to wear two layers of thinner socks/stockings, than one thick pair.
Avoid tight shoes/stockings and warming feet too quickly e g. by toasting in front of the fire,
by using hot water bottles directly on the feet or by very hot baths.
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DIABETIC FEET
It is very important that people with diabetes take great care of their feet, as they may be at
risk of damage to their circulation (vascular disease) and/or damage to the nerves, leading
to reduction in sensation (neuropathy) in the feet.
CIRCULATION
The blood vessels that supply the leg and the foot may become narrowed or blocked
leading to problems with walking distances (claudication - when the muscles ache to the
extent that the individual has to stop and rest). This may also affect the healing of wounds,
and could lead to ulceration of pressure points.
NERVES
A wide range of symptoms may result from diabetic nerve damage including:
- Painful feet
- Numbness
- Creepy crawly feelings
- Muscular weakness
- Toe deformity
- and/or a combination of all of the above.
A reduction in the sensation in one’s feet means that an individual may
not be aware if they injure their feet and further problems can occur.
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FOOTCARE RULES FOR PEOPLE WITH DIABETES
1.
INSPECT THE FEET DAILY
Check between the toes
Around the heel
Under the foot
Checking for cuts, bruises, foreign bodies, swellings, hot spots or anything out of the
ordinary
If the person can’t see the bottom of their feet get someone else to check them or use
a mirror
If a problem is found make an appointment with a Podiatrist,
Practice Nurse or Doctor immediately
2.
CHECK FOOTWEAR
Check fit
Check inside for foreign objects
Feel inside for rough seems, loose linings, damaged insoles
Check soles of shoes for damage or foreign objects
3.
NEVER WALK BAREFOOT!
4.
AVOID EXTREMES OF TEMPERATURE
Avoid any direct source of heat on your feet, e.g. Hot water bottles, radiators, hot
sand or concrete, bath water.
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ASSESSING MEDICAL HISTORY
Patients who suffer from the following MEDICAL CONDITIONS,
toe nails should NOT be cut ONLY filed by you.
If further care is required refer to In-patient Podiatrist.
Anyone with Diabetes (At Risk)
Definition: - Person has an increased risk of complications such as ulceration and
infection if attempted treatment leads to a breach of skin.
Anyone with an Infection
Definitions:The pathological state resulting from the invasion of the body by pathogenic micro
organisms.
Invasion and multiplication of germs in the body. Infections can occur in any part of
the body, and can be localized or systemic (spread throughout the body). The germs
may be bacteria, viruses, yeast, or fungi. They can cause a fever and other
problems, depending on the site of the infection. When the body's natural defence
system is strong, it can often fight the germs and prevent infection.
The state or condition in which the body (or part of the body) is invaded by an
infectious agent (eg, a bacterium, fungus or virus), which multiplies and produces an
injurious effect (active infection).
Invasion and multiplication of micro organisms in body tissues, which may be
clinically in-apparent or result in local cellular injury due to competitive metabolism,
toxins, intracellular replication, or antigen-antibody response. The infection may
remain localized, sub clinical, and temporary if the body's defence mechanisms are
effective. ...
Anyone with Neuropathy
Definition:- Damage or degeneration of the peripheral nerve, supplying the lower limb,
displaying a mixture of sensory.
Anyone with Impaired Circulation
Definition:- Conditions of the circulatory system that may result in an increased risk of
ulceration and increased healing time.
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Anyone who is Immunosuppressed
Definition:- Patients with a compromised immune system are not able to mount the body’s
normal response to pathogenic microorganisms.
Congenital e.g. Chronic granulomatosis
Acquired disease e.g. HIV, endocrine disease (diabetes), auto-immune disease, some
blood disorders (leukaemia) miscellaneous (burns).
Anyone with Anti-Clotting Disorders
Definition:- Bleeding disorders is a general term for a wide range of medical problems that
lead to poor blood clotting and continuous bleeding.
When someone has a bleeding disorder they have a tendency to bleed longer. The
disorders can result from defects in the blood vessels or from abnormalities in the blood
itself. The abnormalities may be in blood clotting factors or in platelets.
E.g. Haemophilia A (Factor VIII Deficiency), Haemophilia B (Factor IX), von Willebrand
disease
Kawasaki Disease
Definition:- A rare condition that mainly affects children under the age of five. It is also
known as mucocutaneous lymph node syndrome.
Kawasaki disease causes the blood vessels to become inflamed and swollen, which
can lead to complications in the coronary arteries (the blood vessels that supply blood to the
heart).
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ASSESSING MEDICATION
Patients who are taking the following MEDICATIONS, toe nails
should NOT be cut ONLY filed by you.
If further care is required refer to In-patient Podiatrist.
Anyone taking Anticoagulants
Definition:- Individual would be at risk of considerable blood loss if attempted treatment
led to breach of skin.
Some medical conditions increase the likelihood of defective platelet function eg,
leukaemia, thrombocytopenia.
NB. Doses of less than 300mg Aspirin are insignificant with regards to reduced
clotting. Always check dose in medical records.
Anyone who is Immunosuppressed
Definition:- Patients with a compromised immune system are not able to mount the body’s
normal response to pathogenic microorganisms.
Drug induced e.g. Various drugs used in oncology, transplantation, auto-immune
disease, rheumatology, dermatology, palliative care, myasthenia gravis, severe asthma
Anyone taking Steroids
Definition:- Long term oral steroid use can lead to thinning of the skin and
immumosupression.
Anyone your are not sure of/or you do not feel confident to treat
REMEMBER YOU CAN FILE ANYONE’S TOE NAILS
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Inpatient Foot Care Pathway
ASSESS IF PATIENT NEEDS OR PATIENT REQUESTS FOOTCARE
Obtain Consent From Patient To Undertake A Foot Assessment
No Consent = No Assessment
NAILS ONLY
FOOT PATHOLOGY
e.g. Corns/Callous/Ulcer
CAN YOU CARRY OUT TREATMENT
YES
REFER TO INPATIENT
PODIATRIST
NO
CHECK PATIENTS NOTES FOR ANY
CONTRAINDICATIONS
e.g. Warfarin, Steroids etc
YES
COMPLETE INPATIENT
REFERRAL CGH/GRH FORM
REF: GHNHSFT/Y1140/07_13
NO
CGH INPATIENT PODIATRY
Fax 01242 215479
St.Paul’s Medical Centre
Podiatry Department
Attention of Podiatry Team Secretary
Please DO NOT contact Podiatry
Department, West Block
Outpatient Department, CGH)
OBTAIN CONSENT
YES
GRH INPATIENT PODIATRY
Fax 0300 422 8396
Or Internal Post to Podiatry GRH
Reception
NO
TREAT PATIENT
DO NOT TREAT PATIENT
RECORD REFUSAL IN
PATIENTS HOSPITAL NOTES
RECORD TREATMENT IN PATIENT’S HOSPITAL NOTES IN THE GENERAL MEDICAL SECTION AND
INCLUDE CSSD LABEL AND COMPLETE CSSD WARD LOGBOOK
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INPATIENT PODIATRY
Cheltenham General Hospital
Inpatient Podiatrist visits to Cheltenham General Hospital will be on a Friday. The Inpatient
Podiatrist is Sarah Trotman.
To refer a patient for Inpatient Podiatric Treatment:1. Nursing staff to identify inpatients foot care needs either Personal Toe Nail Care by
ward staff or referral to Podiatry.
2. Gloucestershire Podiatry Services Application for Inpatient Treatment CGH and GRH
Form (GHNHSFT/Y1140/07_13) Section 1 must be completed in full (a copy of this
form has been included in this booklet for your reference).
3. Referral Forms must be completed and sent in advance by fax to the Podiatry
Department, St Paul’s Medical Centre for the attention of the Podiatry Team
Secretary. (Please DO NOT contact Podiatry Department, West Block Outpatient
Department, CGH)
4. Incomplete or incorrect forms will be returned to the ward which will result in a delay
in treatment.
Gloucestershire Royal Hospital
Inpatient Podiatrist visits to Gloucestershire Royal Hospital will be on a Wednesday. The
Inpatient Podiatrist is Anna Van-Weegen.
To refer a patient for Inpatient Podiatric Treatment:1. Nursing staff to identify inpatients foot care needs either Personal Toe Nail Care by
ward staff or referral to Podiatry.
2. Gloucestershire Podiatry Services Application for Inpatient Treatment CGH and GRH
Form (GHNHSFT/Y1140/07_13) Section 1 must be completed in full (a copy of this
form has been included in this booklet for your reference).
3. Referral Forms must be completed and sent in advance via internal post or fax to the
Podiatry Department at Gloucester Royal Hospital.
4. Incomplete or incorrect forms will be returned to the ward which will result in a delay
in treatment.
If the proposed date of a visit needs to be altered for any reason other than illness the
wards will be informed.
In the event the visit needs to be cancelled (due to illness) the wards will be informed as
soon as possible.
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If more referrals are submitted than there is time to treat, the Podiatrist will initially triage
referral forms and prioritise based on medical history, medication and foot care needs and
will consult with nursing staff.
If you have submitted an application for inpatient podiatry for a patient and they are
subsequently discharged before they have seen the inpatient podiatrist we will endeavour to
send an appointment to attend one of the Podiatry Outpatient Clinics.
However, if the patient is already registered for the Podiatry Outpatient Service we ask that
you advise them to contact the Podiatry Service following discharge to make their own
appointment.
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Application for Inpatient Treatment CGH and GRH Referral Form
(GHNHSFT/Y1140/07_13)
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CHAPTER 5: Personal Toe Nail Care
NAILS
Nails acts as a protective plate and enhance sensation.
The nail plate is made of a protein called Keratin.
The structure is made of thin strips with ridges and grooves on either side that closely
adhere to each other.
This structure gives the nail plate its immense strength whilst remaining a thin plate.
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THE STRUCTURE OF THE NORMAL TOENAIL
A
B
C
D
E
F
G
H
A.
B.
C.
D.
E.
F.
G.
H.
Free margin of the nail
Point of separation of the nail plate from the nail bed (Hyponychium)
Nail plate made of the protein Keratin protecting the vascular bed
Sulci
Lunula
Cuticle
Eponychium
Skin overlapping posterior nail fold (matrix)
The free margin of the nail (A) is the only part of the nail plate to be touched.
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.
NAIL CARE
How to Cut Toe Nails
Only cut the free edge of the nail.
Always follow the shape of the toe.
The cut nail should be the same length as the toe.
Hold the toe between the thumb and middle finger, use the second finger to place
over in front of the nippers to prevent nail flying at you.
If the nails are very long – place a finger on the nail plate to stop the nail lifting when
cutting.
Cut a small piece of nail at a time to prevent chipping or cracking the nail plate.
Never cut down into the sulci of the nail – this can lead to infections or ingrowing toe
nails.
How to File Toe Nails
Everyone can and should have their toe nails filed
For best results always file the nails before you wash your feet or have a bath or
shower, when the nails are dry.
The aim is to maintain your nails at the same length as your toes so lessening the
need to cut the toe nails.
Toe nails should only be filed in one direction.
File across the top of the toe, resting the file on the toenail and pushing away from
the individual. This ensures that the nails are kept to the same length as the toe.
If the toenail grows thick then file the nail over the top of the nail plate to help keep it
level with the toe.
Remember: a little attention given frequently always gets the best results!
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FAMILY PARTICIPATION
Encourage the family to be proactive in finger and toe nail care.
Advise and encourage the family to be proactive with foot hygiene and looking after
their relative’s feet.
ANYONE CAN AND SHOULD HAVE THEIR NAILS FILED
.
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CHAPTER 6: Infection Control
Instruments Used For Nail Care
Nail nippers (5” spring loaded)
Diamond Deb Footdresser
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INFECTION CONTROL
Instruments and Central Sterile Service Department (CSSD)
Cold sterilisation is no longer an acceptable way of cleaning nail cutting equipment and all
instruments should be sent directly to CSSD following use.
Immediately following use, the nail cutting equipment should be:
-
wrapped back in the paper it was removed from.
the packs should be placed in a clear plastic bag inside the red box.
the red box should be sent directly to CSSD for autoclaving.
once sterilised the instruments will be kept by CSSD.
the turnaround for instruments should be 24hrs, depending on transport.
instruments are kept by CSSD in red boxes and are to be collected from CSSD when they
are required by yourselves or via a porter.
For Health & Safety purposes these instruments are sharp and dirty therefore it is
important that they are not left lying around but sent directly to CSSD.
The nail cutting packs supplied by CSSD have TWO self adhesive bar code labels on the
outside of the packaging.
The labels are to ensure a particular set of instruments can be traced if necessary.
IT IS IMPORTANT THAT ONE LABEL IS PUT IN THE PATIENTS NOTES WHERE THE
NAIL CARE PROCEDURE IS RECORDED AND ONE LABEL IN THE WARD CSSD
LOGBOOK.
Example of a Logbook Sheet Section
Nail Care CSSD Ward Log
Cheltenham General Hospital - Ward -………………
Date
Patient ID
26.06.2012
DAVIES
Nail Care Pack Sticker.
Signature
H. Enough
MRN-00055015
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INFECTION CONTROL
To reduce the risk of infection:
Check instruments have been sterilised by CSSD after last treatment
Always wash hands before carrying out the procedure
Wear gloves
Wear a plastic apron
Cover foot stool with a plastic apron before patient rests their foot on it.
Carry out treatment using best practice
Dispose of all waste in the correct bins (orange)
Always wash hands after carrying out the procedure
Wrap instruments up in its paper and place in the clear plastic bag in the red
box and return immediately to CSSD.
Further Reading
Standard Precautions. Safe Working Practices – Clinical Policy Gloucestershire Care
Services - Policy No: CP90k.
Linkhttp://nww.glospct.nhs.uk/C0/C13/INFECTION%20CONTROL%20POLICIES/Document%2
0Library/Standard%20Precautions%20ratified%20May%202011.pdf
Personal Protective Equipment Policy – Clinical Policy Gloucestershire Care Services Policy No: CP90n.
Link http://nww.glospct.nhs.uk/C0/C13/INFECTION%20CONTROL%20POLICIES/Document%2
0Library/PPE%20V2%20back%20from%20author%203.2.11.pdf
Heath, Safety and Environment Policies and Procedures 12. Waste Policy.
Link
http://nww.glospct.nhs.uk/C7/C6/Health%20and%20Safety%20Policies/Health%20Safety%
20and%20Environment%20Policies%20and%20Proc1/Forms/AllItems.aspx
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HAND DECONTAMINATION
Routine/Social Hand Wash
PURPOSE: To reduce the risk of transmission of infection via the hands of staff.
PRINCIPLE: Washing with liquid soap under running water to remove dead skin
scales and transient micro organisms.
Further Reading
Hand Decontamination Guidelines – Clinical Policy Gloucestershire Care Services
- Policy No: CP: CP90e.
Link http://nww.glospct.nhs.uk/C0/C13/INFECTION%20CONTROL%20POLICIES/Docu
ment%20Library/Hand%20Decontamination%20back%20from%20author%203.2.1
1.pdf
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CHAPTER 7: First Aid
In the event that a patient is cut or nicked during the course of treatment, basic first
aid needs to be carried out.
1.
Stop the bleeding by applying digital pressure – preferably using a sterile
swab, clean tissue, or clean towel
2.
Make sure area is clean and dry
3.
Apply an airstrip or a dry dressing (do not wrap tape around the entire
toe as this can restrict circulation)
4.
Record incident in patient records
HOW TO DRESS TOES
APPLYING TUBIGAUZE
1. Tubigauze needs to be 2½ times the length of the toe.
2. Open tubigauze and place over toe and dressing.
3. Twist the excess tubigauze 1½ times at the apex of the toe
4. Open the other end of the tubigauze and fold back over the toe
5. Tape in place using mefix
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NEVER tape/strap around the toes:
for 1st and 5th toes shape mefix into a banana shape
NEVER tape/strap around the toes:
for 2nd, 3rd and 4th toes shape mefix into mushroom shape
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CHAPTER 8: Manual Handling
YOUR BACK IS FOR LIFE NOT JUST FOR WORK
Please ensure a good posture when carrying out nail care on patients.
Remember to move to the best position for you either in front of or to the side of
the patient, do not twist or slouch.
If treating a patient in bed:
 if they have an electronic bed raise it until it is at the correct height for
you
 best positions are either to kneel on one or both knees or to stand with
knees slightly bent
 remove the bed base to allow easy access to the feet
If the patient is in a chair:
 Get the patient to/or help them put their legs on a footstool. If a patient
cannot help to raise their legs, only lift one leg at a time (they can be a
dead weight) and support the leg by placing one hand behind the calf
and the other at the back of the ankle.
 You can either kneel or sit on another footstool in front of them. It is
more comfortable to have something to kneel on a pillow, cushion or
kneeling pad.
 NEVER put the patients foot on your knee;
It is a heavy weight and will restrict your movements
You will be trapped and unable to move quickly if you need to.
You will need to slouch to treat the patient (bad posture)
Further Reading
Heath, Safety and Environment Policies and Procedures 15. Moving and Handling
April 2012
Link http://nww.glospct.nhs.uk/C7/C6/Health%20and%20Safety%20Policies/Health%20Safety%20and%
20Environment%20Policies%20and%20Proc1/Forms/AllItems.aspx
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GUIDELINES FOR PERSONAL TOE NAIL CARE PROCEDURE
FOLLOWING PATIENT ASSESSMENT
DOES THE PATIENT GIVE CONSENT
No
Yes
IS INSTRUMENT CSSD PACK
STERILISED
No
RECORD PATIENTS
REFUTED TREATMENT IN
NOTES
NAIL KIT TO GO TO
CSSD FOR
STERILISATION
Yes
WASH AND DRY HANDS
PUT ON GLOVES AND APRON AND COVER
FOOT STOOL
GET IN THE BEST POSTURAL POSITION
CARRY OUT NAIL CARE
DISPOSE OF WASTE
WASH & DRY HANDS
RECORD TREATMENT IN PATIENTS HOSPITAL NOTES INCLUDE DATE, TREATMENT CARRIED
OUT (AND ANY ADVICE GIVEN), SIGNATURE AND 1 CSSD LABEL
PUT 2ND CSSD LABEL IN THE WARD CSSD LOGBOOK
TAKE INSTRUMENTS TO CSSD FOR STERILISATION
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CHAPTER 9: Record Keeping
All patient records are legally binding documents and as such some rules should
be adhered to:
Treatment must be recorded in the patients hospital notes ideally in the
General Medical Section
Notes MUST be dated and timed
Notes MUST be recorded in black ink.
Any mistakes should be crossed out with a single line.
What should be recorded is:
Consent obtained for treatment
Foot assessment completed
Nails cut and filed or nails filed
What advice if any was given
Notes must be signed with full signature NOT just initials
If consent to treat is not obtained this should also be recorded in the patient
notes and signed
Example of Written Notes
GENERAL MEDICINE
Gloucestershire NHS
CLINICAL RECORD
Name:
Hospital Number:
Date of Birth:
Hospital:
Consultant:
(Affix PAS label here)
Date
Clinical Notes
(Each entry must be signed)
29.06.2012
10.00am
Consent refused for foot assessment for nail care. H. Enough
30/06/2012
2.00pm
Ptjkfjlkdsjf ds fljdsa;ojf fjdjf d djkfld j f flkdjf
01/07/2012
11.00am
Consent Obtained. Foot assessed. Nails all cut and filed. Advised patient
to cream feet daily.
Dr Dolittle
H. Enough
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CHAPTER 10: After Discharge Where Next?
On discharge from hospital you may feel that some patients would benefit from
having further help with their foot care.
A patient who was referred for the Podiatry Inpatient Service but discharged before
podiatry treatment could be provided will be able to access the Podiatry Service.
If the patient has had no contact with Podiatry Service we will endeavour to send
them an appointment for an assessment for podiatry treatment.
However, if the patient is already registered with the Podiatry Service they should
be advised to contact the Podiatry Service for a follow-up appointment.
NHS Podiatry Services in Gloucestershire are available to people who have a
specific medical or podiatry need.
Referrals to the Podiatry Department can be made by:
General Practitioners
Practice/District Nurses
Health Care Professionals
Self Referral
NHS Gloucestershire Podiatry Services cannot accept applications or referrals
from people who require foot-care that is of a personal or uncomplicated nature i.e.
personal toe nail cutting.
On discharge from hospital you may feel that some patients would benefit from
having further help with their foot care. There are now two options depending on
the needs of the patient and where they live:
1. The NHS Podiatry Department.
Patients will only be eligible for Podiatry treatment in the NHS if they have a
podiatric and/or medical need for foot care.
2. Fairford League of Friends Personal Toe Nail Cutting Service.
This is available for patients registered with Fairford or Lechlade GP
Practices who do not fit the criteria for Podiatry treatment in the NHS. This
scheme offers patients personal toe nail care by trained Home Care
Assistants.
If you are unsure which referral form you need to complete please remember if
YOU could provide foot care for the patient they may not be eligible for Podiatry
Treatment.
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PROCESS MAP FOR FOOTCARE
Identification of
persons footcare
needs by Health
Professional
Podiatric pathology
eg corns, callus
(could be shared care)
Toe Nail
Care Only
Circulation
Unable to palpate
pulses
N
H
S
P
O
D
I
A
T
R
Y
S
E
R
V
I
C
E
Pulses
palpated
Sensation
Reduced
feeling
Feeling
Intact
T
O
E
Mental Capacity
Intact
Impaired
MEDICATION
- Steroids
- Immunosuppressants
- Anticoagulants (not Aspirin)
Active Leg Ulcer
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P
E
R
S
O
N
A
L
N
A
I
L
C
A
R
E
Gloucestershire Podiatry Services (GPS)
Podiatry Referral
Gloucestershire Podiatry Service (GPS) aims to provide a comprehensive foot health service to the
local population to maintain mobility. Health Promotion underlies all podiatric activity and patients are
encouraged to take responsibility for assisting with their own foot health. Social nail care is not
provided by the GPS.
All areas of this form must be completed.
……………………………….
……………………………….
……………………………….
……………………………….
……………………………….
……………………………….
Postcode
……………………………….
Telephone No...…………………...............
Mobile No. ……………………………….
Title
Surname
Forenames
Address
Are you happy to receive text reminders? Yes/ No
Work No.
……………………………….
Appointments are offered at short notice over the telephone
Date of Birth
NHS No.
Hospital No.
Podiatry No.
……………………………
…………………....... …..
…………………....... ……
…………………….. (office use only)
GP and Code …………………………..
Address
…………………………..
…………………………..
…………………………..
Next of Kin / Chief Carer (where
appropriate)
Name
…………………………..
Address
…………………………..
…………………………..
Postcode
………………………….
Tel. No
…………………………..
Relationship …………………………..
Referred By ………………………….
Self / GP / Other ………………………
Reason For Referral (foot/lower limb problem)
DATE:
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………..
Medical History (please attach full list of current medication)
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
…………………………………………………………………………
Recent Investigation and dates:
Blood test
X-ray /MRI scan
Microbiology
To enable the Podiatry department to offer the most appropriate assessment we require as much information
as possible. If necessary the referral may be returned for additional information.
OFFICE USE ONLY
MRN
Consent Triaged
to text
patient
Date
received
Date Offered Assessment
Date
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Clinic
Gloucestershire Podiatry Services (GPS)
Podiatry Referral
CLINICS OF CHOICE
We aim to offer you an appointment within two weeks. To be able to achieve this we may offer an
appointment in an alternative clinic. Please indicate ALL of the locations you are willing to attend.
Churchdown
Cinderford
Coleford
Dursley
Lydney
Newent
Rikenel – Gloucester
Stonehouse
Stroud
Tetbury
Wotton-Under-Edge
Bourton-on-the-Water
Cheltenham (St Paul’s Medical Centre /
For clinics above please forward
completed form to:-
For clinics above please forward
completed form to:-
The Podiatry Department
Gloucestershire Royal
Hospital
Great Western Road
Gloucester
GL1 3NN
The Podiatry Department
St. Paul’s Medical Centre
121 Swindon Road
Cheltenham
GL50 4DP
Independent Living Centre)
Cheltenham (Hester’s Way)
Cirencester
Fairford
Moreton-in-Marsh
Tewkesbury
Winchcombe
Domiciliary Visit (see below)*
If you have ticked clinics in both columns please send the form to EITHER
address. The Podiatry Department will offer an appointment at the clinic with
the shortest waiting time.
INFORMATION FOR HEALTH CARE PROFESSIONALS
Domiciliary Visiting
Gloucestershire Podiatry Services recognise that there may be a need for some
patients to be seen within their own home.
*Referrals for domiciliary assessment will ONLY be accepted via a letter from
the patients GP. Please include a detailed medical history/medications and eligibility
criteria for the domiciliary visit
Criteria
A housebound patient is classed as a patient who is unable to leave their home
without the need for an assisted escort with Patient Transport Services Ambulance
PTS/ hospital transport criteria C2+
Patients who are terminally ill /end of life.
For further information on Domiciliary criteria please telephone either
0300 422 8131 OR 01242 215470
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PERSONAL TOE NAIL CARE SCHEME
ELIGIBILITY CRITERIA
The object of the service is to provide personal toe nail care for individuals who are
not eligible for NHS Podiatry Treatment – IT IS NOT PODIATRY IN THE HOME.
If the patient suffers with problematic foot pathologies then dual care may be
required. The dual care package consists of the Personal Toe Nail Cutting
Scheme providing regular nail care and Gloucestershire Podiatry Services
providing occasional treatment to deal with problematic foot pathologies.
All participants of the scheme receive a basic foot screening during every visit to
continually assess if any changes occur in their feet e.g. impairments in circulation
and/or sensation or medication.
Individuals who are NOT eligible for Personal Nail Care Schemes are: Individuals with impaired circulation (pulses cannot be palpated)
 Individuals with neuropathy (reduced sensation in the feet)
 Individuals whose cognitive state is impaired to the extent that they cannot
understand or respond to simple instructions
 Individuals residing in nursing or residential homes
 Individuals with an active leg ulcers
 Individuals prescribed any of the following medication:- Steroids
- Anticoagulants (not Aspirin)
- Immunosuppressants
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PERSONAL TOE NAIL CARE SCHEME – REFERRAL FORM
Please state which Agency:
Please complete the form and return the address of the relevant agency on the other side of the page
Date of Referral
Date Referral Received
Mr/Mrs/Miss/Ms/Dr
Surname
Forename
Address
Date of Birth
GP Name & Address
Postcode
Telephone Number:
Name of Referrer
GP Practice Code
Referrers Address
Currently receiving Social Services care?
YES / NO
General Health (please tick appropriate boxes )
Impaired Eyesight
Unable to bend
Impaired Hearing
Frail
Physical Disability (Please specify)
Ethnic Origin
Stiff joints
Thick nails
Confused
Mental Disability (Please specify)
Medical History (Please specify eg. Diabetic, neurological, stroke, leg ulcers, Parkinson’s disease, spinal
injury etc.)
To be completed by Health Care Professionals:
PULSES: are they palpable (please mark + for present and – for absent)
Right Foot
Left Foot
Dorsalis Pedis
Posterior Tibial
Sensation: Please specify if patient has full sensation in feet, or reduced feeling, numbness etc.
Current Medication (Please tick the appropriate boxes)
Anticoagulants
Steroids
To be completed by Podiatrist (Please tick box if appropriate)
Individual to receive dual care with Gloucestershire Podiatry
Services
GPS F11- Standard Referral Form
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Personal Toe Nail Care Scheme
Eligibility Criteria
The object of the service is to provide personal toe nail care– IT IS NOT
PODIATRY.
All participants of the scheme receive a basic foot screening during every visit to
continually assess if any changes occur in their feet eg impairments in circulation
and/or sensation or medication.
Individuals who are NOT eligible for Personal Nail Care Schemes are: Individuals with impaired circulation (pulses cannot be palpated)
 Individuals with neuropathy (reduced sensation in the feet)
 Individuals whose cognitive state is impaired to the extent that they cannot
understand or respond to simple instructions
 Individuals residing in nursing or residential homes
 Individuals with an active leg ulcers
 Individuals prescribed any of the following medication:- Steroids
- Anticoagulants (not Aspirin)
- Immunosuppressants
Personal Toe Nail Care Scheme Address:
Fairford Personal Footcare
South Cotswolds Fairford Hospital
League of Friends
Fairford Hospital, The Croft,
Fairford. GL7 4BB
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CHAPTER 11: Advice
HOW TO LOOK AFTER YOUR FEET
File callus (hard skin) use a nail file or pumice stone before washing feet.
Wash your feet regularly with warm water and soap, do not soak them for
longer than 5 minutes.
Dry carefully, especially between the toes. Do not force them apart as this
may split the skin.
If you have a build up of moist skin between the toes apply surgical spirit
using a cotton bud.
Do not use talc.
Improve skin conditions by applying a moisturising cream on the tops &
bottom of the foot but not between the toes. If possible continue using
cream up the leg. This also helps the circulation.
Never use corn plasters or paints – they do more harm than good
Wear clean hosiery daily.
FAMILY PARTICIPATION
Encourage the family to be proactive in finger and
toe nail care
EVERYONE CAN AND SHOULD HAVE THEIR
NAILS FILED
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HELPFUL HINTS ON HOSIERY
Change regularly after washing your feet.
Make sure socks are the right size – hold the sock against the foot to ensure
the heel and toe match.
Ensure that they do not cramp your toes.
If legs and feet swell make sure the top of the socks/stockings are not too
tight. If they are the tops can be cut.
Natural fibres (cotton and wool) socks are much better for your feet as they
keep the feet drier.
If there is a large seam in the socks, turn them inside out.
Support stockings if prescribed they should be worn as they are essential to
the circulation. It is important to get the right fit – if the toes are squashed try
toeless stockings.
Keep the feet warm – if circulation is poor encourage wearing trousers, long
johns or leg warmers.
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FOOTWEAR
CHOOSING YOUR SHOES
The choosing of a shoe is perhaps the single most important factor in maintaining
the health of your feet. The shoe must protect and support yet at the same time
allow enough room for growth in children or room to wiggle your toes if you are an
adult. When selecting a shoe shop you should always go to one where they are
prepared to measure your feet and where the staff is properly trained in measuring
feet.
You should look for shoes with following features:
1. Available in half sizes as well as whole sizes
2. That there is a range of width fittings
3. A roomy toe shape which avoids pressure and gives the toes the space they
need
4. Wrap around protection for ankle and instep support if required
5. Adjustable fastenings to hold the foot firmly but gently at the back of the shoe
6. Plenty of depth at the instep
7. No hard seams that will cause discomfort or rubbing
8. The sole should be soft and flexible to bend with the foot, and that anti-slip
soles are safe and inspire confidence
9. The best uppers are made of leather. It can be stretched if required, and will
bend with the foot.
FINDING THE FIT
Shoes should be checked every 2 to 3 months, this is particularly important with
children’s’ feet as they tend to grow in spurts. Measuring is only a first stage in
shoe fitting. No two feet are the same and each foot must be measured for both
width, depth and length. Shoe shapes must be matched to the foot and not the
other way around. Don’t be frightened to ask the shoe fitter to see different styles
and types.
With the fastening undone, the shoe should be slipped on with a gentle twisting
action. The heel of the foot needs to be held securely in the back of the shoe.
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HANDY HINTS:
i) Stand on a piece of card and draw around your foot with a pencil. Cut out
the template and take this with you to the shoe shop. If the template does
not fit into the shoe then don’t buy them.
ii) A quick and rough guide for fitting is to place your foot on top of the shoe
with your heel firmly placed back in the heel cup whilst in a standing
position. If your toes extend beyond the shape of the shoe, then they are
not big enough.
LENGTH
Free movement of the toes is essential. A minimum of half an inch is required.
Check for width fitting at (i) the widest part of the forefoot (usually from the big toe
joint across to the base of the little toe) and (ii) across the toes.
DEPTH
Often not considered, but particularly important is the toe box. Inadequate depth
here causes pressure on the toes which can lead to blisters, calluses and corns.
BACK OF THE SHOE
There should be no pressure between the back of the shoe and the heel. The
curve of the shoe must match the curve of the heel. The heel of the shoe should
not slip. If it does you are likely to claw your toes in order to hold it on.
INSTEP FASTENINGS
It is essential that the shoe is held firmly on your foot. This requires the shoe to
have laces, buckles or “velcro” style fastenings.
The higher up the instep the shoe comes the more successful the shoe is at
holding the foot.
WALKING
This is the final test of a good fit. Always insist on walking up and down in the shoe
shop before you purchase your shoes. Look at the shoes to ensure there is no
excessive creasing across the forepart or gaping at the sides. Check to make sure
they do not slip up and down or that they cramp your toes in anyway.
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FOOTWEAR FITTING SERVICE
Gloucestershire Podiatry Service offers a free footwear fitting and advice service.
The service operates at the following clinics:o
o
o
o
o
o
o
St Paul’s Medical Centre in Cheltenham
Cirencester Hospital in Cirencester
North Cotswolds Hospital in Moreton – In – Marsh
Beeches Green Health Centre in Stroud
Gloucestershire Royal Hospital in Gloucester
Lydney Health Centre in Lydney
The Health Centre in Cinderford.
We have trained footwear technicians who will measure your feet, assess your feet
and give advice on the style of shoes which would best accommodate your foot
type. We have a large range of shoe styles by a number of manufacturers. This
service is open to all members of the public.
For further advice and education and to book a shoe fitting appointment please fill
in the Gloucestershire Podiatry Service Footwear Service Self Referral Form
and return to the appropriate address (see form). The two main clinics for referral
returns are:
Podiatry Department
Gloucestershire Royal Hospital
Great Western Road
Gloucester
GL1 3NN
 Queries 0300 422 8499
Or
Podiatry Services
St Pauls Medical Centre
121 Swindon Road
Cheltenham
GL50 4DP
 Queries 01242 215470
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Gloucestershire Podiatry Service
FOOTWEAR SERVICE SELF REFERRAL FORM
To request an appointment with a Footwear Technician at one of our Footwear Service
Clinics please complete your details below.
Name
Address
Postcode
Telephone
Numbers
Date of Birth
Home
Number
Mobile
Number
NHS
Number
or MRN
(if known)
Signed
Reason for Referral:
Date
□ Advice & Education
□ Purchase of Footwear
PLEASE TURN OVERLEAF TO INDICATE THE CLINIC YOU WISH TO ATTEND
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Gloucestershire Podiatry Service
FOOTWEAR SERVICE SELF REFERRAL FORM
Please tick the box below of the location you wish to attend:
St Paul’s Medical Centre
Cheltenham
Gloucestershire Royal Hospital
Gloucester
Lydney
Cirencester
Cinderford
Moreton- in-Marsh
Stroud
For clinics above please forward the
completed form to:-
For clinics above please forward the
completed form to:-
The Podiatry Department
Gloucestershire Royal Hospital
Great Western Road
Gloucester
GL1 3NN
The Podiatry Department
St Paul’s Medical Centre
121 Swindon Road
Cheltenham
GL50 4DP
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FOOT HEALTH ADVICE FOR CHAIR-BOUND
INDIVIDUALS
Even though a person may be quite immobile and confined to a chair for much of
the time it is important to take care of their feet.
Footwear - chair bound people can tend to get swollen feet so it is important to
check that their footwear, or socks/stockings are not too tight and can expand to
allow for any swelling.
A bootee slipper with a Velcro fastening is ideal for this, or even a warm, thick
sock.
Positioning - feet left continually on the ground without being moved could end up
with severe circulatory problems and should therefore be raised off the ground as
often as possible. This can be achieved by placing them on a stool or foot- rest so
that they are on the same level or higher than the bottom.
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FOOT HEALTH ADVICE FOR BED BOUND
INDIVIDUALS
Hygiene is important. Wash the feet daily and check particularly between the toes.
Make sure they are dried properly in between the toes and that there is no soggy
skin present to harbour germs and cause infection.
Check around the heels as this is the area where they could get bedsores. If the
heels do get sore they can be rubbed well with a moisturizing cream.
To keep the weight of the bedclothes from the feet a bed cradle can be used, or an
empty cardboard box.
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FOOT EXERCISES
Why do we need to exercise our feet?
To improve circulation
To strengthen weak muscles
To keep joints mobile
1. TOE POINTS
Sit with legs crossed. Point the foot of the uppermost leg down and then up. Repeat
movements. Cross the other leg and repeat.
2. ANKLE ROTATIONS
Raise one foot off the ground.
Rotate it in a complete circle six times.
Stop and repeat with the other foot.
3. FOOT FANS
Place both feet on the ground 24” apart.
Turn left foot outwards as far as it will go (3)
Turn left foot inwards as far as it will go (2)
Repeat exercises with the right foot.
4. KNUCKLING
Stand up with shoes and socks off. Press toes down to make knuckles on top of the foot then
turn the toes up – repeat six times.
5. SPREADS
In bare feet spread & wriggle your toes.
6. TIP TOES
Stand up, support yourself. Raise heels until you are on tip toe- lower heels- repeat.
7. WALKING
Walking is still one of the best exercises. Try 15-30 minutes steady walk a day.
REMEMBER – IF YOU FEEL ANY PAIN WHILST EXERCISING
STOP & REST
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CHAPTER 11: Useful Contacts
YOUR NHS PODIATRY DEPARTMENTS
CONTACTS FOR PERSONAL NAIL CARE
Senior Sister Leads:
Cheltenham General Hospital
Annie Elyan
Hazleton Ward
Gloucester Royal Hospital
TBC
At present contact Anne Elyan CGH
Ext (0300 422) 4470
or (0300 422) 4006
Modern Matron (Overall Lead for CGH and GRH)
Sandra Attwood
Ext (0300 422) 8972
Bleep 2255
Podiatry Department
Head of Services: Dr C Boden
Main Offices:
Podiatry Services
St Paul’s Medical Centre
Swindon Road
Cheltenham
GL50 4DP
Podiatry Services
Gloucestershire Royal Hospital
Great Western Road
Gloucester
GL1 3NN
Tel – 01242 215470
Fax – 01242 215479
Tel – 0300 422 8499
Fax – 0300 422 8396
For any questions or queries regarding Basic Nail Care Training contact:
Emma Cronin and Helen Edge
Podiatry Services
St Paul’s Medical Centre
121 Swindon Road
Cheltenham
GL50 4DP
 01242 215470
Emma.Cronin@glos.nhs.uk and Helen.Edge@glos.nhs.uk
If you have any other questions or queries please email Podiatry.Info@glos.nhs.uk
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INDEX
CHAPTER
1
2
3
4
5
6
7
8
9
10
11
12
SUBJECT
Content
Introduction
Podiatry
Consent
Foot Assessment
Assessing the Feet to Determine the Level of Foot Care
Required
Foot Pathologies
Diabetic Feet
Assessing Medical History/Medication
Inpatient Foot Care Pathway
Inpatient Podiatry Service
Application for Inpatient Treatment CGH and GRH Referral
Form. Reference – GHNHSFT/Y1140/07_13
Personal Toe Nail Care
Structure of a Toe Nail
How to Cut and File Toe Nails
Family Participation
Infection Control
Nail Care Instruments & CSSD
Infection Control-PPE, Standard Precautions and Waste
Hand Decontamination
First Aid
Manual Handling
Guidelines for Personal Toe Nail Care Procedure Following
Patient Assessment
Record Keeping
Foot Health Options Following Discharge
Podiatry Department Referral Form
Personal Toe Nail Care Agency Fairford League of Friends
Foot Care Advice
Advice on Hosiery
Advice on Footwear & Shoe Fitting
Footwear Fitting Referral Form
Foot Health Advice for Chair Bound Individuals
Foot Health Advice for Bed Bound Individuals
Foot Exercises
Contact Numbers
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PAGE
NO:
2
3
4
5-6
7
7
8-9
10-11
12-14
15
16-17
18
19
20
21
22
23
23-24
25
26-27
28-29
30
31
32
33-34
35-36
37-40
41
42
43-45
47-48
49
50
51
52
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