# Presentation: 104632

## Developing an SCI Nail Care Program: How to Make It Happen

**Kelly D. Skinner, MSN, CRRN, ANP, GNP, James T. Daniel, BSN, RN,**
**Nancy Brooks, BSN, RN, & Melody White, BSN, RN**
**VA Boston Healthcare System**

**Anatomy of the Nail**

**SCI Nail Care Electronic Note & Consult**

**Abstract**

**The Process**

**“****Equipment**** Raiser**

**Competencies**

**  ****Routine nail care is essential for spinal cord injured persons.   **
**  ****Spinal cord injured persons with hyperkeratotic **
**and elongated toenails are certainly at risk for complications since they have limited or no sensation**
**in their lower extremities.  **
**  ****But, who is going to provide this service regularly **
**to the spinal cord injured veterans?  Podiatry services are limited at this facility related to increased workload and limited staffing.  Therefore, it became apparent that the SCI Nail Care Program was needed in order **
**to meet the foot and nail care needs of the spinal cord injured patients. **
**  ****This poster presentation illustrates the major steps involved in the implementation of this SCI Nail Care Program.**

** ****Determining the Need and Interest**
** ****Administration and Labor Union Approval**
** ****Nail Care Training and Clinical Experience for **
**     ****Selected Staff**
** ****Competencies**
** ****Equipment and Supplies**
** ****Electronic Consult & Note**
** ****Staff and Patient Education**
** ****Program Implementation**

**SCI Nail Care Competencies**
**  **
**METHOD OF VALIDATION:**
**(O) OBSERVATION       (V)VERBAL     (W) WRITTEN ASSESSMENT     (D) DEMONSTRATION      (PR) PEER REVIEW **
**                                                                             **
_**COMPETENCIES                                                                                               MET                            NOT MET                   COMMENTS**_
** ****Performs a clinical assessment of the spinal cord injured person.**
**            ****Collects a health history.**
**            ****Assesses medication history**
**2. Performs a physical assessment of the spinal cord injured patient: **
**            ****Assesses patient for functional disabilities (e.g., gait, mobility, balance, visual, cognitive) **
**            ****Assesses patient for health habits (e.g., smoking, exercise, hygiene, nutrition) **
**            ****Assesses foot circulation by palpation (e.g., pulses, blanching, capillary refill) **
**            ****Assesses foot circulation by Doppler **
**            ****Assesses legs and feet for temperature **
**            ****Assesses hair growth on legs and feet **
**            ****Assesses foot skin integrity (e.g., fissures, ulcers, corns, calluses, dermatitis) **
**            ****Assesses physical/musculoskeletal function of the foot (e.g., range of motion, deformities, strength) **
**            ****Assesses toenails and cuticles **
**3. Performs skin care on the spinal cord injured patient: **
**Performs hygiene to the feet and nails **
**Identifies appropriate interventions for managing hyperkeratotic areas **
**Implements off-loading **
**Applies padding **
**Identifies the need for compression therapy (e.g., to manage edema) **
**Applies moisturizers to skin **
**Performs cuticle care **
**Identifies and make recommendations for skin conditions: **
**Blisters                                Tinea pedis                            Trauma                            Other skin conditions **
**Paronychia                         Plantar warts                         Maceration**
**Identifies the need for use of therapeutic interventions (e.g., topical therapy) for skin conditions.**
**4. Performs nail care on the spinal cord injured patient: **
**Defines free nail border (i.e, removes debris) **
**Conducts debridement of toenails **
**Performs cleaning and sterilization of equipment **
**Uses personal protective equipment **
**Maintains infection control for tinea pedis and candidiasis **
**Identifies and makes recommendations for the following conditions: **
**Onychomycosis                Ingrowing/ingrown toenail **
**Trauma                            Other conditions of the toenails**
**Prescribes antifungal agents or antibiotics for infections (nurses with prescriptive authority)**
**5. Provides education when appropriate:**
**Provides patient/caregiver education related to: **
**foot care (e.g., hygiene, skin care, inspection, nail care) anatomy and physiology of the foot **
**pathophysiology affecting the foot                        weight management **
**age-specific changes of the foot                             prevention of specific problems**
**proper footwear                                                      problems that should be reported **
**plan for follow-up care **
**6.    Identifies and initiates appropriate referrals (primary care provider, podiatry, orthopedics, dermatology, endocrinology, vascular surgery, general surgery, **
**        ****physical therapy, OT, pedorthist/orthotist, home health, pain management, diabetes education, smoking cessation, case manager or social worker, wound care) **
**       ****and consults with the spinal cord injured patient’s SCI MD/DO prior to initiating the appropriate consult.**
**7.    Acts as a patient advocate regarding issues of foot care.**
**_________________________________________  DATE:___________________    ****/  **** ______________________________________  ****	****    DATE:______________**
**(Rating Official)                                                                                                                      (Employee Signature)**

**Education about Toenail Disorders**

**                                          ****SCI ****Nail Care Note:**
**Medical History:**
**Allergies:**
**Medications:**
**O: **
**   ****Nail tissue: veteran received routine and palliative nail care for elongated **
**   ****and thickened nails.  All nails were reduced/debrided without incident.**
**   ****Callouses: [  ] none**
**              ****[  ] locations:**
**   ****Other issues:**
**A: [ ] onychomycosis**
**       ****[  ]debridement of 1-5 digits**
**       ****[  ]debridement of 6-10 digits **
**   ****[ ] onychauxis **
**   ****[ ] onychocryptosis **
**   ****[ ] paronychia **
**   ****[ ] wound**
**   ****[ ] tinea pedis**
**   ****[ ] cellulitis **
**   ****[ ] hyperkeratosis-callous**
**   ****[ ] other: **
**P: [ ] toenail care performed without incident           [ ]  lamb's wool**
**     ****[ ] callous debridement without incident                [ ]  lachydrin as ordered**
**     ****[ ] attending notified and consult placed                [ ]  absorbase emollient   **
**     ****[ ] lamisil as ordered                                                 [ ]  x-ray as ordered                                                                                                   **
**     ****[ ] bacitracin as ordered                                           [ ]  carmol as ordered**
**     ****[ ] povodine iodine swabbed in web spaces            [ ] oral antibiotic as ordered**
**     ****[ ] povodine iodine foot soak **
**FU plan:**
**   ****[ ] PRN                      [ ] q 5 months                [ ] other:**
**   ****[ ] q 3 months           [ ] q 6 months**
**   ****[ ] q 4 months           [ ] consult DPM clinic**
**Recommendations:**

**       ****Plantar Warts                 Onychogrypsosis                  Melanonychia                  Median Nail **
**                                                                                                                                           ****Dystrophy**

**      ****Onychomycosis                          Corn                                 Bunion                       Onychocryptosis**** **

** ****Longitudinal  Ridging         Digital Mucous Cyst         Acute Paronychia          Chronic Paronychia**** ****                                                                                          ****   **

**   ****Subungual Hematoma                    Tinea Pedis                             Melanoma                             Hang Nail**