2 Foot Productions

Basic Foot Care for Nurses and Carers across Australia

Basic Foot Care in Aged Care Facilities Here are some of the issues that need to be ironed out to have a successful foot care program in your aged care facility.  Consent Assessment Documentation Who cuts toenails? When do you find time to cut toenails? What basic foot care equipment do you use? Where do you get basic foot care equipment from? Who pays for the equipment? Where do you store the equipment? How do you clean the equipment? Other infection control measures Occupational health and safety issues Residential Classification Scale

Consent

Consent for basic foot care to be performed needs to be gained from the client and/or relative for legal reasons. But what exactly are resident consenting to?

Are they giving consent for

• Staff to perform all aspects of basic foot care?
• To be billed for a basic foot care kit including toenail clippers?
• For a podiatrist to see them every so often or as needed?
• To be charged by a podiatrist $X?

Consent for basic foot care services should be gained on admission to a residential aged care facility (RACF). This process of gaining consent should involve giving out information about the way your foot care program works in your facility.

Consent should also be gained, where possible, prior to each episode of basic foot care - particularly toe nail cutting. If a resident has a sore toe they may wish to see a podiatrist rather than have a carer do the job. It is simply a matter of asking “Mrs Smith - are you happy for me to cut your toenails today?”

Assessment

On admission to a RACF a basic foot assessment will help determine the level of foot care required. A resident with lots of foot problems and poor circulation may need to see a podiatrist regularly. Someone else with good feet and adequate circulation may see a podiatrist once a year.

If you have a good basic foot assessment tool a registered nurse can perform the assessment. However, you may like all residents to see a podiatrist on admission and have the podiatrist perform that assessment.

It is very important that all staff know how to conduct a cursory foot assessment as foot condition can change very rapidly. A carer needs to know the signs of poor circulation and infection and be able to identify common foot problems, so that potential problems can be reported as they arise.

Documentation

Where will you document basic foot care? In progress notes, on a care plan, on a special care day form?

Which aspects of basic foot care do you document?

Where will the podiatrist document document their findings and treatment?

Who cuts toenails?

Basic foot care as a personal grooming and hygiene service is not regulated in Australia. This means legally, any carer in the RACF can cut toenails. However, only carers trained in the provision of basic foot care should be allowed to cut toenails. Too many complications can arise from untrained carers attempting this important job.

Training can include:

One of the nationally accredited basic foot care courses available.

www.ntis.gov.au

For more details. Training can also include a work placed based training exercise where an experienced nurse can guide others through the foot care basics. Some facilities have one or two nurses that cut toenails when asked by other staff members. Some facilities have all staff cutting toenails as needed.

When do you have time to cut toenails?

What a question! This is a tough one.

JUST REMEMBER - TOENAILS ONLY NEED TO BE TRIMMED EVERY THREE TO FOUR WEEKS, OFTEN EVEN LESS FREQUENTLY.

In theory it only takes five minutes to cut toenails - if you know where the clippers are, if you know what you are doing, if the resident is being co-operative. And who has a spare five minutes anyway?

Some ideas for fitting toenail cutting into the working day include:

• Incorporating it into the shower routine.
• Incorporating basic foot care into a diversional therapy activity
• Incorporating it into the “special care day” routine

What basic foot care equipment do you use?

To care properly for feet, you will require the following aids:

A soap free cleanser

Generally, whatever cleanser is used on the rest of the body will be adequate.

A moisturiser

Nine times out of ten, sorbolene is all you need.

Toenail clippers

There are several options available:

Swabs

Before you cut toenails, the toes should be swabbed. Individually wrapped medi wipes are ideal and easy to store, but skin wipes can also be used.

A nail file

Cheap, disposable emery boards are available from the local pharmacy. Metal nail files are also available, which are particularly good for thickened toenails. A thickened toenail can be kept short by regular filing, so you will find one of these handy. Please note however, that these should either be appropriately sterilised / disinfected, or used for one person only. and other specialised foot care products (such as toe and foot paddings, a pumice stone or foot file, anti-fungal agents etc)

Where do you get basic foot care equipment from?

You can get most of your basic foot care needs from your local pharmacy.

Who pays for the equipment?

This may depend on the level of care the resident receives.

It may be appropriate for some residents to supply their own “basic foot care kits”, or purchase the kits you require. Something to watch out for is each resident having different types toenail clippers. This makes it hard for staff to become proficient with any one type of clipper.

Your facility may supply all basic foot care needs, whether it is a kit for each individual, or a shared pool of instruments that get appropriately disinfected / sterilised.

Where do you store the equipment?

One thing that is certain is that equipment goes missing. Toenail clippers are especially easy to lose as they make their way to the bottom of pockets, laundry hampers and toiletry bags.

If you have individual kits for each resident - a snap lock sandwich bag is ideal to keep basic foot care equipment together, as long as everything is dry when you store it. You can put a name sticker on the outside of the bag to help identify the kit. Some kits come with handy storage cases.

If you are sterilising equipment, items need to be packaged appropriately and stored in a clean, dry environment.

It is important that you have a well known location for storing clippers. It is difficult if you have some kits in residents rooms and others in a nurses station - try and be consistent.

If resident's supply their own basic foot care kits, perhaps they can be kept in resident's bathrooms or with other toiletries.

If the facility supplies equipment, consider storing the kits in a central location such as in the nurses station. You can store individual kits in a shoe box in alphabetical order. This will save a lot of time when it comes to finding equipment.

How do you clean the equipment?

There a two main options for cleaning equipment.

Individual kits for each resident: Clippers should be washed in warm water with a neutral detergent. A hard jet of water should be used to remove debris. A brush can be used to clean the clippers, but this then becomes another item to be bought, kept and stored. The clippers should be dried thoroughly prior to storage.

Shared kits for all residents: There is a real risk of penetrating skin with most basic foot care equipment - even emery board can tear the skin if used incorrectly. Any basic foot care equipment that is to be used on more than one resident should be cleaned and sterilised after each use.

Options for getting equipment sterilised include:

• Keeping sterilising equipment on site such as an autoclav (expensive and difficult to set up and maintain)
• Sending equipment off site to get sterilised. Options could include using a local doctors surgery, podiatry clinic or local hospital.

ANY EQUIPMENT THAT CAN NOT BE DISINFECTED OR STERILISED, SHOULD BE SINGLE USE OR KEPT FOR ONE RESIDENT ONLY.

Other Infection Control Measures

“Standard precautions are standard operating procedures that apply to the care and treatment of all patients, regardless of their perceived infectious risk.

These precautions include:

aseptic technique,
hand washing,
use of personal protective equipment,
appropriate reprocessing of instruments and equipment
and implementation of environmental controls.

Standard precautions should incorporate safe systems for handling blood (including dried blood), other body fluids, secretions and excretions (excluding sweat), non intact skin and mucous membranes."

Aseptic technique

Asepsis is defined as the absence of infectious agents that may produce disease. Aseptic technique refers to practices used by health care workers to:

• reduce the number of infectious agents;
• prevent or reduce the likelihood of transmission of infectious agents from one person or place to another; and
• render and maintain objects and areas as free as possible from infectious agents.

Techniques to maintain asepsis may be categorised into ‘clean’ and ‘sterile’ techniques.

Clean technique

Clean technique refers to routine work practices that reduce the numbers of infectious agents.

• Routine practices include:
• personal hygiene, particularly hand washing, to reduce the numbers of infectious agents on the skin;
• use of barriers to reduce transmission of infectious agents;
• use of environmental controls to reduce transmission of infectious agents; and
• reprocessing of instruments and equipment between patient use.

The above section is taken from "Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting"

Occupational Health and Safety Issues

The resident should be positioned appropriately so that the health care worker (HCW) is able to practice safe posture maintenance and manual handling principles. The (HCW) should at all times:

* maintain a straight back, hips at 90 degrees and slightly tilted forward
* have freedom of movement through a full 180 degrees
* ensure the client’s feet are not resting on the carer’s body, so that movement is not restricted

The ideal conditions to perform basic foot care under, are with the resident in a hydraulic chair (fully height adjustable), and the care worker sitting on an adjustable “operators chair”.

Another option, perhaps more practical, is to have the resident sitting in a recliner arm chair on which the legs can be elevated. You could also have the resident in a regular chair, with their feet elevated to a reasonable height on an ottoman or foot stool. You may need to further elevate the legs with a pillow or cushion. In this situation, in order to maintain a straight back, the HCW needs to sit on a lower seat such as a low stool or a sturdy tool box. The hips wont be at 90 degrees in this situation, but the back will be kept as straight as possible.

Something else to consider is the possibility of having the resident lay on their bed, with legs fully extended and feet hanging slightly over the end of the bed. The bed can then be elevated to the appropriate height. It can be quite awkward trimming toenails with someone lying on a bed - but it may be worth a try if there are no other options.

Adequate lighting is also an important factor. Good overhead fluorescent lighting will provide better illumination than natural light from a window.

Waste is disposed of as normal unless there is blood contamination. If there is blood contaminated waste, the care worker should adhere to workplace policies in regards to contaminated waste disposal.

Residential Classification Scale

As a general rule, basic foot care falls under Q4 Personal Hygiene. For more details go to the Residential Classification Scale page