4.7 Nail Care

Providing hand, foot, and nail care for a client offers an opportunity for HCAs to observe the health of their client’s skin, nails, and the strength of their hands and feet. It also provides a sense of comfort and promotes self-esteem for the client.

While many clients may enjoy having their hands and feet cared for, take special care with clients who do not find it pleasurable. Additionally, some clients have sensitive feet and may be ticklish. You should always tell a client when you are going to touch their feet and inform them of what you are doing so that the client expects the touch.

HCAs may assist with hand and foot care tasks that are listed below. However, a regulated health professional, such as a registered nurse, must first assess the client before the HCA can be assigned to the following tasks:

  • Observing for any changes and reporting to the supervisor
  • Nail clipping for clients without chronic diseases or conditions like diabetes, swollen feet, compromised skin, or compromised nail integrity.
  • Soaking, massaging, and applying lotion to hands and feet as per the care plan.

Clients with chronic diseases or compromised skin/nail integrity require special care from a podiatrist or specially trained nurse. While it is acceptable for HCAs to wash and inspect these clients’ hands and feet, they should never clip their fingernails or toenails (Sorrentino, et al., 2019; McLain, et al., 2018). Nail care should not be provided by HCAs for clients with the following chronic diseases and conditions:

  • Diabetes or circulation problems
  • Swelling in hands or feet
  • Medications that affect blood clotting
  • Fingernails or toenails that are weak, brittle, thick, or ingrown
  • Infections, rashes, or skin damage in hands, fingernails, feet, or toenails

Make sure to follow directions from a supervisor and those written in the care plan for any nail care that is performed.

Hand and Nail Care​

Table 4.7.1 Procedure: Hand and Nail Care​
STEP ACTION REASON/CONSIDERATIONS
1. Gather information from the activities of daily living, care plan, report, and team leader before beginning. This helps ensure that you are aware of the client’s needs and any changes to the client’s health status that may impact your ability to complete the task.
2. Before entering the clients room, perform hand hygiene. This reduces the spread of pathogens between client rooms.
3. Confirm the client’s identity and explain the procedure. Evaluate the client’s needs (e.g., do they need to use the toilet, are they thirsty, are they experiencing any pain?). This ensures that the client is ready for the procedure.
4. Observe the client’s hands for rashes, open areas, skin colour, temperature, swelling, excessive dryness, and calluses. If you notice any changes in the health or condition of the client’s skin or nails compared to the information you received from the nurse, the activities of daily living plan, or the care plan, or if anything has changed since the last time you trimmed the client’s nails, or if you have any concerns about the client’s condition, report these changes to the nurse first.

Do not proceed with the nail cutting until the nurse has reassessed the client’s hands and fingernails and you have received confirmation that you can proceed.
5. Perform hand hygiene. This can be done by washing your hands or using hand sanitizer, as per the infection prevention and control standards.

This procedure does not require gloves unless the client’s hands are visibly soiled or isolation precautions are in place.
6. Gather all necessary equipment and place them on the overbed table. This includes:

  • a large wash basin
  • towel
  • small nail clippers
  • nail file (emery board)
  • wooden nail stick
  • paper towels
  • no rinse soap
  • lotion
 It is important to collect all the equipment prior to starting the task. This will allow you to save time and energy by decreasing the chance you will need to leave the client to collect forgotten equipment.

 
7. Assist the client to sit on a chair and position the overbed table in front of the client. Ensure that the client is comfortable and place the call bell within reach. Having the call bell within reach allows you or the client to call for assistance without getting up and moving all the supplies out of the way.

If necessary, this procedure can also be done while the client is in bed, with a basin on top of a soaker pad or some absorbent cloth.
8. Spread the paper towels on the overbed table. You will need the paper towel later as part of the nail cleaning and clipping.
9. Provide privacy. This supports the client’s dignity.
10. Fill the basin half way with warm water, which is about 40°C.

If you do not have a thermometer, check the temperature of the water with the inside of your wrist.

Allow the client to test the water for comfort.

 Water should feel warm, not hot, cold, or cool, as warm water is most comfortable for soaking.

Do not use your fingertips to test the water as they may have small calluses and be slightly less sensitive to heat.

Be aware that clients who have circulation issues may not feel the water temperature appropriately.

It is acceptable to warm up the water if needed, but ensure that it is not too hot, to avoid burning the client.
11. Place the basin on the paper towels.
12. Have the client immerse their hands in the water and soak for up to 5 minutes. Soaking hands and fingernails in warm water helps to clean and soften the fingernails prior to cutting.

However, soaking for longer than 5 minutes causes the skin to swell, which may cause issues with nail cutting because the swollen skin could get trapped more easily in the nail clipper. Consider how your skin looks like a prune after you have been swimming. These bumps in the skin make it more difficult to safely cut the nails.
13. Remove the client’s hands from the basin and take the time to dry them thoroughly. Do not cut nails instantly after soaking fingers, as skin around the fingernails can be puffy and more prone to cuts when moistened.
14. Gently clean under each fingernail using the wooden cuticle stick.

After cleaning each nail, wipe the nail debris on one of the paper towels.

 Cleaning under the nails allows you to see how much of the nail can be carefully trimmed.

Be very careful not to dig too deep under the nails, as this could cause pain or bleeding.

Do not interact with the cuticles. Managing cuticles is outside of the HCA role.
15. Dispose of the paper towel when finished cleaning under the nails. This maintains a clean working area.
16. Carefully clip the client’s nails in a gentle curve using the nail clippers so that nails are even with or just below tips of the fingers.

Do not clip the sides. Instead, use the nail file to shorten the sides and sharp edges.

 Clipping the sides of the nail may cause you to accidentally cut the skin as visibility is poor and skin often gets trapped in the clippers along with the nail.

Also, take care not to clip the nail too short as this can cause injury and pain.

If the client is accidentally cut by the nail clippers, inform the nurse right away.
17. After clipping, or if not clipping, use an emery board or a file to carefully shorten, shape, and smooth the nails.

To maintain nail integrity, file in one direction instead of back and forth.

 Filing back and forth can create small tears and splits in the nail, leading to weakening and broken nails.
18. Once you have completed clipping the client’s nails, dispose of the paper towel with the nail clippings. This maintains a clean working area.
19. Offer the client a hand massage using lotion. If the client has their own preferred lotion, use that lotion to respect their preference. If able, use a lotion where the first few ingredients do not include alcohol. Lotions with heavy alcohol content dry the skin. It is especially important to avoid heavy alcohol content with diabetic clients as dry skin tends to crack, which creates portals of entry for bacteria and wound formation.
20. Gently massage the hands. Most people like to receive massage and a gentle hand massage can provide comfort and relaxation to the client.
21. Return the client to a comfortable position.
22. Please ensure the call bell is within reach.
23. Clean the nail clippers with alcohol and clean and replace your equipment as per facility policy.

If you are using communal nail clippers, ensure proper medical asepsis and sterilization of the equipment as per facility policy.

 Unless sterilization procedures are in place at the facility, using communal (shared) nail clippers is not advised.
24. Perform hand hygiene.
25. Report and record your observations.

Foot and Nail Care

Table 4.7.2 Procedure: Foot and Nail Care
STEP ACTION REASON/CONSIDERATIONS
1. Gather information from the activities of daily living, care plan, report, and team leader before beginning. This helps ensure that you are aware of the client’s needs and changes to their health status that may impact your ability to complete the task.

Some facilities do not allow their staff to cut toenails and have a specialized foot care nurse visit on a regular basis. Ensure you know your facility’s policies regarding nail cutting. If you are not cutting toenails, you may still be able to soak feet and provide a massage.
2. Before entering the clients room, perform hand hygiene. This reduces the spread of pathogens between client rooms.
3. Confirm the client’s identity and explain the procedure. Evaluate the client’s needs (e.g., do they need to use the toilet, are they thirsty, are they experiencing any pain?). This ensures that the client is ready for the procedure.
4. Gather all necessary equipment and place the equipment on the overbed table. This includes:

  • large wash basin
  • basin cover
  • large nail clippers
  • nail file (emery board)
  • wooden nail stick
  • white bath towel
  • washcloth
  • paper towels
  • no rinse soap
  • lotion
  • gloves
 It is important to collect all the equipment prior to starting the task. This will save you time and energy by decreasing the chance that you will need to leave the client to collect forgotten equipment.
5. Assist the client to sit on a chair. Ensure that the client is comfortable and place the call bell within reach. Having the call bell within reach allows you or the client to call for assistance without getting up and moving all the supplies out of the way.
6. Spread the paper towels on the overbed table. You will need the paper towel later as part of the nail cleaning and clipping.
7. Provide privacy. This supports the client’s dignity.
8. Apply the basin cover to the basin. Disinfection and sterilization procedures will vary from facility to facility. In some facilities, a basin cover will not be used. Follow the disinfection and sterilization of equipment procedures as per your facility’s policy.
9. Fill the basin half-way with warm water, which is about 40°C.

If you do not have a thermometer, check the temperature of the water with the inside of your wrist.

Allow the client to test the water for comfort.

 Water should feel warm, not hot, cold, or cool, as warm water is most comfortable for soaking.

Do not use your fingertips to test the water as they have small calluses and are slightly less sensitive to heat.

Be aware that clients who have circulation issues may not feel the water temperature appropriately.

It is acceptable to warm up the water if needed, but ensure that it is not too hot, in order to avoid burning the client.
10. Apply gloves and assist the client with the removal of their footwear. Footwear can be dirty.
11. Spread paper towels on the floor under the client’s feet so that their feet are not touching the floor. The floor is considered contaminated.
12. Inspect the client’s footwear for holes, foul odours, and the need for replacement. Give each shoe a quick shake to see if anything falls out of them. Clients who have memory challenges and/or circulation issues may put bandages or cotton swabs between their toes. However, these can fall off and stick to the inside of the shoe, causing pressure and skin integrity problems.

If the client walks barefoot or in socks in home support or assisting living settings, they may unknowingly pick up debris from the floor and transfer it into the shoe.
13. Change your gloves. Footwear can be dirty, so change your gloves after removing the footwear before proceeding with foot care.
14. Place the wash basin on paper towels so that the basin is not touching the floor. The floor is considered contaminated.
15. Help the client immerse their feet in the water. Soak the feet for up to 5 minutes. Soaking feet in warm water helps to clean and soften the toenails prior to cutting. However, soaking for longer than 5 minutes will cause the skin to swell, causing issues with nail cutting because the swollen skin could get trapped easily in the nail clipper.

Diabetic skin should be soaked as little as possible as soaking will increase dryness of the skin, therefore increasing the risk for skin cracks.
16. Remove the client’s feet from the basin and take the time to dry them thoroughly, especially between the toes. Taking the time to dry thoroughly also ensures that you are not cutting the nails right after soaking the feet, as the skin around the nails can be puffy and so more prone to cuts.
17. As you dry observe the feet for rashes, open areas, skin colour, temperature, swelling, excessive dryness, calluses, or corns.

Inspect between the toes and check the toenail health and length.

Use a white towel as white will show any discharge or blood.

 If you notice any changes in the health or condition of the client’s skin or nails compared to the information you received from the nurse, the activities of daily living plan, or the care plan, or if anything has changed since the last time you trimmed the client’s nails, or if you have any concerns about their condition, report these changes to the nurse first.

Do not proceed with the nail cutting until the nurse has reassessed the client’s feet and toenails and you have received confirmation that you can proceed.
18. Gently clean under each toe using the wooden cuticle stick.

After cleaning each nail, wipe the nail debris on one of the paper towels.

 Cleaning under the nails allows you to see how much of the nail can be carefully trimmed.

Be very careful not to dig too deep under the nails as this could cause pain or bleeding.

Do not interact with the cuticles. Managing cuticles is outside of the HCA role.
19. Dispose of the paper towel when done cleaning under the toenails. This maintains a clean working area.
20. Carefully clip the client’s toenails in a gentle curve using the large nail clippers so that nails are even with or just below tips of the toe.

Do not clip the sides. Instead use the nail file to shorten the sides/ sharp edges.

 Clipping the sides of the toe nail may cause you to accidentally cut the skin as visibility is poor and skin often gets trapped in the clippers along with the nail.

Also, take care not to clip the nail too short as this can cause injury and pain.

If the client is accidentally cut by the nail clippers, inform the nurse right away.
21. After clipping, or if not clipping, use an emery board or a file to carefully shorten, shape, and smooth the toenails.

To maintain nail integrity, file in one direction instead of back and forth.

 Filing back and forth can create small tears and splits in the nail, leading to weakening  and broken nails.
22. Once you have completed clipping the client’s nails, dispose of the paper towel with the nail clippings. This maintains a clean working area.
23. Apply lotion and massage the client’s feet.

Using your thumbs, massage the top of the client’s foot. Work from the ankle to the toes and downwards to the side of the feet.

Next, massage the sole of the foot, working from the toes to the heel and from the middle to the sides.

Ensure all lotion is absorbed, especially if any ends up between the toes. You can use the towel to wipe away excess lotion.

 Leaving excess lotion between the toes could increase the chances for bacterial growth in that area.

If the client has their own preferred lotion, use that lotion to respect their preference.

However, if able, use a lotion where first few ingredients do not include alcohol as this dries the skin.
24. Re-apply the client’s socks and footwear.
25. Remove your gloves.
26. Perform hand hygiene.
27. Return the client to a comfortable position.
28. Ensure that the call bell is within reach.
29. Apply new gloves.
30. Clean the nail clippers with alcohol. If you are using communal nail clippers, ensure proper medical asepsis and sterilization of the equipment as per facility policy.

If using a basin cover, dispose of the water before removing the basin cover. Then clean and disinfect the basin as per facility policy.

 Unless sterilization procedures are in place at the facility, using communal (shared) nail clippers is not advised.
31. Remove gloves.
32. Perform hand hygiene.
33. Report and record your observations.

Watch the videos:

Hand and Nail Care for Health Care Assistants by Daniela Randell and Lisa Beveridge from Vancouver Community College, is licensed under CC BY-NC 4.0.

Foot and Nail Care for Health Care Assistants by Daniela Randell and Lisa Beveridge from Vancouver Community College, is licensed under CC BY-NC 4.0.

  1. Under what conditions can HCAs clip a client’s fingernails and toenails?
    1. Only after the client has been assessed by a regulated health professional.
    2. After the HCA receives nail care training during their HCA program.
    3. On clients without chronic diseases or compromised skin or nail integrity.
    4. A and C
    5. B and C
    6. A, B, and C
  2. Which of the following clients is NOT suitable for nail clipping by an HCA?
    1. A client with healthy nails and no chronic diseases.
    2. A client with swollen hands.
    3. A client who has been assessed by a registered nurse.
    4. A client who does not take medications affecting blood clotting.
  3. Why are HCAs restricted from performing nail care on clients with diabetes?
    1. Because the client has not been assessed by a regulated health professional.
    2. Because clients with diabetes often have compromised skin or nail integrity.
    3. Because clients with diabetes often have circulation problems.
    4. Because clients with diabetes have very thick or ingrown nails.
    5. B and C
  4. What should you do if you notice a difference in the client’s hand or fingernail condition from the information provided by the nurse or care plan?
    1. Continue with the fingernail cutting
    2. Report back to the nurse first
    3. Ignore the changes
    4. Ask the client if they are feeling okay
  5. Which of the following conditions should be checked before proceeding with nail cutting?
    1. Rashes, open areas, skin colour
    2. Skin temperature, swelling, excessive dryness
    3. Calluses and any changes from the previous assessment
    4. All of the above
  6. What is the recommended maximum duration for soaking a client’s hands and feet before cutting their nails?
    1. 2 minutes
    2. 5 minutes
    3. 10 minutes
    4. 15 minutes
  7. Why is it important not to soak a client’s hands or feet for longer than 5 minutes before cutting their nails?
    1. The water will get cold
    2. It will make the nails harder to cut
    3. The skin will swell, making it easier to trap in the nail clipper
    4. It will dry out the skin
  8. What is the recommended method for clipping a client’s toenails?
    1. Clip the nails straight across
    2. Clip the sides of the nails
    3. Clip the nails in a gentle curve, even with or just below the tips of the toes
    4. Clip the nails as short as possible
  9. When should you provide foot care and toenail cutting after observing a potential issue with the client’s feet?
    1. Immediately, without consulting anyone
    2. Only after the nurse has reassessed the client’s feet and given confirmation
    3. After discussing your concerns with the client’s primary HCA
    4. When the client insists on having their toenails cut
  10. Hand care, foot care, and the cutting of healthy and non-compromised fingernail and toenails are:
    1. Restricted activities that must be delegated to HCAs
    2. Care activities that only nurses can perform
    3. Tasks that can be assigned to HCAs
    4. Care activities that only specialized foot care nurses can perform

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Personal Care Skills for Health Care Assistants - 2nd Edition Copyright © 2023 by Tracy Christianson and Kimberly Morris, Thompson Rivers University is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

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