What is the best practice for providing nail care to inpatients with various medical conditions, such as diabetes, poor circulation, compromised immune systems, or cognitive impairment?

Best Practice for Inpatient Nail Care

Nail care in hospitalized patients should be performed by trained healthcare professionals using proper protective equipment, with nails trimmed straight across after softening, and special attention given to high-risk patients with diabetes, neuropathy, or immunocompromise who require daily foot inspection and specialist referral. 1

Risk Stratification and Assessment

High-Risk Patients Requiring Specialized Care

• Diabetic patients with neuropathy (loss of protective sensation) must have visual foot and nail inspection at every healthcare encounter, not just annually 1
• Patients with peripheral arterial disease, history of foot ulcers, bony deformities (hammertoes, Charcot foot), or immunocompromise require evaluation by podiatry or foot care specialists 1
• Infected nails in diabetic patients can lead to foot ulcers, osteomyelitis, cellulitis, and gangrene, making proper nail care a critical intervention to prevent morbidity and mortality 1
• Patients with cognitive impairment or visual difficulties cannot perform self-surveillance and require family members or healthcare staff to provide nail care 1

Standard Risk Assessment Components

• Inspect for dystrophic nails, onychomycosis, ingrown nails, subungual hematomas, and signs of infection (erythema, warmth, purulent drainage) 1, 2, 3
• Assess protective sensation using 10-g monofilament testing in diabetic patients 1
• Evaluate pedal pulses and screen for peripheral arterial disease 1

Proper Nail Care Technique

Preparation and Equipment

• Healthcare providers must use personal protective equipment when filing, trimming, or using rotary tools on patient nails - 91.5% of surveyed wound care specialists reported using self-protection, but only 25.6% provided patient protection during filing 4
• Soften nails before trimming by soaking in warm saline water or during bathing 1
• Use appropriate instruments: nail clippers for trimming, emery boards for filing 1

Trimming Technique

• Trim toenails straight across, never rounded at corners, to prevent ingrown nails 1
• File nail surfaces with an emery board after trimming to smooth edges 1
• For thickened dystrophic nails, apply urea-based keratolytic cream daily to weekly to reduce nail thickness before trimming 1

Management of Specific Conditions

• Calluses should be debrided with a scalpel only by foot care specialists or healthcare professionals with specific training in foot care 1
• Onychomycosis requires antifungal treatment as infected nails serve as reservoirs for spread to other body sites and family members 1
• Minor skin conditions like dryness and tinea pedis must be treated to prevent progression to serious complications 1

When to Refer to Specialists

Immediate Podiatry Referral Indications

• Patients with extreme bony deformities requiring custom-molded shoes 1
• History of foot ulcers requiring evaluation of underlying pathology 1
• Suspected Charcot neuroarthropathy (acute onset red, hot, swollen foot/ankle in neuropathic patient) 1
• Dystrophic nails requiring chemical or laser ablation 1

Surgical Consultation Needed

• Subungual hematoma or abscess requiring partial or total nail avulsion 5, 6
• Severe painful lesions significantly impacting daily activities 6
• Pressure hematomas under the nail 6

Infection Management

Recognition and Treatment

• Signs requiring antibiotics include increased pain, redness, swelling, purulent drainage, or warmth around the nail 5
• Obtain bacterial cultures before starting antibiotics if pus is present or infection is clinically suspected 5, 6
• First-line oral antibiotics for nail infections include first-generation cephalosporins, amoxicillin-clavulanate, clindamycin, or doxycycline targeting Staphylococcus aureus and gram-positive organisms 5
• Most diabetic foot infections are polymicrobial with aerobic gram-positive cocci (staphylococci and streptococci) as the most common causative organisms 1

Adjunctive Wound Care

• Daily dilute vinegar soaks and mid-to-high potency topical steroid ointment reduce inflammation and edema 5
• When nail removal is performed, thoroughly clean the nail bed and obtain cultures if infection is suspected 6
• Regular monitoring for complications including chronic infection or abscess formation is essential 5

Patient and Family Education

Essential Teaching Points for High-Risk Patients

• Patients with loss of protective sensation must substitute visual inspection and hand palpation for daily foot and nail surveillance using an unbreakable mirror if needed 1
• Educate on implications of sensory loss, proper nail and skin care techniques, and importance of daily monitoring 1
• Instruct on appropriate footwear selection: broad square toe box, laces with 3-4 eyes per side, padded tongue, quality lightweight materials, cushioned insole 1
• Patients with neuropathy should break in new shoes gradually to minimize blister and ulcer formation 1

Critical Pitfalls to Avoid

• Never perform callus debridement without proper training - this must be done by foot care specialists 1
• Do not round nail corners when trimming, as this promotes ingrown nails 1
• Failing to remove the nail when indicated (severe pain, pressure hematoma, subungual abscess) leads to chronic onycholysis and persistent subungual hyperkeratosis 6
• Prophylactic antibiotics are not indicated for clean wounds without infection signs 5, 7
• Inadequate cleaning and debridement of the nail bed during nail removal leads to complications 6