Improving Hand Hygiene after a Cerebral Vascular Accident Elizabeth Carr elizabeth.carr@boltonft.nhs.uk October 2016 Stroke Specialist Nurse 17.10.16

The Black Hole Literature about hand washing of patients is scant There is even less information on care of finger nails Many agencies and NHS discourage staff from cutting finger nails and suggest referral to podiatry Great confusion (podiatry don't cut finger nails either)

5 Key Points Hand washing and nail care are basic, but essential task Spasticity after a neurological diagnosis can make opening the hand difficult Clear care planning and a consistent approach to hand care are needed Specialist training to improve confidence and skill in this area Commissioned care should include time for this task to be carried out as part of holistic intervention

What is spasticity ? Spasticity is a symptom of upper motor neurone damage. Muscles involuntarily tighten and, in the upper limb, a common pattern is of a flexed elbow, flexed wrist and clenched hand and fingers. If not managed correctly, the tight muscles of spasticity can cause problems.

Spasticity Problems Difficulty opening the hand Clenching causing pressure areas between the fingers or on the palm Changed nail growth Muscle shortening Hypersensitivity Pain These problems can lead to eventual changes in the joints and tendons(Bandi and Ward,2010).

Duke L et al (2015) Suggested that caring for hands tightened by spasticity after a stroke ,brain injury or other neurological conditions can be challenging for care staff. Opening and cleaning the hand ,managing pressure areas, cutting nails and reducing pain become more complex if muscles are tight and short Hand hygiene is key for staff but literature on patients hand and nail care is lacking.

Role of Care Staff Health professionals hand-washing compliance is globally accepted as the most important procedure in preventing infection. (National Institute for Health and Care Excellence,2014;Dougherty and Lister,2011) That means our patients hands too.

The Importance of hand hygiene Good skin care involves four processes being carried out on a regular basis: Cleaning Hydrating Protecting Replenishing (Voegeli,2008) Absence of any one of the processes increases the risk of skin damage

Factors affecting hand care Pain Anxiety Limited communication and understanding Cognitive impairment Lack of inhibitory control Overstimulation Mental health issues(Bowers,2010).

Basic hand care advice Explain procedure Gain consent or establish that what you are doing is in the patient`s best interest Visually inspect the hand for any skin/nail damage Report any problems to nurse in charge/line manager/inform GP. These may include; skin breaks, maceration, fungal infections,ingrowing nails, thickened nails or exudate.

Washing Hands Do not force the hand open or move the finger quickly. Use slow, but firm movements. Immerse in a basin /bowl of warm soapy water (check temperature first) The use of non-perfumed aqueous cream can help to lift any dried/dead skin or use hand wipe You may need two people if the hand is very tight-one to hold the hand and distract the patient and one to wash

Washing Hands Dry the hand thoroughly (using clean towel or paper towel) Apply hand cream if the patient wishes and has no relevant allergies Document and report what you have done and any problems encountered

Keep nails short If the patient has a diagnosis of diabetes, rheumatoid arthritis, HIV, or is prescribed anticoagulation medication, do not start nail care without discussing the patients care plan with the nurse or doctor /manager in charge. Perform regular nail care Visually inspect the nails and surrounding skin, check under the nails Clean under the nail

When possible, use single-use nail file or disposable emery board to keep nails short; this reduces need for scissors Shape and shorten the nail following natural shape Dispose of, or clean any equipment used Document and report what you have done. Before using scissors training in general nail care is required and needs to be discussed with line manager

Stretching the hand Needs to be discussed with the occupational therapist or physiotherapist You need to be competent and confident Identify training needs If competent and stated in care plan Continue Take your time

Stretching the hand Gain consent or act in best interest and as care plan Open the hand slowly Use techniques (as trained) for example gently bending the wrist to gain more access to the palm of the hand Carry out stretching/opening of the hand regularly Use hand splint/palm protectors, if provided, for the recommended time scale Monitor the fit, observing for pressure ulcers, reporting any problems to person in charge Hold the hand open with other options, for example a roll of bandage Do not force the hand open or move fingers quickly Do not allow the hand to be unopened for a long period of time

Remember If in doubt give the stroke team a shout Base: Crompton Health Centre Telephone: 01204 46 35 50

Any questions