Copyright EMAP Publishing 2015 This article is not for distribution Keywords: Hand care/Hand hygiene/ Nursing Practice Neurological injury/Stroke Review ●This article has been double-blind Hand hygiene peer reviewed Although it can be difficult to maintain hand hygiene in patients with neurological injury, with the correct approaches, staff can ensure effective care is delivered Improving hand hygiene after neurological injury In this article... 5 key Why hand hygiene is important points Hand washing Complexities of hand hygiene after acquired brain injury 1and nail care How to improve staff confidence and patient compliance are basic, but essential, tasks Spasticity after Authors Lynsay Duke is advanced Other neurological conditions can also 2 a neurological occupational therapist, Lucy Gibbison is affect the upper limbs, including spinal diagnosis can specialist clinic nurse, Victoria McMahon is cord injury and multiple sclerosis. make opening healthcare assistant; all at Walkergate Park, These figures indicate that there is a the hand difficult Centre for Neurological Rehabilitation and potentially large population in hospital Clear care Neuropsychiatry, Newcastle upon Tyne. and community settings who have upper- 3 planning and Abstract Duke L et al (2015) Improving limb and hand difficulties. They may be a consistent hand hygiene after neurological injury. unable to use their hands to wash or approach to hand Nursing Times; 111; 45, 12-15. manage the hygiene of their affected care are needed Caring for hands tightened by spasticity hands, and therefore need help in main- Care staff after stroke, brain injury or other taining hygiene. 4 may need neurological conditions can be specialist training challenging for care staff. Opening and The importance of hand hygiene to improve cleaning the hand, managing pressure Skin is our barrier to the external environ- confidence and areas, cutting nails and reducing pain ment but is vulnerable and requires skilled skill in this area becomes more complex if muscles are care. Good skin care involves four pro- Commissioned tight and short. Hand hygiene is key for cesses being carried out on a regular basis: 5care should staff but literature on patients’ hand and » Cleaning; include time for nail care is lacking, so specialist education » Hydrating; these tasks to be and care planning may be needed to help » Protecting; carried out staff ensure these activities are done well. » Replenishing (Voegeli, 2008). regularly as This article outlines the importance of Absence of any one of the processes part of holistic maintaining patients’ hand hygiene, increases the risk of skin damage. Risk is intervention explores the barriers to providing effective care and discusses how they might be overcome. and hygiene is an important aspect of infection prevention, but can be challenging for Hpeople with neurological con- ditions that affect their upper limbs. One of the main causes of neurological condi- tions is acquired brain injury (ABI), which results in an average of 956 UK hospital admissions every day. In 2013-14 there were a total of 348,934 admissions for ABI. Of these, 445 were due to head injury and 358 to stroke – the two most common ABIs (Headway, 2015); it is predicted that 50-80% of people who have a stroke have SPL involvement of their arms (Dobkin, 2005). Care staff must be confident in cleaning and moving hands after acquired brain injury 12 Nursing Times 04.11.15 / Vol 111 No 45 / www.nursingtimes.net Copyright EMAP Publishing 2015 This article is not for distribution further increased by adding sustained BOX 1. CasE stUDY high pressure, friction and shear, and the presence of moisture (Glasper et al, 2009). Emily Chase, aged 69, lived in a nursing hands due to the pain she experienced. Much has been written about the mainte- home and was dependent on staff for She shouted, screamed and repeatedly nance of skin care in relation to pressure all of her daily activities. She refused any attempt from staff to open ulcers and continence care focusing on experienced a subarachnoid her hand. She had been prescribed the main areas of heels and sacrum, but haemorrhage in 2001 and now had a liquid morphine for pain; the medication there is little information relating to skin left-sided hemiplegia. She was able to was being given just before lunch. care in hands with spasticity. communicate fully and had the capacity Personal hygiene and care, however, Spasticity is a symptom of upper motor to consent to treatment. usually took place at 9am. neurone damage. Muscles involuntarily Ms Chase was wheelchair dependent Staff reported they were scared tighten and, in the upper limb, a common and had a tight left hand as a result of of using scissors to cut Ms Chase’s pattern is of a flexed elbow, flexed wrist spasticity. Her fingers were fully fingernails and she indicated that she and clenched hand and fingers. clenched into the palm of her hand with knew they lacked confidence. There was If not managed correctly, the tight the joints of her fingers hyperextending no individualised care plan for her hand muscles of spasticity can cause problems, due to the pressure being exerted on and nail care, despite the difficulties such as: the palm. She was in considerable pain being experienced. » Difficulty opening the hand; as a result of the pressure and Discussions were held with staff » Clenching causing pressure areas deterioration in her skin integrity. Her and Ms Chase about the timing of her between the fingers or on the palm; nails were long, digging into her skin. analgesia. A more suitable time for hand » Changed nail growth; It was difficult to access the palm of and nail care was identified after the » Muscle shortening; Ms Chase’s hand due to the tightness of liquid morphine had been administered. » Hypersensitivity; her muscles and the orthopaedic Several practical sessions with the care » Pain. changes that had occurred as a result of staff and Ms Chase were undertaken on These problems can lead to eventual her hand being held in that position for how best to open her hand, gain access changes in the joints and tendons (Bandi several years. However, it was possible to the palm for cleaning and trimming and Ward, 2010). to make a small gap between the her nails. Consideration was also given If the hand is held tightly in a fist and is fingers and the palm. The skin of her to how Ms Chase could help care staff difficult to open, skin can break down, hand was dirty, her nails were long and with these activities. leading to an increased risk of infection. dirty, and the palmar skin was hot and A care plan was devised and used This can also lead to pain and reluctance macerated. There were large deposits of by all staff involved in Ms Chase’s to allow the hand to be handled. dried skin between her fingers and in care. This improved her confidence the palm of the hand. in the staff managing her hand and Role of care staff Ms Chase’s right hand, of which she reduced her pain; consequently, Health professionals’ hand-washing com- had full use, was also dirty and had long staff gained better access to her hand pliance is globally accepted as the most nails. Staff reported that they were and their confidence levels and skills important procedure in preventing infec- unable to help Ms Chase to wash her were enhanced. tion (National Institute for Health and Care Excellence, 2014; Dougherty and Lister, 2011) but literature about the hand al, 2008) but there are many misunder- hygiene including nail care” (Malkin and washing of patients is scant. standings surrounding the role paid staff Berridge, 2009). In addition to physical disability, neu- can play in undertaking fundamental but rological events can cause cognitive, com- undervalued interventions such as hand Factors affecting hand care munication and mental health impair- and nail care. Many agencies discourage For individuals with neurological impair- ments, which can increase dependence on staff from cutting fingernails and many ments, several factors may influence their carers (Malkin and Berridge, 2009; Sackley NHS trusts indicate that nurses should response to staff who try to open tight, et al, 2006). With impaired or limited refer patients to chiropody services (Nicol painful hands to provide care: ability to communicate their views, con- et al, 2012). However, most published lit- » Pain; sent to interventions, express discomfort erature advocating caution discusses » Anxiety; or pain, and complain about the quality of issues around toenail cutting and the risks » Limited communication and care they have received, patients become inherent with conditions such as diabetes understanding; vulnerable to harm, abuse or exploitation. and peripheral artery disease; the mainte- » Cognitive impairment; Staff who are providing hand care should nance of fingernails is not mentioned. » Lack of inhibitory control; ensure care plans identify the person’s Some authors say this causes confusion » Overstimulation; individual needs, as well as their skills about who should, and could, cut or file » Mental health issues (Bowers, 2010). and abilities. fingernails (Nicol et al, 2012; Malkin and A negative cycle of behaviour and Maintaining hand hygiene for people Berridge, 2009). Others state categorically response can quickly build up between the who cannot manage this task indepen- that routine nail care for all patients patient and the staff member providing dently will usually fall to a formal paid should be undertaken by nurses (Dough- care. If the patient displays what is carer – be that in a hospital setting, care erty and Lister, 2015) or others providing perceived as a “challenging behaviour” home or patient’s own home – or family or personal hygiene care, and that is reason- during painful or difficult tasks, these friends.