Nail Removal: Procedure Preparation

00:01 Hello, my name is Glenna Lashley and I'm a family nurse practitioner.

00:05 Here at Lecturio, we realize that students always don't get an opportunity to see skills or get to practice in clinical rotations.

00:15 Our content today is nail assessment and removal.

00:18 If the nail is already falling out or it's barely torn, you may not need to remove the nail.

00:24 In situations where the patient has made it all the way to see you as an advanced practice provider, it's likely that you will need to remove the nail and perform a digital block. In every situation, removal will involve careful assessment of the nail bed and foot for signs of infection, symptoms of associated trauma, and nerve damage.

00:46 Make sure you get the whole story from your patients so you know what happened prior to coming into your office.

00:51 Some patients may need a toenail removed because of trauma, or sometimes it can be due to an ingrown toenail.

00:58 This history has implications for whether post-procedure antibiotic therapy is needed.

01:04 Also, think ahead about what teaching you may want to teach post procedure to the patient.

01:09 If you are working in the urgent care setting or in pediatrics.

01:13 Finger or toenail removal may come up a lot more in your practice.

01:18 There are some things that you can do right, and there are some things that you can do wrong. This with this skill.

01:23 So it's important that you know the anatomy and learn the steps.

01:27 As you can see here, here are some information about the anatomy of the toenail.

01:34 As with any procedure, there are supplies that you need to know and steps along the way. I will talk you through the steps and then show you the procedure itself. As always, I'll give you some insights as we go along.

01:49 First, you want to obtain patient consent.

01:52 This is very important because you will be doing a digital block and this is considered an invasive procedure.

01:58 Make sure that you follow your organization's policy when getting patient consent.

02:03 You also want to document that you discuss the risks and benefits of the procedure with the patient. So we would be talking about risk of bleeding risk of infection.

02:14 We would be the benefits would be that this would actually clear up the infection.

02:19 And the patient wouldn't have the pain any longer.

02:22 You want to gather your supplies, prepare your working area and perform hand washing. You want to have iodine available if they're allergic, you can use the chlorhexidine.

02:33 You also will need lidocaine.

02:35 1% without epi is what I'm using today, but you can use with epi but use it with caution. You need a 25 to 27 gauge needle, sterile gloves.

02:47 You'll need a English anvil splitter or a nail splitter.

02:51 A nail elevator, bandage scissors, Hemostats, gauze , non-adherent dressing, self adherent wrap, which we have in our example, cling wrap and antibiotic ointment.

03:04 Make sure you check for allergies with your patient.

03:08 Because this procedure likely involves pain and can be anxiety-producing, you want to make sure that you make your patient as comfortable as possible.

03:17 Most of the time my patients are laying down on the exam table.

03:20 Also, if they faint at the sight of blood, you don't want them looking at it.

03:24 So having them lay back where they can't see what you're doing is very good.

03:28 But you want to explain what you're doing as you do the procedure.

03:31 Complete and document neurovascular exam which includes checking capillary refill, sensation and motor function pre-procedure.

03:40 So next you're going to clean the nail area with iodine or you can use chlorhexidine swab. Also, something that I do in my practice is I actually have a basin and I put warm water and iodine, if they're not allergic.

03:53 If they are allergic, then I use soapy warm water.

03:57 What this does is actually soften up the nail and the nail bed, so it will be easier for you to remove less tugging and pressure that the patient will feel, so it makes it a better experience for them.

04:08 Then you're going to want to do the digital nerve block.

04:10 You can use aseptic technique to perform this.

04:14 This allows me to go ahead and do the nerve block and let them wait for 10 to 15 minutes.

04:19 That way I can ease out, go see another patient, and then come back in the room and get ready to do the procedure with sterile technique.

04:26 You want to make sure that you allow adequate drying time as well, when you're using the iodine or the chlorhexidine.

04:34 Sometimes you may want to apply a tourniquet to the base of the toe.

04:38 You do not always, but this may be needed, particularly if someone's on anticoagulants.

04:43 You want to use a nail splitter to divide the nail longitudinally into the appropriate sections, based on the area requiring removal.

04:51 A lot of times, you're going to do partial removal, so you split down the middle, taking out either side that's affected.

04:58 Sometimes the whole nail will have to be removed.

05:01 I also want to let you know that if someone has had several ingrown toenails and they actually need the nail bed to be killed.

05:08 That is something you would refer to podiatry.

05:11 You are not able to do that as an advanced practice nurse.

05:15 You want to insert your nail elevator between the nail plate and the nail bed at the proximal nail fold. You'll advance it slowly, maintaining a downward pressure to separate the nail from the bed using a gentle rocking motion. Once separated, grasp the nail section firmly with hemostats and remove steadily distal to proximal traction.

05:37 Avoid lateral movement as this can cause damage to the nail matrix.

05:43 Post procedure you want to inspect the nail bed for retained fragments or matrix damage.

05:49 You want to remove any irregular edges, so this may require you using your scissors.

05:54 Apply pressure for hemostasis.

05:57 Sometimes at this point you might use a cautery pencil, or you could also use some Monsell solution to help with that.

06:05 Clean with sterile water.

06:07 You want to apply antibiotic cream and a non-adherent dressing.

06:11 You want to wrap with self-adhering bandage.

06:15 I frame away from using coban as that might get too tight for the patient.

06:20 So I usually use cling wrap.

06:22 You want to document post-procedure, the neurovascular check again.

06:27 And then you want to teach the patient.

06:29 So I'm going to tell the patient I want them to keep the site clean and dry.

06:33 I usually tell them they got to keep it wrapped with initial wrapping for 24 hours.

06:38 I also tell them if they have a little bleeding to reinforce it, but if they continue to have bleeding, they need to call the office because something else will need to be done.

06:47 Review the signs and symptoms of infection.

06:50 We want to remind them to use warm, soapy water daily.

06:54 We want them to use dry socks daily and to follow up with their primary care provider as needed. And we want antibiotics for high-risk situations.

07:04 This would be oral antibiotics.