Transcript Airgas template

Chapter 37
Hygiene
Six Functions of the Skin
• Protection
• Body temperature regulation
• Sensation
• Excretion
• Maintenance of water and electrolyte balance
• Vitamin D production and absorption
Factors affecting the Skin
• Unbroken and healthy skin and mucous membranes
defend against harmful agents.
• Resistance to injury is affected by age, amount of
underlying tissues, and illness.
• Adequately nourished and hydrated body cells are
resistant to injury.
• Adequate circulation is necessary to maintain cell life.
Developmental Considerations
• Infant’s skin and mucous membranes are easily injured
and subject to infection.
• Child’s skin becomes increasingly resistant to injury and
infection.
– Requires special care because of toilet and play
habits
• Adolescent has enlarged sebaceous glands and increased
secretions.
• Adult’s tissue becomes thinner and wrinkles appear; liver
spots occur.
Causes of Skin Alterations
• Very thin and very obese people are more susceptible to
skin injury.
– Fluid loss during illness causes dehydration.
– Skin appears loose and flabby.
• Excessive perspiration during illness predisposes skin to
breakdown.
• Jaundice causes yellowish, itchy skin.
• Diseases of the skin cause lesions that require care.
Factors Influencing Personal Hygiene
• Culture
• Socioeconomic class
• Spiritual practices
• Developmental and knowledge level
• Health state
• Personal preference
Interview Questions/Skin Alterations
• How long have you had this problem?
• Does it bother you?
• How does it bother you (itching)?
• Have you found anything helpful in relieving these
symptoms?
Factors to Consider When Examining Skin
• Cleanliness
• Color
• Temperature
• Turgor
• Moisture
• Sensation
• Vascularity
• Evidence of lesions
At Risk for Skin Alteration
• Lifestyle variables
• Changes in health state
• Illness
• Diagnostic measures
• Therapeutic measures
Focus of Self-Care Deficit Diagnoses
• Feeding
• Bathing and hygiene
• Dressing and grooming
• Toileting
Early Morning Care
• Assist patient with toileting.
• Provide comfort measure to refresh patient to prepare for
day.
• Wash face and hands.
• Provide mouth care.
Morning Care (AM Care)
After breakfast, nurse completes morning care:
• Toileting
• Oral care
• Bathing
• Back massage
• Special skin measures
• Hair care, cosmetics
Morning Care (AM Care) (continued)
• Dressing
• Positioning for comfort
• Refreshing or changing bed linens
• Tidying up bedside
Afternoon Care (PM Care)
Ensure patient’s comfort after lunch:
• Offer assistance with toileting, handwashing, oral care
• Straighten bed linens
• Help patients with mobility to reposition themselves
Hours of Sleep Care (hs Care)
Before patient retires:
• Offer assistance with toileting, washing, and oral care
• Offer a back massage
• Change any soiled bed linens or clothing
• Position patient comfortably
• Ensure that call light and other objects patient requires
are within reach
As Needed Care (prn Care)
• Offer individual hygiene measure as needed
• Change clothing and bed linens of diaphoretic patients
• Provide oral care every two hours if indicated
Reasons for Providing Back Massage
• Acts as a general body conditioner
• Relieves muscle tension and promotes relaxation
• Provides opportunity for nurse to observe skin for signs
of breakdowns
• Improves circulation
• May decrease pain, distress, and anxiety
• May improve sleep quality
Purposes of Bathing
• Cleanses the skin
• Acts as a skin conditioner
• Helps to relax a person
• Promotes circulation
• Serves as musculoskeletal exercise
• Stimulates the rate and depth of respirations
Purposes of Bathing (continued)
• Promotes comfort through muscle relaxation and skin
stimulation
• Provides person with sensory input
• Helps improve self-image
• Strengthens nurse patient relationship
Providing a Bed Bath
• Provide articles for bathing on over-bed table or bedside
stand.
• Provide privacy for patient.
• Remove top linens and replace with bath blanket.
• Place cosmetics in convenient place.
• Assist patients who cannot bathe themselves completely.
Physical Assessment of Oral Cavity
• Observe for oral problems.
– Dental caries
– Periodontal disease
– Other oral problems
• Identify actual or potential oral problems that nurses can
treat.
• Identify appropriate nursing measures.
• Carry out the plan of care.
Administering Oral Hygiene
• Moistening the mouth
• Cleaning the mouth
• Caring for dentures
• Toothbrushing and flossing
• Using mouthwashes
Care of Eyes
• Clean from inner to outer canthus with wet, warm cloth,
cotton ball or compress.
• Use artificial tear solution or normal saline every 4 hours
if blink reflex is absent.
• Care for eyeglasses, contact lens, or artificial eye if
indicated.
Ear and Nose Care
• Wash external ear with washcloth-covered finger; do not
use cotton-tipped swabs.
• Perform hearing aid teaching and care if indicated.
• Clean nose by having patient blow it if both nares are
patent.
• If indicated, use nasal suctioning with bulb syringe.
• Remove crusted secretions around nose and apply
petroleum jelly.
Providing Hair Care
• Identify patient’s usual hair and scalp care practices and
styling preferences.
• Note any history of hair or scalp problems, such as
dandruff, hair loss, or baldness.
• Treat any infestations, such as pediculosis and ticks.
• Groom and shampoo hair.
• Care for beards and mustaches.
• Assist with unwanted hair removal.
Nail and Foot Care
• Assess nails for color and shape, intactness and
cleanness, and tenderness.
• Check for history of nail or foot problems.
• Soak nails and feet and assist with cleaning and trimming
nails (if not contraindicated).
• Massage the feet to promote relaxation and comfort.
• Provide diabetic foot care if indicated.
Perineal and Vaginal Care
• Assess for perineal or vaginal problems and related
treatments.
• Perform a physical assessment of male and female
genitalia.
• Perform perineal in matter-of-fact and dignified manner
according to procedure.
• Cleanse vaginal area with plain soap and water.
Guidelines for Applying
Antiembolism Stockings
• Measure patient’s leg for size of stocking.
• Apply stocking in morning before patient is out of bed
and while patient is supine.
• Do not massage the legs.
• Check legs regularly for redness, blistering, swelling, and
pain.
• Launder the stockings as necessary.
Applying Intermittent Pneumatic
Compression Stockings
• May be used in conjunction with antiembolism stockings
• Require a physician’s order
• Are prescribed for high-risk surgical patients and patients
with chronic venous disease or at risk for deep-vein
disorders
• Are knee-length or thigh-high cuff connected to hoses
and a pump
• Stimulate normal muscle-pumping action in the legs
Ensuring Bedside Safety
• Patient call light is functioning and within reach
• Bed is positioned properly, at appropriate height, wheels
locked
• Side rails are safely used when indicated
• Principle of medical asepsis are followed
• Electrical equipment is safely grounded
• Walk space is uncluttered
Patient Outcome Achievement
• Level of patient participation in hygiene program
• Elimination of, reduction in, or compensation for factors
interfering with independent execution of hygiene
measures
• Changes related to specific skin problems