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PRINCIPLES OF HYGIENE Michele Archdale Risks of Hospitalisation • • • • • • • Functional Decline Iatrogenic Illnesses Cognitive Impairment Mood Disorders Immobility/Gait Disorders Malnutrition Restraints 2 FUNCTIONAL DECLINE – older patients • “Older patients often experience a loss of independent physical functioning during the course of an acute illness requiring hospitalisation” • Patient’s potentially will become dependent in one or more ADLs 3 • It is our role to assist our clients with achieving optimum health and independence, Assisting with ADL’s is a large part of that process. 4 WHAT ARE ADL’S? *ACTIVITIES OF DAILY LIVING * 5 ACTIVITIES OF DAILY LIVING • Self Care– - dressing / undressing – - grooming, hygiene, elimination. • Mobility– - sleep patterns – - exercise – - housework – -ability to move around safely – -specific difficulties 6 HYGIENE Hygiene needs are individualised depending on the patient’s • level of dependence for assistance • Level of illness • Cultural diversity • Normal practices • Emotional state PURPOSE OF NURSE PROVIDED HYGIENE • Remove microorganisms • Do a head to toe physical assessment • Increase circulation – Peripheral to central – arms and legs inwards – Return to heart • Improve self image • Provide comfort HYGIENE includes: • • • • • • Cleansing of patient Communicating with the patient Bedmaking Room straightening Emptying garbage Removal of used supplies, dishes, flowers, newspapers, etc. • Assessing patency of and cleansing equipment • Placement of necessary supplies Hygiene involves cleansing of the: • Skin • • • • • • • • • Mouth Teeth Hair Nails Eyes Ears Nose Perineal Area Feet PRIORITIES OF HYGIENE Depends upon Patient’s general physical condition Individual hygiene requirements Preferences and requests from the patient The number of patients you are caring for Remember that some types of hygiene are necessary for the patient’s wellbeing – even if it may cause some discomfort. SKIN • • • • • Regulates body temperature First line of defense against harm Antibacterial and antifungal Transmits sensations Signs of problems • Redness (erythema) • Wet or damp • Not intact NURSING ASSESSMENT WHILE BATHING • • • • • • • • • • History Relationship Color and condition of skin Pain on movement Level of consciousness Injuries Scars Skin dryness Presence of moles Weight loss or gain NURSING INTERVENTIONS • General health important • Intact skin – Caution in movement – Don’t overbathe elderly • Protein in diet • Avoid periods of moisture – Change frequently – Dry carefully – Rinse soap • Sun screen important – Especially with certain medications PATIENTS AT RISK FOR SKIN PROBLEMS • • • • • • • Altered level of consciousness Altered nutrition Immobility Dehydration Altered sensation Secretions on skin Mechanical devices, casts, restraints • Altered venous circulation GENERAL PRINCIPLES • • • • Client safety Nurse safety Work in time constraints & be organised Allow privacy and dignity – Only body part being washed is uncovered – Curtain is closed • Change water, washcloths, towels, linen as needed • Call bell available CONFIDENTIALITY • In providing hygiene, may find very personal details • Report on “need to know” basis • Tell instructor; decide together on what to take further • Must break confidentiality if signs of abuse PATIENT PREFERENCES • Try to involve patient in care • If too ill, we must do all • Give control over soap, deodorant, mouthwash, nail length, water temperature • Must work within time constraints • Be very cautious with delegation of care to others • Must carefully assess refusal of bathing; speak to Team Leader. BATH REFUSAL What is real problem? • Power issue? • Fatigue? • Visitors? Assessment • Patient continent? • Skin care? • Level of exertion? Comfort education and negotiation ATTENTION TO BODY IMAGE ISSUES • Body image is the meaning that the person attaches to body part • Person may have radical changes in body image • You may be one of first to see this • How nurse responds to body image changes sets tone to last a lifetime SOCIOCULTURAL FACTORS • It is common to bathe daily; not all cultures do • Economics is an influence • Different cultures shave different body parts and hair on head differently • Some cultures wear items not to be removed in bath – examples: wigs, headdressings, amulets, turbans, religious medals or shawls • Male nurse only or female nurse only may be necessary in some cultures SOCIOCULTURAL FACTORS • In some cultures, male relative may not allow male nurse alone with woman patient • In some cultures, autonomy of patient is paramount; in others, family makes decisions for care • Level of education may influence care • Legal and presumptive relationships – Gay and lesbian partners – Teen friends of emancipated minors • Nurse accepts all who lovingly participate POVERTY OR HOMELESSNESS • • • • • • Influences hygiene May have body parasites May have unhealed/untreated wounds Dental issues Clotting problems from alcohol Drug entry sites, abscesses KNOWLEDGE LEVEL • May need teaching regarding: – Front to back perineal care – Brushing gum line, not just teeth – Special foot care for circulatory problems – Skin inspections by dermatologist Hospital acquired infection • Also called iatrogenic • Patient illness brought on simply by being in the hospital and being exposed to organisms not found outside the health care setting Hospital acquired infection • Hands washed with antiseptic soap and friction • Short fingernails; artificial nails now being forbidden • Soiled linen kept off uniform • Gloves – if client has open or draining wound or is incontinent – if nurse has skin breaks on hands • No sharing supplies without proper sanitation SAFETY Electrical supplies must be checked by engineering department prior to use; and not left near pan of water ◦ hair dryers ◦ electric shavers Bed raised to working height and lowered when finished Side rails up for patients requiring All spilled water immediately wiped Caution with use of powder Caution with use of latex SHAVING • Shaving reflects level of caring • Safety razor not used on certain patients – – – – Those on anticoagulant drugs Those with liver disease causing clotting disorders Confused patients Suicidal patients • Use electric razor after engineer check • If using hair depilatory, always test area first SAFETY • All patients will need attention to water temperature • Patients with impaired level of consciousness will need special care – – – – – gentle eye care, possibly patching frequent mouth care proper positioning care to bed linen water temperature PATIENTS RECEIVING CHEMOTHERAPY • Special mouth care – nausea – oral thrush or stomatitis • Special hair care • Rest periods PATIENTS RECEIVING RADIATION THERAPY • Do not wash off markings • No bath salts • No heating pads or hot water bottles UNCONSCIOUS PATIENT • Maintain normal range of movement • Maintain patient safety • Patient lifts with 2 or more staff members • Regular mouth care with head to side and semi dry swabs • Priority to perineal care and incontinence FATIGUE AS A FACTOR • Nurse’s job to monitor patient tolerance – Respiratory response – Heart rate – Can patient tolerate being flat? Do they need to sit upright? – Confusion level – Shower less taxing than bed bath – May be easier on patient to be up in chair than rolled side to side DEVELOPMENTAL LEVEL: NEWBORNS • Do not place under running water • Do not submerge until umbilical cord drops off • Dry carefully, especially the head • Dress warmly following a bath – dependent on room temperature. DEVELOPMENTAL LEVEL: YOUNG CHILDREN • Children can drown in 2 inches of water; never leave alone during bathing • Teach parents about fluoride • No milk or juice bottles in bed • Wipe off teeth after eating with soft cloth DEVELOPMENTAL ISSUES: CHILDREN • Children may have natural parents, stepparents, four sets of grandparents, all involved in care • For decision making, some cultures must ask father, some must ask grandmother DEVELOPMENTAL LEVEL: ADOLESCENTS • Modesty essential • Normal clothes, not gowns • Bed pans not acceptable • Allow decision making • No tampons in the hospital DEVELOPMENTAL LEVEL: OLDER ADULTS • Heat insensitivity; can burn easily • Foot care • Skin very fragile STUDENT NURSE ISSUES • Be aware of inappropriate behavior or comments • Personal space of patient – Undress, examine, wash and groom stranger – Incontinence can cause discomfort – Sexuality may be an issue • Patient really asking “Am I still desirable despite my illness?” • Take a break if uncomfortable; tell facilitator, preceptor • Attraction? Ask for patient change STUDENT NURSE ISSUES • • • • • Your safety and well being is our job Care of your back Lifting and bending appropriately Protected against infection transmission Tell facilitator, preceptor if pregnant or immunosuppressed • Ask for help (physical and emotional) • Learn assessment skills THERAPEUTIC BATHING (not common) • • • • • Physician ordered; nurse suggestion Water temperature usually 100-115 F Medications are ordered to be put in water Time usually 20 minutes Don’t leave patients alone – Be very clear delegating TYPES OF THERAPEUTIC BATHS • Saline – 0.9% NaCl Normal body consistency for wound care and irrigations • Pinetarsol bath additive for itching • Iodine for antibacterial action (Ask about allergies) SHOWERING PREPARATION • Check patient case notes for any mobilization restrictions • Organize your supplies first • Consider if pain medication is needed first • Remember patient dignity/privacy • Keep curtains/doors closed • Dry carefully – Pat dry • Include oral care, shampoo, and shave • Don’t ever leave them alone in shower BEDBATH / SPONGEBATH • • • • Change linen as needed Do range of motion as needed Do oral care, hair care, and give back rub Leave bed in low position, rails up, and call bell in place. • Tidy room. Replace wet linen with fresh • Report and chart findings BEDBATH • Wash head to toe, front to back, distal to proximal, clean to dirty. • Physical assessment as you are washing; must also loosen and secure lines as moving and turning patient • Change wash clothes for different areas • Change water if cold or soiled or very soapy • Some put oil in bath water of elderly • Talk and make conversation – relax a potentially difficult situation WHO BATHES PATIENT? • More complexly ill, higher level of caregiver – In ICU, registered nurse – In General Wards, nurse – In intensive care nursery, nurse – In nursing home, may be nursing assistant, nurse but nurse is responsible for training and delegating BACK RUB • Purpose - Pressure Area Care – Relaxation – Circulation – Pain relief • Assess skin integrity on back • Assess all bony prominences • Always done as part of good nursing care BACK OR BODY MASSAGE • Warm lotion first • Use continuous strokes • Does not include back of calves • Ensure privacy is maintained • Not too firm PERINEAL CARE • Professionalism always • Not deferred in cases needing nursing assessment • Female – Always clean to dirty (urethra to rectum) – Use absorbent pads for females menstruating (no tampons) – If large breasts, need to dry underneath carefully • Male – Assess for circumcision • If not, cleanse under foreskin and replace FOOT CARE • • • • • Soak feet as part of bath Clean toes and toenails Teach as you go Range of motion of legs Feet of diabetic patients and patients with vascular disease are inspected carefully; Never cut toenails of these patients • Many facilities have podiatrist visits NAIL & HAND CARE • • • • • Observe circulation; color, capillary refill time Observe color, sensation, and movement (CSM) Polish removed to observe color and use pulse oximeter Assess for clubbing sign of long term lack of oxygen Assess for rings too tight or too loose MOUTH CARE – ORAL HYGIENE • Examine with gloves and light, especially smokers • Use only water soluble lubricants • Unconscious patient has no gag reflex, position on side for care • May have gum hyperplasia (bleeding gums) from medication • May have teeth staining from medication • Teach about brushing and flossing CARE OF DENTURES • Assess for fit • If removed, keep in covered cup with water • Label cup with patient’s name • Keep in bedside table • Pad sink when cleaning • Use cool water HAIR CARE • Culture may influence care – – – – Hmong – do not touch without permission Muslim and Orthodox Jew – May keep covered, wear wig Sikh – Does not cut Different parts of body have hair shaved HAIR CARE • Hair is combed daily and shampooed prn • Dredlocks & braids not to be undone to shampoo – Patients may use hair oil on these • Both wet and dry shampoo available • Send to operating room or surgical procedure with clean hair and shaven (see surgeon’s standing orders) EYE CARE • • • • • • • • • Contact lenses usually removed Stored in saline liquid; case labeled Also label and safeguard glasses in drawer Clean inner to outer canthus Patient must be able to blink to protect cornea Never use cotton near eyes Treat each eye separately Eyes considered sterile Care of artificial eye similar to dentures EARS • Allow nothing sharp in ears • Hearing aids now very small in size – don’t lose! Label case • Cerumen (wax) in ears may need softening and removing • Speak directly to patient’s face if hard of hearing - deaf ASSESSING TUBES AND LINES • Oxygen – stays on during bath, check connections, liters per minute, cleanliness of prongs or mask, water if used, plugged in if concentrator • IV lines – use special gown, don’t open lines to change gown, look at IV site, rate and solution • Urinary catheter – draining, unkinked, bag below bladder • Enteral tubes – in place, running or draining properly, or clamped properly • Dressings – Clean and dry, drains properly working • Does anything need to be emptied, changed or cleaned? • Ensure your patient is not lying on tubing or equipment BEDMAKING • Make bed for patient comfort • If incontinent, wash, rinse, dry, change linen • Use aids to relieve pressure points – heel, elbow protectors – bed frame with trapeze – frame to keep covers off feet – special beds and mattresses • Position as ordered NURSE SAFETY IN BEDMAKING • • • • • • • Raise bed to working height Face patient Bend knees Conserve steps Don’t lift alone Side rails as ordered Lower bed and place call bell when leaving CHARTING • • • • How patient tolerated bath Any unusual findings What was done about findings Comparative progress