Ch. 19

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Ch. 19
2011-09-22 19:20:51

Assisting with hygiene, personal care, skin care, and prevention of pressure ulcers
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  1. Functions of the skin (Protection)
    first line of defense against bacteria and other organisms; protects against thermal, chemical and mechancial injury
  2. Sensation (functions of the skin)
    contains sensory organs for touch, pain and heat and cold
  3. Temperture Regulation
    regulates temperture by constricting or dilating blood vessels and activating or inactivating sweat glands
  4. If the patient is sweating profusily make sure what......
    Make sure their getting an adequate amount of FLUID
  5. Excretior and secretion (Functions of the skin)
    sweat glands help maintain the homestasis of fluids and electroytes

    sweat glands serve as organs of excretion secretingn nitrogenous waste

    sweat glands in axillae and external genitalias secrete fatty acids and protiens

    • sebrum lubricates skin n hair
    • sebum keeps structures pilate and elastic
    • sebrum decreases heat loss
    • sebum decreases bacterical growth
  6. Skin changes occuring with AGING
    1. loss of elastic fibers cause skin to wrinkle and sag

    2. skin becomes thinner, fragile and slower to heal

  7. SKIN changes occuring with AGING
    3. Decrease sebacous activity leaves skin dry and itchy, temperture control is altered by decrease sebacous gland activity and thinner

    4. Hair becomes thinner, grows more slowly and loses its color from loss of melanocytes
  8. Nursing Process (hygiene)
    the practice of cleanliness that is conductive to health
  9. List factors effecting hygiene
    • socioeconomic background
    • economic status
    • knowleadge level
    • abitity to perform self-care
  10. What is the biggest factor effecting hygiene
  11. Bath affords opportunity for assessing?
    the skin

    physical apprerance

    emotional and mental status

    learning needs
  12. If the patient is imobile and cannot move they are at risk for?
    Presure ulcers
  13. How are ulcers formed?
    Ulcers are form from local interfernce with circulation usually in one area
  14. Skin and presure ulcers (skin)
    the skin blanches and becomes pale

    If interference (pressure) is removed, skin will become darker as blood supply returns [reactive hyperemia]
  15. Pressure Ulcer Risk Factors
    • 1. Confinement to bed or chair
    • 2. Inability to move
    • 3. Loss of bowel or bladder control
    • 4. Poor nutrition
    • 5. Lowered mental status
    • 6. Dehydration
    • 7. Obesity
    • 8. Excessive diaphoresis
    • 9. Extreme age
    • 10. Edema
  16. Pressure ulcer MAJOR risk factors
    1. Confinement to bed or chair

    2. Inability to move

    3. Loss of bowel or bladder control

    4. Poor nutrition

    5. Lowered mental status
  17. Obesity
    loss of muscle control causes the skin to sag, if skin is not clean and dry there will be a yeast infection

    move the skin and wash really well and dry well to prevent infection
  18. Assessment (braden scale)
    Perform on admission, use

    • braden scale- predicting pressure sore risk
    • (sensory perception, moisture, activity, mobility, nutrition, friction n shear)
  19. Assessment
    Reassess often every 24 hours

    Check for bony prominences and reactive hyperemia


    reassess patients that cant move or incontinent or confined to bed

    also patients that are (sitting, laying on back and side)
  20. Most common places (Bony Prominences)
    elbows, heals, scapula, knee, hips, ankles
  21. Stages of Pressure Ulcers
    ( stage 1)
    Area of reddened skin that does not blanch when touched. Area still intact

    In people with darker skin, discoloration of the skin, warmth, edema or induration (area feels hard)
  22. Stages of Pressure Ulcers
    (stage 2)
    Partial thickness skin loss

    involving epidermis and dermis. It may look like an abrasion, blister, or shallow crater

    surrounding skin may feel warmer
  23. Stages of Pressure Ulcers
    (stage 3)
    Full-thickness skin loss

    looks like a deep crater, may extend into the fascia subcutaneous tissue damaged or necrotic

    Bacterial infection of the ulcer id common and causes drainage from ulcer
  24. Stages of Pressure Ulcers
    (stage 4)
    Full-thickness skin loss

    • Extensive tissue necrosis or damage to muscle or supporting structures may
    • appear dry and black

    there is no circulation to it, cant have a pressure heal if there is no circulation

    surgerons can cut away to healthy tissue (bleeding)

    these ulcers cant heal any other way but from the inside out
  25. Eschar
    the ulcer may appear dry and black with a buildup of tough, necrotic tissue

    (wet and oozing)
  26. Stages of Pressure Ulcers
    loss of full thickness of tissue. The base of the ulcer is covered by eschar (tan, brown or black

    or base of ulcer contains slough (yellow, tan, gray, green, or brown)

  27. Whirpool
    to get rid of dead tissue (debris) taking off dead
  28. Pressure Ulcers
    document what you see

    • 1. Depth
    • 2. Size
    • 3. Color
    • 4. Warmth
    • 5. Drainage
    • 6. Location
  29. Preventing Pressure Ulcers
    • 1. assess skin carefully and frequently
    • 2. change patient postion every 2 hrs
    • 3. keep heals of immobile patients off the bed

    4. Avoid positioning the patient directly on the trochanter (hip)

    5. Use a trapeze or lift shet to change the patient's posisition
  30. Preventing Pressure Ulcers
    6. Use pressure reducing devices such as (foam pads or mattresses)

    • 7. Use pressure reducing devices for patients in a wheelchair
    • (shift weight at least once an hour, preferably 15 minutes)

    8. Restore circulation to areas by rubbing AROUND a reddened area
  31. Preventing Pressue Ulcers
    9. DO NOT massage reddened skin or over a bony prominece

    10. Wash and dry incontinent patients promptly

    11. Avoid mechanical injury from cast, braces, etc

    12. Avoid skin injury caused by friction and shear

    13. Provide adequate nutriton and hydration

  32. Hydration
    every 1-2 hours offer a drink for patients that cannot eat or feed themselves

    It is the NURSE responsible to make sure their hydrated 8oz
  33. What is the best prevention to treat ulcers?
    Excellent Nursing Care
  34. Skin tear (prevention)
    Lift patients up, Hydrated them, good nutrition

    • If patient has a skin tear the dont remove it, they lay it back down & put a dressing over it. When they remove the dressing the skin will come off
  35. Pressure Ulcer Treatment
    Excellent nursing care is the main factor in prevention of pressure ulcers and is a team effort

    Inital care include:

    • 1. Debridement
    • 2. Wound cleansing
    • 3. Application of dressing

    the patient, family, and health care providers (team approach) the patient should be encouraged to be acitve participant. Educate the patient on how pressure ulcers are develop and how to treat them.

    Initial care may require antibiotic therapy
  36. Nursing diagnoses
    • Self care deficit
    • Impaired physical mobitity
    • Impaired skin integrity
    • Pain
    • Imbalanced nutrition
  37. Planning Care
    (early morning)
    Try to get most patients up before breakfast and fully dressed.

    • Offer bedpan or urinal and provide help to bathroom
    • 2. Wash hands and face
    • 3. Clean and clear the over the bed table
    • 4. Provide oral care
    • 5. Prepare for tests or surgery (shaves)
  38. Planning care
    (A.M care)
    Usually occurs after breakfast and is the main hygiene

    • 1. Offer bedpan or urinal
    • 2. Provide oral care
    • 3. Straighten the unit
    • 4. Nail care
    • 5. Give back rub
    • 6. Shave and provide hair caere
    • 7. Dress
  39. Planning care
    (Afternoon care)
    • 1. Offer bedpan or urinal
    • 2. Provide care after any dianositic test as needed
    • 3. Provide oral care
  40. Planning care
    (Hour of sleep care)
    • 1. Offer bedpan or urinal
    • 2. Wash hands and face
    • 3. Provide oral care
    • 4. Change gown if needed
    • 5. Give back rub
    • 6. Help adjust patient position in bed
    • 7. Straigten the unit
    • 8. Fresh water

    Linens are straighten and changed as needed throughtout the day
  41. Bathing (4 purposes)
    • 1. Promote Comfort
    • 2. Cleanse the skin
    • 3. Stimulate circulation
    • 4. Remove waste products

    Patient should be covered to prevent chills

    Water temperture should be approximately 105 degrees
  42. Nursing goals for hygiene
    • 1. The patients skin integrity wil be maintained
    • 2. The patients hair is clean and neatly styled
    • 3. The patients mouth is intact and free of odor
  43. Types of Bath
    The most common done in bed, tub or shower offer patient use of toilet before setting up for bath

    May need assistive devices such as chair or stool in shower or tub

    Once patient is in the tub add warmer water as desired. A call bell should be within reach

    • check on patient every 5 mins
    • and it shouldnt exceed 15-20 mins
  44. Types of Baths
    Whirlpool bath- done in bathtub or special whirlpool tub that has a device that agitates the water

    they cleanse, stimulate peripheral cirulation and provide comfort

    Oatmeal and starches are added for patients with dermatitis

    Sitz baths
    used to apply moist heat and clean the perineal or anal area

    promote healing, relieves pain and discomfort

    commonly used after birth or vaginal or rectal surgery
  45. Back rubs
    • 1. Communicates caring
    • 2. Fosters trust in the nurse patient relationship
    • 3. Provides an opportunity for skin assess
    • 4. Stimulates circulation of blood to the area
    • 5. Reduces tension and promotes relaxtion
  46. Routine Care
    • routine care is usually preformed in the morning
    • consists of bathing (full or partial bed bath), perinela care, oral care, hair care and shaving

    Mouth care helps to remove food particles and secretions which prevents (halitosis) feellings of uncleanliness and dental caries

    Oral care may need to be performed several times a day

    Performed on unconscious patients every 8 hours (sitting on their side)

    is at the bedside because it removes any secretion from the mouth to prevent it from getting in their lungs and causing patient to asparate.
  47. Routine Care
    (Denture Care)
    • 1. If patient is not awake dont put dentures in
    • 2. Prior to putting dentures in mouth need to be clean
    • 3. Clean dentures before and after bed

    PUT WASHCLOTH down in sink before cleaning the dentures to prevent breakage

    4. Dentures should be kept in a label denture container cool water or normal saline

    5. Brush from gumline to the edge of teeth

    6. Raise head of bed 45 degrees
  48. Hair care
    Brushing hair stimulates circulation which promotess hair growth, prevent hair loss, distribute oil along hair shafts and bring nutrients to the roots

    Should be brushed from scalp to end to help with oils

    Use alcohol or water to dantangle hair

  49. Routine Care

    Know what medication their on because some meds cause patient to bleed heavy like anticoagulant (blood thinner) COMUDAN, ASPIRIN

    Patients on blood thinning meds can not use a disposable razor you must use an electrical razor

    If patient is taking an aspirin once a day use a electrical razor because blood is thin

    Shave in the direction of hair growth, gentle strokes, before shaving take warm washcloth and sofen the skin and hold skin

    • stroke up under the chin and down on the cheecks
    • 30-45 degree angle

    rinse after every 2-3 strokes
  50. Routine Care
    Nail care may need to be provided with patients that are unconscious, blind, confused unsteady or in cast traction.

    Diabietics patients should not have theri toenails cut without a doctors order

    Use an orangewood stick to clean under nails and push back cuticles
  51. Routine Care
    (Eye Care and Ear)
    Glasses store glasses in case, clean lenses with warm water and a soft cloth to wipe dry, Do NOT use a paper towel

    Contact lenses to remove a hard lens wash hands and remove it by lifting up eyelid

    Hearing aids- 1. body worn, 2. behind the ear, 3. attached to the eyeglases 4. in the ear 5. in ear cancal

    store hearing aids in case and clean them with soap and water dont submerge them in water