Culture and religion: privacy issues, timing, taboos against animal products, hair care, etc.
Economic status: homeless? running water? power?
Developmental level: infants, elderly, adults will have different motor skills and special needs related to skin care, mobility, etc.
Knowledge level: will be doing tons of teaching.
Physical factors: health status, mobility, can pt assist?
Cognative: Depressed, ALOC,
Assess self-care abilities: Encourage as mucindependence as possible. Your pt is the 4th of July! Bathing is one of the best opportunities to assess your pt. ROM? Exersion tolerance? Skin integrity? LOC?
Provide assistance with ADLs (as needed)
Promote self-care in ADLs
Delegate appropriate parts of hygiene care
Always remember confidentiality!
Things you might not think about that can affect skin condition
Illness: All the symptoms of the illness.
Changes in weather
Changes in lifestyle: smoking, drugs, hiegyne
Risk factors for alteration in skin integrity
Immobility: bed sores
Limited activity levels
Incontinence: urine/feces break down skin.
Impaired nutritional status
Altered level of consciousness
Friction and shear injury
Nursing Intervensions to reduse risk to skin.
Use soap sparingly: will dry skin.
Use only light friction
Bathe less frequently: Not daily. Pt. is in a "sterile" enviroment so not necessary.
Use moisturizing lotions and creams
Increase fluid intake: to replace lost fluids.
Reposition patient q2h
TED/SCD (Sequential Compression Device) Hose: Compression stockings. SCDs actually inflate and massage. Decreases DVTs. Makes sure they fit, and fit can change espeically if edema decreases.
Identifying Level of Impairment in Skin Integrity
Tissue ischemia: lack of blood flow
Blanching: lack of refill
Normal reactive hyperemia: normal erythema which will blanch and return to normal normal color < 1hr.
Abnormal reactive hyperemia: Skin will not blanch, erythema doesn't go away.
Nurse's clinical judgement about the response to actual or ptoential health conditons or needs.
Self-Care Deficit Bathing/Hygiene
Ineffective Health Maintenance
Early morning care: on awakening – wash face and hands, mouth care A.M. care: after breakfast – bathing, toileting, hair, skin, bedmaking
P.M. care: afternoon – toileting, hand washing, oral care, readying for visitors
H.S. (before bed) care: prior to sleep – relaxation activities, readying environment to facilitate sleep
Privacy: door open, bed pointing in inopportune position