Card Set Information

2012-06-11 11:54:04

Nurse's duty to facilitate hygiene
Show Answers:

  1. Purposes of Hygienic care
    • Maintenance of personal hygiene: psychological well being, bacterial elimination,
    • Protection: against skin breakdown
    • To improve Circulation: ↑ Activity leads to ↑circulation; wash distal to proximal with long, strong strokes to improve venous return.
  2. FActor that influence hygien and self care practices
    • Psychosocial factors: routines, habits, personality quibbles.
    • Personal preferences
    • 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,
  3. Nursing Roles
    • 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!
  4. 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
  5. Risk factors for alteration in skin integrity
    • Immobility: bed sores
    • Limited activity levels
    • Incontinence: urine/feces break down skin.
    • Impaired nutritional status
    • Infection
    • Anemia
    • Diminished sensations
    • Altered level of consciousness
    • Cachexia (emaciation)
    • Friction and shear injury
    • Obesity
    • Hydration
    • Aging skin
  6. Nursing Intervensions to reduse risk to skin.
    • Use soap sparingly: will dry skin.
    • Rinse well
    • 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.
  7. 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.
  8. Diagnosis
    • Nurse's clinical judgement about the response to actual or ptoential health conditons or needs.
    • Self-Care Deficit Bathing/Hygiene
    • Ineffective Health Maintenance
  9. Scheduling
    • 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
  10. Hygiene planing
    • Privacy: door open, bed pointing in inopportune position
    • Safety: bed rails/locks
    • Warmth
    • Independence: Bed rest? ambulatory?
    • Supplies
    • Anticipate patient needs
  11. Delegating Hygiene Care
    • Assess prior to delegating

    • Instruct UAP (Unlicensed Assisstive Personel) regarding...
    • Client’s limitations
    • Amount of assistance needed
    • Use of assistive devices
    • Presence and care of tubes
    • Observations to make during hygiene care, ie what are we looking for here?

    Must reassess after delegated activities have been performed.
  12. Types of Baths
    • Assist bath: Bathe areas hard to reach, ie nooks and crannies.
    • Partial bath: only the good parts. The "bear" necessities.
    • Bathe only those areas absolutely necessary, including perineum
    • Bed bath
    • CompletePartial
    • Help bath
    • Towel Bath
    • Bag Bath
    • Shower: usually in a chair.
    • Tub: Pretty rare now.
    • Therapeutic bath: OT, PT
  13. Considerations Prior to Bath
    • Review orders
    • Explain procedure
    • Prepare room
    • Assemble equipment
    • Offer a bedpan: Warm water makes you pee. It will make your pt pee too.
    • Water or bag bath temperature: ~100.5. No microwaves.
    • Privacy
  14. The Bed Bath
    • Maintain Comfort
    • Temp -105 degrees F
    • Use soap/oil: Move clean --> dirty. Save the butt/groin for last.
    • Proper lighting
    • Eliminate odors
    • Maintain Distal to Proximal: Remember we're trying to improve venous return.
    • Support extremities
  15. Eyes, Ears, Nose, Mouth
    • Inner to outer canthus.
    • Remove artificial eye (depress on lower lid to pop out
    • Remove hearing aids.
    • Reposition nasal tubes to wash around. Use water soluble lubricant. No Vaseline! Will ignite with O2.
  16. Oral Care
    • Oral care facilitates:

    • Removal of food particles and secretions
    • Improved appetite
    • Assessment of client’s oral status: Especially for pt on vent, inspect at least twice daily to prevent VAP (Ventilator Assisted Pneumonia). Also, if pt has dentures, remove and look at oral cavity.
    • Care of dentures
    • Assessment of the oral cavity
    • If pt is unconscious, position pt on side (to prevent aspiration) and use mouth swabs with suction.
  17. Other Areas of Hygienic needs
    • Care of the feet: Usually will not clip nails, especially with diabetic pts. Will not be able to feel their feet.
    • Special considerations for care of the diabetic client
Care of the nails
: File only.
    • Hair care: Can use dry shampoo if necessary.
    • Special considerations for cultural variations in hair
    • Care for mustaches and beards
    • Backrubs: Slow, sliding strokes up the back = efflourage
    • Perineal Care: Encourage self care, remember privacy.
    • Contact lenses? Use their cleaner.
  18. Bed Making
    • Linens : clean, dry, wrinkle free (do not through used linens on floor). Do not fluff! Do not tuck under chin.
    • Medical asepsis
    • Proper body mechanics
    • Privacy, comfort and safety
    • Avoid the floor
  19. Evaluation
    • How did the patient tolerate the procedure?
    • Documentation:
    • Type of bath
    • Patient’s level of assistance
    • Any assessment findings
    • Tolerance to procedure
    • Patient status