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ch. 27 mod 3 hygiene and personal care
Terms in this set (68)
practices such as cleanliness that promote and preserve health
cleansing the genital area, urinary meatus and anus
skin, hair, and nails
tissue that lines tubes and cavities and the surface of the skin
absence or loss of hair
due to hereditary factors, certain illnesses, or effects of drugs such as those in chemo
secrete an oily substance that keeps that hair and skin soft
normal nails are smooth and pink
surface that lines the passages and cavities of the body, such as nasal, oral, vaginal, urethral, and anal areas
fluid secreted by mucous membranes
tiny hair lining the nasal passages
mouth secrete mucus, enzymes, and a watery fluid, which mix to form saliva
Alterations in suture and function affecting hygienic care
Ulcers, incisions, and wounds
Ulcers, Incisions and Wounds
many patients have openings in the layers of skin caused by wounds, incision or ulcers/ may lead to infection
red, scaly areas with surface loss of skin tissue
also occurs in areas where skin rests on skin, such as axilla; under large, prendulous breasts, or in abdominal folds
damage to peripheral nerves occurs for variety of reasons
ex: if cannot feel heat, and takes shower and water is hot may burn skin
caused by pediculus humanus capitis; known as head lice
itching/ redness of the scalp
fungal, bacteria, and viral infections of the fingernails and toenails occur that cause discoloration and thickening of the nails
any cut in the skin can lead to ulcer in these patients
alterations in hear of the oral cavity can affect the patient's ability to chew or overall health
inflammation of the gums
assessing the patients level of ability to perform skills such as self-bathing helps the nurse devise an appropriate plan of care and assist the patient when needed
assess skin, hair, nails and oral cavity
assessment of skin occurs before and during hygienic care
while gathering the health history, the nurse observes patient's hair for cleanliness and grooming. (if poor, you would notice oily, matted, or tangled hair)
inspection of the oral mucosa and teeth is part of head to toe assessment (broken/missing teeth, red gums, halitosis, and open sores are all indications of altered oral health and poor oral hygiene.
assess dryness/color of oral mucosa/ presence of any sores
scaling and flaking of scalp skin
Assess self-care abilities
ADLs includes bathing, mouth care, grooming, toileting, dressing, and eating.
Hygiene and Infection
presence of skin, scalp and oral infections may indicate poor hygiene.
Bathing self-care deficit
dressing self care deficit
readiness for enhanced self care: present patient expressing a desire to be independent in ADLs
ineffective health maintenance: related to impaired ability to understanding due to cognitive changes as evidenced by poor hygiene, unkempt appearance and halitosis
disturbed body image
hygiene self-care deficit: related to weakness due to decreased tissue perfusion as evidenced by strong body odor and unkempt hair
considering the patient's self-care abilities, available resources, and family involvement.
examples of goals/outcome statements follow
patient will accept assistance with hygiene within 24 hours.
Patient will begin to perform 50% of her ADLs within 24 hours.
Patient will remain free of body odors during hospitalization.
Nursing care plans for hygiene-oriented nursing diagnoses are tailored to the patients' specific needs.
Bathing and Skin care
essential components of patient care
individual bathing preference should be taken into account when planning bathing care.
bathing removes dead skin, bacteria, and body fluids that build up on the skin.
after bath documents: date/time/assessment/patients current position/ ability to assist/ and response to bathing
breakdown of the skin caused by fluid
Complete Bed Bath
performed for patients who are bedridden or depend totally on others for care
equipments: bath basins/washcloths/ towels/and soap or skin cleanser/ whereas others use prepackaged bath cloths
Partial Bed bath
performed when only part of the body is washed
some patients want to wash their hands and face before breakfast
others perineal care after using bed pan
if extremely dry skin, might decide to do partial bath
patients who are ambulatory may prefer to wash while standing or sitting in front of a bath basin or sink
some long term care patients are washed in the shower while sitting in a shower chair
shower chair is durable, water proof and easily disinfected
for patients with dementia or other cognitive impairments: adapting the routine to the patient helps maintain a calm environment
soft voice, soothing music, and a warm room help the patient relax
involves cleaning genital area, urinary meatus, and anus
provided during a bath or shower but may be necessary more frequently; especially incontinence patients.
male perineal care
male patient may have erection during care, which is normal response to tactile stimulation
doc any redness, drainage, odor, edema, or skin changes
female perineal care
front to back of the perineal area
doc redness, drainage or swelling
Foot and Hand Care
avoid nicks and cuts in the skin when cutting toenails of a patient with circulatory impairment in the lower extremities due to the decrease ability to heal
provides relaxation and comfort, increase circulation and promotes sleep
doc date/time and duration and any tenderness should be notated
massage techniques that employs long hand movement s along the length of back muscle.
performed by using a kneading motion with the fingers and thumb along the patients back and shoulders
involves tapping or percussion motion with the palm or ulnar side of the hand
shampooing a patient's hair and cleansing the scalp increases comfort and provides sense of well-being
doc includes assessment of patients scalp and tolerance of the procedure
what shampoo is used when patient have lice?
essential nursing intervention provides patient comfort, removes plaque and bacteria, reduces the risk for tooth decay, and decreases halitosis (bad breath)
should wear gloves
doc of oral care includes procedure, time, patient's tolerance, and findings of unusual sores, bleeding or tenderness
artificial teeth should be performed least every morning and evening
Patients with special needs
patients who are to receive nothing by mouth (NPO) or are receiving O2 are susceptible to drying of the oral mucosa.
patients who have oral cancer have oral care needs
disposable foam swab that is used for oral care
washed with plain water from inner to outer canthus, using a different part of the washcloth for each eye
patients whose eyes do not totally close at night , and eye patch and prescribed eyedrops may be necessary to prevent corneal drying
patients who need glasses or contact lenses should be encouraged to use them in health care setting.
if patients wear contact lenses, it is important for the nurse to know the type of lens. Some contact lens are disposable; others are made more rigid plastic and are cleaned after wearing
artificial, eye may be a permanent implant or one that is removed for cleaning.
eye can be removed by pulling down on the lower lid with a gloved hand and exerting pressure on the lower edge of the artificial eye
can be cleaned with saline
nurse may have to remove mucus or secretions from the nares of patients who are unable to blow into the tissue.
if patient is on O2 by nasal cannula, the nasal passages may become try. Humidifying the O2 can help alleviate this problem
crusting may only be removed using saline on gauze or a cotton tipped applicator.
accomplished during bathing.
washing ear with washcloth and soap is sufficient for most patients
if there is cerumen; may order special oil drops to soften the wax before irrigating the ear canal
do not try to remove the wax using cotton-tripped applicator because it can push the wax farther into the ear canal
build up of wax
doc date, time, body part shaved, type of razor, and skin issues observed during or after shaving.
provide patient with clean, dry bed that is free of wrinkles is a basic nursing measure.
can be done during or after bath or after perineal care for inconsistence.
if bed is not soiled, can wait after patient is sitting or off the nursing unit
focus of the care plan is on helping the patient self- care abilities and move toward independence
What does the nurse refrain from using while providing hygiene care for a comatose patient receiving an anticoagulant?
with arabic women you should not have a male do perineal care.
Before providing oral hygiene, the nurse turns the patient to a side-lying position. What is the reason for this nursing intervention?
What is the priority concern when providing oral hygiene for a patient who is unconscious?
The nurse instructs an unlicensed assistive personnel (UAP) to provide hygienic care for a patient with dementia. Which intervention provided by the UAP indicates effective learning?
following same routine everyday to provide consistency
A patient is diagnosed with meningitis. The nurse performs an assessment of the gag reflex and the corneal reflex, and conducts Rinne's and Weber's tests. Which of these tests helps determine if the patient is at risk for aspiration?
Which part of the body does the nurse examine if assessing a patient's peripheral vascular system?
The registered nurse instructs the unlicensed assistive personnel (UAP) to give a perineal bath to a patient who has undergone perineal surgery. Which type of bath will the registered nurse prefer to use for the patient?
sitz bath: baths for soaking patient's perineal
A nurse is assessing the skin. Which condition might result in excessive sweating?
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