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Module C Notes 102
Module C Notes 102
Nursing 102
Personal Hygiene: How an individual maintains their health with their hygiene
practices
Individual Factors hygiene practices very individualized. Get input from pt. or pt. family
– Social practices can influence times of day, number of times, etc. Ex. Shaving in
diff. cultures
– Personal preferences different brands, etc… Can educate or introduce new
practices; don’t force.
– Body image affects how comfortable a person is w/ help. Weight, pregnancy,
strokes…
– Socioeconomic status homelessness. Mental problems. Poverty, cannot afford
things needed for hygiene.
HYGIENE includes many different concepts these are: make pt feel comfortable,
refreshed and renewed.
Bath, Back Rub, Nail and Foot Care, Oral Hygiene, Hair, Bed
Goals and planning for client hygiene : be sure to schedule around other activities in
hospital (rounds, diagnostics, etc…) as much as possible. Try to schedule around pain assess
for pain.
– Provide Privacy treat with respect. Keep door closed, pull curtain in semi-private
room.
– Maintain Safety remain cautious. Bedrails, water, etc…
– Maintain Warmth check room temp before bath, ask client about room setting.
– Promote Independence include pt as much as possible. Allow to do what they can.
– Anticipate needs pain needs. Elimination needs. Etc…
– Assess assess skin, nails, breathing, cognition, etc. while you are bathing. Saves
time.
– Teach whatever you can about illness. Try to make it relevant to pt.
TYPES OF SCHEDULES:
– Early morning care always offer elimination. Offer to wash face and hands before
breakfast. Oral care.
– Morning care offer elimination, bathing, peri care, foot and/or hair care, shaving, get
dressed. Help straighten up room.
– Afternoon care
– Evening care may want shower in evening.
Schedules include changing sheets. Do not have to change everyday as long as there is not
any visible soiling and pt does not want them changed.
A bed bath may be just a nursing task to you, but to your patient it is a highly
personal and intimate experience think about how you would feel.
BATHS :
Complete-for clients who are totally dependent and require total hygienic care
every square inch.
Partial-involves bathing only body parts that would cause discomfort or odor if left
unbathed-includes perineal care allowing pt to do what they can do. Assist only on parts
they want assistance on.
Self-care
– Intact with no abrasions can only apply to this type of skin. All others require Dr.
Rx.
– Warm to touch
– Skin color varies take into account ethnicity.
– Smooth, dry, elastic & firm turgor
– Texture – soft, flexible
Feet, Hands, and Nails always look in between digits of fingers and toes when assessing.
Conditions that interfere with movement of the hand can affect a client’s ability for
self care
Nail terms: Cuticle-fold of skin at nail bed root, and Lunula-crescent shaped white
area of nail bed
Normal nail: transparent, smooth, convex, with a pink nail bed and translucent
white tip
Oral Cavity
Three pairs of salivary glands that produce 1 L of saliva per day (Buccal glands)
Gingivitis, or gum inflammation, can occur without adequate, regular oral hygiene
Eyes, ears, nose and throat-require special attention during cleansing scleral color,
pupil size, etc… Nasal obstruction or drainage.
ASSESSMENT!
When giving hygiene care, the smart nurse will use this time to also assess the
client’s skin, feet, hands, nails, hair, eyes, ears, nose, and oral cavity!
Be alert for those clients with impaired sensation, vascular insufficiency, and
immobility
Feet: examine all skin surfaces including areas between the toes, and the soles of
the feet; note shape and size of toes
Clients with peripheral vascular disease (such as diabetes) should be assessed for
adequate circulation and sensation
Nails: inspect condition, and look for dryness, inflammation, lesions, or cracking.
Observe for change in shape, and curvature
Assess hair…
Normally eyes are free of infection, clera are visible and white, conjunctiva (lining of
the eyelids) are clear, pink, and free of inflammation, lashes outward, lid margins
are without inflammation, drainage, or lesions
Eyebrows-symmetrical
Inspect nares for signs of inflammation, discharge, lesions, edema, and deformity
Tubing
– Immobilization
– Reduced sensation
– Nutrition and hydration alterations
– Secretions and excretions on the skin
– Vascular insufficiency
– External devices
– Pressure Ulcer
– Immobilized
– Equipment
– Advanced therapies (such as Cancer therapy)
– Dehydration
– Surgery
– Sensory impairment
– Blood coagulation problems
Eye care
Eyeglasses
Contact lenses
Perineal Care
Clients most in need are those with secretions or Foley catheters and following
rectal surgery or childbirth
Turn to page 877, Potter & Perry, and we will review supplies and steps
Soak/soften cuticles.
Trim nails straight across (check agency policy regarding trimming of nails).
Oral Hygiene
Unconscious client check for gag reflex. May require suction if they do not have good
reflex.
Denture care ask preference for cleaning solution. TEPID water. Hot will warp them. Pull up
and out on bottom. Down and out on upper. Same sequence as teeth in mouth. Store in
appropriate container.
Procedure for Oral Hygiene top palate- inner, bottom, outer lower palate- inner, top,
outer.
We will go over the supplies needed and the steps for oral hygiene
Denture care procedure: page 891, Box 39-13
Brushing and combing helps to distribute natural oils evenly throughout scalp
Shampooing
Shaving be sure to check pt chart to find out if there are any bleeding precautions such as
illnesses or meds like Coumadin or heparin.
Pull skin taut, use short firm razor strokes in the direction the hair grows
Bed Making
Client’s bed should be kept clean and comfortable. Helps prevent injury. Makes pt feel
better.
General Guidelines…
“Open” bed has comforter, blanket, and top sheet folded down to bottom of bed ready for
pt to get back in. When pt. is in and out of bed or gone but coming right back.
“Surgical” bed Covers and sheets pulled to the side so when pt is brought from surgery
they can slide them off stretcher into bed easier.
– Meal preparation
– Shopping
– Money management
– Telephone use
– Light/Heavy housework
LIFESPAN depending where you work you may run into all or some of these age groups.
There are differences in conducting hygiene in different age groups.
Developmental Issues
Be aware that the process of aging affects the condition of body tissues and
structures fatty distribution, osteoporosis.
Chronic foot problems seen more in the older adult loss of nerve sensation in feet.
Older adults may have sensory aids and sensory deficits hearing aids, glasses, etc…
Infant Bath
Steps similar
– Temperature control very immature in a neonate. Easily chilled.
– Preserve body heat Keep covered amap
– Acidic covering helps prevent microbe growth. Do not scrub too much and change
pH.
– Soap Choices use body wash like johnsons, etc…
– Avoid alkalines delicate soaps. Johnsons baby wash, etc… Not using powder as
much because of inhalation.
Infant bathing wait about one hour before bathing new baby. Allow parent to assist if they
are able and want to. Bonding.
Umbilical cord sponge bathe until stump falls off usually within 14 days.
Circumcision sm. Amount of blood is natural. Keep clean and dry as possible.
– Vernix caseosa cheese like substance on skin, grayish white. Protects baby in
womb. Usually dries up after 24-48 hrs.
Infant bathing
Childhood
– Toddler never leave unattended when providing hygiene. Keep hazardous materials
out of reach.
– School-age respect wishes and privacy amap. Allow to conduct as much of their own
hygiene as they can.
– Adolescents skin very active due to hormonal changes. Respect privacy and wishes
amap. Just assist unless physical condition does not allow.
Room environment
Back Rub
Environmental Safety
Definition-Safe environment
– Procedure-related accidents med errors, anything that happens in care of pt. Fluid
admin errors.
– Equipment-related accidents orient pt to facility. Make sure machines work
properly.
– Special equipment necessities