Hygiene and Skin Integrity

NURSING INTERVENTIONS
I. HYGIENE
 Hygiene
● It is the science of health and its maintenance.
● It is a highly personal matter determined by individual and cultural values and practices.
● It involves care of the skin, feet, nails, oral and nasal cavities, teeth, hair, eyes and
perineal-genital areas.

Personal Hygiene
The efforts people take to keep their bodies clean are referred to as personal
hygiene. Personal hygiene neglect can have a negative impact on an individual's
physical and psychological health as well as their comfort.
Hygienic Care

● Early Morning Care

- it is provided to clients as they awaken in the morning

● Morning Care
- is often provided after clients have breakfast, although it may be provided before
breakfast
● Hour of sleep (HS) or PM care
- is provided to clients before they retire for the night.
- Activities: providing for elimination needs,washing face and
hands, giving oral care, and giving a back massage.

● As-needed (prn) care

- Is provided as required by the client.
SKIN
Functions:
1. Protects underlying tissues from injury by
preventing the passage of microorganisms.
2. Regulates the body temperature.
3. Secretes sebum
4. Transmits sensations through nerve receptors
5. Produces and absorb vitamin D
A. Assessment

Assessment of the client’s skin and hygienic practices includes:

1. A nursing health history to determine the client's:

● skin care practices
● self-care abilities
● and past or current skin problems

2. Physical assessment of the skin

Common Skin Problems

● Excessive Dryness
● Abrasion
● Ammonia Dermatitis
● Acne
● Erythema
● Hirsutism
B. Diagnosis

- specified as altered self-care (bathing,dressing, feeding and toileting)

Difficulties encountered by the client in performing:

● Bathing activities
● Dressing and Grooming
● Toileting
C. Planning

- set outcomes for each nursing diagnosis

- nurse then performs nursing interventions and activities to achieve the
client outcomes

Nursing Activities:
● Assisting dependent clients with bathing, skin care and perineal care
● Providing back massages to promote circulation
● Instructing clients and family about appropriate hygienic practices and
alternative methods for dressing
D. Implementing
- The nurse applies the general guidelines for skin care while providing one of the
various types of baths available to clients.

General Guidelines for Skin Care:

1. Intact, healthy skin is the body’s first line of defense.
2. The degree to which the skin protects the underlying tissues from injury depends on the
general health of the cells, the amount of subcutaneous tissue, and the dryness of the
skin.
3. Moisture in contact with the skin for more than a short time can result in increased
bacterial growth and irritation.
4. Body odors are caused by resident skin bacteria acting on body secretions.
5. Skin sensitivity to irritation and injury varies among individuals and in accordance with
their health.
6. Agents used for skin care have selective actions and purposes.
 NURSING INTERVENTIONS

BETTER HEALTH
MAIN GOAL: COMFORT
CONFIDENCE
Nursing Diagnosis and Nursing Interventions
related to Hygiene
Example 1:

Nursing Diagnosis: Self-care deficit related to

musculoskeletal impairment as evidenced by
patients being unable to use the bathroom and
provide hygiene.
Nursing Diagnosis: Self-care deficit related to musculoskeletal impairment as
evidenced by patients being unable to use the bathroom and provide hygiene.

Nursing Interventions:
➢ Assess the patient’s ability to bathe on his/her own
➢ Identify degree of individual impairment and functional level according to scale
➢ Assist with places that are difficult to reach
➢ Provide for or assist with grooming activities on a routine, consistent basis
➢ Provide for adequate warmth
➢ Plan activities to prevent or accommodate fatigue and/or exacerbation of pain
➢ Collaborate in treatment of underlying conditions
➢ Provide accurate and relevant information regarding current and future needs
➢ Instruct in or review appropriate skills necessary for self-care, using terms
understandable to the client
➢ Establish ‘contractual’ partnership with client
Hair Hygiene
Example 1:
Nursing Diagnosis: Intense itching as
evidenced by visible lice and nits on the
hair.
Nursing Intervention:
● Identified the phase of the infestation.
- To check for the severity of the infestation.
● Administered lice removal shampoo with the prescription of the physician.
- To reduce or eliminate the parasites.
● Taught the patient on aftercare treatment.
- To maintain aftercare and avoid reinfestation.
Oral Hygiene
 Example 1:
Nursing Diagnosis: Thrush

Thrush is a condition in which the fungus

Candida albicans accumulates on the lining of
your mouth. Candida is a normal organism in
your mouth, but sometimes it can overgrow and
cause symptoms.
Example 1:
Nursing Diagnosis: Thrush

Nursing Intervention:
● Brush teeth/ dentures after each meal.
- Prevents organisms being trapped on gums,dentures, or teeth.
● Soak dentures overnight in corsodyl.
- To prevent reinfection of oral mucosa
● Give antifungal medicines if necessary or prescribed.
- To reduce and treat infection.
Example 2:
Nursing Diagnosis: Sore Mouth

Canker sores are small, shallow

lesions that develop on the soft
tissues in your mouth or at the base
of your gums.
Example 2:
Nursing Diagnosis: Sore Mouth

Nursing Intervention:
● Brush teeth and tongue twice daily with a soft toothbrush soaked in Difflam.
- To aid in the lifting of debris.
● Offer fizzy drinks or soda water hourly.
- Effervescence aids the lifting of debris.
Example 3:
Nursing Diagnosis: Ulcerated Mouth

Mouth Ulcers are either caused by

trauma to the mouth, or by a viral
infection
Example 3:
Nursing Diagnosis: Ulcerated Mouth

Nursing Intervention:
● Remove dentures and soak in fresh cold water (change water daily).
- Dentures may be too painful to wear. If exposed to heat or left to dry,
dentures can become warped and ill fitting.
● Discuss with medical staff a prescription for a local anesthetic mouthwash / gel.
- Can offer relief (and coating initially) so enabling oral intake to continue
Feet Hygiene
Example 1:
Nursing Diagnosis: Athlete’s Foot

Athlete's foot is a common fungal

infection that affects the feet.
Example 1:
Nursing Diagnosis: Athlete’s Foot

Nursing Intervention:

● Keep the feet clean and dry. Wash the feet twice a day and gently towel-dry
between the toes.
● Change socks regularly. Change the socks at least once a day — more often if
your feet get really sweaty.
● Alternate pairs of shoes. Use different shoes from day to day. This gives your
shoes time to dry after each use.
● Don't share shoes. Sharing risks spreading a fungal infection.
Example 2:
Nursing Diagnosis: Ingrown Toenails

An ingrown nail occurs when the

skin on one or both sides of a nail
grows over the edges of the nail,
or when the nail itself grows into
the skin.
Example 2:
Nursing Diagnosis: Ingrown Toenails

Nursing Intervention:
● Washing the feet with antibacterial soap and keeping them clean and dry.
● Cutting the toenails straight across after a bath when the nails are soft.
● Avoiding cutting the nails in a rounded pattern, as it can increase the risk of
inward growth.
● Wearing shoes that fit well and do not have a pointy tip.
Example 3:
Nursing Diagnosis: Corns and Calluses

Corns and Calluses are thick,

hardened layers of skin that
develops from repeated friction,
rubbing or irritation and pressure
on the skin.
Example 3:
Nursing Diagnosis: Corns and Calluses

Nursing Intervention:

● Moisturize your skin. Use moisturizer on your feet regularly to prevent dryness
and friction.
● Wear comfortable shoes and socks. Wear well-fitting, cushioned shoes and socks.
Make sure that at the end of the day, your feet should not be swollen.
● Trim your toenails. If your toenails are too long, they can force your toes to push
up against your shoe. This can create pressure that causes a corn to form over
time.
● Keep your feet clean. Wash your feet daily with soap, water, and an appropriate
scrub brush.
Nail Hygiene
How to assess nails?
a. Inspect nail shape
Normal Findings:
● It is smooth and round. Even nail edges are smooth, rounded, and clean.
● It should be 160 degrees.
Abnormal Finding:
Clubbing (curved nails). Often associated with diseases of lungs, heart, and liver.
● The Profile sign
● The Schamroth’s Window test
b. Inspect consistency
Normal findings:

● The surface is smooth and regular, not brittle or splitting.

● Nail thickness is uniform.
c. Inspect Color
Normal Findings:

● The translucent nail plate is a window to an even, pink nail bed underneath.

Abnormal findings:

● Blue nails: not enough oxygen

● White nails: Liver diseases
● Pale nails: Anemia
● Half pink, half white: Kidney disease
● Yellow: lung disease or nail infection

*Capillary refill test: to monitor dehydration and blood supply.

How to take care of nails?
● Keep fingernails dry and clean.
● Practice good nail hygiene.
● Use moisturizer
● Do not bite fingernails
● Pull of hangnails
II. SKIN INTEGRITY
 SKIN INTEGRITY
The term 'skin integrity' refers to the skin being a sound and complete
structure in unimpaired condition.

Impaired skin integrity

Altered epidermis and/ dermis (NANDA)
Risk for Impaired Skin Integrity
Susceptible to alteration in epidermis and/or dermis, which may compromise
health (NANDA)
Pressure Injuries
Pressure Points

Bony prominences are the areas of

bone that are close to the skin's surface.
These areas are most susceptible to
pressure injuries because they have the
least amount of cushioning.
Pressure Injuries
1. Pressure against the skin reduces the
blood flow to the skin and nearby tissue,
stopping the flow of oxygen

2. Shearing wounds occur when forces

moving in opposite directions are applied
to tissues in the body

3. Friction wounds are caused when the

skin is rubbed against another object.
Pressure Ulcers
Pressure ulcers are a type of injury that
breaks down the skin and underlying
tissue when an area of skin is placed
under constant pressure for certain
period.
 Risk Factors

External Factors Internal Factors

● Hyperthermia/ Hypothermia ● Weight

● Moisture/ secretions ● Physical immobilization
● Chemicals ● Water-electrolyte balance
● Psychomotor Agitation ● Incontinence
● Malnutrition
● Psychogenic factors (OCD)
 NURSING INTERVENTIONS

PREVENTION
MAIN GOAL:
DETECTION
WOUND CARE
 Nursing Assessment for Impaired Skin Integrity

1. Complete Skin Assessment

- Note stage, size, color and drainage (Notify physician)
2. Braden Skin Assessment
- Sensory, Moisture, Activity, Mobility, Nutrition, Friction and Shear
3. Assess skin turgor, sensation, and circulation
4. Monitor Ambulation status and mobility
5. Consider incontinence or self care deficit
6. Proper Documentation
 Nursing Interventions for Impaired Skin Integrity

1. Continued assessment of skin and wounds

2. Keep the skin clean and dry
3. Use appropriate devices and air mattresses
4. Encourage nutrition and hydration
5. Repositioning and support of bony prominences
Sample Nursing Diagnosis and Nursing
Interventions
Example 1:

Nursing Diagnosis: Impaired skin integrity related to dry skin and

behaviors as evidenced by scratching of scabs
Example 1:
Nursing Diagnosis: Impaired skin integrity related to dry skin and behaviors as
evidenced by scratching of scabs

Nursing Interventions:
➢ Assess mood, abilities, and personal styles.
- To evaluate a patient's attitude which may contribute to skin breakdown.
➢ Provide health teachings regarding the importance of maintaining an intact and
moist skin.
- To increase the knowledge thus, prevention of skin breakdown is realized
and taken into consideration.
➢ Encourage the client to have balanced and nutritious food specially foods rich in
Iron and vitamin C.
- To improve clients' immune systems.
Example 2:
Nursing Diagnosis: Impaired skin integrity related to immobility as evidenced by stage
2 pressure ulcer to the sacrum
Example 2:
Nursing Diagnosis: Impaired skin integrity related to immobility as evidenced by stage
2 pressure ulcer to the sacrum

Nursing Interventions:
➢ Perform wound care per guidelines and orders
➢ Continued assessment of skin and wounds
➢ Repositioning and support of bony prominences
➢ Keep the skin clean and dry
➢ Use appropriate devices and air mattresses
➢ Encourage nutrition and hydration
Example 3:
Nursing Diagnosis: Impaired skin integrity related to surgical incision and stoma
creation to the abdomen
Example 3:
Nursing Diagnosis: Impaired skin integrity related to surgical incision and stoma
creation to the abdomen

Nursing Interventions:
● Assess incision and stoma
-Following surgery, the stoma should be pink-red in color and wet. Although it
can be bloated, it should protrude from the incision. Its size will decrease
over the coming weeks.
● Collaborate with wound/ostomy specialist
-To make sure the stoma is healing properly and the necessary ostomy
equipment are being used to fit the stoma properly, a new stoma creation
requires evaluation and education from a wound care/ostomy professional.
Example 3: continuation…
● Educate on recommended diets to control output
-Dietary factors may vary from person to person and involve some trial and
error. As the bowel recovers, a low-residue diet is frequently advised initially.
Limiting foods that are hot, alcoholic, and heavy in fiber may be
recommended since these substances can increase output and leakage risk
by causing diarrhea.
● Encourage use of pastes/powders to prevent irritation
-It may be required to use barrier pastes and powders to stop leaking around
the stoma, which might irritate nearby skin. Using adhesive removers makes
it simpler to remove the pouch without causing skin damage.
● Educate on proper fitting and emptying of the ostomy pouch
-To seal around the stoma and prevent leakage and irritation of the
peristomal skin, the adhesive wafer and pouch system must be fitted properly
and measured. To keep them from tearing away from the skin, pouches
should be drained when they are 1/3 to 1/2 filled.
Example 4:
Nursing Diagnosis: Impaired skin integrity related to decreased skin sensation
secondary to diabetic neuropathy as evidenced by redness and an open area to
the left lower leg
Example 4:
Nursing Diagnosis: Impaired skin integrity related to decreased skin sensation
secondary to diabetic neuropathy as evidenced by redness and an open area to
the left lower leg

Nursing Interventions:
● Educate on diabetic neuropathy and the importance of daily skin checks
● Ensure socks or non-slip footwear is worn at all times
● Maintain normal blood glucose levels
● Assess skin for infection
Example 5:
Nursing Diagnosis: Development of red sores around the wound area in a
patient diagnosed with Impetigo, with itching and discharge from the wound.
Example 5:
Nursing Diagnosis: Development of red sores around the wound area in a
patient diagnosed with Impetigo, with itching and discharge from the wound.

Nursing Interventions:
● Isolation of the patient
- Impetigo is highly infectious. The patient would have to be isolated for
around 7-10 days while being treated.
● Administer the prescribed antibiotics and ensure completion of the course
- Impetigo is treated by antibiotics that can be given orally or topically.
Further infection can reoccur, hence the completion of the regimen is
necessary.
● Educate the caregivers about hygiene and scratching
- Scratching worsens Impetigo and aggravates healing wounds. The
patients and the caregivers need to be particular about hygiene and
scratching to prevent this.
Example 6:
Nursing Diagnosis: Necrotizing fasciitis confirmed by positive biopsy leading to
the development of gangrenous skin tissue accompanied by erythema at the
infected site.
Example 6:
Nursing Diagnosis: Necrotizing fasciitis confirmed by positive biopsy leading to
the development of gangrenous skin tissue accompanied by erythema at the
infected site.

Nursing Interventions:
● Monitor infection and its spread
- Necrotizing fasciitis can easily spread if not managed carefully. It needs
to be monitored very closely.
● Administer the antibiotics as prescribed
- Treating the bacterial cause behind Necrotizing fasciitis can reduce the
gangrenous tissue.
● Encourage hygiene and skincare
- To prevent the spread of the infection and compensate for the loss of
protective bacteria due to antibiotics
Example 7:
Nursing Diagnosis: Decreased circulation from dorsal arteries in a patient with
diabetes which poses risk for impaired skin integrity.
Example 7:
Nursing Diagnosis: Decreased circulation from dorsal arteries in a patient with
diabetes which poses risk for impaired skin integrity.

Nursing Interventions:
● Encourage continuous use of footwear
- Diabetic patients often suffer from loss of sensations. This may cause
them to not notice any injuries and infections.
● Assess skin integrity regularly
- In cases of interventions and evaluations, baseline data is pertinent in
tracking progress.
● Encourage daily moisturization and prevention of hot water use
- Hot water can cause drying of the skin which may impair the skin
integrity further. Moisturization can prevent this.
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Edition).

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(PMC). Retrieved from: https://doi.org/10.4103/0970-0358.155260

Cowdell, F., Jadotte, Y. T., Ersser, S. J., Danby, S., Walton, S., Lawton, S., Roberts, A., Gardiner, E., Ware, F., & Cork, M. (2014,
December 1). Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care
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