Chapter 7 Assisting Clients With Hygiene
Good physical hygiene is necessary for comfort, safety, and well-being. Whereas well people are usually capable of meeting their own hygiene needs, ill people may require assistance. The nurse determines a client’s ability to perform self-care and provides hygiene care according to the client’s needs and preferred practices.
The nurse carries out many hygiene measures each day. These are commonly performed at specified times (see section 5 of this chapter.) Hygiene practices involve care of the teeth, oral cavities, hair, skin, perineal areas. Because hygiene care often requires intimate contact with the client, the nurse uses communication skills to promote the therapeutic relationship and to learn about a client’s emotional needs. During hygiene care the nurse can also assesses readiness to learn and teach health promotion practices. The nurse must also consider clients’ specific physical limitations, beliefs, values, and habits. The nurse preserves as much of the clients’ independence as possible, ensure privacy, and fosters physical well-being.
Section 1 Oral Care
The major part of a tooth is the dentin, an ivory substance harder than bone. Dentin surrounds a tooth’s pulp cavity. A layer of enamel covers the upper portion of each tooth at the crown. The periodontal membrane, just below the gum margins, surrounds the tooth root and holds it firmly in place. Healthy teeth are white, smooth, shiny, and properly aligned.
Oral hygiene helps to maintain the healthy state of the mouth, teeth, gums, and lips. Brushing cleans the teeth of food particles, plaque, and bacteria. It also massages the gums and relieves discomfort resulting from unpleasant odors and tastes. Complete oral hygiene enhances well-being and stimulates the appetite. The nurse’s responsibilities in oral hygiene are maintenance and prevention. The nurse can help clients to maintain good oral hygiene by teaching correct techniques or by performing hygiene for weakened or disabled clients.
Assessment
Condition of oral Hygiene
A thorough assessment for problems related to oral hygiene should be included in every client’s care. During the assessment the nurse can inform the client about good oral hygiene habits. The nurse may also refer the client to a specialist if common oral problems are found. Early identification of poor oral hygiene practices and common oral problems can reduce the risk of gum disease and dental caries or cavities.
Examine the lips for color, moisture, lumps, ulcers, lesions, and edema. Examine the buccal mucosa for color, moisture, lesions, nodules, and bleeding. Examine the color of the gums and surface of the gums for lesions, bleeding, edema, and exudates. Examine for loose, missing, or carious teeth. Note the presence of dentures or other orthodontic devices. Examine the tongue for color, symmetry, movement, texture, and lesions. Examine the hard and soft palates for intactness, color, patches, lesions, and petechiae. Examine the oropharynx for movement of the uvula and condition of tonsils, if present. Note unusual mouth odors. Assess adequacy of mastication and swallowing. Clients who do not follow regular oral hygiene practices may have receding gum tissue, inflamed gums, a coated tongue, discolored teeth, dental caries, missing teeth, and halitosis. Localized pain is a common symptom of a gum disease and certain tooth disorders.
It is especially important to examine the oral cavity of clients receiving radiation or chemotherapy. Both treatments can cause serious changes in salivary gland function and mucosal integrity. The nurse’s assessment serves as a basis for preventive care for clients as they undergo treatment.
Self-Care Ability
The nurse assesses a client’s physical and cognitive ability to perform basic hygiene measures. Client’s self-care abilities determine if assistance is needed in managing activities of daily living, including routine hygiene. The nurse’s assessment must include measurement of a client’s muscle strength, flexibility and dexterity, balance, coordination, and activity tolerance necessary in performing activities such as brushing teeth. The degree of assistance needed by a client during hygienic care may also depend on vision, the ability to sit without support, attached equipment, hand grasp, and the range of motion in the client’s extremities. The nurse can assess self-care ability by asking clients to perform activities such as tooth brushing. Observe the client carefully and note not only if the activity is performed correctly, but also if the client is able to thoroughly complete the task.
Knowledge About oral care
Ask clients about habit and preferences (e.g., frequency of brushing and flossing, dental products used, denture care, and visits to dentist). Have client demonstrate practices.
Examination of Denture
Before the denture is picked off, observe whether the denture wears suitable. After it is picked off, examine whether its inner sheath is covered with tartar, plaque, food particles, and whether it is broken and cracked.
Implementation
Complete oral hygiene enhances well-being and comfort. Oral problems can cause appetite reduction, localized pain and systemic disease. Broken, absent, unclean, or crooked teeth can affect self-image. Halitosis can negatively influence social interaction. The condition of the oral cavity hygiene affects nutritional intake. The nurse assists clients in maintaining good oral hygiene by teaching the importance of correct techniques and a routine daily schedule. Education about common gum and tooth disorders and methods of prevention can motivate clients to follow good oral hygiene practices. The nurse also assists in performing hygiene for weakened or disabled clients. When clients have variations in oral mucosal integrity, the nurse provides hygiene techniques to ensure thorough and effective care.
Teaching Oral Hygiene
Thorough brushing of the teeth is important in preventing tooth decay. The mechanical action of brushing removes food particles that can harbor and incubate bacteria. It also stimulates circulation in the gums, thus maintaining their healthy firmness.
Dental products used
A toothbrush should be small enough to reach all teeth. It should be cleaned and dried between uses. Rounded, soft bristles provide gum stimulation without causing abrasion. Replace toothbrushes every 3 months. Fluoride toothpaste is often recommended because of its antibacterial protection.
Brushing
Brushing is usually done upon arising and at bedtime, but brushing should also be done after each meal. Daily tongue brushing and teeth flossing are also recommended in aspects of oral hygiene.
Brushing removes dental plaque from the teeth and beneath the gum margin. For cleaning the outside surfaces of all teeth and inside surfaces of back teeth, place the bristles of the brush at a 45°angle to the teeth. Place the brush with the tips directed slightly onto the furrow surrounding a tooth. Without disengaging the brush tips, vibrate the brush back and forth with short strokes. The toothbrush will reach only two or three teeth at a time. After brushing one area, overlap placement with an adjacent position. For inside surfaces of front teeth, use the bristles on the end of the brush in a vibratory motion. To clean the chewing surfaces, brush back and forth. The nurse observes the client to be sure proper techniques are used.
After brushing the teeth, brush the tongue. Tongue brushing decreases the number of microorganisms and removes debris. When helping someone, ask the person to protrude the tongue. Holding the brush at a right angle to the length of the tongue, direct the bristle tips toward the throat. With light pressure, bring the brush forward and over the tip of the tongue. Then brush the tongue’s sides. Now have the person thorough rinse the mouth. Repeat brushing and rinsing as needed until the mouth is clean. Thorough rinsing after brushing is important to remove dislodged food particles and excess toothpaste. Cleanse the toothbrush under running water to remove debris. Shake out excess water and allow to dry.
Flossing
Brushing alone cannot completely remove dental plaque and debris round the teeth. Flossing removes dental plaque between teeth, helps prevent periodontal disease, and helps remove oral debris. Flossing once a day is sufficient. Unwaxed dental floss is recommended because it is thinner, slides easily between teeth, and is more absorbent than waxed floss.
Loosely wrap floss around index or middle finger of each hand. To floss the lower teeth, hold the floss so that the foreigners of both hands are on top of the strand. Loop the floss around a tooth and pull the ends forward to curve it into a C shape against the sides of the tooth. Then slide the floss to the gum line. Move the floss back and forth to clean both sides of the tooth. Carefully work the floss under the gum until it meets resistance. Then bring the floss toward the biting surface.
To floss the upper teeth, hold the floss so that it is over the thumb of one hand and the foreigner of the other hand. The thumb is to the outside of the teeth to hold back the cheek work the floss between the teeth as done with the lower teeth.
When floss becomes soiled or frayed, move to a new section by slipping a turn of floss from the middle finger of one hand and adding a turn to the finger on the other. After flossing, rinse vigorously to remove loose debris. Although firm pressure is needed against the sides of the teeth, do not traumatize the gums. Placing a mirror in front of the client will help the nurse to demonstrate the proper method for holding the floss and cleaning between the teeth.
Denture Care
Dentures collect debris, dental plaque, and tarter just as natural teeth do. They need to be cleaned regularly, at least once a day. The same type of toothbrush used for natural teeth can be used for dentures. Clients should be encouraged to clean their dentures on a regular basis to avoid gingival infection and irritation. When clients become disabled, the nurse or family caregiver can assume responsibility for denture care. Wearing gloves, remove dentures to clean them and provide oral care. The dentures are rinsed well after cleaning. The client should be given the opportunity to rinse the mouth before the dentures are replaced. Dentures must be removed at night to give the gums a rest and prevent bacterial buildup. When dentures are removed from the mouth, store them in a labeled denture cup to prevent loss or breakage. Denture should not be wrapped in toilet tissue or disposable wipes because these are likely to be thrown away. Encourage people to wear dentures continuously during the day. This improves eating technique, speech, appearance, and contour of the mouth.
Special Oral Care
For the client who is debilitated or unconscious or who has excessive dryness, sore, or irritations of the mouth, it may be necessary to clean the oral mucous and tongue in addition to the teeth. Mouth care for unconscious or debilitated people is important because their mouths tend to become dry and consequently predisposed to infection. Dryness occurs because the client cannot take fluids by mouths, is often breathing through the mouth, or may be receiving oxygen, which tends to dry the mucous membranes. Normal saline solution is recommended for oral hygiene for the dependent client. While cleaning the oral cavity, the nurse should never use fingers to hold the client’s mouth open. A human bite is highly contaminated. Special oral hygiene focuses on oral care for unconscious person but may be adapted for conscious persons who are seriously ill or have mouth problems.
Skill 5-1 Performing Mouth Care for an Unconscious or Debilitated Client
Purposes
1.To clean and moisten the membranes of the mouth and lips, to prevent oral infections
2.To prevent or eliminate odor, improve appetite
3.To promote comfort
Equipment
●bowl(one contained with tampon, one with collutory) ●pipette
●tweezers ●cotton-tipped applicator
●curved forceps ●paraffine
●kidney basin ●flashlight
●spatula ●towel
●gauze
Common Solutions for Mouth Care
Table 5-1 Common Solutions for Mouth Care
Solution name / Concentration / FunctionNormal saline solution
Hydrogen peroxide solution
Sodium bicarbonate solution
Chlorhexidine solution
Furacilin solution
Acetic acid solution
Boric acid solution
Metronidazole solution / 1%-3%
1%-4%
0.02%
- 02%
2%-3%
0.08% / Cleaning mouth cavity, preventing infection
Preventing oral cavity odor, using for the client whose oral cavity has ulceration, necrosis tissue
Alkaline solution, using for fungus infection
Cleaning oral cavity, eliminating bacterium
Cleaning oral cavity, eliminating bacterium
Using for aeruginosin pyocyanolysin bacilli infection
Acid solution, restraining bacterium
Using for anaerobic bacilli infection
Section 2 Hair Care
A person’s appearance and feeling of well-being often depend on the way the hair looks and feels. Illness or disability may prevent a client from maintaining daily hair care. An immobilized client’s hair soon becomes tangled. Dressings may leave sticky blood or antiseptic solutions on the hair. Proper hair care is important to the client’s body image. Brushing, combing, and shampooing are basic hygiene measures for all clients. Clients should be permitted to shave when their condition allows.
Assessment
Condition of Hair and Scalp Hygiene
Before performing hair care, the nurse assesses the condition of the hair and scalp. Normally the hair is clean, shiny, and untangled, and the scalp is clear of lesions. Illness affects the hair, especially when endocrine abnormalities, increased body temperature, poor nutrition, or anxiety and worry are present. Changes in the color or condition of the hair are related to changes in hormonal activity or to changes in the blood supply to hair follicles. Assess condition of hair and scalp. Consider age-appropriate changes. Consider racial or ethnic differences. Determine reasons for change in distribution or loss of hair. Check oiliness and texture of hair. Inspect scalp for lesions, inflammation, infection, or parasites. Findings will reveal the frequency and extent of care needed. Table 1 summarizes hair and scalp problems the nurse may identify.
Knowledge About Hair care and Self-Care Ability
Assess client’s ability to grasp comb or brush. Determine client’s ability to physically care for hair. Does client become easily fatigued? A client’s self-care ability can be altered by conditions such as arthritis, fatigue, and the presence of physical encumbrances (e.g., cast or IV). The nurse assesses the client’s physical ability to perform hair care. It is also essential to consider a client’s personal hair care practices so every effort can be made to maintain the client’s preferred appearance. Assess client’s preferences in hair styling. Identify client’s preference for hair care and shaving products. Assess adequacy of client’s hygiene practices. Determine client’s perceptions of own appearance. Assess client’s socioeconomic background.
Illness of patients and its therapy
Illness affects the hair, especially when endocrine abnormalities, increased body temperature, poor nutrition, or anxiety and worry are present. Changes in the color or condition of the hair are related to changes in hormonal activity or to changes in the blood supply to hair follicles.
Implementation
Basic daily hair care consists of brushing, combing, and shampooing. Nurses provide or facilitate hair care at least once a day. Hair care may be done with morning care so the person feels refreshed and well-groomed for the day.
Combing Hair in Bed
Daily brushing of the hair helps to keep it clean and distributes oil along the shaft of each hair. Brushing also stimulates the circulation of blood in the scalp. When possible, have the person sit up in the chair or in high Flower’s position in the bed. Place a towel over the client’s shoulders to catch loose hair and dirt.
Long hair may present a problem for clients confined to bed as it may become matted. It should be combed and brushed at least once a day to prevent this. The best way to protect long hair from matting and tangling is to ask the client for permission to braid it. Parting the hair in the middle on the back of the head and making two braids, one on either side, prevents the discomfort of lying on one heavy braid on the back of the head. Use fingertips for scalp massage. Occasionally, a client’s hair is almost hopelessly matted, and cutting the hair may be necessary. Before recommending cutting, try applying water with alcohol to hair to help remove matting and tangles. Section the hair and firmly hold one section at a time between your index finger and thumb as you work with it. Brush or comb in similar manner as with curly hair. Start at the ends, with your hand just above the snarled area, and gently remove snarls. Repeat with all other sections.