In the Early Morning, Morning Care; Hour of Sleep (HS) Or PM Care, As Needed (Prn)

Chapter 33 - Hygienic Care

Hygiene care Involves care of: Skin, Nails, Hair, Eyes and Ears. Teeth; Oral and nasal cavities, Perineal-genital area. May be performed:

•In the Early morning, Morning care; Hour of sleep (HS) or PM care, as needed (prn)

•Assess the amt. of assistance required to assist the client

•Determine the type of bath & care to provide: (bedbath, shower, activity tolerance, functional level)

Assessment includes factors Influencing Personal Hygiene

•Culture, Religion, Environment, Developmental level, Health and energy, and Personal preference

•Ask client if they have a preference

Nursing Process: the nurse’s Assessment should determine Self care hygiene practices, Self-care abilities,

Past or current problems of hygiene provision ;andIdentifify clients at risk for developing impairment

Abnormal Findings of the Skin

•Abrasion, Excessive dryness, Fissures, scaling and cracking of skin

•Dermatitis, Acne, Psoriasis,

•Erythema – redness of skin; from irritation, inflammation or swelling

•Hirsutism – excessive growth hair in unusual places

•Swelling and pitting edema of the extremities

•Weak or absent pulses; plantar warts

•Cool skin temperature in one or both feet

•Abnormal Findings of the Nails: Spoon nails, grooves or furrows, excessive thickness or clubbing of nails. Beau’s lines – white lines on fingernails, usually a sign of systemic disease. Discolored or detached; hangnails or paronychia (infection); Bluish or purplish tint or pallor; Delayed capillary refilling time

•Abnormal Findings of the Mouth like Halitosis, Glossitis, Gingivitis, Periodontal disease, Reddened or excoriated mucosa, or excessive dryness of the buccal mucosa. Cheilosis – inflammaiton of the lips; Dental caries; Sordes – crust or accummulation of food & bacteria; Stomatitis – inflammation os, teeth, gums; Parotitis – inflammation of parotid gland

•Abnormal Findings of the Hair like Dandruff, aloplecia, Ticks, Pediculosis (lice), Scabies or excessive hair (Hirsutism)

•Abnormal Findings of Eyes, Loss of hair, scaling, flaky eyebrows, Redness, swelling, flaking, crusting, discharge, asymmetrical closing, ptosis of eyelids, Jaundiced sclera, Unequal pupils, Pupils that fail to dilateor constrict in respond to light; Inability to see

•Abnormal Findings of the Ears: Asymmetry, excessively red or tender auricles, Lesions, flaky or scaly skin over auricles. Normal voice tones not heard. DON’T forget to check behind the ears

•Abnormal Findings of the Nose: Asymmetrical, deviated septum, Discharge, Localized redness, tenderness or lesions, Dry mucosal linings

Nursing Process: Nursing Diagnoses (after your client assessment and physical assessment

•Deficient knowledge

•Situational low self-esteem

•Risk for impaired skin integrity

•Impaired skin integrity

•Self-care deficit

•Risk for infection

•Impaired oral mucous membrane

•Disturbed body image

•Risk for injury

Nursing Process: Planning

•Nurse and, client and/or family set desired goal outcomes

•Nurse identifies interventions to assist the client to achieve the designated outcomes

Nursing Process: Interventions

•Assist dependent clients with hygiene activities

•Educating clients/family about appropriate hygienic practices

•Demonstrate use of assistive equipment and adaptive activities

•Assess and monitor physical and psychological responses

Purposes of Bathing

•Remove transient microorganisms, body secretions and excretions, and dead skin cells

•Stimulate circulation; Produce a sense of well-being; Promote relaxation and comfort; Prevent or eliminate unpleasant body odors

Types of Baths - Done for Cleansing or Therapeutic (to provide a physical affect) such as a Sitz baths, medication

•Complete bed bath; Tub or shower; Sponge, bag (commercially prepared)

•Self-help or partial baths

•Hospitalized Client

Early morning care (before breakfast). Offer Urinal or bedpan; assist in Washing face and hands,provideOral

care

Morning care is usually after breakfast Includes Elimination, Bath or showers, Perineal care, Back massage if

not contraindicated; and Oral, nail, and hair care

Hour of sleep (HS) or P.M. care includes: Elimination; Washing face and hands; Oral care and Back massage if

not contraindicated.

PRN Care (as needed) - As required by client need. May require more frequent bathing, Changes of clothes pr

soiled linen

Provide Privacy -- Do Not strip client of their dignity

See Taylor’s for hygiene procedures andbedmaking

•To ensure continued safety of the client after making an occupied bed:

–Raise the side rails

–Place the bed in the low position

–Put items used by the client within easy reach

–Attach the signal cord