Hygiene and Personal Care PDF - Nursing

Hygiene and Personal Care L EA RN I NG OB JEC TI V ES Describe the importance of hygiene related to skin, hair, nails, and mucous membranes. Identify how alterations in skin, hair, nails, and mucous membranes affect hygiene care. Assess patients’ hygiene status and need for ass...

Hygiene and Personal Care L EA RN I NG OB JEC TI V ES Describe the importance of hygiene related to skin, hair, nails, and mucous membranes. Identify how alterations in skin, hair, nails, and mucous membranes affect hygiene care. Assess patients’ hygiene status and need for assistance with care. Prioritize nursing diagnoses, after analysis of cues, for patients who need assistance with hygiene or are experiencing alterations in self-care abilities. Generate measurable, patient-centered goals for patients with hygiene concerns and self-care alterations. Implement and evaluate nursing care plans that include actions to address the hygiene needs of patients. 2 H YG I E N E Hygiene practices include bathing, oral care, perineal care (cleansing the genital area, urinary meatus, and anus), foot care, and shaving Practices vary according to personal habits, cultural beliefs, ethnic customs, and age The nurse assesses patients’ backgrounds and provides hygiene care in a manner sensitive to their differences in habits and customs During patient care, the nurse communicates with the patient, assesses the skin, and looks for any abnormalities Bathing cleans the skin, removes organisms that can cause infection and odor, provides comfort, and contributes to the patient’s health and well-being S T RU C T U RE A N D F U N CT I O N O F S K I N , H A I R , A N D N A I L S Integumentary system: skin, nails, hair, sweat glands, and sebaceous (oil) glands Sweat glands: activated by heat, nervousness, or stress; can produce a foul-smelling body odor During hygiene care, the nurse cleanses all areas of the integumentary system to maintain healthy tissue, reduce body odor, and enhance comfort Cleansing rids the skin of microorganisms that can cause infection and odor Hair follicles: begin in the dermis and arise through the epidermis Sebaceous glands secrete an oily substance called sebum that keeps the hair and skin soft If left unwashed, hair becomes oily as a result of these secretions Nails: arise from the epidermis and are composed of keratinized epithelial cells. Grow from the nail matrix (actively growing portion of the nail) and protect the ends of fingers and toes Do not slough off and must be cut 4 S T RU C T U RE A N D F U N CT I O N O F S K I N , H A I R , A N D N A I L S Nose, mouth, and oral cavity Mucous membranes are surfaces that line the passages and cavities of the body, such as nasal, oral, vaginal, urethral, and anal areas The outer layer of mucous membranes is composed of epithelial cells Mucus (fluid secreted by mucous membranes) traps particles in the nose, and cilia (tiny hairs lining the nasal passages) help move the trapped particles to the throat, where they are swallowed Salivary glands in the mouth secrete mucus, enzymes, and a watery fluid, which mix to form saliva. This fluid begins chemical digestion of food and keeps the oral cavity moist Teeth begin mechanical digestion through mastication or chewing The roots of the teeth are surrounded by gingivae (gums), which are composed of connective tissue and epithelial cells The ability to ingest and chew food depends on the health of all parts of the oral cavity 5 A LT E R AT I O N S I N S T RU C T U R E A N D F U N C T I ON A F F E C T I N G H YG I E N I C C A R E Ulcers, incisions, and wounds Excessively dry skin can lead to cracks and openings in the integumentary system Excoriation (red, scaly areas with surface loss of skin tissue) occurs in patients whose skin is exposed to bodily fluids such as stool, urine, or gastric juices; also occurs in areas where skin rests on skin A LT E R AT I O N S I N S T RU C T U R E A N D F U N C T I ON A F F E C T I N G H YG I E N I C C A R E Decreased sensation Patients with neurologic deficits, such as peripheral neuropathy due to diabetes, may not be able to identify extremes of hot and cold The nurse should monitor the temperature of bath water for patients with decreased sensation Alopecia Due to hereditary factors, certain illnesses, or the effects of drugs (e.g., chemotherapy) Collaboration with a beautician or barber may be needed if a patient is actively losing hair as a result of treatment A LT E R AT I O N S I N S T RU C T U R E A N D F U N C T I ON A F F E C T I N G H YG I E N I C C A R E Pediculosis (head lice): transmission occurs through contact with infested personal items such as combs, hats, or linens Nails: discoloration caused by fungal, bacterial, and viral infections; order from the primary care provider (PCP) may be necessary for nail trimming, or a podiatrist may be consulted Oral cavity: note gingivitis, broken or missing teeth, halitosis Self-care alterations: recent surgery, immobility, cognitive dysfunction; asse ASSE SSMENT Assess skin, hair, nails, and oral cavity Before care, ask the patient about skin changes Observe the condition of exposed skin and note odors Observe the hair for cleanliness and grooming Observe fingernails and toenails when assessing peripheral vascular status Assess oral hygiene as part of a head-to-toe assessment 9  Assess self-care abilities ASSE SSMENT Ask questions about home care Observe the patient’s ability to complete ADLs Refer to community resources for assistance after discharge if needed Hygiene and infection Observe skin for signs of infection due to poor hygiene Provide patient education as needed P R I O RI T Y P RO B LE MS ( NU RS I N G D I AGNO S I S ) Self-Care Deficit (i.e., bathing) Supporting Data: Respirations 28 and labored, strong body odor, uncombed hair, skin on feet dry and flaky Able to Perform Self-Care Supporting Data: Patient able to get out of bed and stand at sink, patient expressing a desire to be independent in ADLs Impaired Health Maintenance Supporting Data: Lack of understanding of diabetes care, inability to recall most recent meal, poor hygiene, unkempt appearance, halitosis 11 PLANNING Prioritize identified hygiene-related nursing diagnoses according to patient needs and recognized risks Develop a nursing care plan for each nursing diagnosis, considering the patient’s self-care abilities, available resources, and family involvement Collaborate with other health care professionals, patients, and families when setting long- and short-term goals 12 I M P L E M E N T AT I O N A N D E VA L U AT I O N Interventions Bathing and skin care Complete bed bath Partial bed bath Sink bath Shower Chair shower I M P L E M E N T AT I O N A N D E VA L U AT I O N Interventions Perineal care Male: may have an erection during care = normal response to tactile stimulation; note care steps for intact foreskin Female: cleanse from the front to the back of the perineal area Foot and hand care Provides comfort while preventing odors and skin breakdown Patients with peripheral neuropathy should not soak their feet due to drying of the tissue and the risk for infection Care is taken to avoid nicks or cuts in the skin when cutting toenails of a patient with circulatory impairment in the lower extremities due to the decreased ability to heal After washing with warm water, patients with diabetes should have their feet carefully dried. Apply lotion is applied to the tops and bottoms of the feet only; avoid lotion between the toes, since this could lead to infection In some care settings, a PCP order is necessary before trimming toenails, or patients are referred to a podiatrist for this procedure Massage Effleurage: long hand movements along the length of the back muscles Pétrissage: kneading motion with the fingers and thumb along the patient’s back and shoulder Tapotement: tapping or percussion motion with the palm or ulnar side of the hand I M P L E M E N T AT I O N A N D E VA L U AT I O N Interventions Hair care Shampooing Shower Shampoo basin No-rinse shampoo Shampoo cap Pediculicidal shampoo I M P L E M E N T AT I O N A N D E VA L U AT I O N Interventions Eye care Visual aids Glasses Contact lenses For patients whose eyes do not totally close at night, an eye patch and prescribed eyedrops may be necessary to prevent corneal drying Prosthetic eye Most patients care for their own prothesis 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 to break the suction that holds the eye in the socket; clean with saline Nose care Remove moist secretions using suction Remove dried mucus using a moistened, cotton- tipped applicator I M P L E M E N T AT I O N A N D E VA L U AT I O N Interventions Ear care Cerumen: PCP may order special oil drops to soften wax before ear canal irrigation Hearing aids: keep dry; clean with dry cloth Shaving a patient Should not be performed without consent Consider patients on anticoagulants Bed making Reduces the risk of skin breakdown Beds may be made while unoccupied or occupied I M P L E M E N T AT I O N A N D E VA L U AT I O N Evaluation Observes the patient during care to assess the attainment of self-care goals. When goals are reached, establish new goals that may be longer-term goals Patients who are able to do more of their own care on a daily basis are showing increased self-care abilities 18