Hygiene Care and Elimination PDF

Welcome to our next lab lecture on Promotions and Integrity, Hygiene Care and Elimination and Continence Care. I'm Moira Bazin and I'm here with you this afternoon. So we have some learning outcomes so I'll just move to that slide. So there's a number of them and we're going to apply some patient...

Welcome to our next lab lecture on Promotions and Integrity, Hygiene Care and Elimination and Continence Care. I'm Moira Bazin and I'm here with you this afternoon. So we have some learning outcomes so I'll just move to that slide. So there's a number of them and we're going to apply some patient exemplar. We're going to look at some exemplars with some clinical reasoning and judgment. We're going to look at hygiene and bathing practices, functional ability, independence in relation to hygiene care and bathing, expected and unexpected findings related to skin integrity and elimination, factors that affect elimination, both urinary and we're going to look at interventions. Now the majority of this information is in your textbook so please make sure that you read it thoroughly because it has a lot more detail than I provide in our lab lectures. I provide an overview and in some cases I don't get into the depth that you require in some areas. So what is hygiene? Hygiene is conditions or practices of cleanliness or care of the body that are conducive to health and wellness. I want to say, interestingly, the word hygiene is a Greek word and there is a goddess, Hygia, and she is one of the daughters of the goddess of medicine or the god of medicine I should say. It's really fundamental to care and comfort and well-being and nurses are should ideally be experts in this area as we are often the ones that are at the bedside 24-7 and provide this care with our patient. And we also are very privileged in that we are often involved in giving newborns their first bath and may even be involved with giving someone their last bath. So it's a very sacred space in terms of providing care. What is self-care? Well, this is probably a review for you and related to the concept of self-care, which is in 220. It refers to the person's ability to perform care functions in the following areas, bathing, feeding, toileting, and dressing without the help of others. It can be on a spectrum though, it can be someone might be able to be partially bathe themselves and you might be assisting with things affect self-care and such as illness, age, culture, they'd have an impact, mental health, cognition, functional ability. As we discussed in ADLs, we assess self-care and we look for a self-care deficit. So, this might be a self-care deficit that might be ongoing or it might be temporary. So, we have a patient, Mrs. Hicks, is an 82-year-old female who is a resident in a long-term care facility. She was admitted three years ago as her husband could no longer care for her at home due to her advancing dementia. She has osteoarthritis in her hands and knees, which affects her grip and mobility. Areas of her skin are often dry and flaky, and she spends long periods of time sitting in her chair. She wears an incontinence brief due to urinary incontinence. In this scenario, what stands out for you regarding Mrs. Hicks? And what additional information would be important? So, if you'd like to pause the video to go ahead and look more thoroughly, that would be important. So, there's several things that are very important to note. For one, in here, she has advancing dementia. So, what is her ability to let us know she needs to go to the washroom? and also that her skin is dry and flaky. She spends long and she wears an incontinence due to urinary incontinence. incontinence due to urinary incontinence. So this has a big impact on her hygiene. What additional information do we need? What additional information do we need? So what do we know? We know regular bathing is essential to promote healthy skin integrity. It's very personal. very personal. It requires intimate contact. So what do we need to know for her in terms of how is she with her bath and what type of bath does she prefer? and what type of bath does she prefer? And also what kind of practices does she enjoy? Like is there something that she prefers for herself during the bath routine? Another is, some find it extremely personal, so it may be that a person of the opposite gender may not be, they may not be comfortable with them bathing. So what can they do also, what can she do independently? What does, what can the, what will the medical condition allow? For example, if the patient is a patient who has a surgical wound, there might be a moratorium on bathing in a bathtub, rather they might have to have showers or no bathing at all. What is required? What preferences and normal practices? What are their needs related to hygiene? hygiene. hygiene. So for example, if they are experiencing a fever, maybe there's a lot of sweat and they would require some removal of that and a nice sponge bath would be helpful. Who usually assists with hygiene care and to what degree? As mentioned, what are their teaching needs, and what else is important for them at this time? them at this time? So for example, what practices, cultural practices I talked about before, but what other, depending on the life experience that they're going through at this time, is there a cultural practice that they have to practice? Do they have access to resources for bathing, such as a bathtub, a bathroom, soap, water, shampoo, etc. And one might think that this might be commonplace, but for some this is not. So we need to know what can they, what do they have access to. So, in practice, in the care settings, there's usually a routine related to hygiene care. And so this is just out of your Gregory text outlining what we refer to as early morning care, morning care, afternoon care, and HS care or evening care. So these are usually put into practice. the morning care and the early morning care might be separated a bit. The morning care, such as a bath, might be more scheduled. It may often only occur several times a week, but we also want to ensure that they feel very clean every day. So it might be that they have a partial bath during the day at this time. It's also a time to put on clean clothes or change their gown and change their linen. In the afternoon it's a nice time, especially if they have had, they've been out for tests that we check them and provide an opportunity to have oral care, hand washing, their eliminations need met and their linens cleaned, adjusted or cleaned if necessary. This is particularly important because it might also help with other things such as nutrition. Maybe washing them their hands and face and providing oral care will enhance their appetite. In HS care this one is very important as well and this is where the patient is getting ready for bed. So washing face and hands, providing oral care, but elimination needs, changing into a new gown or bed clothes. It may even include a back massage so providing some sort of comfort before them prior to going to bed and getting the area ready for the nighttime. So this is a usual practice. Sometimes though we have to provide what we call bed baths and they may be partial or complete depending on the needs and ability of the patient and the timing. So, for example, a patient might be coming back from surgery so we might provide a partial bed bath at that time. It's always an opportunity to assess skin integrity and other systems such as the MSK. It is done in a structured way and certain principles apply. So what are those principles? Can you think of any that might apply? So I've listed quite a number here and they might also in your readings you might add to them. So number one, provide privacy, maintain safety, maintain warmth. So we're going to only expose the areas that are being washed at that time by keeping other areas underneath a bath blanket. Promote independence, so if a patient can provide assistance, so for example, if they would prefer to wash the perineal area, we would provide them with the tools to do so. So the washcloth or whatever is needed, a towel. Anticipate their needs and also anticipate what you will need. So this might be getting all the equipment ready prior to starting. you would hate to leave a patient partially covered in the midst of a bath and having to leave the room to go get equipment. Ensure you're working safely. So this means using your It's Your Move principles, so safe height. Do a risk assessment and apply routine practices. So this would be gloving if needed, a down, whatever is needed, making sure you've washed your hands, and also knowing when you need to glove as well. So for example, when you're cleansing the perineum and the bottom area, you need to make sure you are wearing gloves. Cleanse from clean to dirty areas, so change the washcloth and water is needed. So for example when cold or dirty you need to change the water. And what we mean by cleanse from clean to dirty you always are cleaning from the head to the toes and the perineum area and the bottom area are last. So you will learn that in lab this week. Use long strokes on limbs from distal to proximal and this encourages circulation and venous return. Rinse and pat dry areas well so we would not want our patients to have example, in skin folds, we'd hate to have moist, warm areas where infection can occur. Explain and communicate well what you're doing. So for example, explain prior to doing it. So when you're going to move their arm, you're going to cleanse their chest. Do this preemptively so that they understand what you're going to go can do ahead of time. So another way to bathe and use tools that we use are what we call a bath and a bag. And so this is what you might see in acute care or some areas. And this is washcloths that are pre-moistened and what you might find them, where you might find them, is in a warmer. And so they are nice and warm when you're going to use them. They're disposable, they're convenient, there's no drying needed because you wouldn't dry the patient because there's emollients in the water. So you just let them dry. And there's no cleaning of equipment or basins. So this is quite helpful and also helps with infection control. The one area that you had to read this week was about safe bathing temperatures and frequency policy, and this is highly important. It's a policy of 2022, however, it's been in place for a number of years. Standards are laid out to prevent harm to patients as a result of incorrect water temperature. so it applies to all care settings and applies to showers as well. It is required by all staff members including students and the temperature required might change or be different depending on the age of the patient. For example for adults it's between 38 and 43 degrees. It cannot be higher than 43 degrees for patients 12 years and younger, never over 38 degrees. So you would use a thermometer that is provided in the environment to measure the temperature. It also indicates in the policy when to take the temperature and how to monitor. So for example, you're monitoring as well touching the water and monitoring with the tent thermometer but also you're doing this prior to the patient being in the water. Continuing care homes also have preferred bathing frequency policy added to this and it indicates the preferred bathing at least twice per week and it may be adjusted depending on what else is going on for the patient. For example, if they're frequently incontinent or they have some skin problems, that bathing might be more often. There's a lot of products out there to maintain skin integrity and hygiene care and these are just a few. The ones that I'm going to speak to here in this slide include cleansers and wipes. So this might be something you're pharmaceutical creams and powders and incontinence products. So as you can see here these are wipes so it's a washcloth that you might use when you're providing perineal care. There might be a spray to cleanse the area and here's a perineal cleanser. Moisturizers, many of your patients might have an issue with dry skin, particularly the older adult. And so it's called xerosis. So moisturizers provide cream or some type of lotion to help repair the skin barrier, increasing water content in the skin and reducing water loss. And it depends on the type of skin lotion or cream or product that you're using. So it's really important that you look at the products that are out there and do they fit with what the patient requires. Emollients are fatty acid containing lotions that replenish the oils in the skin surface. Humectants are additives such as alpha hydroxy acid, serrhea, that draw water from the deeper layers in the skin surface. So this is drawing the water up from the skin itself rather than putting water on the skin and occlusives prevent water loss from the skin. loss from the skin. So what do we know as nurses if we move to urinary and bowel elimination? What do we need to know? need to know? We need to know factors that affect urinary and bowel elimination, the expected findings, unexpected, what strategies we need to implement, and what do we need to consider when monitoring and evaluating. As well, we need to know what's an urgent situation. So considerations that we need to think about are the for sure relate to the growth and development of the patient. So we need to know, for example, the age of the patient, what are unexpected findings and what changes might be occurring. So these are some findings from the older adult that might be happening and changes. So these are what we need to keep in mind. So decreased sensation of thirst. So if we are having to increase, we want to increase urine output, we cannot rely on their sensation of thirst, we might have to promote fluids. We need to also look at the other aspects, so reduction in lumbular filtration rate, They might get up with nocturia, so that has a big impact related to falls. Maybe they're less efficient in terms of their bladder emptying, and they might have decreased muscle tone of their perineal floor and **** sphincter. So when we're assessing urinary function, we of course always start with the health history and ask a lot of questions and gather all that information. There might be a physical assessment related to that, and we did that in 125 related to abdominal assessment. We'd also include assessment of the year in itself, the color, the clarity, the quantity, the output, and the odour. So if there's any changes related to that. So we should be seeing a light yellow colour. Clarity should be clear, quantity depends a lot on intake but we should not see an overly amount of urine or under amount and we're going to talk about that more thoroughly later. The odour we should smell, it should be very light in odor. If it smells noxious or heavy, then we have some concerns. Lab tests might be also included in terms of the assessment, and this would be ordered. And so, for example, urine culture, urinalysis, specific gravity, blood work, just to name a few. And also, So if the patient is having difficulties or issues, they might have some diagnostic tests. So we also have to assess the bowels. Again, many things are included in the bowel history, health history, the physical assessment. It would also, in both of them, include your skin integrity. So, for example, if a patient is incontinent, we'd really want to know how their skin integrity is and also the rectal area. Are they having any problems with that? We'd look at the assessment of the stool and we're going to talk more about that with the Bristol School stool chart. And we'd look at the color, shape, odor, and amount of stool. there might be lab tests ordered such as fecal specimen, blood work, serum electrolytes, CBC, etc. and diagnostic tests such as an x-ray, colonoscopy, ultrasound, CT scan, etc. So this is what we call a bladder and bowel diary and so for some patients if they are having issues with their bladder or bowel they might be asked to keep a frequency chart. It would also be helpful to identify if they're having any problems with incontinence and how often that is occurring. So for example here it talks about the amount of fluid they're taking in and also how much they're expelling through their bladder and how many bowel movements. And here it talks about the type of bowel movement and we're going to talk about the Bristol Stool Chart. It also asks some qualitative information such as the urge and the leaking amount and pain. Here's the Bristol Stool Chart and it gives you an example of what you would document related to this. For example, type I and II are very dry stools and might be indications of constipation. From III, IV, you might see more normal stools. And then V and VI, V indicates lacking fiber, so they're soft blobs. This might be what is indicated. Type 6 and 7 are mild to severe diarrhea and it is more, you can indicate for example, mushy consistency with ragged edges and type 7 is liquid consistency with no solid pieces. So this is what you would want to record. Also for type 6 and 7 as you can see on this chart indicates that when you get to this type of stool you also need to put it on your output. So for example if you are looking at a small amount of stool less than half a cup you'd indicate that. Type medium would be half a cup to one cup or the amount there and large would be greater than a cup. So you would be measuring this in a measuring container that the patient would expel the stool into and then you can include that on the in and out. And this is highly important because patients can with severe diarrhea lose a lot of fluid very fast and it has to be replaced. So red flags in urgent situations, here's some that are indicated. And one of the ones that you need to really be mindful of is a decrease in urine output. So if the patient is in decreasing, has a decreased urine output and you've noticed that trend, and it's absolutely urgent if it's less than 30 mils over an hour. So it has to be reported. So if you notice that the patient over the course of several hours, they're only avoiding small amounts that should also be reported. If they have increased amount of urine output, that too is something that we need to be really mindful of because it could be a sign of something else such as ketoacidosis or that we need to be mindful of. So if they're starting to put out large amounts of urine. Increase or change in pain, distension, signs of infection or septicemia, ****** stool or urine. Those are also really important signs and sometimes how it can look in urine it could look like it's more brownish or tea-colored so that could be an indication of your blood in the urine. In ****** stool what we're always looking for is the color of change so if it's starting to get darker the stool is starting to get really dark. Our tarry black, that might indicate blood in the stool, also if it's frank blood so such as red, reduced or no black bowel sounds or no bowel movements or movement of gas and diarrhea. So for example if they're starting to have frequent diarrhea as I mentioned this can be problematic as they might be losing a lot of fluid fast and who can be really vulnerable to this are our younger and our older patients. So for example our infants. One of the things that we also know is some of our patients might be incontinent of stool or urine and so there it's important that you review in your text and in the module that's in 1220 the the nature of incontinence. So there's certain types of incontinence that might be you can identify for example urge incontinence, stress incontinence. So identify that and know what type of incontinence your patient is experiencing because that also might impact the care plan. So it is important More than that, we keep the patient's skin integrity maintained, dry and clean. The fecal matter and urine is very caustic to the skin. So we want to make sure that we are not breaking down that barrier. We want to make sure that the patient feels safe, comfortable, with dignity and privacy maintained. A wide range of treatments might be instilled, such as bladder retraining, kind voiding, prompted voiding, maybe part of the care plan, but also thinking about things such as comfort rounds where the patient might be encouraged to, we might come around every two hours and And the patient might be encouraged to void. And the other thing we have are a variety of incontinence products. And they may be used for the patient and such as a condom catheter at night for a male or a special type of brief for either male or female. So perineal care is highly important and might be part of the complete or partial bed bath, but it's also done as needed. So for example, when a brief is being changed, there might be a need to do a lot of perineal care. It's highly personal and maybe embarrassing to the patient. So we have to make sure that we are doing it very professionally and skillfully. If patients are able to do their own care, they might be encouraged to do so. Routine practices and PPE must be applied, and it is important that the cleansing technique be correct when wiping the perineal area for the male and female. And also you may have a patient who's catheterized, maybe a postpartum patient, or having their men cease. So for example for females we want to cleanse from area of clean to dirty, so that would be wiping down the perineal area. To start though, we would wipe the upper and inner thighs. We would clean the *****, majora, and minora, and it would be from an up-to-down motion. For males, again, we clean the upper and inner thighs, the ***** area, so around the ***** and if it is a patient who has uncircumcised we would retract the foreskin and cleanse the glands of the ***** and making sure that it is also retracted back into the original position once it's clean and dry so it's And then after that, you clean the **** area for all of the patients. Okay. You're going to have an opportunity to practice that in lab with models. So plastic models that we have. Incontinence products are highly important to identify what is the best unique fit for the patient. Your area will have incontinence supplies on the area, but if there's something that a specific patient might benefit from, you might have to advocate. You need to make sure it is comfortable and is the right size, that the patient is kept dry and protected, and that privacy and dignity is maintained. Also, it's interesting if you look at the type of product. Some of them might be a nighttime product or a daytime product. And so making sure that the right product is used at the right time. So we have the patient. It is Mrs. Hicks. She's an 82 year old female, and I introduced her prior. In this scenario, while changing her brief, you notice reddened and shaved appearing skin in the inner and upper thighs, and over her perineal area. She is also complaining of pain and frequency on voiding. So it is important we look at this and we look at this situation because things have changed for this patient and so now we need to be very concerned. So what are the areas that you're concerned about? So take a moment to look at that. So it is the skin integrity has changed and is concerning. Also the patient is having complaints of pain and frequency on voiding. So what is going on in this area? So interventions to consider, report and document findings. So we need to report that the patient's skin integrity is impacted and also that there's some concerns and possible changes related to her urinary tract function. concerns and possible changes related to her urinary tract function. So could this be a urinary tract infection going on? this be a urinary tract infection going on? The benefit is we might promote fluids and monitor intake and output, monitor vital signs regularly to identify any changes. For example, is she having any systemic changes related to an infection? Other symptoms, nausea and vomiting, chills, fever, malaise. Ensure safety when mobilizing, so if she's having frequency she might want to get up suddenly and move and so we need to make sure that we are watching her carefully and not having a sudden movement or fall. There might be prescribed creams provided, so if there is, if the redness in her perineal area, let's say, is due to a fungal infection, for example, maybe there is a cream that is being ordered, a prescribed cream, so that would be applied and also or a barrier cream might be applied so that we're protecting the perineal area and keeping the skin free from the irritation of the urine. We might also want to change her briefs more frequently and giving her more bathroom breaks so her skin is not exposed to any warm moist area as often. And we also do patient teaching and discussion related to why we're doing this and with the family as well. Maybe the fluids have to be promoted and also enhance her nutritional intake. So if she is starting to have problems with infections then we need to encourage a good diet. So James Beck is an 87-year-old male resident in a long-term care facility and while taking his file signs, you inquire about his level of pain. He states he has abdominal pain which is new for him. He has a history of arthritis with pain in his right hip and he has been ordered Tylenol No. 3 which he takes several times per day. He says he drinks less and does not like to walk because it aggravates his hip pain and tends to sit most of the day. What additional assessment data would be helpful to collect on Mr. Beck? So I'll give you a moment to find that. You may want to pause the video. Okay so we are collecting more data and we're finding out that he denies nausea and vomiting indicates his pain is three out of ten over his left abdominal area. The pain began last evening and says he is more uncomfortable this morning. He feels bloated and is passing very little gas. His last bowel movement was four days ago and indicates the stool appeared hard and he had to strain. Normally he says he goes every one to two days but he has had problems in the past. From the nurses gave him meditmusal to get things going. On examination, John's abdomen is rounded and firm with few vowel sounds. Upon palpation, he winces when you palpate his left side. What alteration is maybe James experiencing? So if you think that he might be experiencing an issue with vowel function of course. He might be experiencing constipation but for certain he is not moving his bowels and gas. So this is very important that he be seen and you report your findings. And also there might be interventions that we can employ as nurses. And also there might be interventions that we can employ as nurses. So for example, can you think of any interventions that might be helpful for James? be helpful for James? So we would report and document. We could encourage fluence, non-caffeinated, increase fiber in his diet. diet. Is there a need for re-evaluation of pain management and his pain medication? medication? We know that Tylenol-3 may have a constipating effect, so this might be adding to that. He's saying he's not mobilizing because of his pain in his So, is there something we can do to increase his mobilization and his exercise and also take care of his pain? Ensure he is in appropriate position for bowel movements with privacy. So there might be a problem, maybe he's sharing a bathroom or he's not feeling that he's having the privacy he needs and that is impacting the length of time. he stays on the toilet. he stays on the toilet. So how can we increase that or help him with that? For the position as well, it is a squat position. So is he able to maintain that squat position and use his abdominal muscles to exert the maneuver that he needs? that he needs? Are we monitoring his intake and output of urine and stools? So another thing might be he's not as mentioned encouraging fluids, but is he not increasing or taking in enough and maybe that is his problem. He shouldn't be teaching regarding why we need to increase our fluids, pain management diet and fiber. Maybe he's avoiding certain foods, so for example in nutrition maybe he doesn't have good dentures and he's not chewing his certain foods well and he's avoiding them. Talking about the importance of mobility and how to reduce constipation. So for this patient maybe he will be ordered a stool softener or laxative or enema and so that might be something that is happening and you need to provide for him as it's been ordered by the physician so you'd find out more about that but waiting this length of time especially when he's starting to be symptomatic is very not very good for him so we'd get that movement going and And also we would try to prevent and maintain regular bowel movement patterns. So there's a lot of reading this week related to that. And I'm hoping that some of these portions might be helpful for you, these aspects or highlighting these areas. It is going to be interesting in your care environments to see the different patients and what their care needs are related to this, related to hygiene and also elimination. So I hope you learn lots out there. So we'll end now with a few questions. And so just here is a question. During the tub bath, Mrs. Hicks asks for the water to be hotter. What does the nurse do? Turn on the tap and add more water. Immediately remove Mrs. Hicks from the water as she must find it cold. Explain you need to keep the temperature within the Alberta Health Services Policy Guidelines. So the correct answer would be C. Explain you need to keep the temperature within the Alberta Health Services Policy Guidelines. However, what may be happening is you might be hearing that because she has arthritis, find out more information about what's going on and also retake to the temperature. Maybe it's cooled off significantly while she's been in there but you'd never just add more water to the tap of the bath because you're adding hot water which may scald the patient while they're in there. If the patient is cold, you could remove the patient from the bath and warm them up with a nice warm blanket and get them quite warmed up, but be careful. It also is, maybe she's used to having these warmer baths for her arthritis, and you may want to look at other mediums to treat her arthritis. treat her arthritis. For example, is there something that from physio that in collaboration with them that might be helpful for this patient? collaboration with them that might be helpful for this patient? Another question, in caring for Mrs. Hicks, which is the following is important? And I'll let you read that. So the answer is all of the above. So especially for her, she is if she's sitting for long periods of time we'd want her to we want to perform a skin assessment and especially because she's wearing a brief and incontinence brief to find out how her skin is her skin is especially on those dependent areas. We'd pat dry and keep those areas dry in her skin folds, we'd ensure privacy and comfort during her bath. So the last question is, you are performing a bed bath on your patient and you know that you may not use soap in which is the following areas. So I'll let you look at these areas and determine which is the correct answer. So the correct answer is the eye area. So this is somewhere where you would not use soap, you would use a clean washed cloth and in fact this is usually where we start a bed bath, the cleanest area, and you would use a different area of the washcloth for each eye. So if you need to cleanse the area because of some kind of debris there you'd use warm water and try and cleanse it away for sure. So that is the end of our lecture today and I hope you have a good week!