Personal Hygiene - Key Nursing Skills PDF

CHAPTER 4 Personal hygiene Frances Gordon Aims and learning outcomes This chapter considers how the needs of patients who are unable to undertake their normal hygiene and grooming activities can be met. By the end of this chapter you will be able to: understand the importa...

CHAPTER 4 Personal hygiene Frances Gordon Aims and learning outcomes This chapter considers how the needs of patients who are unable to undertake their normal hygiene and grooming activities can be met. By the end of this chapter you will be able to: understand the importance of hygiene and grooming to a sense of self and personal dignity understand how hygiene and grooming contributes to the total health of the patient assist a patient to maintain normal grooming habits while con- fined to bed ensure the maintenance of a healthy mouth through adequate mouth care promote a return to patient independence in meeting hygiene needs as recovery proceeds. Personal hygiene needs Attending to personal hygiene needs can, at first sight, seem a very simple set of activities. Many people care for their children and at times adult members of their family in this way without any special training or preparation. However, ensuring that patients feel clean and comfortable is one of the most important and skilled elements of nurs- ing work. Meeting the hygiene needs of a person who is seriously ill or has restricted mobility can be very challenging. The skills required are 60 Personal hygiene vital to a patient’s wellbeing and dignity. We all carry notions of what we would ideally wish to look like, and we manage our appearance in ways that take us as near to this ideal as possible. Most adults expect to be able to maintain their own personal hygiene and grooming and to present themselves to the world in ways that satisfy their personal image, and if this ability is compromised, so may be that person’s sense of self and dignity. Most of us would feel somewhat alarmed if we had to present ourselves to the public gaze straight from bed without a wash, without cleaning our teeth, without having a shave or putting on make-up, without washing our hair or arranging it as we like, or with- out being dressed in clothes that we feel suit us. A high standard of hygiene and grooming helps to maintain dignity and a sense of self in vulnerable patients, and reassures their friends and relatives that their loved one is cared for. Apart from personal presentation, meeting the hygiene needs of ill and dependent patients is vital to the functioning of the body. The skin provides an effective barrier against pathogens and physical forces. Neglected hygiene can increase the incidence of infection and break- down of the skin and the mucosa of the mouth. This is even more problematic where patients are ill and debilitated and so have de- pleted body defences against infection. Personal hygiene is a prime marker of the standard of care a patient receives. It provides a line of defence against infection and is therefore important to the patient’s physical safety. How should the professional carer think about planning care that meets the hygiene needs of individual patients? We are all different and all meet our personal hygiene needs according to our acquired behaviours and lifestyle. This can be a sensitive issue when the nurse’s and patient’s notions of an acceptable standard differ, and will need to be negotiated by listening to and respecting the patient’s views. Making an assessment of the patient’s normal grooming habits and considering the additional needs imposed by his illness are an appro- priate starting point. For instance, a patient who is perspiring freely because of his illness may require additional access to washing facilities compared to his normal daily washing activities. People who take a daily shower but have mobility problems that confine them to bed will need to have a daily all-over wash by methods that can be used at the bedside. 61  Key Nursing Skills The following classes of patients are likely to need assistance with their hygiene and grooming needs: people with limited mobility or restricted movement patients with pain that is debilitating unconscious patients patients with cognitive problems, such as confused older people. Patient history Mrs Jenny Brown has been admitted to a general medical ward via the Accident and Emergency Department. Mrs Brown is 74 years old and has had a stroke that has left her with a one-sided paralysis. Mrs Brown is conscious but at present is not able to eat or drink due to her condi- tion. She also has difficulty in communicating. Mrs Brown’s daughter, Judith, has explained to the nursing staff that Mrs Brown, previous to her stroke, was active and meticulous in her personal hygiene and grooming. She believes that her mother will be very distressed due to not being able to attend to her appearance. It is clear to the admitting nurse that Judith is herself distressed by her mother’s helplessness and by her not looking as she normally does. It is noted that Mrs Brown is perspiring, and that as she fell onto her bedroom floor during the night she has not had her usual morning bath. At this stage, three main prob- lems can be identified regarding Mrs Brown’s personal hygiene and grooming. These are concerned with Mrs Brown’s inability to maintain skin and mouth hygiene due to her present illness and the emotional impact these factors may have on her sense of self and dignity. NURSING PROBLEM 4.1 Problem: Mrs Brown is unable to maintain her skin hygiene needs due to impaired mobility and increased perspiration. Goal: Mrs Brown’s normal level of skin hygiene will be maintained. Maintaining skin hygiene A physical assessment of Mrs Brown’s skin should be made while 62 Personal hygiene assisting her to meet her hygiene needs. The assessment should include (Penzer and Finch 2001): observing for skin changes (Colour: jaundice, bruising, pallor and inflammation.) skin integrity (Is the skin intact or are there lesions, sores or ulcers?) texture, moisture and heat (Use the back of the hand to assess the temperature of the skin.) hygiene (Is there evidence of neglect of grooming – strong or strange odours? Evidence of infestation – spots, scratching?). A daily bed bath will be undertaken until Mrs Brown can be taken to the bathroom for a normal bath and, due to her increased perspiration, additional sponging will be administered as necessary. The feeling of comfort that follows a well-executed bed bath should not be underestimated for its potential to lift the patient’s morale and to induce feelings of wellbeing. A daily wash removes skin cell build-up and the bacteria that interact with perspiration to pro- duce body odour. Bath time is a good opportunity for the nurse to give private, personal time to Mrs Brown, talking with her and encouraging her to express herself as best she can. This is also a good opportunity for the nurse to assess the state of the patient’s skin and note the con- dition of pressure areas (see Chapter 5). Intervention: the bed bath Equipment Clean linen. Bowl of warm water (should be bowl for patient’s personal use). Large bath towel, or small cotton blanket and smaller towel. Disposable wipes. Patient’s wash cloth (should not be used for perineal area). Disposal bag. Patient’s toiletries: soap or emollient, deodorant, cologne and talcum powder if used. Procedure The nurse should explain that Mrs Brown is to be washed in bed and why, and reassured that as soon as possible she will be offered a normal bath. 63  Personal hygiene The water should be changed whenever necessary but always after the genitals have been washed and before moving to the lower part of the body. Recommended practice is to have a separate basin available for washing the genital and perineal area and using disposable wipes. The body is then systematically washed, using soap or emollient, and then rinsing and drying from neck downwards towards the feet. One part of the body should be washed, rinsed and dried before moving to the next to prevent chilling and chafing. The suggested order is: – face and neck – chest – axilla and arm furthest away from water basin – axilla and arm nearest water basin – genitalia and perineum – change water – back – leg furthest away from water basin – leg nearest water basin – foot furthest away from water basin – foot nearest water basin. When washing the hands and feet note any abnormalities and record these. To enhance future mobility and comfort, it may be necessary to refer to a chiropodist if the patient’s feet are in poor condition. Check that nails are clean and trim if required. It is necessary to check your Trust policies with respect to the clip- ping of nails, particularly those of diabetic patients. However, general principles are that fingernails and toenails should be softened by soaking in warm water prior to trimming. If dirty underneath, the nails should be cleaned with an orange stick whilst soaking in the water. After drying, the fingernails and/or toenails should be gently trimmed with nail scissors or clippers. Fingernails should be shaped following the curve of the fingertip and can be smoothed with an emery board. The toenails should be cut straight across. TIP! Enabling the patient to put hands and feet in basin to be washed is refreshing and achieves maximum comfort. The limbs should be supported and the basin steadied. 65  Key Nursing Skills Toiletries such as anti-perspirant deodorants, talcum powder and cologne should be applied according to the patient’s preferences. The use of toiletries helps to maintain skin freshness, and ensur- ing that a patient’s preferences and normal habits are followed promotes the patient’s dignity and sense of control. TIP! Protect the patient’s face when using powders and sprays, as it is easy to affect the eyes and breathing with these when the patient is confined to bed. Talcum powder should be used lightly to prevent it ‘pilling’ into abrasive balls when patient’s skin becomes damp with perspiration and should be avoided in the genital area if a patient has a urinary catheter in situ. Mrs Brown should be assisted into clean, ‘light’ (preferably cotton) nightclothes or other appropriate garment and her bed made up with clean linen as appropriate. The use of natural fibres such as cotton helps in the absorption of perspiration. Clean bed linen promotes the comfort and dignity of the patient. Mrs Brown’s hair should be brushed/combed into a style that is acceptable to herself and/or her daughter and comfortable to wear in bed. Mrs Brown may not be able to adequately communicate her likes and dislikes and the nurse may need to consult with Judith to maintain or adapt Mrs Brown’s grooming preferences. Maintaining as far as pos- sible usual grooming routines promotes Mrs Brown’s sense of self and individuality. On completion of the procedure: If Mrs Brown is well enough to sit out in a chair, that is an ideal time to do her hair and teeth, since sitting up is a more normal position in which to attend to these areas. Mrs Brown’s bed should be remade with fresh linen and she should be left comfortable with items she may require, such as call bell and tissues in reach. The basin should be cleaned, dried and stored according to Trust policy, disposable items placed in the appropriate receptacles, and soiled linen placed directly into the linen skip. Wash hands to prevent the spread of infection. 66 Personal hygiene Record the procedure and any pertinent observations in the nursing records. This maintains necessary records and charts the patient’s progress. Mrs Brown should be sponged as necessary due to her increased perspiration, and garments changed if necessary. Excessive perspiration on the skin is uncomfortable, can lead to chilling and disrupts the skin’s protective functions. Remembering that the skin of older people is prone to dryness, over-frequent washing with soap should be avoided. However, for some patients where their med- ical condition may cause them to perspire freely, their comfort should be maintained by gentle sponging and drying of the skin (avoiding chilling) and providing fresh linen as necessary. Mrs Brown should be offered handwashing facilities or the use of antiseptic hand wipes or rubs following the use of bedpans or other san- itary aids. Hand cleansing following the use of toileting aids is vital to the control of infection and maintains the normal routine of the patient. As Mrs Brown recovers, she can gradually be encouraged to be more independent in washing and drying the parts of her body that she can reach herself during bathing in bed or in a chair at the side of the bed. This should be carefully managed, ensuring that Mrs Brown is act- ing within her capabilities and hygiene standards are maintained to her satisfaction. As soon as Mrs Brown is able, she may be taken to the bathroom for a bath or shower and to have her hair washed. This return to a more normal routine will promote her dignity, recovery and rehabil- itation. Evaluation Mrs Brown is clean and comfortable and either she or her family (if she is unable) expresses satisfaction with her personal hygiene. Intervention: helping a patient have a bath or shower in the bathroom Equipment Soap or emollient. Flannel or sponge. Disposable cloths if required for perineal care. 67  Key Nursing Skills Shampoo if required and brush and comb. Deodorant and other preferred toiletries. One small and one large towel. Toothbrush and paste. Clean nightclothes or other appropriate clothing. Procedure Prepare the bathroom by ensuring that it is warm, the bath is clean and the necessary equipment is available, such as hoists, a shower chair, a shower trolley and non-slip mats. Gather washing equipment. Run the bath at a temperature that will be comfortable to the patient or arrange the bathroom for the patient to take a shower. Serious burn accidents have occurred in relation to baths. Use TIP! a bath thermometer to ensure that the bath water is approx- imately 43°C and never more than 46°C (Potter and Perry 1997), taking great care with elderly patients who are more vulnerable to burn injury. The nurse should wear a clean plastic apron. Assist the patient to use the lavatory prior to commencing the bath or shower procedure. Assist the patient to the bathroom, ensure privacy can be main- tained by locking the door or placing an ‘engaged’ notice on the door, and provide a screen to shield the bath area. If the patient is able to bath himself unaided, ensure that a TIP! call button is available. Help the patient to undress, checking the skin condition and noting any bruising, rashes, lesions or other breaches of skin integrity. Recheck the water temperature of the bath or shower; if possible, the patient could use his hand to confirm the temperature is comfortable. Assist the patient into the bath, using a hoist if necessary, or into the shower, using a shower chair. 68  Personal hygiene Assist the patient to wash, encouraging him to do as much as pos- sible for himself. If necessary, help the patient with hair washing, providing a cloth to protect the patient’s eyes. TIP! Iffrom washing the hair with the patient in the bath, use fresh water the sink and either a jug or shower connection to rinse the hair. Check the water temperature is warm, not hot, to touch, before pouring it over the patient’s head. Some elderly patients may find it difficult to lean their head back to prevent water flowing over their face as you rinse the hair, so provide a cloth to protect the eyes. Wrap the hair in a towel after washing, and make sure it is dried thoroughly to prevent the patient getting chilled. Style it appropriately after the bath; many clinical areas have rollers and hairdryers that can be used. In cases of patients suspected as having infestations of head lice, no form of treatment should be instigated until a confirmed diagnosis is gained. Local policies will direct interventions of ‘wet combing’ and specific insecticide treatment. Alternatively the ‘Bug Busting’ method may be implemented. ‘Bug Busting’ involves washing the hair with ordinary shampoo and fine- combing the damp, well-conditioned hair on repeated occa- sions. Recent studies have, however, suggested that insecticide lotion is more effective than ‘Bug Busting’ (NHS Direct Online 2001). Use the small towel to blot dry the hair and the face, and assist the patient out of the bath or shower. Cover the patient with the larger towel as soon as possible to pre- vent chilling and ensure privacy. Assist the patient to dry his body, apply preferred toiletries and dress. TIP! Ensure crevices and creases are thoroughly dried. Obese patients or those with certain deformities may find it difficult to keep dry, particularly in the groin, under breasts, between the buttocks or in the umbilicus, and may develop skin lesions in these areas. If these occur, advice regarding appropriate dressings should be sought from senior staff, and all such lesions recorded in the nursing documentation. 69  Key Nursing Skills Facilitate teeth brushing/denture cleansing and assist arrange- ment of hair in preferred style. Male patients should be assisted to shave. Use a disposable or patient’s own razor for wet shaving. If TIP! using a communal electric shaver, ensure it is thoroughly brushed out between patients and cleaned according to man- ufacturer’s instructions. Help the patient back to bed or chair and ensure he is comfort- able. Return the patient’s belongings to his locker. Clean the bath/shower according to Trust policy and leave it tidy. Record in the nursing notes the assessment of the patient’s skin and the care that has been given. Accurate and complete records must be kept for all aspects of the patient’s care. This adheres to the legal requirement of documenting and provides a baseline of data from which to monitor progress. Evaluation Has Mrs Brown had her personal hygiene needs met by having a bath or shower? Did she have sufficient energy for the procedure or was it too taxing? Did she manage to wash some parts of herself independently? Some patients are able to wash a little independently, but have TIP! not got the energy to have a full bath or shower. They may be assisted to have a wash either in bed or sitting out in the chair. The required equipment will be as for a bed bath, and the patient should be encouraged to wash as far as they are able. Clean hot water should be provided at appropriate intervals. The nurse can expect to assist washing the patient’s back or feet or wherever is unreachable. It is helpful if the nurse is in the vicinity while the patient is washing in case the activity is too demanding, so that nursing support can be given quickly. Alternatively the patient may like to wash himself at the bath- room basin, as it is a more natural environment. Ensure privacy and dignity is maintained whichever location is chosen. 70  Personal hygiene NURSING PROBLEM 4.2 Problem: Mrs Brown is at risk of developing mouth infections and discomfort due to being unable to maintain her usual mouth hygiene or to eat and drink. Goal: Mrs Brown’s mouth will remain clean, moist and free from infection. Oral hygiene Mouth hygiene is an essential aspect of care for the dependent patient, and the nurse/carer must be able to assist patients to achieve an accept- able level of oral hygiene. Assistance with oral hygiene will be needed for patients with: limited mobility debilitating pain or movement restrictions altered consciousness levels cognitive problems, such as confusion in older people eating or drinking difficulties, resulting in the loss of the natural cleansing actions of saliva and potential dehydration breathlessness, due to loss of fluid from the respiratory tract compromised immune systems leading to increased risk of infection radiotherapy treatments to the head and neck oxygen therapy, which has drying effects on the oral mucosa. Many people in the United Kingdom do not receive regular dental care and nurses may encounter hospital patients with problems with their teeth and gums or whose dentures no longer fit and/or are in poor con- dition (Evans 2001). Assessment of the mouth is therefore an impor- tant preliminary step in mouth care. Effective oral hygiene helps to prevent infection, distress and discomfort, and, in the case of patients such as Mrs Brown who may require speech therapy, it is a vital com- ponent of rehabilitation. 71 Key Nursing Skills Patients who have natural teeth must be enabled to brush and irri- gate their teeth. Brushing removes food particles, loosens plaque and stimulates blood flow to the gums. For patients who normally wear dentures, it is essential that they are enabled to wear them whenever possible. This promotes dignity and comfortable eating and maintains the shape of the mouth. However, it is not possible for some patients to wear their dentures, for example, if they are unconscious. Patients such as Mrs Brown will require a specialized assessment to determine when it becomes safe for her to wear her dentures. Intervention: oral hygiene Assess Mrs Brown’s needs with respect to mouth care. Assessment to obtain initial information regarding the patient’s oral health is neces- sary to provide baseline information and to assist the evaluation of mouth care interventions. The following are indicators of a healthy mouth (Evans 2001): pink moist tongue, oral mucosa and gums teeth/dentures clean and free of debris well-fitting dentures adequate salivation smooth and moist lips no difficulties with eating and drinking. Undertake mouth care on a regular basis according to the patient’s needs. Cleaning the teeth or mouth after every meal will refresh patients’ mouths but toothpaste should not be used too frequently (see below). Patients with dry mouths may appreciate opportunities to rinse their mouths with diluted mouthwash or fresh water several times a day between meals. Equipment Disposable cup. Small torch. Mouthwash solution made up with fresh water. Receiver or small bowl. Protective towel. Tissues. 72  Personal hygiene Foam sticks. Wooden spatula. Small-headed soft toothbrush. Toothpaste. Disposable gloves. Denture pot and denture cleaning agent and brush. Procedure The nurse should explain to Mrs Brown that her mouth is to be examined and cleaned, to reassure her and gain her consent and cooperation. The nurse should wash her hands and then prepare the solutions; disposable gloves should be worn to undertake the procedure and the protective towel placed over Mrs Brown’s chest. This prevents cross-infection and avoids spillage on Mrs Brown’s gown and linen. If Mrs Brown is wearing dentures, they should be removed, rinsed and placed in a denture pot with cleansing solution. If assessment indicates that it is not yet safe for Mrs Brown to wear her dentures, they should be cleaned and stored in a named container. This ensures safe-keeping of Mrs Brown’s property and maintains hygiene of dentures. TIP! Removing dentures is easier if a tissue or gauze swab is used to hold them with. The nurse/carer should inspect Mrs Brown’s mouth, using the wooden spatula to hold the tongue down gently. Care should be taken not to place the spatula too far back on the tongue as this may induce the gag reflex and make Mrs Brown frightened and uncomfortable. Mrs Brown’s mouth should be pink and moist. The condition of her mouth should be noted and any bleeding areas or ulcers should be reported to the nurse in charge of her care. This ensures that the baseline condition of the mouth is established. The small-headed soft toothbrush and toothpaste should be used to gently brush any natural teeth Mrs Brown may have, and her gums and tongue (Turner 1996), again taking care not to induce the gag reflex. 73  Key Nursing Skills TIP! A child’s or baby’s toothbrush is an ideal size to use if the patient cannot manipulate the toothbrush himself as it is less likely to cause trauma to the gums and palate. Inner and outer aspects of any teeth should be cleaned with the soft toothbrush, brushing away from the gums. Gums and tongue should be brushed very gently to prevent any injury. Foam sticks are soft and can be used frequently to refresh the mouth, but do not remove plaque (Burglass 1995; Moore 1995). Toothpaste is drying and can burn vulnerable gums. It should be carefully rinsed away. Where patients are able to rinse out their mouths, offer the disposable cup containing fresh water or mouth- wash. Where patients are unable to rinse out their mouths them- selves, use a rinsed toothbrush and swab the mouth with a foam stick. Use the tissues to wipe the mouth. When cleaning an unconscious patient’s teeth, use the oral TIP! suction equipment and Yankuer sucker to aspirate all fluid whilst rinsing the teeth to prevent it from trickling down the patient’s throat and causing them to cough or gag (see Chapter 8). Vaseline or soft paraffin can be applied to the lips with a gauze swab to keep lips moist and soft. Mrs Brown’s dentures should be thoroughly cleaned with denture- cleansing products and brush and replaced if appropriate or stored in a named container/denture pot. All solutions should be discarded and the equipment cleaned and replaced. Mrs Brown should be made comfortable. The nurse/carer should wash her hands. Evaluation Does Mrs Brown have a moist, clean mouth and gums? Is her mouth free from infection? 74  Personal hygiene NURSING PROBLEM 4.3 Problem: Mrs Brown may be distressed and her dignity compromised by not being able to maintain her normal grooming habits. Goal: Mrs Brown will have her normal grooming habits met. Personal dressing and grooming Mrs Brown’s condition will have resulted in an alteration in her body image. How a person feels about himself is directly related to how the body is perceived by that person (Salter 1988). Disturbances in body image can, therefore, be distressing. An attempt to maintain Mrs Brown’s usual grooming habits and to promote her presentation as attractively as possible positively influences her sense of self and gives her some control over her personal environment Maintain Mrs Brown’s privacy at all times when undertaking per- sonal care. Ensure Mrs Brown’s privacy is protected, thus demonstrat- ing respect to her as a person and assisting her to maintain dignity and control over her personal environment. Ensure that Mrs Brown’s own toiletries are available for use when attending to her hygiene needs. TIP! Advise Mrs Brown’s daughter to provide toiletries that Mrs Brown prefers but to select those with scents that are light and fresh. Heavy perfumes can seem unpleasant to ill people. Think carefully about whether it is advisable for Mrs Brown to use her favourite scents. She may find this comforting but she may also later come to associate that scent with the unpleasant experience of being ill. Encourage Judith to help her mother to apply moisturizer and make-up prior to visitors if she wears it as this assists both Mrs Brown and her family to maintain her personal image. 75 Key Nursing Skills Ensure that Mrs Brown’s hair is styled in her preferred manner, as guided by herself or her daughter. She may like to visit the hospital hairdresser when she is feeling better, or be helped to wash and style her hair when her medical condition allows. Encourage Judith to provide attractive nightwear or other gar- ments for Mrs Brown to wear; she may require some advice about appropriate garments. For example, if Mrs Brown is incontinent, clothing that is easily laundered will be necessary, and items that are easy for Mrs Brown to put on and off should be provided. It will be essential for Judith to bring in well-fitting house shoes or slippers that have non-slip soles and that support Mrs Brown’s feet so that as she begins to mobilize her safety needs can be met. Further advice as to suitable footwear can be obtained from the physiotherapist. Nightclothes may not always be appropriate for daywear, espe- cially for long-stay patients who may need to attend therapy sessions in the hospital. Daywear should be easy to put on, especially if there is paralysis in upper or lower limbs. It is good practice to insert the af- fected limb first into clothes and remove it last as the other non- paralysed limb is more flexible. Aids to assist dressing such as button or bra hooks may be required, and the occupational therapist will assist in assessing Mrs Brown’s additional dressing needs. Ensure that, if appropriate and safe, Mrs Brown is wearing her dentures during the day. Evaluation Is Mrs Brown well-presented in her own clothes? If Mrs Brown is able to express a preference, is she satisfied with her personal grooming and presentation? Is her daughter? Further reading Burglass EA (1995) Oral hygiene. British Journal of Nursing 4(9): 516–19. Evans G (2001) A rationale for oral care. Nursing Standard 15(43): 33–36. Moore J (1995) Assessment of nurse-administered hygiene. Nursing Times 91(9): 40–41. NHS Direct Online (2001) http://www.healthcareguide.nhsdirect.nhs.uk/conditions/ lice/lice.stm (accessed 26/09/01). Penzer R, Finch M (2001) Promoting healthy skin on older people. Nursing Standard 15(34): 46–52. 76 Personal hygiene Potter AP, Perry AG (eds) (1997) Fundamentals of Nursing: Concepts, Process and Practice, 4th edn. St Louis: Mosby. Salter M (ed.) (1988) Altered Body Image: The Nurse’s Role. London: Wiley. Turner G (1996) Oral care. Nursing Standard 10(28): 51–54. 77