Unit 4 Hygiene.pdf

Sri Rahaya Nafitri Abdul Razak U6240037 HYGIENE CARE Learning Outcomes After completing this topic students will be able to: 1. Describe hygienic care that nurses provide to patients 2. Identify factors influencing personal hygiene. 3. Identify normal and abnormal assessment f...

Sri Rahaya Nafitri Abdul Razak U6240037 HYGIENE CARE Learning Outcomes After completing this topic students will be able to: 1. Describe hygienic care that nurses provide to patients 2. Identify factors influencing personal hygiene. 3. Identify normal and abnormal assessment findings while providing hygiene care. 4. Identify the purpose of bathing 5. Describe various types of baths. 6. Discuss factors that support a positive and safe environment for the patient. 7. Verbalize the steps used in: i. Bathing an adult patient. ii. Providing perineal-genital care. iii. Providing foot care. iv. Brushing the teeth v. Providing special oral care vi. Providing hair care 8. Demonstrate appropriate documentation and reporting of hygiene skills. A. INTRODUCTION  Hygiene is the self-care practice which involve ; bathing, toileting, general body hygiene, and grooming. B. HYGIENE CARE 1. NURSING MANAGEMENT 1. Assessing Skin & hygiene practices a) Health history  To determine – assistance for patient/ function level / type of bath (eg; bed, tub, shower); skin care practices; past and current skin problem. Definition and descriptors for function level (0 (+1 Semidependent Moderatel Totally ) ) (+2) y Dependen Dependen t (+4) t (+3) Bathing Nurse provides all Nurse Client equipment; supplies all needs positions client in equipment; complete bed/bathroom. positions bath; Client completes client; cannot bath, except for washes assist at back and feet. back, legs, all. perineum (the area between your vaginal opening and back passage  (anus)) and all other parts as needed. Client can assist. Oral hygiene Nurse provides Nurse Nurse equipment; client prepares completes does task. brush, entire rinses procedure. mouth, positions client. Dressing/groomin Nurse gathers Nurse Client g items for client; combs needs to may button, zip or client’s be dressed the clothing. Client hair, assist and cannot dresses self. with assist the dressing, nurse; buttons nurse and zips combs clothing, client’s ties shoes. hair. Toileting Client can walk to Nurse Client is bathroom/commod provides incontinent e with assistance; bedpan, ; nurse nurse helps with positions places clothing. client on or client on off bedpan, bedpan or places commode. client on commode.  b) Physical assessment –skin  To collect data – skin (inspection & palpation): color, uniformity of color, texture, turgor, temperature, intactness & lesion.   Common Skin Problem Problem and Appearance Nursing Implications Abrasion: Superficial layers of the skin are  Prone to infection; wound should be kept scraped / rubbed away. Area is reddened and may clean and dry. have localized bleeding / serous weeping.  Do not wear rings or jewelry when providing care to avoid causing abrasions to clients.  Lift, do not pull, a client across a bed.  Use two/more people for assistance. Excessive dryness: Skin can appear flaky and  Prone to infection if the skin cracks; rough. provide alcohol-free lotions to moisturize the skin and prevent cracking.  Bathe client less frequently; use no soap/ use nonirritating soap and limit its use. Rinse skin thoroughly because soap can be irritating and drying.  Encourage increased fluid intake if health permits to prevent dehydration. Ammonia dermatitis (diaper rash): caused by  Keep skin dry and clean by applying skin bacteria reacting with urea in the urine. The protective ointments containing zinc oxide skin becomes reddened and sore. to areas at risk: buttocks & perineum.  Boil an infant’s diapers/ wash them with an antibacterial detergent to prevent infection. Rinse diapers well because detergent is irritating to an infant’s skin. Acne: Inflammatory condition with papules and  Keep the skin clean to prevent secondary pustules. infection.  Treatment varies widely. Erythema: Redness associated with variety of  Wash area carefully to remove excess conditions: rashes, exposure to sun, elevated body microorganisms. temperature.  Apply antiseptic spray/lotion to prevent itching, promote healing, and prevent skin breakdown. Hirsutism: Excessive hair on a person’s body and  Remove unwanted hair by using face, particularly in women. depilators, shaving, electrolysis/tweezing.  Enhance client’s self-concept. 2. Planning  Assisting dependent client with bathing, skin care n perineal care, providing back massages to promote circulation  Instructing clients/families about appropriate hygiene practice & alternative methods for dressing & adaptive activities Home Care Assessment Client and Environment  Self-care abilities for hygiene: assess the client’s ability to bathe, to regulate water faucets, to dress and undress, to groom, and use the toilet.  Self-care aids required: determine if there is a need for a tub/ shower seat, a hand shower, a nonskid surface or mat in the tub or shower, hand bars on the sides of the tub, or raised toilet seat.  Facilities: check for the presence of laundry facilities and running water.  Mechanical barriers: note furniture obstructing access to the bathroom and toilet, or doorway too narrow for a wheelchair. Family  Caregiver availability, skills and responses: determine whether individuals are available and able to assist with bathing, dressing, toileting, nail care, hair shampoo for hygienic and grooming aids.  Education needs: assess whether the caregiver needs instruction in how to assist the client in and out of the tub, on and off the toilet and so on.  Family role changes and coping: assess effects of client’s illness on financial status, parenting, spousal roles, sexuality and social roles. Community  Explore resources that will provide assistance with bathing, laundry, and foot care (e.g. home health aide, podiatrist).  Consult a social worker as needed to coordinate placement of a client unable to remain in the home or to identify community resources that will help the client stay at home.  Consider a consult with; a physical therapist to assess, develop and improve the client’s motor function; a home health nurse to provide follow-up for care, teaching and support; an occupational therapist to assess and develop abilities to perform activities of daily living. 3. Implementing - Skill 33-1 pg-702 – 706 ( providing bed bath – adult) - Skill 33-2 pg 708 – 709 (providing perineal-genital care)  4. Evaluation: desired outcome have been achieved / not. If not, why;  Did the nurse overestimate the client’s functional abilities (physical, mental, emotional) for self-care?  Were provided instructions not clear?  Were appropriate assistive devices/supplies not available to the client?  Did the client’s condition change?  Were required analgesics provided before hygienic care?  What currently prescribed medications and therapies could affect the client’s abilities or tissue integrity?  Is the client’s fluid and foot intake edequate or appropriate to maintain skin and mucuous membrane moisture and integrity? 2. General guideline for skin care I. Intact  Prevent injury and irritation  Jewelry/long, sharp fingernails will scratching the skin  Harsh rubbing/use rough towels/washcloths lead to tissue damage, particularly when skin is irritated/circulation/sensation is diminished  Make sure bottom bed sheets are kept taut and free from wrinkles to reduce friction & abrasion  Top bed linens were arranged to prevent undue pressure on the toes/can use footboards to keep bedclothes off the feet II. Dryness of skin  Skin poorly nourished/dry easy to injured  Lotion/creams with lanolin applied to dry skin  Bathing is limited once/twice a week to prevent the natural oils removed III. Dried – moisture in contact with the skin for more than a short time can increased bacterial growth & irritation  After a bath, skin is dried carefully  Attention to areas; axillae, groin, beneath the breast, between toes, had high potential for irritation and fungal infection. A nonirritating dusting powder tends to reduce moisture & can be applied to these areas after they are dried  Clients who are incontinent of urine/feces/who perspire excessively are provided immediate skin care IV. Body odors – caused by resident skin bacteria acting on body secretions  Commercial deodorants & antiperspirants applied after skin cleaned.  Deodorants diminish odors, antiperspirants reduce perspiration, neither is applied immediately after shaving cause of the possibility of skin irritation, nor used on the skin that is already irritated V. Skin sensitivity  Mostly in infants, very young children and elderly, nutritional status effect the skin sensitivity  Emaciated(kurus kering)/obesity/poor dietary habits/ insufficient fluid intake tend to experience more skin injury/irritated  Healthy people, from skin care/cosmetics; the can use hypoallergenic cosmetics & soap/soap substitutes  VI. Agents used for skin care – have selective actions and purpose Soap Lowers surface tension & thus helps cleaning. Some soap contain antibacterial agents, which can change the natural flora of the skin Chlorhexidine A disposable cloth saturated with 2% CHG & skin moisturizing gluconate (CHG) substances. An advantages is continued antimicrobial activity after application. These cloths are often used in critical care settings Bath oil Used in bathwater; provides an oily film on the skin that softens and prevents chapping. Oils can make the tup surface slippery, client should instructed about safety measure (e.g. using nonskid tub surface/mat) Skin cream, lotion Provides a film on the skin that prevents evaporation and therefore chapping Powder Used to absorb water and prevent friction; example: powder under breast can prevent irritation, some powders are antibacterial Deodorant Mask/diminishes body odors Antiperspirant Reduces the amount of prespirant 3. Bathing an adult patient - Skin problem & care ( refer pg-710) Skin Problem Care Dry skin  Cleansing creams to clean is better than soap/detergent, cause it can drying/allergic reaction  Bath oils, but take precautions to prevent falls caused by slippery tub surfaces  Rinse soap/detergent if used, from the skin  Bathe less frequently when environmental temp and humidity low  Increase fluid intake  Humidify the air with humidifier/by keeping a tub/sink full of water  Moisturizing/emollient creams that contain lanolin(a yellow fat obtained from sheep’s wool), petroleum jelly, cocoa butter to retain skin moisture Skin rashes  Keep the area clean by washing with mild soap. Rinse the skin well, pad it dry  To relieve itching, try tepid bath/soak. Some over-the-counter preparations, Caladryl lotion may help but used with full knowledge of the product  Avoid scratching the rash to prevent inflammation, infection, futher skin lesions  Choose clothing carefully. Too much can cause perspiration(peluh) & aggravate rash Acne  Wash the face frequently with soap/detergent and hot water to remove oil & dirt  Avoid using oily creams  Avoid using cosmetics that block the ducts of the sebaceous glands & the hair follicles  Never squeeze/pick at the lesions, it will increases the potential of infection and scarring  Types of bath i. Cleansing baths – for hygiene, 43°C-46°(110°F-115°F), make sure not too hot to prevent burning, change bed bath when its dirty/cold Complete bed bath - Nurses washes the entire body of a dependent client in bed Self-help bath - Clients confined(terbatas) to bed are able to bathe themselves with help from nurse of washing back and feet perhaps Partial bath (abbreviated - Only part of client’s body cause by discomfort/odor bath) - If neglected, are washed: the face, hands, axillae, perineal area, back - Omitted arms, chest, abdomen, legs, feet - This care for dependent clients & assist self-sufficient clients confined to bed by washing their back - Some ambulatory clients prefer partial bath at sink, nurse can assist them by washing their backs Bag bath - Its commercially prepared product that contains 10-12 presoaked disposable washcloths that contain no-rinse cleanser water, its warmed in microwave in 1mins but nurse need to determine how long it takes to attain a desirable temp. - Each part of body cleaned with different cloth and then air dried - Not rubbed dry, cause emollient(ingredients in moisturizer to soft the skin) in the solution remains on the skin Towel bath - Similar to bag bath but use towel - For bedridden & dementia client - Its covered client and kept warm throughout the bathing process by a bath blanket - Nurse gradually replaces bath blanket with a large towel that already soaked with warm water & no-rinse soap - Gently massaged the client with warm, wet, soapy towel - Wet towel replaced with a large dry towel for drying Tub bath - Often preferred to bed bath cause easier to wash and rinse - Use for therapeutic bath - Amount nurse assistant depends on client abilities - Special design tubs for dependent client, to reduce work in lifting in and out clients - More better than sponge bath in bed Sponge bath - Usually for newborn - Infant should wrapped and dried immediately after bath to prevent heat loss - Infant’ s ability to regulate body temp not fully developed yet - Infant’s body surface very large in relation to body mass, the body loss heat more fast Shower - Usually with aids shower chair, easy to transported from room to shower, its facilitate with client’s perineal area i. Therapeutic baths  For physical effect; soothe irritated skin/treat an area e.g. perineum  Can put meds in the water  Generally in a tub one third /one half full  Bath 20-30 mins  If client’s back, chest, arms are treated, these area need immersed in the solution.  The bath Temp. – adult: 37.7°C - 46°C(100°F-115°F), infant: 40.5°C(105°F)  Purposes  To remove transient microorganisms, body secretions and excretions, and dead skin cells.  To stimulate circulation to the skin.  To promote a sense of well-being.  To produce relaxation and comfort.  To prevent & eliminate unpleasant body odors Assessment  Physical / emotional factors - (e.g. fatigue, sensitivity to cold, need for control, anxiety/fear)  Condition of skin – (color, texture, turgor, presence of pigmented spot, temp, lesions, excoriation, abrasions, bruises). Areas of erythema (redness) on the sacrum, bony prominences, heels for pressure sore  Presence of pain and need for adjunctive measure e.g. an analgesic before bath  Range of motion – joints  Any other aspect of health e.g. mobility, strength, cognition  Need for use – clean glove during the bath 4. Feet 1. Assessment of feet : Inspect each foot & toe shape, size, presence of lesions. Palpate areas of tenderness, edema, circulatory status Common foot problems: calluses, corns, unpleasant odors, plantar warts, fissures, fungal infection e.g. athletes foot, ingrown toenails Callus - Thickened epidermis (keratotic material) - Painless, flat, found over the bottom/side of foot over a bony prominence - Caused by pressure from shoes - Can be softened by soaking in warm water with Epsom salts, and abraded with pumice stones/similar abrasives, and cream with lanolin Corn - Keratosis caused by friction & pressure from shoes - Occurs on the 4th/5th toe, on a body prominence, e.g. joint - Usually conical (circular and raised) - Base is the surface of corn, apex is in the deeper tissue, sometimes attached to bone - Remove by surgery - Prevention: wearing comfortable shoes, massaging tissue to promote circulation - Avoid use oval corn pad cause its increase pressure & decrease circulation Unpleasant odors - Cause of perspiration n interactions of microorganism - Prevention: regular n frequently wash and clean feet, wearing hosiery, foot powders and deodorants Plantar warts - On the sole of foot - Caused by papovavirus hominis virus - Moderately contagious - Painful and difficult to walk - Primary care: curettage the warts, freeze them with solid carbon dioxide several times/ apply salicylic acid Fissure/deep - Frequently occur between toes because of dryness & grooves cracking of the skin - Treatment: good foot hygiene, antiseptic Athlete’s foot/tinea - Caused by fungus pedis (ringworm of - Symptoms: scaling, cracking of the skin, particularly the foot) between toes, small blister containing thin fluid, lesions Plantar warts Fissure/deep grooves Athlete’s foot/tinea pedis 2. (Refer Table 33-5 ; pg 711) – normal / abnormal finding Method Normal finding Abnormal finding Inspect all skin surfaces, Intact skin Excessive dryness particularly between the Absence of Areas of toes, for cleanliness, swelling/inflammation inflammation/swelling odor, dryness, (e.g. corns, calluses) inflammation, swelling, Fissures abrasions, other lesions Scaling and cracking of skin (e.g. athlete’s foot) Plantar warts Palpate anterior and No swelling Swelling/pitting edema posterior surfaces of ankles and feet for edema Palpate dorsalis pedis Strong, regular pulse Weak/absent pulse pulse on dorsal surface of in both feet foot Compare skin temp of Warm skin temp Cool skin temp in both feet one/both feet 3. Client teaching on foot care (refer pg-712) a) Wash the feet daily, dry them well, especially between toes b) When washing inspect for skin breaks/red/swollen areas. Use mirror if needed c) Check water temp before immersing feet to prevent burning d) Cover feet with creams/lotions except toes. Lotion soften calluses and reduce dryness cause its mixture of lanolin & mineral oil e) Wash feet frequently, change socks & shoes daily, use special deodorant spray, absorbent, foot powder to prevent/control unpleasant odor due to excessive foot perspiration f) To avoid skin injury, file the toenails straight across the ends of the toes rather than cutting them. If nails to thick/misshapen to file, consult podiatrist(feet/lower leg specialist) g) Wear clean stockings/socks daily. Avoid socks with holes/darns can cause pressure areas h) Wear comfortable, well-fitting shoes that neither restrict the foot nor rub on any area; rubbing cause corns & calluses. Check worn shoes for rough spots in the lining. Break in new shoes gradually by increasing the wearing time 30-60 min per day i) Avoid walking barefoot/ wear slippers in public shower & in change areas to avoid injury and infections j) Exercise the feet to promote circulation in a few days. Point the feet upward, point them downward n move them in circles k) Avoid wearing constricting garments e.g. knee-high elastic stockings and sit with cross legs will decrease circulation l) Use extra blankets n wear warm socks are better than use heating pads/hot water bottles when feet are cold. Test bathwater to prevent skin burning m) Wash any cut on the foot, apply antiseptic, notify primary care provider n) Avoid self-treatment for corns and calluses. Pumice stones and some callus and corn applications are injured to skin, consult with podiatrist/primary care provider o) Notify primary care provider if you notice abnormals/sores/drainage/pain/changes in temp/color/sensation of the foot 4. Foot care (refer pg-713) 5. Nails 1. Assessment – Inspection nails; nail shape, texture, nail bed color, tissue surrounding the nails 2. Diagnosing – Bathing Self-care Deficit: impaired vision n cognitive impairment. Risk for Infection around the nail bed related to: impaired skin integrity of cuticles n altered peripheral circulation 3. Implementing - Nurse need nail cutter/sharp scissors/a nail file, orange stick to push back cuticle, hand lotion/mineral oil to lubricate dry tissue, a basin of water to soak if nail thick/hard - Consult with podiatrists if clients had DM, peripheral vascular disease, long term steroid therapy and anticoagulant therapy - Client who have DM/circulatory problems should have their nails filed rather than cut; inadvertent injury to tissue occur if scissors are used 6. Mouth 1. Assessment : Plague  invisible soft film that adhere to the enamel surface of teeth  consist bacteria, molecules of saliva, remnants of epithelial cells, leukocytes  when plague unchecked, tartar formed Tartar (dental calculus)  Visible, hard deposit of plague, dead bacteria that form at gum lines  Can alter the fibers that attach to gum and disrupt bone tissue Gingivitis  Red, swollen, gingiva  Bleeding  Receding gum lines  Formation of pockets between teeth n gums Pyorrhoea (periodontal disease)  Teeth are loose, had pus when the gums pressed. Oral assessment guide (OAG) tool for detecting early signs of oral problem  a) Common problems of the mouth ( refer Table 33-6) Problem Description Nursing Implications 1. Halitosis Bad breath Teach / provide regular oral hygiene 2. Glossitis Inflammation of the tongue Teach / provide regular oral hygiene 3. Gingivitis Inflammation of the gums Teach / provide regular oral hygiene 4. Periodontal Gums appear spongy n bleeding Teach / provide regular oral hygiene 5. Reddened / excoriated Check for ill-fitting dentures mucosa 6. Excessive dryness of the Increase fluid intake as health buccal mucosa permits 7. Cheilosis Cracking of lips Lubricate lips; use antimicrobial ointment to prevent infection 8. Dental caries Teeth have darkened areas; may Advise client to see a dentist be painful 9. Sordes Accumulation of foul matter Teach / provide regular cleaning (food, microorganisms, epithelial elements) in the mouth 10. Stomatitis Inflammation of the oral mucosa Teach / provide regular cleaning 11. Parotitis Inflammation of the parotid Teach / provide regular oral salivary glands hygiene b) Measures to prevent tooth decay (refer table in pg -717) Brush the teeth thoroughly after meals n at bedtime. Assist children / inspect their mouths to be sure the teeth are clean. If teeth cannot be brushed after meals, vigorous rinsing of with recommended water Floss the teeth daily Ensure an adequate intake of nutrients , particularly calcium, phosphorus, vit A, C, D and fluoride Avoid sweet foods and drinks between meals. Take them in moderately at meals Eat coarse, fibrous foods(cleansing foods), e.g. fresh fruits, raw vegetables Have topical fluoride applications as prescribed by the dentist Have a checkup with dentist every 6 months 2. Implementation a) Brushing and flossing the teeth – conscious client ( refer skill 33-4 ;pg 719 - 721) b) Oral care – unconscious client ( refer skill 33-5; pg 722-723) 7. HAIR 1. Physical assessment: Dandruff Occur accompanied with itchy Appears as diffuse scaling of the scalp, sometimes involves the auditory canal & eyebrow Treated: shampoo/advice from primary care provider Hair loss Some permanent thinning occurs with aging, mens: baldness Treatment: wearing hairpiece/ hair transplant/meds Ticks Small gray-brown parasite that bite into tissue and suck blood Transmit several disease to people: Rocky Mountain spotted fever, Lyme disease, tularemia To remove: blunt tweezer/gloves finger; remove ticks n wash area antibacterial soap Ineffective/dangerous method: apply heat with a match/apply petroleum jelly/gasoline Pediculosis(Lice) Parasitic insect that infest mammals Pediculus Capitis(the head louse), Pediculus Corporis(the body louse), Pediculus Pubis (the crab louse) Sucked blood from scratches skin Treatment: over-the-counter permethrin (Nix), synergized pyrethrins (Rid), Malathion, Lindane Non recommended treatment: oily substance, olive oil, mayonnaise, petroleum jelly to smother the lice, it leads to irritation n inflammation Scabies Contagious skin infestation by itch mite Signs: burrow lesions (short, wavy, brown/black), secondary lesions; scratching vesicles, papules, pustules, excoriations, crusts The place is between the fingers, creases of the wrist n elbows, beneath breast tissue, groin area Treatment: cleansing with soap n water, apply scabicide lotion, all bed linens n clothing wash with very hot/boiling water Hirsutism Growth excessive body hair (at axillae n legs n facial) due to the action of endocrine system 2. Implementation – washed, brushed, combed daily to keep clean 3. Skill 33-6; pg -726 – 727  4. Shampooing the hair  Depends on strength, health and age  Client unable to shower, will given shampoo while sitting on the chair in front of sink  Client back-lying can move to stretcher, will given shampoo on a stretcher wheeled to a sink  Client bedridden, shampoo will brought with water to the bedside  “Head bath” with designed cap (like shower cap), contains shampoo n conditioner  Portable shampoo chair at beauticians  Water used 40.5°C  Meds shampoo to destroy lice  Dry shampoo, will remove dirt, odor, oil but will dry hair n scalp 8. EYES 1. Care - Contact lenses  Thin curved disks of hard / soft plastic that fit on the cornea over the pupils  Advantages: they cannot been seen n have cosmetic value, highly effective in correcting some astigmatisms, they do not fog, provide better vision  Hard contact lens – rigid, unwettable, airtight plastic that does not absorbed water/saline solutions, cannot be worn more than 12-14 hrs, not recommended for first time users  Soft contact lens – more pliable, soft, firmer, can wear 1-30 days, requires scrupulous(teliti) care n handling  Gas-permeable – rigid but more flexible, oxygen can enter cornea, more comfort, can left in place for several days  Cleansing: warm tap water, normal saline, special rinsing/soaking solutions  Had special containers : stored wet/stored dry 2. Eye care – comatose client (refer box 33-4 ; pg 729)  Administer moist compresses to cover the eyes every 2-4 hrs  Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct  Use a new cotton ball for each wipe. This prevents extending infection in one eye to the other eye  Instill ophthalmic ointment/artificial tears into the lower lids as ordered. Thid keep eyes moist  If the client’s corneal reflex is absent, keep the eyes moist with artificial tears and protect the eye with a protective shield. These should be ordered by a primary care provider  Monitor the eyes for redness, exudate/ulceration  3. General eye care ( refer ; pg 729)  Avoid home remedies for eye problems. Eye irritations/injuries at any age should be treated medically n immediately  If dirt/dust gets into the eyes, clean them copiously with clean, tepid water as an emergency treatment  Take measures to guard against eyestrain and to protect vision; maintaining adequate lighting for reading and obtaining shatterproof lenses for glasses  Schedule regular eye examinations, particularly after age 40, to detect problems; cataracts and glaucoma 4. Evaluating ( refer pg ;730 )  Conjunctiva and sclera free of inflammation  Eyelids free of secretions  No tearing  No eye discomfort  Demonstrate appropriate methods of caring for contact lenes  Describe interventions to prevent eye injury and infection 9. EARS – cerumen (earwax) Cleaning ears  Remove excessive visible cerumen/that causes discomfort/hearing difficulty  How to clean: loosed and removed by retracting the auricle and back, use cerumenolytic(wax-softening agents), irririgation  Irrigation can cause : pain, tinnitus, external otitis media  Client with hearing aids greater risk for cerumen  Hearing aids cause excessive cerumen production & presence of the hearing prevents the body’s normal mechanism for removal of cerumen from functioning  Never use bobby pins, toothpicks, cotton tipped applicators Care of hearing aids – battery powered, sound amplifying device, had several types; Behind-the-ear (BTE) open fit  No earmold  Visible with clear tube that runs down into ear canal but didn’t occlude it Behind-the-ear (BTE) with earmold  fits snugly behind ear  the hearing aid case, hold microphone, amplifier, receiver that attach the earmold by a plastic tube In-the-ear (ITE) aid  one piece aid has all its components housed in earmold  more visible & more room for features : volume control In-the-canal (ITC) aid  compact & barely visible  fits completely inside the ear canal  if having cosmetic appeal, ITC didn’t interfere with telephone use/ wearing eyeglasses  not suitable for clients with progressive hearing loss Completely-in-the-canal(CIC) aid  almost invisible  had to custom designed to fit the ear Eyeglasses aid  similar to behind-the-ear aid  the components are housed in the temple of eyeglasses  hearing can be in one/both temples of  glasses Body hearing aid  pocket size aid  used for more severe hearing losses  clips onto an undergarment, shirt pocket/harness carrier supplied by the manufacture  containing microphone & amplifier, connected by a cord to the receiver, which snaps into the earpiece  10. NOSE  Nurse not provided cleansing  Client can blowing gently into a soft tissue  External cares are encrusted with dried secretions, cleaned with a cotton tipped applicator/moistened with saline/water  The applicator should not inserted beyond the length of the cotton tip; cause it can injured mucosa REFERENCES; https://www.youtube.com/watch?v=WOLQLvExIwE ( Bed Bath & change linen) https://www.youtube.com/watch?v=hYXYcOHT6aE (Giving a Patient a Bed Bath) https://www.youtube.com/watch?v=LcaiMHduqPc (Bed Bath)