Wk 1 Bed Bath, Back Rub, ROM, Skin Care Goergen PDF

Hygiene: Bed Bath, Backrub, Range of Motion, Skin Breakdown NURS 1090  Unit Outcomes  Provide personal hygiene to patients according to their specific needs.  Demonstrate range of motion exercises.  Define basic techniques to prevent skin breakdown.  Assess functional...

Hygiene: Bed Bath, Backrub, Range of Motion, Skin Breakdown NURS 1090  Unit Outcomes  Provide personal hygiene to patients according to their specific needs.  Demonstrate range of motion exercises.  Define basic techniques to prevent skin breakdown.  Assess functional status of hospitalized older adults  Personal Hygiene  Definition:the self-care by which people attend to such functions as bathing, toileting, general body hygiene, and grooming.  Personal hygiene affects patient’s comfort, safety and well-being  Includes:  Bath/shower  Brushing teeth/dentures  Hair care  Nail care  Shaving (male)  Properties of Skin The largest organ of the body  Protects underlying organs  Excretion and Secretion by preventing the passage of  Sebum: oily substance microorganisms and trauma that lubricates skin and  Assists in Regulation of hair Body Temperature  Sweat: promotes heat  Dilationof blood vessels loss by evaporation enable body to release  Sensation excess heat  Synthesizes  Skincontains sensory Vitamin D  from organs for touch, pain, ultraviolet light heat, cold, and pressure  Principles of Skin Care  Intact Skin: 1st line of defense  Be mindful of jewelry and fingernails to protect patient’s skin  Avoid harsh rubbing, rough towels  Keep linens free from wrinkles  Dry Skin: more vulnerable to injury/infection  Use moisturizing cream  Decrease frequency of bath  Moisture & Skin: can cause increased bacterial growth and irritation  Dry carefully especially axilla, groin, breast –  Immediate skin care if incontinent  Principle of Skin Care  Body Odor: caused by resident skin bacteria acting on body secretions  Cleanliness is best deodorant  Apply deodorants, antiperspirants AFTER cleaning  Skin Sensitivities: vary among individuals and developmental level  Baby: gentle, thin  Teens: oily  Older Adults: dry, thin, bruises easily  Nutritional status; obese, emaciated, dehydrated  Hygienic Care  Early Morning Care  Bedpan, urinal; wash hands/face; oral  Morning Care  Bath, linen change, perineal care, back rub, hair care, nail care  Shower may need physician order /RN judgment  Afternoon Care – Same as Early AM care  Evening Care (HS care, PM care) – Same as early AM / back rub  As-needed (PRN) Care – As needed for soiling, diaphoresis  Bath  Good opportunity to communicate with patient  Patient teaching  Assess skin  Frequency of bath is individualized  Certain body areas need more frequent cleansing: face, axillae, perineal area, hands  Use mild soap or cleansing agent  Decreases irritation and drying  Types of Bed Baths Depend on patient’s physical abilities, health problems, and degree of hygiene required  Complete bed bath: Patient totally dependent  Partial bed bath: Bathing selected body parts such as hands, face, axillae, perineal area  Assist bed bath  Patient assists with bathing/may also be done at sink  Nurse completes body parts that patient unable  Legs, feet, back  Promotes independence  Need to help with set up of bathing items  Bathing Procedure Concepts  Universal Steps  Physician/HCP order  not required for bed bath, but IS required for shower/tub  always verify with instructor/facility  Hand Hygiene  Approach: (identify self, identify patient, patient assessment, explain procedure)  Equipment  Privacy/ use bath blanket to cover exposed areas  Safety  Body mechanics  Medical asepsis  Bathing Procedure Concepts  Bath basin or Bag bath  Principles  Clean to dirty  FACE 1st /no soap  Strokes: distal to proximal to promote circulation –  Order: face, arms, abdomen, legs, feet, back and buttocks, perineal area  Perineal care  Gloves  Female/male (Pearson, Volume Three, Skill 2.8,pp.122-123)  Complete Care  Remove equipment  Bed down/rails up  Document  Hygiene: Bed Bath, Backrub, Range of Motion, Skin Breakdown PART 2  Bag Bath  Heat in warmer to safe temperature  Useone cloth for each body area to prevent cross contamination  Do not rinse or dry patient as the cleaning solution will evaporate quickly leaving behind an emollient  Bathing Video Kaplan  Go to your Kaplan site, and click on the “Bathing a Client” video in the Clinical Skills section  Back Massage  Purpose  Contraindications: Promote relaxation Burns, rib fractures, Stimulate circulation open wounds Decrease Patient declines muscular tension Don’t massage reddened  Takes3-5 minutes to be skin that does not effective blanch with pressure Don’t massage broken skin  Back Massage Video (Kaplan) Go to your Kaplan site, click on Therapeutic Back Rub in the Clinical Skills section  Oral Hygiene  Independent  Equipment:  Provide supplies to patient Toothbrush  Dependent Toothpaste  Nurseperforms oral hygiene Mouthwash for patient Emesis basin  Unconscious Water cup Head of bed lowered Clean gloves Turn head to side Have Towel/washcloth suction available  Oral Hygiene Videos Available on Blackboard in the Personal Hygiene and Comfort Folder: 1. Brushing Teeth Dependent Patient 2. Oral Care for the Unconscious Patient  Denture Care  Remove Dentures  Clean the dentures Hold dentures firmly and take care not to drop them Place a washcloth under them if using a sink  Inspect dentures and mouth  Return the dentures to the mouth  **Review Denture Care video in the Blackboard folder  Hair Care Includes brushing, combing, Shampooing shampooing Brushing and combing: May need provider order Brush from scalp toward for patients with limited hair ends May need to moisten hair mobility with water No rinse shampoo Do not cut without patient Shampoo cap consent Consider cultural preferences Hair Care: Shampoo Tray  Nail Care Nail Trimming  Fill emesis basin with warm  Check agency policy for order water  Clip fingernails straight across  Allow fingernails to soak for and even with the tops of the 10-20 minutes fingers  Clean under nails if  Check agency policy for toenail indicated trimming-often performed by  Dry thoroughly podiatrist  Foot Care  **Check agency policy for order Contraindicated for diabetic patients  Fill basin with warm water  Patient to sit in chair  Soak feet for 10-20 minutes  Cleanse with washcloth  Dry thoroughly  Shaving a Male Patient  Use safety razor  Shave in the direction of hair growth.  Use longer strokes on the larger areas of the face.  Use short strokes around the chin and lips Anti-embolism Elastic Stockings TED Hose Promotes venous return  Aids in prevention of thrombus formation  Maintainsexternal pressure on muscles of lower extremities  Select correct size  Remove for bathing  Application of Elastic Stockings #1 #2  Turn elastic stocking inside  Slideremaining portion of out up to heel stocking over patient’s foot  Place toes into foot of elastic stocking  Application of Elastic Stockings #3  Slide top of stocking over patient’s calf  Instruct patient not to roll stockings partially down Pneumatic Compression Device: Helps prevent blood clots in deep veins of the legs  Skin Integrity  Skin composed of two layers: Epidermis : top layer Stratum corneum : thin, outermost layer of epidermis Dermis: inner layer of skin  Subcutaneous tissue: underlies the dermis Composed of loose connective tissue and fat cells  Risk for Impaired Skin Integrity  Immobility  Increased aging  Diminished sensation  Altered nutrition and hydration  Secretions/excretions on skin  Impaired vasculature (circulation)  External devices: casts, restraints  Altered cognition  Edema  Impaired Skin Integrity  Skin Tears  Traumatic wounds caused by shear and friction  Epidermis is separated from the dermis  Aging skin has thinner epidermis, decreased collagen, and decreased subcutaneous tissue Impaired Skin Integrity  Pressure injury: (pressure sore, pressure ulcer, decubitus ulcer, bedsore) – areas of skin that break down as a result of pressure Localized injury to the skin and underlying tissue Usually over a bony prominence Result of pressure or pressure in combination with shear and/or friction.  Tissue Damage 3 factors contribute to tissue damage:  Pressure intensity Tissue ischemia  Pressure duration Low pressure/prolonged time High intensity pressure/short time  Tissue Tolerance Condition of skin and supporting structures  Tissue Damage cont.  Assessment: Blanchable erythema area turns lighter in color and erythema returns Non-blanchable erythema Unable to blanch Impending tissue damage Friction  Asthe HOB increases, the skeleton slides down and the skin stays fixed, resulting in shearing  Tissue Damage cont.  Partial thickness skin loss Loss of dermis and/or epidermis Abrasion, blister  Full thickness skin loss Damage to underlying subcutaneous tissue Also may have extensive destruction to muscle, bone, and/or supportive structure Nursing Interventions  Perform total body skin assessment daily  Minimize direct pressure  Change position at least every 2 hours  ROM: active/passive  Keep skin dry and clean May use moisture barrier ointment  Nursing Interventions Utilize pressure relieving devices Specialty mattress: air mattress, alternating pressure mattress, egg crate mattress Pillows, wedge, heel protectors Use assistive devices to move patient and minimize friction Pad or draw sheet overhead trapeze Provide adequate nutritional and fluid intake  Activities of Daily Living (ADLs)  Activities performed in the course of a normal day  Day-to-day functioning Ambulation Eating Dressing Bathing Grooming  Asindividuals age or become ill, assistance may be required with ADL’s  Functional Status Assessment  Important in the care of older adults  Helps to identify normal aging changes and changes due to illness, disability  Functionaldecline may be the first sign of changing health status in the older adult  Assessmentof the patient’s functional status important during hospitalization  Katz Index of Independence in Activities of Daily Living  Scale that ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding.  Patients are scored yes/no for independence in each of the six functions.  Provides objective data that may indicate future decline or improvement in health status, allowing the nurse to intervene appropriately.  **Will do as a clinical activity on older adults.