Ch. 22 Facilitating hygiene Flashcards
______ _______ promotes comfort, improves self image, decreases infection and disease
Personal hygiene
What is the nurses role in patient hygiene?
Assess self care abilities
Provide assistance w/ ADLs
Promote self care in ADLs
Delegate appropriate parts of hygiene care
Activities of daily living (ADLs) : Bathing Complete = head to toe Showering Combing hair
Which factor influence hygiene and self care?
Psychosocial/physical factors
Personal preferences (showers vs baths)
Culture and religion (Beliefs about hygiene and cleanliness)
Economic status/living environment (homeless, etc.)
Developmental level (parents bathe children, depending on age children dislike baths, then puberty comes and showering becomes more frequent)
knowledge level (does a woman know to wipe front to back? does pt understand flossing importance)
Physical factors:
- Pain: limits mobility and energy.if pain give medication, wait a half hour to see pain level then give bath
- Limited mobility: decreased range of motion, weakness, bedrest
- Sensory deficits: decreased independence and increased safety concerns (example: loss of eyessight, cannot find supplies w/out asst; pt with hearing loss on anticoagulant needs electric razor to avoid cutting himself)
- Cognitive impairment - doesn’t udnestand need for hygiene, cannot problem-solve, forgetful,
- emotional or mental disturbances - Patients suffering from depression often report a profound lack of energy or motivation and may neglect their grooming and hygiene practices because of thi
What is the importance of maintenance of personal hygiene?
Promotes comfort (hair style) Improves self-image Decreases infection and disease Contributes to physical and psychological well-being Fosters activity and movement Provides comfort
Which factor would be most likely to influence the hygiene practice of the homeless client?
a. The client’s degree of mental illness b. The client’s cultural beliefs c. The client’s living environment d. The client’s knowledge level
Correct answer: C
The homeless client may have no access to facilities in which to perform routine hygiene measures.
Why should you respect and accommodate your patients’ hygiene preferences?
Respecting the patient’s hygiene preferences promotes maximum participation and independence with ADLs and reflects caring. Nothing turns someone off more than being forced to do anything!
T or F: In a study of ICU unit, 48% of hygienes performed resulted in “adverse event.” Therefore, in ICU you should avoid hygiene care.
False! Modification should be made to decrease the chances of an adverse event. You could provide care in small segments, allowing rest periods.
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Why asess pt willingness and ability to perform ADLs?
enables us to determine the type of help needed and to encourage self care. p467
What are the steps in assessing self-care abilities?
- Obtain health history - identify self care deficits and tolerance for hygiene care
- assess cognitive and physical ability - level of consciousness, memory function, ability to follow instructions, mobility, energy level
- Identify other factors influencing - religion/culture/etc/
- Assess for sensory disturbances - senses in tact? ex. no tactile sensation for heat may burn themself.
- determine preferences - FOcus on ability to perform self care and the need for assistance (in what capacity)
T or F: Hospitals have standard routines for hygiene care and you should not deviate from them.
False. You must tailor to the patient preferences, needs and tolerance, etc.
What is the purpose or hourly rounding?
offer help with self-care needs such as pain relief, positioning and toileting
also called safety and comfort rounds
What are typical things we do during:
- early morning care
- a.m. care
- p.m. care
- H.S. care
- Early morning care: on awakening – wash face and hands, mouth care
- A.M. care: after breakfast – bathing, toileting, hair, skin, bedmaking
- P.M. care: afternoon – toileting, hand washing, oral care, readying for visitors
- H.S. care: prior to sleep – relaxation activities, readying environment to facilitate sleep, back massage. lights and tv off, close the door!
You may delegate hygiene care to a NAP. It is your responsibilty to assess pt to ensure it is safe to do so. If the pt is unstable or the NAP is inexperienced or unfamliar, what do you do?
Assist or perform the care yourself!
Before turning hygiene care over to the NAP what should you do?
Assess prior to delegating Instruct NAP regarding Client’s limitations Amount of assistance needed Use of assistive devices Presence and care of tubes Observations to make during hygiene care (look for lesions, skin over bony prominence, ulcers,
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A)What are the layers of our skin? .
B)What are the main functions of the skin?
A:
- epidermis - replaced every 3-4 weeks
- melanin - protects against UV rays
- dermis - contains blood/lymphatic vessels/nerves/sweat and sebaceous glands.
B:
- protection
- sensation - heat cold pressure pain
- REgulation - maintain f&e balance; sweat cools
- secretion/excretion-perspiration of waste products
- vitamin d formation - sun + form of cholesterol = vitamin d
Factors affecting the skin:
- dampness
- dehydration - can lead to dry cracked skin
- nutritional status - morbidly obese may not be able to reach areas and develop odors/fungal infections
- insufficient circulation - can lead to tissue death
- skin disease
6 jaundice - lifestyle person choices - tanning, tattooing
When bathing a client, you have opportunity to asess the skin. Look for:
OBJECTIVE DATA:
Color: pallor, erythema, jaundice, cyanosis
Conditions that affect the skin: maceration (softening of skin from prolonged moisture: urinary incontinence)
pruritus (itching), excoriation (loss of superficial layers due to scratching and enzymes in feces; acne;
Alterations in skin integrity: abrasions, pressure ulcers
Take picture of anything dr needs to assess
Document every single wound/bruise etc upon arrival, this will keep you from being blamed
SUBJECTIVE DATA:
- ask about usual pref
- past or current skin problems? effects on pt?
- Prescription meds, OTC etc, that is being used to treat skin
- allergies
- history of disease of the skin
Bathing serves three purposes: health, social interaction, and pleasure or relaxation. What other benefits can you think of?
- bath water and friction of bathing dilate the blood vessels increasing circulation
- stimulates depth of resp and provide sensory input
- bonding time with pt
When giving a bed bath to a patient, what supplies do you need?
- Basin of water (105 degrees)
- bath linens
- clean gown
- bathing supplies - soap etc
What is the difference between a complete and partial bed bath?
Complete is from head to toe while partial is on a focused area. Both are performed by the RN or NAP.
Partial is given when the pt is experiencing stress from the activity.