Ch. 40 Hygiene (Week 2) Flashcards
When performing hygiene on a patient, what is this a good time to also do
Perform ongoing assessment such as range of motion, application of dressings, observation of pressure injuries or inspection of IV sites
Proper hygiene care requires an understanding of what
anatomy and physiology of skin, feet, hands, nails, oral cavity, hair, eyes, nose and ears
What are some factors that influence hygiene
- Social practices - in some cultures they may only wash themselves every other day
- Personal preferences - if you have oily hair you may want to wash your hair every other day
- Body image
- Socioeconomic status - people that are unhoused they may have a hard time finding the necessities
- Health benefits and motivation
- Cultural variables
- Developmental stage - things will look different depending on what developmental stage the patient is in
- Physical condition - can the patient do their own hydient are they parapelegic
How would you use critical thinking while performing hygiene
- Integrate nursing knowledge with knowledge from other disciplines
- Think about prior experiences
- Determine whether there are any environmental factors that will impact patient care
- Prior to assessment review the patient’s medical record for new information
- Rely on professional standards
What is the cornerstone of everything we do
Assessment
What is the first step of the nursing process and how can we apply it to hygiene
First Step is Assessment
- Through the patient’s eyes - explore a perspective regarding hygiene care by asking about personal care products desired
- Assessment of self care ability
- Any environmental factors that will affect patient care and hygiene practices
- Assessment of a patients hygiene status requires a complete nursing history and a physical assessment (brief history to determine priority areas) - skin, feet and nails, oral cavity, hair, eyes, ears, nose, use of sensory aids, hygiene care products, cultural influences
Patients that are at risk for hygiene problems may be at risk that results from what
- Side effects of medications or other medical therapy
- Lack of knowledge
- immobilization
- inability to perform hygiene
- Physical condition that potentially injures the skin, mouth, feet and nails or hair
What are some examples of nursing diagnosis
Activity intolerance
impaired mobility
impaired health maintenance
impaired skin integrity
low self esteem
How does planning from the nursing process apply to hygiene
- Outcomes. - Partner with the patient and family to identify expected outcomes to develop a mutually agreed on plan of care based on the patients nursing diagnosis - make outcomes measurable and achievable.
- Setting priorities
- Teamwork and collaboration - collaborate with other health team members, family caregivers, community agencies as needed
How does the implementation step from the nursing process apply to hygiene
- health promotion
- Acute and continuing care
- Bathing and skin care - complete bed bath, partial bed bath and perineal care
- Back rubs
- Foot and nail care
- Oral hygiene - brushing, flossing, patients with special needs
- Hair and scalp care - brushing, combing, shampooing, shaving and mustache and beard care
- Care of the eyes, ears and nose
How does the implementation step from the nursing process apply to hygiene
- Environment - look at the environment make sure that everything is clean
- maintain comfort
- beds, bedmaking, linens are all clean
What are common bed positions
Fowlers - semi sitting position - 45 to 90 degrees
Semi-Fowlers - head of bed raised to 30-45 degress
Trednelenburg’s - entire bedframe tiled with head of bed down
Reverse trednelenburg - entire bedframe tiled with foot of bed down
How does the evaluation step of the nursing process apply to hygiene
Evaluation of hygiene is based on outcomes of care, a patients sense of comfort, relaxation and well being and a patients understanding of hygiene techniques
What are some safety guidelines for nursing skills
- Follow safety principles for prevention of infection and patient injury
- perform hygiene measures while moving from clean to dirty
- Continence issues pose threats to a patient’s skin integrity, increase the risk of falls and increase social isolation
- wear PPE
- Test the temperature of water or solutions
- keep personal hygiene items in patient reach
- Give proper direction to AP when delegating
- Monitor lab findings such as coagulation studies before administering oral hygiene or shaving a patient
- Determine patient’s or family caregiver’s knowledge, experience and health literacy
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration
Modified left lateral recumbent position and Semi-Fowler’s position with head to side
What safety precautions are important when doing foot care for a patient that has diabetes
Assess skin for redness, abrasions and open areas daily
apply lotion to feet daily
clean between toes after bathing
Because of a patient’s risk for infection, it is important to assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut nails or soak the feet of a patient with diabetes mellitus without a health care provider’s order because this may create skin breakdown and open sores, leading to skin breakdown or infection.
Which of the following factors directly impairs salivary gland secretion
Radiation therapy and dehydration
When performing mouth care to a patient who has a reduced level of consciousness which physical assessment techniques should you apply
oxygen saturation
respirations
gag reflex
The american dental association suggests that patients who are at risk for poor hygiene use the following interventions
use fluoride toothpaste
use 0.12% cholorhexidine gluconate oral rinses for high risk patients
use a soft toothbrush for oral care
What are the steps to providing oral care to a patient who has a decreased level of consciousness
- Raised bed, lower, side, real, and position in Patient, close to side of the bed with head of bed raised up to 30°.
- Remove partial plate or dentures if present.
- If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.
- Using a brush moistened with Clore hexedine paste, clean, chewing an inner tooth surface his first.
- Gently brush tongue, but avoid stimulating, gag reflex.
- For patients without teeth, use a toothette moistened in chlorhexidine, rinse to clean oral cavity 
The nurse delegates to the assistive personnel, hygiene, care for an alert, older adult patient who had a stroke which interventions would be appropriate for this assistive personnel to accomplish during the bath
Providing range of motion exercises to extremities
Providing special skin care as indicated by nurse
Checking distal, pulses, determining the type of treatment for stage, one pressure injury, and changing a dressing over an intravenous site. All require a nurses assessment and clinical decision making and should not be delegated to assistive personnel. 
The nurse will delegate hygiene care for two patients of different cultures to the assistive personnel. What cultural information does the nurse need to provide to the assistive personnel?
Specific hygiene products
Timing of hygiene care
The need for gender, congruent caregiver
Religious practices 
