Chapter 40: Hygiene (IRAT/GRAT #1) Flashcards
Personal hygiene affects patients comfort, safety and well-being by
- promoting comfort and relaxation
- fostering a positive self-image
- promoting healthy skin
- helping to prevent infection and diseases
Close contact provided by administering hygiene also promotes
- the nurse-patient therapeutic relationship
- patient teaching and counseling
- opportunities for ROM
- thorough physical assessment especially of the integument, oral cavity and sensory organs
Functions of the skin include
protection, secretion, excretion, body temperature regulation and cutaneous sensation
Skin consists of 2 primary layers
- epidermis
2. dermis
epidermis
shields underlying tissue against water loss and injury and prevents entry of disease-producing microorganisms with the aid of normal flora
dermis
supports the epidermis. Nerve fibers, blood vessels, sweat glands, sebaceous glands and hair follicles all run through the dermal layer.
subcutaneous layer contains
blood vessels, nerves, lymph, loose connective tissue (fat cells)
Subcutaneous tissue supports
upper skin layers to guard against pressure and injury.
Changes in skin condition result in alterations of
color, thickness, texture, turgor, temperature and hydration
turgor
the resilience of normal skin when subject to physical distortion.
ex) pinching or pressing (good indicator of hydration).
Risk factors for skin impairment
immobilization, reduced sensation, nutrition/hydration alterations, secretions/excretions on the skin, vascular insufficiency, external devices and altered cognition.
sebum
has bactericidal action
What factors influence hygiene?
social practices, personal preferences, body image, socioeconomic status, health beliefs/motivation, cultural variables, developmental stage, and physical condition.
Assessment of the skin
- head to toe assessment of skin
- inspect beneath medical devices (if possible) such as antiembolic stockings and orthopedic devices for skin breakdown, redness and rashes
Head to toe assessment of the skin includes
less obvious or difficult to reach surfaces: under the breasts, folds of skin, scrotum, groin, female perineum.
Patients may be unable to
see or sense (decreased sensory perception) pressure points such as the heels and bony prominences.
Common sites for pressure sores
lying on back: back of the head, shoulder, elbow, buttocks and heal
lying on side: ear, shoulder, elbow, hip, thigh, leg, and heal
lying on stomach: elbow, rib cage, thigh, knees and toes
Documentations of skin
accurate documentations of skin condition is essential for patient safety and CMS reimbursment
if lesions, blisters, pressure ulcers are noted,
use institutional policy and procedure to document these findings.
including photo documentation: size, location, stage (if a pressure ulcer), undermining, tunneling
True or False: Never use a previous shifts assessment
True. Trust but Verify!
The oral cavity
mucous membranes of the mouth (especially under the tongue) are filled with blood vessels
Saliva
cleanses the mouth, dissolves food chemicals to promote taste, moistens food to aid in bolus formation, contains enzymes that aid in the breakdown of starchy foods.
What impairs salivary function?
medications, exposure to radiation, dehydration and mouth breathing
