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
Assessment of the oral cavity: assess for
- poor fitting dentures
- general condition of the oral cavity: halitosis, receding gum tissue, gingivitis, glossitis, cavities, pain/infection, missing teeth
gingivitis
inflammation of the gums
glossitis
inflammation of the tongue
Oral Hygiene
mouth is a breeding ground for bacteria
Evidence of poor oral health results in an increased risk for
impaired nutrition and pneumonia (especially in intubated patients and those with decreased gag reflex).
What is the problem with using commercially made foam swabs?
they are ineffective in removing plaque
What is the problem with using lemon-glycerin sponges?
they dry mucous membranes and erode tooth enamel
Unconscious patients cannot
swallow secretions. Secretions often contain gram-negative bacteria that cause pneumonia if aspirated.
halitosis
foul-smelling breath
cheilitis
cracked lips
What has current evidence shown that reduces the risk for ventilator associated pneumonia (VAP)?
chlorhexidine/water rinse
What should nurses consider when performing oral hygiene?
never use your fingers to hold a patient’s mouth open (don’t stick your fingers in anyone’s mouth.
handle dentures with care: they are expensive!
Assessment of Feet and Nails
- assess all patients with particular attention to those with disease that impair peripheral circulation and sensation. May notice an unequal gait.
- always remove socks/non-skid socks to check the backs of heels.
Diabetes and foot/nail hygiene
foot ulceration is the most common single precursor to lower-extremity amputations.
Teach preventative foot care include:
good fitting shoes, wearing socks, inspect daily;use family members if poor mobility/flexibility, never go bare foot or wear open toe sandals, keep nails trimmed and feet moisturized, make regular check ups with podiatrist.
Assessment of eyes
-check for drainage, crusting.
-Wash gently, inner to outer canthus.
If patient wears glasses, keep them in reach.
Assessment of ears
cerumen (ear wax).
Does the patient wear hearing aids?
Assessment of nose
drainage.
decreased sense of smell -> decreases sense of taste -> decreasing appetite -> leads to decreased nutritional status.
Special Considerations for an Uncircumcised male
imperative to return foreskin to its natural position after cleaning.
Why is it imperative to return foreskin to its natural position after cleaning?
tightening of foreskin around the shaft of the penis causes local edema and discomfort.
patients with reduced sensation may not feel tightening.
How aging affects body tissues: Skin
- decreased elasticity, epidermal cell replacement and resiliency
- increased dryness and increased risk of bruising
How aging affects body tissues: feet and nails
- chronic foot problems
- systemic disease (diabetes)
- increased dryness
- perhaps poor eyesight and mobility to care for feet and nails.
How aging affects body tissues: mouth
increased dryness due to medications
decreased vascularity in gums, dentures
How aging affects body tissues: hair
hair distribution changes, scalp hair is thinner and drier
How aging affects body tissues: eyes, ears, and nose
affects ADL’s
How aging affects body tissues: physical condition
safety is a priority, limited ROM, impaired sensation
Use Critical Thinking Attitudes When Planning Care including:
confidence (builds trust), thinking independently, fairness, responsibility/accountability, risk taking, discipline (orderly approach), perseverance, creativity, curiosity, integrity, and humility.
Assessment of Self-Care Ability
ability to perform or assist with ADL’s safely and efficiently.
Assessment of Self-Care Ability includes
- muscle strength, flexibility and balance
- visual acuity
- ability to detect thermal/tactile stimuli
- mental status
- orientation and cognitive function
- activity tolerance
- family involvement
Nursing Diagnosis
use defining characteristics to support actual or at-risk for hygiene related diagnosis
Nursing Diagnosis: Note
- Self-care deficit (specify): r/t impaired mobility disease process, and depression.
- impaired tissue integrity (risk or actual)
- impaired oral mucous membranes
- activity intolerance
- risk for infection
Patient teaching
- use teamwork and collaboration with nursing assistive personnel and other health-care disciplines. PT/OT
- make instruction relevant
- adapt instruction to developmental level and personal resources
- teach how to avoid injury
- reinforce infection control practices
What kinds of patients should not shave with a razor? Why?
patients on anticoagulant therapies, with low platelet counts and bleeding disorders.
razors can cause nicks/micro nicks in the skin which can lead to infection.
SCIP (Surgical Care Improvement Project)
Measure Set: Surgical Care Improvement Project (SCIP)
Set Measure ID#: SCIP-Inf-6
Performance Measure Name: Surgery Patients with Appropriate Hair Removal
Description: Surgery patients with appropriate surgical site hair removal,. No hair removal, or hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate.
CHG
chlorhexidine gluconate is used for daily bathing. Can leave skin feeling sticky. It helps reduce occurrence of HAI’s.
stomatis
inflamed, sore mouth
