Class 3-Hygiene Flashcards
Personal Hygiene
-cleanliness and grooming that promotes physical and psychological well being and enhances the healing process
-the nurse is responsible for the patient’s hygiene
4 principles of skin function
- intact skin is the body’s first line of defense; resistance to skin injury varies among people
- adequate nutrition and hydration (2-3 L) of cells helps to prevent skin injury
- adequate circulation is needed to maintain skin cell life
1. intact skin
2. nutrition
3. hydration
4. circulation
**3 things that decrease patient outcome: failure to recognize, rescue, plan
What is the Braden scale used for?
-risk assessment for pressure injury
-lower the score the higher the risk for injury
Skin in the elderly (gerontology)
-thinning of subcutaneous and dermal layer (more injury prone)
-decrease activity of glands (dryer skin; sebaceous glands)
-longer time window for cell renewal (if breaks down longer to heal)
-nail changes (nails grow up & thicker)
-decrease in collagen fiber (need collagen to heal)
Morning care (a.m. care)
-after breakfast, nurse completes morning care
-toileting (normal 1st thing)
-oral care
-bathing & ROM
-back massage
-hair care
-denture care
-anti embolism stockings (come off when washing)
-shaving (face: down; legs: up)
-nail and foot care
-eye, ear, & nose
-perineal care (genital care)
-linens
-position for comfort
-organize & clean up bedside
Oral care
Assessment:
-lips
-color and surface of gums
-teeth
-tongue
-hard & soft palates
-dentures
Care:
-the gold standard is brushing the patient’s teeth (oral care with mouth breathing/O2 breathing is drying)
-poor oral care can lead to cardiac, renal, dementia? problems
Cleaning dentures
-wear gloves
-use toothbrush
-use washcloth in bottom of sink
Tooth brushing
-brush teeth, gums, tongue
Swabbing
-use with no teeth or in-between tooth brushes
Do we brush an unconscious patient’s teeth?
yes! tilt face to side
Medical treatments and/or diseases that create a dry oral cavity
-oxygen therapy
-nasogastric tubes
-side effects of medications
-mouth breathing that occurs with infection
-mechanical ventilation
Observing oral care in the mechanically ventilated patient
-oral hygiene is standard nursing care; often neglected in critically ill patients on ventilators or performed by swabbing patients’ mouths
-lack of oral care leads to VAP
oral care on mechanically ventilated patients
-observed during random 4 hour time blocks over 2 months at 5 hospitals in chicago
-conclusion:
-effective oral care is lacking for majority of mechanically ventilated patients
-gap exists between evidence-based research and actual nursing practice
-despite importance of brushing teeth to remove dental plaque, swabbing remains primary oral cleansing tool
Poor oral hygiene in long term care
-evidence links poor oral care to serious disease processes
-typically assigned to CNA’s
-only 16% of ECF residents received oral care
-average tooth brushing time for ECF residents was 16.2 seconds..DO LONGER!
Purposes of bathing
-cleansing and conditioning of skin
-relaxation
-promotes circulation (movement on skin)
-improvement of self-image and emotional well being
-movement and exercise
-assessment opportunities
-strengthens nurse/patient relationship
Types of baths
-showers
-bathing:
-complete
-partial assist
-CHG baths (vascular catheter, central line, surgery, have AV fistulas, things that invasively break skin)
-bag baths (no rinse; good for elderly)
The bath
-gather all equipment
-wash using no rinse cleansers
-dry
-lotion
-privacy & warmth (close door; close curtain)
**soap is drying & needs to be rinsed; don’t use powders
Why CHG baths
-studies show daily baths with CHG cloths reduce the risk of MDRO (multi drug resistant organisms) and HAI’s
-Chlorhexidine baths on medical/surgical units
-central IV lines
-PICC lines & mid lines
-hemodialysis catheters
-bath patient first then chlorhexidine wipe all body areas, then use a lotion compatible with CHG
CHG wipes
-rinse free; need 3 packs
-don’t bring into room until ready to use
-CHG bath wipes come prepackaged in a single packet that contains 3 individual packets
-each individual packet contains 2 CHG impregnated wipes
-CHG wipes will be warmed using the CHG warming cabinet
-warming helps activate
Indicator lights
Yellow light:
-cloth is warming, not ready yet
Solid green light:
-cloth is ready to. use
Blinking green light:
-cloth is aging out, use this one first
Red light:
-cloth is expired, do not use, dispose of it
CHG bath instructions
**see slide 29 for picture
-Use one wipe each (6 total)
1. to clean neck, chest, abdomen, & groin
2. to clean back & buttocks
3. to clean left arm
4. to clean right arm
5. to clean left leg
6. to clean right leg
-do not wash face or perineal area with CHG wipes
-do not use CHG on mucous membranes or severely abraded skin (mouth)
Remember to chart it
all CHG baths should be documented in EPIC
Purewick external female catheter
Criteria:
-strict I&O ordered, incontinent & unable to use a bedpan or commode
-post surgery and requires immobilization
-approved by wound care and/or surgery
-palliative care CMO
-patient is critically ill with life threatening hemodynamic/respiratory instability
Purewick external female catheter
Best practice:
-attach to low suction
-replace at least every 8-12 hours
-empty the urine container Q8 hours or more frequently
-do not use barrier cream-cream may impede suction
-change suction tubing at least every 30 days
-not recommended for agitated patient’s or having frequent BM’s
Perineal care
-clean from LEAST contaminated to MOST contaminated (front to back)
-clean vaginal area with no rinse cleansers not soap
-peri-bottles for rinsing and cleaning
-apply skin barrier creams/ointments if appropriate
-condom catheter
-retract foreskins to clean then replace
Foley care
- wash peri area
- clean 6 inches down tubing
- catheter has to be attached to leg
- green clamp attached to bed
- no lose tubing; no kinks
- bag kept lower than bladder and not touching floor
Products to think of using
-mepilex (for pressure injuries?) 18 or less Braden scale: sacral & heels-use in ICU’s
-moisture barrier cream/ointment (for incontinence)
Eye, ear, nose care
-only water soluble ointment for nose
-cleaning eyes from inner to outer canthus
-don’t forget those glasses
-assess hearing aid function
-elderly might have breakdown from nasal cannula but vaseline is for lips only
-check to see if O2 tubing is breaking down skin behind ears
-diabetics change socks daily
Benefits of back massage
-acts as a general body conditioner
-relieves muscle tension and promotes relaxation
-provides opportunity for nurse to observe skin for signs of breakdowns
-improves circulation
-may decrease pain, distress, and anxiety
-may improve sleep quality
Providing hair care
-wash hair
-comb hair
-offer to shave face
-care for beards and mustaches
Taking care of your feet in diabetes
1.wash your feet daily with lukewarm (cannot feel) water and soap
2. dry your feet well especially between the toes
3. apply moisturizing lotion, but do not apply between toes
4. check your feet for blisters, cuts, redness, etc. If present, consult your doctor
5. trim nails straight across and file the edge with a nail nile (do not trim/use clippers!)
6. change socks daily; avoid dirty and tight socks (cotton socks)
7. never walk barefoot either indoors or outdoors
8. examine your shoes daily for cracks, stones, nails which may irritate feet
Making the bed
-occupied
-unoccupied
**gather linens first thing in the morning
Before you leave the room comfort & safety
-position for comfort
-lighting/noise of TV
-call light in reach
-bed in low position
-HOB elevated
-side rails as appropriate
Environmental care:
-label everything
-remove trash
-bedside bag
-curtains open
-room stocked
-check sharps containers
