Lesson 4 - Hygiene and Skin Care Flashcards
Importance of Hygiene
-affects comfort, safety, well-being
-use therapeutic communication
-completing hygiene care can tell more about a patient
Role of Nurse
-ensure privacy
-be respectful
-comfort
-safety
-encourage self-care
SDOH and Hygiene
-cultural
-personal
-social
-environmental
Newborn Hygiene
-rely on others
-have thin skin that can dry out quickly
-skin folds increase incidence of infection
-oral care is important
Children
-like to mimic influences
-oral care is important
-head lice is possible
Adolescents
-have hormone changes
-body image concerns
-personal grooming is important
Adults
-varying skin condition
-practices depend on learned behaviours
-preferences
-expectations from others
Older Adults
-skin loses resiliency and moisture due to less active glands
-skin is fragile
-practices depend on varying events
Diabetes Mellitus
-chronic vascular changes that impair healing of skin and mucosa
AIDS
-fungal infections of the oral cavity are common
Stroke
-blind reflex can be impaired
-increased risk for corneal drying
Thin Skin
-prone to dryness and breakdown
-less frequent bathing
Skin Risks for Older Adults
-risk for infection
-skin folds
-pressure points
-perineum
Dry Skin
-cracks
-allows bacteria to enter
Xerostomia
-decreased saliva with medications
-common in older adults
Risks of Oral Care for Older Adults
-gum disease
-denture damage
-improper denture fit (decreased vascularity)
Gingivitis
-gum inflammation
Feet in Older Adults
-joint deformity in toes (wear shoes)
-keep feet clean and dry
-watch for sores and ulcers (esp. diabetic)
-ROM limitations prevent seeing feet
Individualizing Care
-patients perform tasks differently and nurses need to respect and acomodate that
Level 1 Care
-independent
Level 2 Care
-assistive devices to complete self care activities
Level 3 Care
-One person assistance
Level 4 Care
-dependent, requires complete care from provider
Assessment before hygiene care
-observe physical condition, integrity of integument, oral cavity, sense organs
-developmental factors
-self-care ability
-hygiene practices
-cultural preferences
Pre-Breakfast AM Care
-wash hands and face
-assist to bathroom
-assist with oral care
Post-Breakfast AM Care
-bath/shower/bedbath
-foot care
-pericare
-assist to bathroom
-oral hygiene
-change into clean clothes/gown
-attending to bed linens
-tidy room
Hours of Sleep Care
-attend to bed linens
-change clothes/gown
-wash hands and face
-oral care
-assist to bathroom
-place necessities close to bedside
Skin Condition/Folds Assessment
-skin colour
-skin moisture
-bruises
-tears
-sores
-pressure points
Hair Assessment
-moisture
-distribution
-smoothness
-cleanliness
Nails Assessment
-length
-condition
-cleanliness
-abnormalities
Oral Assessment
-xerostomia
-thirst
-halitosis
-teeth condition
-denture equipment
-abnormalities
Assessment During Grooming and Dressing
-clothing preference
-clothing cleanliness
-eyewear
-hearing aids
-hair style
-deodorant, lotion, make-up
-self-care ability
Shaving and Hair Cutting
-make sure to get permission
Tub Bath Safety Considerations
-water temp
-mobilizing in and out of tub
-slippery surfaces
-supervision
-tub cleanliness
Bed Bath Safety Considerations
-side rails
-warmth
-privacy
-bed linens
-gloves
-back care for caregiver
Shower Safety Considerations
-water temp
-slippery surface
-supervision
-ability to sit/stand
-call bell
Confused Patient Care
-caregiver preference
-least distressing method
-prepare environment in advance
-minimize clothesless time
-distractions
-priorities
-visual/hearing aids
-praise
-calm/unrushed
Nursing Diagnosis: Hygiene
-use critical thinking after assessing patient to identify actual or potential health problems
-ie. arthritis may lead to inability to turn faucet to wash self
Steps to Determining Nursing Diagnosis
-observe
-assess strength, ROM, coordination
-level of fatigue
-vital signs
Planning for Hygiene
-involve pt and family
-know available community resources
-consider timing of care
Educating About Hygiene
-relevant instructions
-adapt to patients facilities
-teach injury prevention
-reinforce infection control
Skin
-largest organ of the body
-first line of defence
-prevents water loss
Epidermis
-outermost layer
-mostly dead skin cells
Dermis
-inner layer
-tensile strength
Aging Skin
-reduced elasticity
-decreased collagen
-thinning of muscle and tissue
-easily torn skin
-attachment between epidermis and dermis is flattened
-diminished inflammatory response
-slower wound healing
-less subcutaneous padding over bony prominences
-reduced nutritional intake
Expected Skin Findings
-colour matches genetic background and is consistent
-skin is warm and dry
-brisk turgor return
Unexpected Skin Findings
-cyanosis, jaundice, pallor
-hot, cool, cold
-sweaty
-clammy (cold and moist)
-delayed turgor
-present pressure wounds
Pressure Injury
-localized to skin and underlying tissue
-usually over a bony prominence
-results from pressure, shear, friction, moisture, nutrition
Effects of Pressure Injuries
-costly
-pain
-decreased mobility
-lowered quality of life
Pressure Related Factors
- Pressure Intensity
- Pressure Duration
- Tissue Tolerance
Pressure Intensity
-tissue ischemia (reduced blood flow)
-decreased sensation, not cue to shift pressure
Nonblanching Erythema
-pressure area should become red after removing your finger
-if not, tissue damage may be evident
Blanching
-occurs in normal red tones of light-skinned patients
Characteristics of Dark Skin (RISK OF BREAKDOWN)
-colour remains unchanged and doesn’t blanch
-previous injury - skin may be lighter
-localized inflammation may be purple rather than red
-skin is warm to touch
-edema is taut and shiny
-stage 1 skin may have low resilience
Pressure Duration
-low pressure over long period of time or high pressure over short period of time
-blood flow and nutrient occlusion = cell death
Tissue Tolerance
-ability of tissue to endure pressure
-shear, friction, moisture affect
Impaired Sensory Perception
-a risk for pressure injury development
-may not feel increased pressure and pain
-may not move away from pain
Impaired Mobility
-a risk for pressure injury development
-unable to reposition = more prolonged pressure
Alteration in Consciousness Level
-don’t understand pressure sensation
-can’t communicate discomfort and pain
Shear
-a risk for pressure injury development
-force exerted parallel to the skin
-from gravity and resistance
-affects deeper skin layers
Friction
-a risk for pressure injury development
-ie. skin dragged across bed linens
-affect epidermis
Moisture
-a risk for pressure injury development
-ulcer formation
-reduced resistance
-soft skin more susceptible to damage
Nutrition
-a risk for pressure injury development
-proteins (ie. collagen)
Tissue Perfusion
-a risk for pressure injury development
-need oxygen to heal
Infection
-a risk for pressure injury development
-prolonged inflammatory phase
-delayed collagen synthesis
-additional tissue destruction
Pain
-a risk for pressure injury development
-pt can’t tolerate movement
-decreased tissue perfusion
Age
-a risk for pressure injury development
-decreased inflammatory response
-many physiological changes
Stage 1 Ulcer
-intact skin
-nonblanchable
-redness over a bony prominence
Stage 2 Ulcer
-partial thickness loss
-shallow open ulcer
-may be serum filled blister
Stage 3 Ulcer
-full thickness tissue loss
-subcutaneous fat may be visible
-no bone or tendon or muscle exposed
-may have tunnelling
Stage 4 Ulcer
-full thickness tissue loss
-exposed bone, tendon, or muscle
-tunnelling
Unstageable
-full thickness tissue loss
-base is covered by slough or eschar
Braden Scale
-assesses patients for risk of skin breakdown
1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction and shear
-the lower the score the higher the risk
