Week 2: Hygiene and Comfort Flashcards
Nursing Diagnosis
- Not a medical diagnosis
- Clinical judgment about responses to actual or potential health problems within the domain of nursing
- Helps communicate thinking among nurses, to other practitioners, and to the public
Examples:
- [Self-care deficit in bathing] related to [upper extremity weakness and generalized fatigued].
- [Descriptor of the issue] linked to [health problems]
Nursing Process
Cognitive framework that systematically guides intellectual reasoning and critical thinking processes
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
Types of Bed Baths (4)
- Complete
- Partial
- Bag bath
- Shower or tub
Benefits of Bed Baths (6)
Bed baths improve:
- Skin integrity (infection) - Opportunity for assessment/ROM exercises - Improve self-image - Improve circulation - Promote relaxation - Promote nurse/client relationship
Importance of Patient Hygiene
- Contributes to sense of comfort, well being, self-esteem, identity
- Contributes to IPAC
- Mitigates risk factors for skin impairments
- Valuable opportunity to connect
- Important to follow the schedule, but adapt schedule to circumstantial factors (e.g., patient needs to rest)
Common bed positions (5)
- Fowler’s (45 degrees)
- Semi-Fowler’s (30 degrees)
- Trendelenburg (slight angle with elevated feet)
- Reverse Trendelenburg (slight angle with elevated head
- Flat
Complete bed bath
Client is totally dependent
Partial bed bath
Bathing only body parts that client can’t do independently
Bag bath
Bathing without water (higher risk of infection from clean but not sterile wash basins)
Shower/tub
More thorough, but we need to consider falls risks, safety, client comfort/ability, check orders if it’s appropriate, supportive equipment available, etc.
Fowler’s position
- Head and shoulders at 45 degree angle
- Good for eating, helps lung expansion
Semi-fowler’s position
- Head and shoulders at 30 degree angle
- Good for eating, helps lung expansion
- A bit less aggressive than Fowler’s
Trendelenburg position
- The entire bed is angled with feet higher than head
- Used for postural drainage
- promotes venous return
Reverse-Trendelenburg position
- The entire bed is angled with feet lower than head
- Promotes gastric emptying, prevents reflux
Factors influencing hygiene habits (7)
- Social practices
- Personal preferences
- Body image
- Socioeconomic Status
- Health Beliefs and Motivation
- Cultural Variables
- Physical Condition/mobility
Risk factors for skin impairment (6)
- Immobilization
- Reduced Sensation
- Nutrition and Hydration Alteration
- Secretions and Excretions on the skin
- Vascular Insufficiency
- External Devices
Perineal care
Usually part of a complete bed bath
Pts most in need are those at greater risk of acquiring infection:
- catheterized patients
- incontinent patients
- morbidly obese patients
Benefits of back rubs (4)
- promotes relaxation
- relieves muscle tension
- stimulates circulation
- improves sleep
Risk of Immobilization
- impacts circulation, causes pressure injuries
Risk of reduced sensation
- cannot sense injury to skin
Risk of Nutrition and Hydration alterations (4)
- thinning of skin
- loss of skin elasticiy
- loss of subcut. tissue
- delayed wound healing
Risk of Secretions and Excretions on the skin
- moisture on skin causes bacterial growth, irritation, skin breakdown, infection
Risk of Vascular Insufficiency
- ischemia and tissue breakdown
- infection resulting from lack of nutrients, oxygen, WBCs to damaged tissue
Risk of External Devices (casts, bandages, etc.)
- cause pressure/friction on skin
Importance of oral care (3)
- enhances well-being and comfort
- stimulates appetite
- prevents pneumonia
Linens should be… (3)
- clean
- dry
- wrinkle-free
Medical asepsis in bed-making (4)
- hold soiled linen away from body
- never shake soiled linen
- place soiled linen in appropriate bag
- do not let linen touch the floor
Comfort factors (4)
- room temperature
- good ventilation
- control noises
- adjust lighting
Flat bed position (3)
Used for pt’s with:
- spinal injuries
- hypotension
- sleeping pts
