Chapter 17 Hygiene All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Hygiene Hygiene promotes comfort, safety, and health. Intact skin: Is the body’s first line of defense against disease Prevents microbes from entering the body and causing an infection Good hygiene: Cleanses the body Prevents body and breath odors Is relaxing and increases circulation Mucous membranes of the mouth, genital area, and anus must be clean and intact as part of the body’s defense against disease. People’s preferences about hygiene vary: Some people take showers. Others take tub baths. Some bathe at bedtime. Others bathe in the morning. Bathing frequency also varies. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Factors That Affect Hygiene Culture and personal choice affect hygiene. Many factors affect hygiene needs—perspiration, elimination, vomiting, drainage from wounds or body openings, bedrest, and activity. The nurse uses the nursing process to meet the person’s hygiene needs. Follow the nurse’s directions and the care plan. Some older persons resist your efforts to assist with hygiene. Review Caring About Culture: Personal Hygiene on p. 265. Illness and aging changes can affect self-care abilities. Some people need help with hygiene. Review Focus on Communication: Hygiene on p. 265. Review Focus on Rehabilitation: Hygiene on p. 265. Review Residents with Dementia: Hygiene on p. 265. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

Daily Care You must: Assist with hygiene whenever it is needed. Protect the person’s right to privacy and to personal choice. Daily care is given at these times: Before breakfast (early morning care, or AM care) After breakfast (morning care) Afternoon care Evening care (PM care) Most people have hygiene routines and habits. Hygiene measures are often done before and after meals and at bedtime. Night shift or day shift staff members give AM care. They get residents ready for breakfast or morning tests. Morning care is given after breakfast. Hygiene measures are more thorough at this time. Afternoon care is done before the person takes a nap, has visitors, or attends activity programs. Evening care is relaxing and promotes comfort. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

Oral Hygiene Oral hygiene (mouth care) does the following: Keeps the mouth and teeth clean Prevents mouth odors and infections Increases comfort Makes food taste better Reduces the risk for cavities (dental caries) and periodontal disease Before providing oral hygiene, be sure to check the resident’s identification (ID). The nurse assesses the person’s need for mouth care. The speech/language pathologist and the dietician may also do so. Illness, disease, and some drugs often cause a bad taste in the mouth, a whitish coating in the mouth and on the tongue, redness and swelling in the mouth and on the tongue, or dry mouth. Dry mouth also is common from oxygen, smoking, decreased fluid intake, and anxiety. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

Oral Hygiene (Cont’d) Flossing: Removes plaque and tartar from the teeth Plaque is a thin film that sticks to teeth and causes tooth decay (cavities). When plaque hardens, it is called tartar. Tartar builds up at the gum line and causes periodontal disease. Removes food from between the teeth Is usually done after brushing You need to floss for persons who cannot do so themselves. Periodontal disease (gum disease, pyorrhea) is inflammation of tissues around the teeth. Gums are red and swollen and bleed easily. As the disease progresses, bone is destroyed and teeth loosen. Tooth loss is common. Plaque and tartar build up from poor oral hygiene. Dental floss is used to clean between the teeth to prevent periodontal disease. Some people floss after meals. If done once a day, bedtime is the best time to floss. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

Oral Hygiene (Cont’d) Most people perform oral hygiene themselves. You may need to brush the teeth for persons who: Are very weak Cannot move or use their arms Are too confused to brush their teeth Some people need help gathering and setting up equipment. Review Delegation Guidelines: Oral Hygiene on p. 266. Review Promoting Safety and Comfort: Oral Hygiene on p. 267. Review the Assisting the Person to Brush and Floss the Teeth procedure on p. 267. Review the Brushing and Flossing the Person’s Teeth procedure on p. 268. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

Oral Hygiene Supplies A toothbrush, toothpaste, dental floss, and mouthwash are needed. Persons with dentures need a denture cleaner, denture cup, and denture brush or toothbrush. Use only denture cleaning products to avoid damaging dentures. Sponge swabs are used for persons with sore, tender mouths and for unconscious persons. You also need a kidney basin, water glass or cup, straw, tissues, towels, and gloves. Many persons bring oral hygiene equipment from home. With sponge swabs, check the foam pad to make sure it is tight on the stick. The person could choke on the foam pad if it comes off the stick. See Delegation Guidelines: Oral Hygiene on p. 266. See Promoting Safety and Comfort: Oral Hygiene on p. 267. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

Oral Hygiene for the Unconscious Person Mouth care for the unconscious person The care plan tells you what cleaning agent to use. Protect unconscious persons from choking and aspiration. Keep the person’s mouth open with a padded tongue blade. Always assume that unconscious persons can hear. Mouth care is given at least every 2 hours. Follow the nurse’s directions and the care plan. Oral hygiene keeps the mouth clean and moist and helps prevent infection. Aspiration is breathing fluid, food, vomitus, or an object into the lungs. To prevent aspiration, position the person on one side with the head turned well to the side to allow excess fluid to run out of the mouth (Fig. 17-5, p. 269), use only a small amount of fluid to clean the mouth, and do not insert dentures. Apply a lubricant to the lips when you are done. Unconscious persons cannot speak or respond to you. However, some can hear. Explain what you are doing step by step. Review Promoting Safety and Comfort: Mouth Care for the Unconscious Person on p. 269. Review the Providing Mouth Care for the Unconscious Person procedure on p. 270 in the textbook. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

Dentures Denture care Mouth care is given and dentures cleaned as often as natural teeth. Dentures are slippery when wet. Dentures easily break or chip if dropped onto a hard surface. To use a cleaning agent, follow the manufacturer’s instructions. Hot water causes dentures to lose their shape (warp). Remind residents not to wrap dentures in tissues or napkins. You clean dentures for those who cannot do so. Many people clean their own dentures. Some need help collecting items used to clean dentures. Full and partial dentures are common: A full denture (Fig. 17-7, p. 271) replaces all of the upper or lower teeth. With a partial denture, the person has some natural teeth. If not worn after cleaning, store dentures in a container with cool water or a denture soaking solution. Otherwise they can dry out and warp. Dentures are usually removed at bedtime. Some people do not wear their dentures. Others wear dentures for eating and remove them after meals. Review Promoting Safety and Comfort: Denture Care on p. 271. Review the Providing Denture Care procedure on pp. 272-273 in the text. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

Bathing Bathing does the following: It cleans the skin. It cleans the mucous membranes of the genital and anal areas. It is refreshing and relaxing. Circulation is stimulated and body parts are exercised. Observations are made. You have time to talk to the person. Complete or partial baths, tub baths, or showers are given. Microbes, dead skin, perspiration, and excess oils are removed during bathing. In nursing centers, bathing usually occurs after breakfast or the evening meal. The person’s choice of bath time is respected whenever possible. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11

Bathing Factors The bathing method depends on: The person’s condition Self-care abilities Personal choice Bathing frequency is a personal matter. Older persons usually need a complete bath or shower twice a week. Dry skin occurs with aging and is easily damaged. Soap also dries the skin. Bathing procedures can threaten persons with dementia. The complete bed bath involves washing the person’s entire body in bed. Thorough rinsing is needed when using soap. Lotions and oils help keep the skin soft. Review Box 17-1 on p. 274 for the rules for bed baths, showers, and tub baths. Table 17-1 on p. 274 describes common skin care products. Review Residents with Dementia: Bathing on p. 275. Review Delegation Guidelines: Bathing on p. 276. Review Promoting Safety and Comfort: Bathing on p. 277. Review the Giving a Complete Bed Bath procedure on pp. 276-278. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12

Towel, Bag, and Partial Baths Towel baths The nurse and care plan tell you when to use a towel bath. To give a towel bath, follow center policy. Bag baths Use a new washcloth for each body part. Let the skin air-dry. You do not need towels. The partial bath involves bathing the face, hands, axillae, back, buttocks, and perineal area. You give partial baths to persons who cannot bathe themselves. For a towel bath, an oversized towel covers the body from the neck to the feet. It’s quick, soothing, and relaxing. Review Residents with Dementia: Towel Baths on p. 278. Bag baths use a plastic bag containing 8 to 10 washcloths. They are moistened with a cleaning agent that does not need rinsing. These are often warmed in the microwave. Check directions and temperature before applying to a person’s skin or body. The rules for bathing apply to partial baths. You assist as needed. Review the Assisting with the Partial Bath procedure on p. 280 in the textbook. Rules for bathing apply; see Box 17-1. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13

Tubs and Showers Tub baths and showers Falls, burns, and chilling from water are risks. Safety is important. The person’s privacy must be protected. A tub bath can make a person feel faint, weak, or tired. These are great risks for persons who are on bedrest. A tub bath lasts no longer than 20 minutes. The person may need one of these devices to get in and out of the tub: a transfer bench (Fig. 17-19, p. 281), a tub with a side entry door (Fig. 17-20, p. 281), a wheelchair or stretcher lift, or a mechanical lift (Fig. 17-21, p. 282). Never let weak or unsteady persons stand in the shower. They need to use a shower chair (Fig. 17-22, p. 282), shower trolley (Fig. 17-24), p. 282, or shower stall or cabinet (Fig. 17-23, p. 282). Safety is important (Box 17-2, p. 281); The measures in Box 17-1 also apply. Review Delegation Guidelines: Tub Baths and Showers on p. 282. Review Promoting Safety and Comfort: Tub Baths and Showers on p. 283. Review Teamwork and Time Management: Tub Baths and Showers on p. 283. Review the Assisting with a Tub Bath or Shower procedure on pp. 283-284 in the textbook. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14

The Back Massage Back massages (back rubs): Relax muscles and stimulate circulation Are given after the bath and with evening care Can be given after repositioning or to help the person relax Last 3 to 5 minutes Be sure to request a person’s consent before performing a back massage. Observe the skin before the massage. Lotion reduces friction during the massage. Lotion is warmed before being applied. Look for breaks in the skin, bruises, reddened areas, and other signs of skin breakdown. To warm lotion, rub some lotion between your hands, place the bottle in the bath water, or hold the bottle under warm water. Review Delegation Guidelines: The Back Massage on p. 285. Review Promoting Safety and Comfort: The Back Massage on p. 285. Review the Giving a Back Massage procedure on pp. 285-286. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15

Perineal Care Perineal care (pericare) involves cleaning the genital and anal areas. These areas provide a warm, moist, and dark place for microbes to grow. Cleaning prevents infection and odors, and it promotes comfort. Perineal care is done: Daily during the bath Whenever the area is soiled with urine or feces The person does perineal care if able. Otherwise, it is given by the nursing staff Be sure to request a person’s consent before performing pericare. This procedure embarrasses many people and nursing staff, especially when it involves the other sex. Review Focus on Communication: Perineal Care on p. 287. Review Delegation Guidelines: Perineal Care on p. 287. Review Promoting Safety and Comfort: Perineal on p. 287. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16

Basics of Perineal Care Standard Precautions, medical asepsis, and the Bloodborne Pathogen Standard are followed. Work from the cleanest area to the dirtiest. The perineal area is delicate and easily injured. Use warm water, not hot. Rinse thoroughly. Pat dry after rinsing. Working from the cleanest area to the dirtiest is commonly called cleaning from “front to back.” Review the Giving Female Perineal Care procedure on pp. 288-289. Review the Giving Male Perineal Care procedure on p. 290. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 17

Reporting and Recording You make many observations while assisting with hygiene. Report and record the care given. If care is not recorded, it is assumed that care was not given. Review the hygiene observations to report at once that are listed in the textbook: Bleeding, signs of skin breakdown, discharge from urinary tract or vagina, unusual odors, any change from prior observation. Also report and record the care given. If care is not recorded, it is assumed that care was not given. This can cause serious legal problems. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 18

Quality of Life Provide hygiene in a way that maintains or improves the person’s quality of life, health, and safety. Protect the person’s rights when giving care. Residents have the right to Privacy and personal choice Freedom from restraint Keep and use personal items Hygiene is a very personal matter. Residents have a say in when and how hygiene is done. Personal choice is allowed in choosing products used, what to wear, and hairstyling. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 19