Chapter 18 Hygiene and Care of the Patient’s Environment Jeanelle F. Jimenez RN, BSN, CCRN Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

Hygiene and Care of the Patient’s Environment Personal Hygiene The self-care measures persons use to maintain their health Hygiene The science of health Includes care of the skin, hair, hands, feet, eyes, ears, nose, mouth, back, and perineum Conscientious personal hygienic practices are essential for the nurse; nurses are role models.

Hygiene and Care of the Patient’s Environment Factors Influencing Personal Hygiene Social practices Body image Socioeconomic status Knowledge Personal preference Physical condition Cultural variables What factors influence personal hygiene? Page 435 Box 18-1 How does culture affect personal hygiene? Examples: Asians may not like touch but Europeans may. Asians do not like immediate baths after childbirth…keep hot.

Patient’s Room Environment Maintaining Comfort Room temperature: 68° to 74° F Good ventilation Bedpans and urinals that are emptied and rinsed promptly Monitored noise level Proper lighting

A typical hospital room. Figure 18-1 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) A typical hospital room.

Patient’s Room Environment Room Equipment Bedside stand Used to store the patient’s personal articles and hygienic equipment Overbed table On wheels; is adjustable to various heights over the bed or a chair Chairs Straight chairs and lounge chairs

Patient’s Room Environment Room Equipment (continued) Lights Lights provide comfort, safety, and ease. Call light signal indicates that a patient needs assistance. Bed Bed is designed for comfort, safety, and adaptability to position changes. It has a number of safety features.

Bathing Sitz Bath Cool Water Tub Bath Cleanses and aids in reducing inflammation of the perineal and anal areas of the patient who has undergone rectal or vaginal surgery or childbirth Water temperature 98° to 102° F Cool Water Tub Bath May be given to relieve tension or lower body temperature Water temperature tepid, not cold—98.6° F Why would a tub bath be less desirable than a sitz bath? A sitz bath focuses on one area of the body because heat is applied every where else reducing heat to the pelvic or perianal region. How long should the patient sit in the sitz bath? 20-30 mins

Figure 18-2 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) The sitz bath.

Bathing Warm Water Tub Bath Hot Water Tub Bath Given to reduce muscle tension Water temperature 109.4° F Hot Water Tub Bath Given to assist in relieving muscle soreness and muscle spasms Water temperature 113° to 115° F

Bathing Other Baths Complete bed bath Tepid sponge bath Medicated bath For patients who are totally dependent and require total assistance Tepid sponge bath Administered to reduce an elevated temperature Medicated bath May include agents such as oatmeal, cornstarch, Burow’s solution, and soda bicarbonate To reduce tension and relax the patient and to relieve pruritus caused by certain skin disorders

Skill 18-1: Steps 8h & 8i Bed bath. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Bed bath.

Skill 18-1: Steps 8r & 8u Bed bath. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Bed bath.

Skill 18-1: Steps 10d(1) & 10d(4) Towel bath.

Skill 18-1: Step 10e2 Towel bath. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Towel bath.

Bathing Back Care/Back Rub Usually administered after the patient’s bath Promotes relaxation, relieves muscular tension, and stimulates circulation Nurse massages for 3 to 5 minutes Contraindicated if the patient has such conditions as fractures of the ribs or vertebral column, burns, pulmonary embolism, or open wounds

Skill 18-1: Steps 14e & 14f Back rub. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Back rub.

Components of the Patient’s Hygiene Care of the Skin When a person’s physical condition changes, the skin often reflects this through alterations in color, thickness, texture, turgor, temperature, and hydration. As long as the skin remains intact and healthy, its physiological function remains optimal.

Components of the Patient’s Hygiene Care of the Skin (continued) Collection of data Normal skin has the following characteristics: Intact without abrasions Warm and moist Localized changes in texture across surface Good turgor; generally smooth and soft Skin color variations from body part to body part How does having “normal skin” (meeting the normal skin characteristics listed) keep the patient healthy? What are skin color variations, and where are these variations located on the body?

Components of the Patient’s Hygiene Care of the Skin (continued) Impaired skin integrity A patient who stays in one position without relief of pressure can develop a pressure sore. Patients especially at risk are the chronically ill, debilitated, older, disabled, or incontinent patient and the patient with spinal cord injuries, limited mobility, or poor overall nutrition.

Thirty-degree lateral position to avoid pressure points. Figure 18-5 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Thirty-degree lateral position to avoid pressure points.

Using a rolled bath blanket as a pressure-reducing device. Figure 18-6 Using a rolled bath blanket as a pressure-reducing device.

Components of the Patient’s Hygiene Care of the Skin (continued) Impaired skin integrity Pressure ulcers occur when there is sufficient pressure on the skin to cause the blood vessels in an area to collapse. The flow of blood and fluid to the cells is impaired, resulting in ischemia to the cells. When the external pressure against the skin is greater than the pressure in the capillary bed, blood flow decreases to the adjacent tissue. If the pressure continues for longer than 2 hours, cell necrosis may occur. Where is pressure most severe on the patient’s body? Bony prominences like the sacrum, ischial tuberosities, trochanteric areas of the hips, heels, and malleoli of the ankles.

Components of the Patient’s Hygiene Care of the Skin (continued) Impaired skin integrity Shearing force The tissue layers of skin slide onto each other, resulting in kinking or stretching of subcutaneous blood vessels; this results in an interruption of blood flow to the skin. Friction Rubbing of skin over a surface produces friction, which may remove layers of tissue.

Diagram of shearing force exerted against sacral area. Figure 18-3 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Diagram of shearing force exerted against sacral area.

Components of the Patient’s Hygiene Care of the Skin (continued) Stages of pressure ulcers Stage I: nonblanchable erythema of the skin Stage II: partial-thickness skin loss; epidermis Stage III: full-thickness skin loss, damage or necrosis of subcutaneous tissue Stage IV: full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures

A, Stage I pressure ulcer. Figure 18-4, A (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) A, Stage I pressure ulcer.

B, Stage II pressure ulcer. Figure 18-4, B (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) B, Stage II pressure ulcer.

C, Stage III pressure ulcer . Figure 18-4, C (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) C, Stage III pressure ulcer .

D, Stage IV pressure ulcer . Figure 18-4, D (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) D, Stage IV pressure ulcer .

Components of the Patient’s Hygiene Care of the Skin (continued) Nursing interventions Assess improvement. Assess size and depth of the ulcer, the amount and color of any exudate, the presence of pain or odor, and the color of the exposed tissue. Specific interventions are determined by the stage of the ulcer.

Components of the Patient’s Hygiene Oral Hygiene Care of the oral cavity Helps maintain a healthy state of the mouth, teeth, gums, and lips Brushing the teeth removes food particles, plaque, and bacteria; massages the gums; and relieves discomfort resulting from unpleasant odors and tastes.

Administering oral hygiene. Skill 18-2: Steps 9a & 9c (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Administering oral hygiene.

Components of the Patient’s Hygiene Oral Hygiene (continued) Dentures A set of artificial teeth not permanently fixed. Should be stored in an enclosed, labeled cup for soaking or when they are not worn Should be cleaned as often as for natural teeth to prevent infection and irritation Oral care provided on a regular basis

Administering oral hygiene. Skill 18-2: Step 10c (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Administering oral hygiene.

Components of the Patient’s Hygiene Hair Care Combing, brushing, and shampooing are basic hygiene measures for all patients. Patient may shampoo in the shower or tub, use a portable chair in front of a sink, or in bed. Shaving the Patient Patient may prefer to shave at the time of bathing. Patients who have a bleeding disorder or are taking anticoagulants should use electric razors. Do not allow a disoriented or depressed patient to use a razor with a blade.

Care of the hair, nails, and feet. Skill 18-3: Steps 9a & 10e (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Care of the hair, nails, and feet.

Components of the Patient’s Hygiene Hand, Foot, and Nail Care Hands and feet often require special attention to prevent infection, odors, and injury. Assessment Examine all skin surfaces. Carefully assess between the toes. Observe for adequate circulation.

Components of the Patient’s Hygiene Eye, Ear, and Nose Care (continued) Care of the eyes Cleansing of the circumorbital area of the eyes is usually performed during the bath. Case involves washing with a clean washcloth moistened with clear water. The use of soap is omitted because it may cause burning and irritation. The eye is cleansed from the inner to the outer canthus. Patient may need assistance with care of eyeglasses or contact lenses.

Components of the Patient’s Hygiene Eye, Ear, and Nose Care (continued) Care of the ears The ears are cleansed by the nurse during the bed bath. A clean corner of a moistened washcloth rotated gently into the ear canal works best for cleaning. A cotton-tipped applicator is useful for cleansing the pinna. The nurse should teach patients never to use bobby pins, toothpicks, or cotton-tipped applicators to clean the internal auditory canal.

Components of the Patient’s Hygiene Eye, Ear, and Nose Care (continued) Care of the ears (continued) Hearing aids This involves routine cleaning, battery care, and proper insertion technique. When not in use, the hearing aid should be stored where it will not become damaged.

Figure 18-8 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Hearing aid.

Components of the Patient’s Hygiene Eye, Ear, and Nose Care (continued) Care of the nose The patient can usually remove secretions from the nose by gently blowing into a soft tissue. Teach the patient that harsh blowing causes pressure capable of injuring the tympanic membrane, nasal mucosa, and even sensitive eye structures. If the patient is not able to clean the nose, the nurse will assist, using a saline-moistened washcloth or cotton-tipped applicator; for excessive secretions, suctioning may be required.

Components of the Patient’s Hygiene Perineal Care Care of the genitalia Part of the complete bed bath Assess for signs of vaginal or urethral exudate, skin impairment, unpleasant odors, complaints of burning during urination, or localized tenderness or pain of the perineum. Catheter care is to be performed twice daily on all patients with indwelling catheters. Includes cleansing of the meatal-catheter junction with a mild soap and water and sometimes application of a water-soluble microbial ointment

Skill 18-4: Step 9b Female perineal care. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Female perineal care.

Skill 18-4: Steps 9e & 9g Female perineal care. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Female perineal care.

Skill 18-4: Step 10c/10d Male perineal care. (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Male perineal care.

Components of the Patient’s Hygiene Bed Making The patient’s bed is usually made in the morning after the bath. When possible, the bed is made while it is not occupied; when the patient is unable to be out of bed, the nurse will make an occupied bed. The patient’s safety is always foremost in the nurse’s mind; comfort and privacy are also important. Use side rails, keep the call light within easy reach, and maintain the bed in the proper position.

Bed making: occupied bed. Skill 18-5: Step 8i (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Bed making: occupied bed.

Bed making: occupied bed. Skill 18-5: Step 8j (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Bed making: occupied bed.

Bed making: occupied bed. Skill 18-5: Step 8m (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Bed making: occupied bed.

Bed making: occupied bed. Skill 18-5: Step 8o (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Bed making: occupied bed.

Bed making: occupied bed. Skill 18-5: Step 8q (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Bed making: occupied bed.

Bed making: occupied bed. Skill 18-5: Step 8r (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Bed making: occupied bed.

Components of the Patient’s Hygiene Bed Making (continued) It is the nurse’s responsibility to keep the bed as clean and comfortable as possible. This may require frequent inspections to make sure the bedding is clean, dry, and wrinkle free. Check the linens for food particles after meals and for urine incontinence or involuntary stool. Use proper body mechanics; raise bed to a working level.

Figure 18-9 The postoperative bed. (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) The postoperative bed.

Selected equipment and supplies for elimination. Figure 18-10 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Selected equipment and supplies for elimination.

The bedside commode has a toilet seat with a container underneath. Figure 18-11 The bedside commode has a toilet seat with a container underneath.

Components of the Patient’s Hygiene Assisting the Patient with Elimination Bedpan A device for receiving feces or urine from either male or female patients confined to the bed Urinal A device for collecting urine from male patients; urinals for females also available Bedpans or urinals are used when a patient is unable to get up to go to the bathroom for the purpose of urination or defecation.

Components of the Patient’s Hygiene Assisting the Patient with Elimination (continued) The nurse should offer the bedpan or urinal frequently, because patients may accidentally soil bedclothes if their elimination needs are not met. Report any abnormalities and record in the nurse’s notes. Flow sheets are usually provided for documentation of normal voidings and stools.

Positioning the bedpan. Skill 18-6: Steps 11b & 11c (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Positioning the bedpan.

Components of the Patient’s Hygiene Care of the Incontinent Patient Incontinence is a very common problem, especially among older adults. Incontinence occurs because pressure in the bladder is too great, sphincters are weak, or the innervation has been compromised due to illness or injury. Incontinence may involve a small leakage of urine when the person laughs, coughs, or lifts something heavy.

Components of the Patient’s Hygiene Care of the Incontinent Patient (continued) Care requires the use of disposable adult undergarments or underpads. Cleansing the skin thoroughly after each episode of incontinence with warm soapy water and drying it thoroughly help to prevent skin impairment. When urinary incontinence results from decreased perception of bladder fullness or impaired voluntary motor control, bladder training can be helpful.