Module 8 Personal Hygiene

Personal Hygiene It is the nurses responsibility to provide the patient with the opportunity for hygiene

HYGIENE PART 6-A Bathing

Purpose of Bathing Cleansing the skin Removes perspiration, bacteria, which minimizes skin irritation and reduces chance of infection Stimulation of circulation Warm water and gentle strokes from distal to proximal increase circulation and promote venous return Improve self-image Promotes feeling of being refreshed, relaxed

Purpose of Bathing Reduction of body odors Especially in axillae and pubic areas Promotion of Range of Motion Movement of extremities while bathing Cleansing removes perspiration, some bacteria, and dead skin cells which minimizes skin irritation and reduces the chance of infection.

Nurse’s Advantage Provides opportunity to develop a meaningful nurse-patient relationship Provides opportunity for assessment of the patient including condition of patient, psychosocial and learning needs. Assessment: of the skin, hair, nails, feet, Psychosocial data collection – where live, family members, occupation, what is on their mind—some will open up at this time Learning needs

Before You Begin Bathing It is the Nurses Role to: Assess Your Patient Assess: preference for bathing, types of hygiene products used current condition of patient– movement, positions, up, bedridden, dizzy, confused

Factors Affecting Personal Hygiene Cultural / Religious Developmental Stage Mobility Emotional Physical Illness Personal Preference North American culture places a high value on cleanliness bathing once or twice a day, whereas other cultures bathe once a week. Body odors may be offensive in some cultures and accepted an normal in other cultures. Some religious beliefs do not allow bathing for certain days and ceremonial washings are practiced by some religions. Develop – the very young and elderly have needs for assistance Mobility – some patients have limited mobility due to weakness or a complete loss of mobility . Determine if the patient can sit without support, stand and amount of range of motion. Emotional – stress and emotional disturbances can cause disruptions in ability to perform self-care Physical – ill patient may not have motivation( not a hierarchy of need) or energy to bath. Consider poor vision Personal preference – each pt. has individual desires and preferences when they want to bath. Consider. Although, realize that it is the “day shift” that bathes pt’s.

Critical Thinking Situation: The Nurse enters Mrs. G’s room to do a complete bed bath and she says “I do not want my bath now, I just want to rest”. What should the nurse do now?

Critical Thinking Situation: The nurse enters Mr. C’s room to do a complete bed bath and he says “I do not want my bath now, I just want to rest”. You notice that his bed is wet and he was incontinent of urine. Now what should the nurse do?

Used to clean the patient Types of Baths Cleansing Baths Used to clean the patient

Cleansing Baths Complete Bed Bath Nurse baths entire body of dependent patient in bed Self-Help Bath Patients confined to bed are able to bathe themselves with some help Partial Bath Parts of the body are washed by the patient and some by the nurse

Cleansing Baths Tub Bath Much easier for bathing and rinsing than in a bed Varies in style

types of baths Shower Used by ambulatory patients who require only minimal assistance Can be used with a shower chair

Bath used for treatment Usually requires a doctor’s order Types of Baths Therapeutic Baths Bath used for treatment Usually requires a doctor’s order

Therapeutic Baths Medicated solutions may be used in bathing Range from warm water baths, cool water baths, cornstarch, oatmeal, Aveno, alcohol

Back Rub May be performed after drying off the back during the bath. Position of Patient: Prone or side-lying Expose only the back, shoulders, upper arms. Cover remainder of body Lay towel alongside back Warm lotion in your hands—still explain that it may be cool and wet.

Back Rub Start in the sacral area, moving up the back. Massage in a circular motion over the scapula. Move upward to shoulders, massage over the scapula Continue in one smooth stroke to upper arms and laterally along side of back down to iliac crests. Do NOT allow your hands to leave the patient’s skin End by telling your patient that you are finished

Guidelines for Bathing Provide Privacy Maintain Safety Maintain warmth Promote the patient’s independence as much as possible

Procedure for Bathing Bed Bath Harkreader p. 799-803 Tub Bath or Shower Harkreader p. 806-807

Hygienic measures related to the care of the genitalia. Part B: Perineal Care Hygienic measures related to the care of the genitalia.

Perineal Care Can be embarrassing for the nurse and the patient. Should not be overlooked because of embarrassment. If the patient can do it themselves—let them. Hand them the washcloth and ask if they would like to “finish their bath.”

Perineal Care Those patients who may need the nurses assistance: Vaginal or urethral discharge Skin irritation Catheter Surgical dressings Incontinent of urine or feces

Perineal Care Procedure Normal conditions, Discharge, Menses Women Wipe labia majora (outer) from front to back in downward motion using clean surface of wash cloth for each swipe. Wipe labia minora (inner) from front to back in downward motion using clean surface of wash cloth for each swipe Wipe down the center of the meatus from front to back. If catheter in place, clean around catheter in circular fashion, using clean surface of wash cloth for each swipe. Wash inner thighs from proximal to distal

Cont. Female Perineal Care Rinse with warm to tepid water using pour from peri-bottle if available. Pat dry using clean towel in same order as wash Remove bedpan if one is used Verbalize turning patient on side to wash anal area from front to back and dry

Perineal Care - Male Retract foreskin of penis if uncircumcised Wash around the urinary meatus in a circular motion, using clean surface of washcloth for each stroke and around the head of penis in circular motion Wash down shaft of penis toward the thighs changing washcloth position with each stroke Wash scrotum – front to back Wash inner thighs continued

Cont. Perineal Care - Male Rinse with clean wash cloth or peri-bottle using warm water in same sequence as the wash Dry with clean towel in the same sequence Replace foreskin, as appropriate Turn patient on side to wash anus from front to back and dry Procedure 31-2: Harkreader, p. 804-805  

Perineal Care with Catheter Follow similar procedure in the male patient. Start at the urethra opening and clean outward.

Part C: Oral Hygiene Why do oral hygiene? Maintains the healthy state of the mouth Cleanses teeth of food particles, plaque, and bacteria Massages the gums Relieves discomfort from unpleasant odors and tastes. Refreshes the mouth and gives a sense of well-being and thus can stimulate appetite.

Assessment: Oral Hygiene a. Frequency Depends on the condition of the patient’s mouth. Some patient’s with dry mouth or lips need care every 2 hours. Usually done twice a day or after each meal b. Assistance Needed Does the patient need assistance to do oral care *The nurse can help patients maintain good oral hygiene by: 1. Teaching them correct techniques 2. Actually performing for weakened or disabled patients.

Oral Hygiene Assessment c. Abnormalities Loose or missing teeth Swelling and bleeding of gums Unusual mouth odor Pain or stinging in mouth structures

Brushing Major concerns are: Thoroughness in cleansing Maintaining the condition of the oral mucosa. Procedure for Conscious Patient: Upright position Get out your textbook--Harkreader: p. 813-814

Brushing: Unconscious Patient See performance checklist in syllabus Safety is of utmost importance Prevent aspiration Positioning—lateral position with head turned to the side or side-lying. Position back of head on a pillow so that the face tips forward and fluid/ secretions will flow out of the mouth, not back into the throat. Place a bulb syringe or suction machine with suction equipment nearby. Yankuer end on suction device.

Oral Hygiene: Unconscious Patient Keeping the mouth open Use a padded tongue blade to open the patients mouth and separate the upper and lower teeth Never place your hand in the patient’s mouth or open with your fingers. Oral stimulation often causes the biting –down reflex and serious injuries can occur. Harkreader p. 814-815

Denture Care Clean dentures as frequently as natural teeth Dentures are the patient’s personal property and should be handled with care because they can be easily broken. Care: Remove before going to bed – allows gums to rest and prevents buildup of bacteria. Store in a labeled container covered with water or denture cleaner if available

Denture Care Procedure: Harkreader p. 815 Tips to remember: Use gauze squares or washcloth to grasp front of dentures to prevent from slipping Place wash cloth or paper towel in sink to line it while you are cleaning the dentures Work close to the bottom of the sink in case you drop them. Use tepid water

Part D: Hair Care A person’s appearance and feeling of well-being often depends on the way their hair looks and feels

Major Goals in Hair Care Stimulate Circulation Prevents Matting

Brushing and Combing Keeps hair clean and distributes oil evenly along the hair shaft Combing styles hair and prevents from tangling Assessment while brushing Scalp lesions, abrasions Dandruff Parasitic infestations Quality of hair Appearance

Hair Care: Shampooing Depends on: Personal preference of the patient, does not have to occur every day with hygiene Condition of the hair Ways to Shampoo If patient can get up and into a shower or sink, use a hand held nozzle If patient can not get up, place on stretcher and roll to a shower area If patient is unable to be moved, may shampoo in the bed – see procedure in Harkreader p. 817-818. “Shampoo in a Bag” or dry shampoos are available

Part E: Shaving Improves self-esteem and emotional needs of the patient Usually done after the bath or shampoo Assessment: Skin for elevated moles, warts, Rashes, patchy skin lesions, or pustules

Shaving Provide Safety When using a razor blade, the skin must be softened to prevent pulling, scraping, or cutting Place a warm wash cloth over area and then apply some gel, cream, foam. Hold the razor at a 450 angle Pull the skin taut Shave in the direction of hair growth

Shaving Safety Precautions Electric razors must be used in patients who are at risk for bleeding, confused, or depressed

Part F: Foot and Nail Care Usually part of the bath Purpose: Eliminate sources of infection and decrease odors Assessment: Color, shape length, texture of nails Condition of skin around nails and between toes and fingers – swollen, inflamed, callused, lesions, temperature

Foot and Nail Care Soak the hand or foot to soften the cuticles Thoroughly cleanse and dry Trim the nails ONLY if you have permission or it is allowed at that institution. Most institutions do not allow nurses to trim the nails.

Foot and Nail Care Teach patient and family that nails should be cut – straight across. May need to get a referral if no one available to cut nails. Show close attention to the feet and nails of the diabetic patient and the elderly ** If feet and nails are in bad condition– notify doctor so a consult can be ordered with a podiatrist

Part G: Ear Care Usually requires minimal care Cleanse the external auricle with washcloth when bathing Avoid insertion of objects into the ear

Hearing Aids Check that the device is functioning correctly and clean any body oils or cerumen from the hearing aid Make sure the hearing aid is off and volume is down before insertion Insert hearing aid in ear by pulling earlobe downward while pressing the hearing aid inward Turn on and adjust volume Ask the patient if comfortable and can they hear!

Part G: Eye Care Assessment: Abnormal lesions Discharge Tearing Presence of any infection Use of Visual Aids (contacts, glasses) Ask when patient needs to use these devices

Eye Care Wash around the eyes with a warm moist washcloth with warm water—NO SOAP! Clean from the inner canthus to the outer canthus of the eye. Pay special attention to the inner canthus. Provide special care for the eyes of unconscious patients. May need to tape the eye lids shut if unable to blink and protect own eyes

Part H: Elimination Care Optimum elimination occurs when the patient can use a toilet and eliminate in private.

Elimination Hygiene There are various circumstances when a patient will have to use a bedpan or urinal for elimination

Elimination Hygiene Assist patient’s in a respectful way Assist to be comfortable especially when using a bed pan Provide privacy Do not hurry

Elimination Hygiene Types of Devices Bedside commode Urinal Bedpan Regular Orthopedic / fracture

Elimination Hygiene Procedure for Using Bedpan / Urinal Bring to the bedside Warm the bedpan if it is metal Place bed in appropriate position Fold the top linen back to allow for placement of bedpan or urinal Have patient assist by bending knees and lifting up, place hand under lower back and slip into place. or

Use of Bedpan Turn to the side and roll back onto the bedpan Check placement Bedpan - when the buttocks rest on the rounded edge of the pan Urinal – penis is inside, urinal rests on the bed

Procedure for using bedpan / urinal Raise head of bed to upright sitting position Place call light and toilet within reach. Leave the patient if safe to do so, with side rails up Removal Same manner as offered; hold steady Cover the pan

May need to clean up the patient Note character of contents, chart Clean the pan or urinal Unglove and Wash hands

Assisting with a Condom Catheter Purpose: Control incontinence in a male patient without the risk of urinary tract infection Greater comfort to the patient than an indwelling catheter Equipment Needed Condom catheter Soap and water, washcloth, towel Disposable gloves Drainage bag and tubing

Condom Catheter - Procedure Wash hands Place patient in supine position, provide privacy, close door and drape with only penis exposed Apply gloves, Cleanse area with soap and water, dry Assess for any skin breakdown, redness Wrap adhesive spirally around the shaft of the penis Place rolled condom over the penis and unroll over the penis and adhesive, press condom to the strip

Attach drainage bag and tubing to the catheter Check that tubing is not twisted and lies over top of leg. Cover the patient, return bed to low position Assess later to be sure that it is secure and not leaking. Empty bag as necessary Remove condom daily to clean the area and assess the skin integrity.

Part I: Antiembolic Prevention Patients who are immobile are at risk for stasis of blood in the lower extremities and development of thrombophlebitis. Contraction and relaxation of skeletal muscles helps to move blood through veins toward the heart Valves within the veins prevent the blood from slipping back toward the feet under the influence of gravity.

When circulation slows, clots (thrombi) are more likely to form in those patients with limited activity or incompetent valves. A blood clot can break loose and travel through the blood stream as an embolus leading to potential severe complications.

Purpose of Antiembolic Measures Promote the circulation of blood from the legs back to the heart- increase venous return; decrease venous stasis Support valves within peripheral leg veins so that blood is less likely to pool in a dependent position- decreases dependent edema Prevent thrombus formation

Assessment Identify conditions that increase the potential for poor circulation and clot formation Post-operative Varicose veins Thrombophlebitis Dehydration Pregnancy Examine lower extremities for poor circulation (Cold, cyanosis), intact skin or ulcerations, distended leg veins, peripheral pulses Assess past history for developing blood clots

Interventions / Preventive Measures 1. Leg and Foot Exercises 2. Antiembolism stockings 3. Sequential Compression Devices 4. Avoiding compression of leg vessels

Leg and Foot Exercises Alternately flex and extend the foot five times. Make circular movement with the feet five times to the left and then repeat to the right. A leg exercise is to bend the knee and draw the foot up to the thigh, and then extend the leg. These exercises can be active – just have the patient do these ever so often on their own; Or passive. It is common to include these range of motion exercises as part of the bath for the immobile patient and at least every 2 hours for the post-operative patient.

Antiembolism Hose Antiembolism stockings are elasticized stockings that provide varying degrees of pressure at different areas of the legs. To provide the optimum amount of pressure, the stockings should fit properly and be free of wrinkles. To ensure a proper fit, the patients leg is measured in length and circumference and then refer to the manufacturer’s chart to obtain the correct hose size. Length Circumference

Procedure for Applying TED Hose Do not follow procedure in book Place patient in supine position in bed with leg horizontal for 15 minutes Turn the stocking inside out by placing one hand into sock, holding the toe with the other hand, and pull inside out Place patient’s toe into foot of elastic stocking

Application of TED Hose Slide remaining stocking over foot, Now the stocking will be right side out Never allow to make a tight band around the leg. Be sure to smooth stocking having no wrinkles.

Antiembolism Hose Nursing Care: 1. Assess the lower extremities EVERY SHIFT. Toe area should have an opening that can be pulled back and the toes and feet assessed for function and any neuro-circulatory problems. Toes should be warm, pink, good capillary refill, can wiggle toes, has feeling in toes with no tingling. 2. Remove ONCE EACH DAY and inspect the feet and toes.

TED Hose Document 0830 -- Calf length TED hose applied, skin warm and pink with no lesions. Instructed patient in use, verbalized understanding. Stated they felt good --------------------------------------J. Ward R.N.

Sequential Compression Devices SCD’s Purpose: Enhance venous return by applying intermittent external compression to the tissues and veins similar to the normal physiologic pumping mechanisms of the muscles.

Sequential Compression Device Disposable plastic sleeve wrapped around the patients leg and secured with velcro. The sleeves are then connected to an air pump that alternately inflates and deflates the air tubes in the sleeves. The sleeves are inflated in sequence from the bottom of the leg to the top, helping to move venous blood out of the leg veins and toward the heart.

Sequential Compression Devices Place patient in supine position with legs horizontal for 15 minutes. Apply antiembolism hose, if desired Measure circumference of upper thigh Open inflatable sleeve on the flat bed, cotton side up, and place the patients leg on the sleeve Wrap sleeve snugly around the leg, fasten with velcro

Sequential Compression Devices Connect tubing on sleeve to compression controller Turn on ordered settings Remove three times daily and inspect skin

Sequential Compression Devices Document: 0900 – sequential compression devices placed on both legs set on low. Skin on lower extremities warm, dry, pink. Explained use to patient, verbalized understanding. -----------J. Ward R.N. 0900 – SCD’s in place on both lower extremities. Toes warm and pink, pedal pulses present---------------------------------------------------J. Ward R.N.

Avoid Compression of Legs Watch positioning of the patient’s lower extremities. Do not allow the tubes, equipment to be placed under the legs to compress circulation Place lower extremities on pillows to position correctly. Encourage patient to not cross legs or feet.