Hygiene
Hygiene Schedule In Acute Care Early Morning or A.M. Care Morning or After Breakfast Care Afternoon Care HS Care Early Morning or A.M. Care Morning or After Breakfast Care Afternoon Care HS Care
Skin Care Assessment- Inspection/ Palpation Determine need for hygiene Observe color (Table 32-9,pg 689), texture, thickness, turgor, temperature, hydration Skin Lesions (Box 32-8, pg.692) Recognize common skin problems (Table 38-2, pg.1009) Assessment- Inspection/ Palpation Determine need for hygiene Observe color (Table 32-9,pg 689), texture, thickness, turgor, temperature, hydration Skin Lesions (Box 32-8, pg.692) Recognize common skin problems (Table 38-2, pg.1009)
Skin Care Nursing Diagnoses Impaired Skin Integrity Altered Peripheral Tissue Perfusion Bathing/Hygiene Self-Care Deficit Planning Goals- Cleanliness, stimulation of circulation, range of motion, improved self- esteem, and reduction of body odors Nursing Diagnoses Impaired Skin Integrity Altered Peripheral Tissue Perfusion Bathing/Hygiene Self-Care Deficit Planning Goals- Cleanliness, stimulation of circulation, range of motion, improved self- esteem, and reduction of body odors
Skin Care Implementation Bathing Perineal Care Back Rubs Implementation Bathing Perineal Care Back Rubs
Perineal Care Assessment- Listen for problems, smell, know at risk clients Indications for Care- Urinary or fecal incontinence, excessive secretions, skin irritation, clients at risk because of indwelling catheters, perineal surgery, or childbirth Goal of Care- Comfort, promote healing, prevent or eliminate odor or infection Assessment- Listen for problems, smell, know at risk clients Indications for Care- Urinary or fecal incontinence, excessive secretions, skin irritation, clients at risk because of indwelling catheters, perineal surgery, or childbirth Goal of Care- Comfort, promote healing, prevent or eliminate odor or infection
Back Rub Goal- Promote relaxation and stimulate circulation Cautions Contraindications Never massage arms and legs Goal- Promote relaxation and stimulate circulation Cautions Contraindications Never massage arms and legs
Nail and Foot Care Assessment Circulation Abnormalities or problems (Table 38-3,pg 1011) Gait Pulses Nails Special considerations- diabetic clients Assessment Circulation Abnormalities or problems (Table 38-3,pg 1011) Gait Pulses Nails Special considerations- diabetic clients
Nail and Foot Care Nursing Diagnoses Pain Impaired Skin Integrity Self-Care Deficit Plan and Implementation Foot and nail care given during bath Nursing Diagnoses Pain Impaired Skin Integrity Self-Care Deficit Plan and Implementation Foot and nail care given during bath
Diabetic Client Foot Care Need meticulous care daily Do not cut corns or calluses or use commercial removers Always dry well between toes, use powder when necessary Avoid doing or wearing anything that impairs circulation Wear clean socks daily Well fitting shoes, no bare feet Need meticulous care daily Do not cut corns or calluses or use commercial removers Always dry well between toes, use powder when necessary Avoid doing or wearing anything that impairs circulation Wear clean socks daily Well fitting shoes, no bare feet
Hair Care Assessment Examine condition of hair and scalp Determine ability to do self care Problems/ abnormalities (Table 38-4, pg.1012) Dandruff Ticks Pediculosis Capitis Pediculosis Corporis Pediculosis Pubis Alopecia Assessment Examine condition of hair and scalp Determine ability to do self care Problems/ abnormalities (Table 38-4, pg.1012) Dandruff Ticks Pediculosis Capitis Pediculosis Corporis Pediculosis Pubis Alopecia
Hair Care Diagnosis Dressing/ Self-Care Deficits Impaired Skin Integrity Pain Body Image Disturbance Planning and Implementation Brushing and combing Shampooing Shaving Mustache and beard care Diagnosis Dressing/ Self-Care Deficits Impaired Skin Integrity Pain Body Image Disturbance Planning and Implementation Brushing and combing Shampooing Shaving Mustache and beard care
Eye Care Assessment Scaliness underlying eyebrow Eyelids- edema, lesions, secretions Eyelashes- styes, irritating lashes (entropian,ectropian) Lacrimal Sac- Sclera or conjunctiva Pupil- Size, shape, light response Eye movement Contacts, eyeglasses, or artificial eye Assessment Scaliness underlying eyebrow Eyelids- edema, lesions, secretions Eyelashes- styes, irritating lashes (entropian,ectropian) Lacrimal Sac- Sclera or conjunctiva Pupil- Size, shape, light response Eye movement Contacts, eyeglasses, or artificial eye
Eye Care Implementation Basic care Unconscious client Eyeglasses Contact lenses Artificial eyes Implementation Basic care Unconscious client Eyeglasses Contact lenses Artificial eyes
Ear Care Assessment Exam external ear Implementation Clean during bath Cautions Assess gross hearing Assessment Exam external ear Implementation Clean during bath Cautions Assess gross hearing
Nose Care Assessment Exam nasal mucosa Position of nasal septum Difficulty breathing from nose Implementation Nasal secretions Suctioning Assessment Exam nasal mucosa Position of nasal septum Difficulty breathing from nose Implementation Nasal secretions Suctioning
Client’s room Maintain comfortable room environment Temperature, ventilation, noises, lighting, controlling stimuli Room equipment Overbed table, night stand, chairs, bed, lights, special equip. Common bed positions Know common bed positions (Table 38-6, page 1054) Room accessories Water pitcher, glass, tissue, lotion, toothpaste, wash basin, etc Bed-making Basic principles of asepsis- Keep linen away from uniform, never fan linen, place nothing on the floor, if clean linen touches floor get new linen Use good body mechanics Be able to make occupied and unoccupied beds (open/closed) Maintain comfortable room environment Temperature, ventilation, noises, lighting, controlling stimuli Room equipment Overbed table, night stand, chairs, bed, lights, special equip. Common bed positions Know common bed positions (Table 38-6, page 1054) Room accessories Water pitcher, glass, tissue, lotion, toothpaste, wash basin, etc Bed-making Basic principles of asepsis- Keep linen away from uniform, never fan linen, place nothing on the floor, if clean linen touches floor get new linen Use good body mechanics Be able to make occupied and unoccupied beds (open/closed)
Summary Evaluation of client’s hygiene is based on the client’s expression of a sense of comfort, relaxation, well-being, and an understanding of personal hygiene techniques