Nursing Management of Clients with Stressors that Affect HYGIENE NUR101 Lecture # 5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by: Sharon Niggemeier, RN MSN Revkburger906,707

Hygiene Principles of skin care Healthy intact skin and mucous membranes are the body’s first line of defense against pathogens Adequate circulation, nutrition, hydration and resistance to injury are necessary to maintain intact skin

Assessing Personal Hygiene Skin Hair Nails Oral Shaving

Skin Assessment Color Temperature Turgor Texture Dryness Lesions Rashes

Factors Affecting Hygiene Needs Developmental Cultural Spiritual Knowledge Physical health Socioeconomic Personal preference

Bathing Cleanses skin Relaxes client Promotes circulation Promotes comfort Sensory input Increases self image Promotes nurse-pt. relationship

Shower/tub safety Gather all supplies Assist into tub/shower Use shower chair Check water temperature Provide privacy Don’t lock door Assist with bathing

Bedbaths Bath given in bed for those on CBR (complete bed rest) Provide privacy/Use a bath blanket Allow pt. to complete as much as possible, assist as needed

Nursing Interventions Bathing Monitor skin integrity Water temp F Use lotions and omit soap if skin is dry Use powder/deodorant as per personal preference Provide massage

Shampooing-Interventions Wet hair, lather, rinse, dry Shampoo in bed-utilize trough and basin Dry/spray shampoos Style as best to pt. likes

Shaving-Interventions Anticoagulant therapy? Wear gloves Pull skin taunt Let soap/shave cream soften hair Shave in direction hair grows Use electric razors if possible

Oral Hygiene-Interventions Wear gloves Assess oral hygiene Assist brushing teeth Assist flossing Denture care Teaching oral care Oral care dependent client

Perineal Care Female-always wash from front (pubic area) to back (to anus), separate labia, cleanse down center of perineum Male-wash from tip of urinary meatus in circular motion then down shaft. If uncircumcised remember to retract foreskin, cleanse, then return foreskin over tip

Assessing Skin Integrity Risk assessment scale BradenBraden Note if skin is intact If not intact note location, size, color, exudate, granulation tissue of lesion Reactive hyperemia- reddened area that fades 1-2 hrs. after pressure has been removed. Not a stage I pressure ulcer

Impaired Skin Integrity Pressure ulcers-lesions caused by unrelieved pressure Pressure causes blood vessels to collapse-necrosis death of cells results Cells die and ulcer develops

Factors Affecting Pressure Ulcer Development Mobility Nutrition & hydration Moist skin Physical health Age Friction Shearing force Mental status

THINK-PAIR-SHARE 60,000 Americans die from complications related to pressure ulcers. The National Pressure Ulcer Advisory Panel estimates that more than 1 million patients in hospitals and nursing homes have pressure ulcers. Approximately $1.3 billion is spent annually in the U.S. on pressure ulcers 2,663 LTC providers received pressure ulcer deficiencies in Average monetary recovery in pressure ulcer cases is $13.5 million; the median recovery is $1.06 million. Juries find in clients’ favor 74% of the time.

Stages of Pressure Ulcers Stage I- reddened area Non-blanchable erythema Stage II – partial-thickness skin loss,abrasion,blister or shallow crater Stage III- full thickness skin loss, open lesion crater exposing subcutaneuos tissue Stage IV- full thickness skin loss, extensive tissue necrosis, damage to muscles and bone possible.

Skin Integrity- Nursing Interventions PREVENTION of pressure ulcers Assess skin especially bony prominences daily Increase mobility and activity T & P q2h Linens dry & wrinkle free Skin and clothing dry

Skin Integrity-Nursing Interventions Avoid friction/shearing Protective positioning: Thirty degree lateral position Maintain proper nutrition/hydration Redistribute pressure by applying specialty mattress ie: air mattress, Clinitron bed; PUP mattress (Specialty mattress requires physician order)

Therapeutic Mattress / Bed Alternating Pressure Mattress Example: PUP Air-fluidized Mattress Example: Clinitron

Evaluation Hygiene Has all clients hygiene needs been met? Is client more comfortable? Have potential problems been resolved?

Critical Thinking Ms Jenkins is a 58y.o. female with metastatic cancer of the bladder. She is alert & oriented X3 but extremely fatigued from her chemotherapy treatments. She has been bedfast for 5 days and is very uncomfortable changing positions in bed. She is often incontinent of urine. Her current ht =5’5” wt =105 lbs and she is anorexic as a side effect of her therapy. USE THE BRADEN SCALE TO ASSESS MS JENKINS RISK FOR PRESSURE ULCER