1. B260: Fundamentals of Nursing
Hygiene
B260: Fundamentals of Nursing

2. Personal Hygiene
It is the nurses responsibility to provide the opportunity for hygiene
The skill may be delegated but not always, depends on facility policy

3. 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

4. Purpose of Bathing Especially in axillae and pubic areas
Cleanse the skin
Stimulation of circulation
Improve self-image
Reduction of body odors
Promotion of Range of Motion
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
Reduction of body odors
Especially in axillae and pubic areas
Promotion of Range of Motion
Movement of extremities while bathing

5. Scientific Knowledge Base
Physical hygiene is necessary for comfort, safety, and well-being.
Ill patients require assistance with personal hygiene.
Several factors influence a patient’s hygiene practices, such as culture and age.
Good hygiene techniques promote normal structure and function of tissues.
Apply knowledge of pathophysiology to provide preventive hygiene care.
Proper hygiene care requires an understanding of the anatomy and physiology of the skin, nails, oral cavity, eyes, ears, and nose. The skin and mucosal cells exchange oxygen, nutrients, and fluids with underlying blood vessels. The cells require adequate nutrition, hydration, and circulation to resist injury and disease.
Recognize disease states that create changes in the integument, oral cavity, and sensory organs.
[Ask the class to suggest examples of how the skin and oral cavity show disease states.]
Use time spent providing hygiene care to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues.

6. Assess your patient before you begin bathing
Apply knowledge of pathophysiology to provide preventive hygiene care.
Skin?
Feet, Hand, Nails?
Oral cavity?
Hair?
Proper hygiene care requires an understanding of the anatomy and physiology of the skin, nails, oral cavity, eyes, ears, and nose. The skin and mucosal cells exchange oxygen, nutrients, and fluids with underlying blood vessels. The cells require adequate nutrition, hydration, and circulation to resist injury and disease.
Recognize disease states that create changes in the integument, oral cavity, and sensory organs.
[Ask the class to suggest examples of how the skin and oral cavity show disease states.]
Use time spent providing hygiene care to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues.
Skin Functions include
Protection, secretion, excretion, temperature regulation, and sensation
Feet, hand, nails The condition of a patient’s hands and feet influences his or her ability to perform hygiene care.
[Ask the class: Why is care of the oral cavity so important? Discuss oral pain interfering with food ingestion.]
Changes in the mucous membranes indicate pathology.
Difficulty in chewing develops when gum tissue becomes inflamed or infected, or when teeth are lost or loosened.
The oral cavity = Lips, cheeks running along the sidewalls of the cavity, the tongue and its muscles, and the hard and soft palate.
Mucous membrane, continuous with the skin, lines the oral cavity. Ulcerations or trauma frequently results in significant bleeding.
Several glands within and outside the oral cavity secrete saliva.
[Ask the class: What are the functions of saliva? Discuss: Saliva cleanses the mouth, dissolves food chemicals to promote taste, moistens food to facilitate bolus formation, and contains enzymes that start the breakdown of starchy foods.]
Strong sympathetic nervous system stimulation almost completely inhibits the release of saliva and results in xerostomia or dry mouth
Difficulty in chewing develops when surrounding gum tissues become inflamed or infected, or when teeth are lost or become loosened.
The hair shaft itself is lifeless, and physiological factors do not directly affect it. However, hormonal and nutrient deficiencies of the hair follicle cause changes in hair color or condition.
Remember to consider ethnic hair variations.

7. Nursing Knowledge Base
Factors influence a patient’s personal hygiene.
Use communication skills to promote the therapeutic relationship.
During hygiene, assess:
Emotional status
Health promotion practices
Health care education needs
Because no two individuals perform hygiene care in the same manner, patient care is individualized on the basis of learning about his or her unique hygiene practices and preferences.
Individualized hygiene care requires use of therapeutic communication skills to promote the therapeutic relationship.
In addition, the opportunity provided during hygiene care should be used to assess a patient’s health promotion practices, emotional status, and health care education needs.
Be aware that developmental changes influence the need and preferences for type of hygiene care.
[Ask the class: What are some factors that influence hygiene? (discussed on next slide).]

8. Factors Influencing Hygiene
Social patterns
Ethnic, social, and family influences on hygiene patterns
Personal preferences
Dictate hygiene practices
Body image
A person’s subjective concept of his or her body appearance
Socioeconomic status
Influences the type and extent of hygiene practices used
These are the first four of eight factors we’ll discuss that influence a patient’s hygiene practices.
Social groups influence hygiene preferences and practices, including the types of hygiene products used and the nature and frequency of personal care practices.
Knowing patients’ personal preferences promotes individualized care.
Surgery, illness, or a change in emotional or functional status often affects a patient’s body image. Discomfort and pain, emotional stress, and fatigue diminish the ability or desire to perform hygiene self-care and require extra effort to promote hygiene and grooming.
When a patient lacks socioeconomic resources, it becomes difficult to participate and take a responsible role in health promotion activities such as basic hygiene.

9. Factors Influencing Hygiene
Health beliefs and motivation
Motivation is the key factor in hygiene.
Cultural variables
People from diverse cultures practice different hygiene rituals.
Developmental stage
Affects the patient’s ability to perform hygiene care
Physical condition
May lack physical energy and dexterity to perform self-care
Patients’ health beliefs predict the likelihood of assuming health promotion behavior such as maintaining good hygiene.
Knowledge about the importance of hygiene and its implications for well-being influences hygiene practices, but motivation is key.
People from diverse cultures practice different hygiene rituals.
[Do not express disapproval when caring for patients whose hygiene practices differ from yours.]
A patient’s developmental stage affects the ability of the patient to perform hygiene care and the type of care needed.
Patients with certain types of physical limitations or disabilities associated with disease and injury lack the physical energy and dexterity to perform hygiene self-care safely.
Acute and chronic cognitive impairments such as stroke, brain injury, psychoses, and dementia often result in the inability to perform self-care independently.
Sensory deficits not only alter a patient’s ability to perform care, they also place the patient at risk for injury.
[See Box 39-1 on text p. 771 Cultural Aspects of Care: Hygiene Practices.]

11. Factors Influencing Hygiene
Developmental stage
Skin (sensitive neonate skin, active glands in puberty, thinning and drying with age)
Feet and nails (dry skin, systemic disease footwear problems, chronic foot problems)
Mouth
Teeth (teething, caries, gum disease, edentulous)
Hair (shaving, puberty, aging)
Eyes, ears, nose
Here is more detail about how developmental stage influences hygiene.
Skin:
Any break in the skin can result in an infection.
Sebaceous glands become more active in puberty, predisposing adolescents to acne (i.e., active inflammation of the sebaceous glands accompanied by pimples).
The condition of the adult’s skin depends on hygiene practices and exposure to environmental irritants.
Feet and nails:
Older adults do not always have the strength, flexibility, visual acuity, or manual dexterity to care for their feet and nails.
Older adults often have dry feet because of a decrease in sebaceous gland secretion and dehydration of epidermal cells.
Common problems of the feet affecting older adults include corns, calluses, bunions, hammer toe, and fungal infections.
Mouth:
From adolescence, when all of the permanent teeth are in place, through middle adulthood, the teeth and gums remain healthy if a person follows healthy eating patterns and dental care. Regular brushing and flossing help to prevent caries and periodontal disease.
As a person ages, numerous factors result in poor oral health. These include age-related changes of the mouth, chronic disease such as diabetes, physical disabilities involving hand grasp or strength affecting the ability to perform oral care, lack of attention to oral care, and prescribed medications that have oral side effects. Gums lose vascularity and tissue elasticity, and this causes dentures to fit poorly. If the older adult becomes edentulous (i.e., without teeth) and wears complete or partial dentures, include assessment of underlying gums and palate.
Hair:
Throughout life, changes in growth, distribution, and condition of the hair influence hair hygiene. With aging, as scalp hair becomes thinner and drier, shampooing is usually performed less frequently.
Senses: Chapter 49 addresses changes in hearing, vision, and olfaction across the life span as a result of growth and development. Alterations in sensory function often require modifications in hygiene care.

12. Integrate nursing knowledge. Be nonjudgmental and confident.
Critical Thinking
Integrate nursing knowledge.
Consider developmental and cultural influences.
Think creatively.
Be nonjudgmental and confident.
Draw on your own experiences.
Rely on professional standards.
Apply the elements of critical thinking as you use the nursing process to meet patients’ hygiene needs.
As your experience and knowledge grow, your comfort and expertise in meeting the individualized hygiene needs of your patients increase.

13. Nursing Process: Assessment
Explore the patient’s viewpoint.
Assess:
Patients at risk for hygiene problems
Self-Care Ability
Skin
Feet and Nails
Oral cavity
Hair and hair care
Eyes, ears, and nose
Use of sensory aids
Hygiene care practices
Cultural influences
Hygiene care should be patient centered; know when to learn more about the patient’s preferences.
Assess a patient’s physical and cognitive ability to perform basic hygiene measures.
Be thorough in assessing the condition of the patient’s tissues; changes may indicate signs of disease.
Perform an assessment of the skin, noting color, texture, thickness, turgor, temperature, and hydration. Be attentive to characteristics of skin problems most influenced by hygiene measures. [Ask the class to list some of these: dryness, rash, etc.]
Examine all skin surfaces of the feet, including the areas between the toes and over the entire sole of the foot.
Common oral cavity problems include receding gum tissue, inflamed gums (gingivitis), a coated tongue, glossitis (inflamed tongue), discolored teeth (particularly along gum margins), dental caries, missing teeth, and halitosis (foul-smelling breath).
Reduced sensation, vascular insufficiency, and immobility place a patient at greater risk for impaired skin integrity.
If you suspect pediculosis capitis (head lice), guard against self-infestation by handwashing and using gloves or tongue blades to inspect the patient’s hair. Note any loss of hair (alopecia).
The healthy eye is not inflamed and is without drainage. Observe for the presence of accumulated cerumen (earwax) or drainage in the ear.
During the assessment phase of the nursing process, you will assess the skin, feet, nails, oral cavity, hair, eyes, ears, and nose. You will need to assess normal developmental changes that occur throughout the life span. Hygiene practices and any cultural factors that influence them should be identified at this time.
[See also Figure 39-1 on text p. 772 Critical thinking model for hygiene assessment.]
[Review Box 39-2 on text p. 773 Nursing Assessment Questions.]
[See Table 39-2 on text p. 774 Common Skin Problems.]
[See also Box 39-3 on text p. 775 Risk Factors for Skin Impairment.]
[Review Table 39-3 on text p. 776 Common Foot and Nail Problems.]
[Review Table 39-4 on text p. 777 Hair and Scalp Problems.]
[See also Table 39-5 on text p. 778 Risk Factors for Hygiene Problems.]

14. Nursing Assessment
The nurse observes the patient brushing teeth. During such observations, the nurse can determine how much assistance the patient may need.
[Image is Figure 39-2 on text p. 774.]

15. Nursing Process: Diagnosis
Common diagnoses associated with hygiene:
Activity intolerance
Bathing self-care deficit
Dressing self-care deficit
Impaired physical mobility
Impaired oral mucous membrane
Ineffective health maintenance
Risk for infection
Use the patients’ actual alteration or the alteration for which they are at risk.
Nursing diagnoses are selected from the NANDA-approved list.
Thorough assessment of a patient’s hygiene status and self-care abilities identifies clusters of data or defining characteristics that support actual or at-risk hygiene-related diagnoses. Identification of the defining characteristics leads you to select the NANDA International diagnostic label that best communicates the individual patient’s situation.
[See also Box 39-4 on text p. 779 Nursing Diagnostic Process: Bathing Self-Care Deficit.]
Completing a nursing diagnosis requires identification of the related factor, which will guide your selection of nursing interventions.
[Ask the class to suggest possible data clusters or defining characteristics for each diagnosis listed.]
The patient with an actual alteration requires extensive hygiene care, often more thorough than routine hygiene. Also provide care to promote healing of injured skin surfaces.
If the patient is at risk for a problem, take preventive measures.
Mucositis is painful inflammation of oral mucous membranes.

16. Nursing Process: Planning
Goals and outcomes
Partner with the patient and family
Measurable, achievable, individualized
Set priorities based on assistance required, extent of problems, nature of diagnoses
Teamwork and collaboration
Health care team members
Family
Community agencies
In many situations, patients present with multiple nursing diagnoses. Use a concept map (see Figure 39-4 on text p. 780) to visualize how nursing diagnoses interrelate.
Establish goals with the patient’s self-care abilities and resources in mind, and focus on maintaining or improving the condition of the skin and oral cavity.
[Ask the class: What are some examples of outcomes for skin hygiene? Discuss the following:
• Patient’s skin is clean, dry, and intact without signs of inflammation.
• Patient’s skin remains elastic and well hydrated.
• Patient’s skin is free from areas of pressure.]
Timing is also important in planning hygiene care.
In hospital or extended care settings, work closely with nursing assistive personnel, who often provide hygiene care.
Collaborate with other health team members as indicated (e.g., work with physical therapy and occupational therapy to enhance the patient’s independence with self-care activities).
When a patient needs assistance as a result of a self-care limitation, the family often becomes a valuable resource to the nurse and helps with hygiene measures.
[Review the Nursing Care Plan on text pp. 781 and 782 Impaired Oral Mucous Membrane.]
[Review Figure 39-3 on text p. 779 Critical thinking model for hygiene planning.]

17. Implementation Use caring to reduce anxiety, promote comfort.
Administer meds for symptoms before hygiene.
Be alert for patient’s anxiety or fear
Assist and prepare patients to perform hygiene as independently as possible.
Teach techniques and signs of problems.
Inform patients about community resources.
In the nursing skills lab, you will practice a variety of skills—for example, providing bed baths, sponge baths, and baths in bags; care of hair, nails, and feet; shaving; perineal and oral care; and overall grooming techniques.
Administering medications to relieve the symptoms before providing hygiene interventions helps patient comfort during hygiene care.
Implementation also focuses on assisting and preparing patients to be able to perform as much of their hygiene care as they can independently. Inform patients about available resources in the community for dealing with these problems if they arise.

18. Implementation Health promotion Make instructions relevant.
Adapt instruction to patient’s facilities and resources.
Teach the patient ways to avoid injury.
Reinforce infection control practices.
Acute, restorative, and continuing care
Hygiene measures vary by patient needs and health care setting.
In primary health care situations, educate and counsel patients and caregivers on proper hygiene techniques.
The hygiene skills described throughout this chapter provide standards for excellent physical care. When caring for patients in primary health care settings, maintain these standards and incorporate adaptations as needed to meet the patient’s lifestyle, functional status, living arrangements, and preferences.
Key points when teaching patients about hygiene include the following:
• Make any instruction relevant based on your assessment of the patient’s knowledge, motivation, preferences, and health beliefs.
• Adapt available resources so the patient can comfortably and safely reach and use needed items.
• Include safety risks and tips with all instructions.
• Determine that the patient understands the relationship among healthy and intact skin and tissues, hand hygiene practices, and the prevention of infection.
In the acute care setting, factors such as more frequent diagnostic and treatment plans and the need for more extensive hygiene care
resulting from acute illness or injury affect scheduling.
In extended care facilities and nursing homes, bathing may be scheduled less frequently.

19. Implementation
Consider normal grooming routines, and individualize care.
Bathing and skin care
Therapeutic: sitz, medicated
Complete bed bath
Self-help bath
Partial bed bath
Back rub
Foot and nail care
In addition to cleansing baths (taught in the skills lab), the health care provider may prescribe therapeutic baths. A sitz bath cleans and reduces pain and inflammation of perineal and anal areas. Medicated baths relieve skin irritation and create an antibacterial and drying effect.
If a patient is physically dependent or cognitively impaired, increase the frequency of skin assessment and provide skin care directed toward reducing the risk for skin breakdown.
A complete bed bath often exhausts a patient. Assessing heart rate before, during, and after the bath provides a measure of a patient’s physical tolerance. (Bath guidelines are presented on the next slide.)
Provide a partial bed bath to patients who are aging, dependent, in need of only partial hygiene, or bedridden and unable to reach all body parts.
In a shower, implement safety measures to prevent fall injuries.
Bag baths were developed because of nurses’ concern for patients who are predisposed to dry skin and the risk for infection. Not cleaning and drying wash basins completely after use provides a risk for contamination by disease-producing gram-negative organisms.
Cleansing patients’ genital and anal areas is called perineal care. It usually occurs as part of a complete bed bath and is also taught in the skills lab. Patients most in need of perineal care include those at greatest risk for acquiring an infection. Stress the importance of perineal care in preventing skin breakdown and infection.
Be alert for complaints of burning during urination or localized soreness, excoriation, or pain in the perineum. Inspect vaginal and perineal areas and the patient’s bed linen for signs of discharge, and use your sense of smell to detect abnormal odors. Risk factors for skin breakdown in the perineal area include urinary or fecal incontinence, rectal and perineal surgical dressings, indwelling urinary catheters, and morbid obesity.
[See also on text p. 783 Box 39-5 Hygiene Care Schedule in Acute and Long-Term Care Settings and Box 39-6 Types of Baths; and on text p. 784, Box 39-7 Evidence-Based Practice: Making Bathing Better for Patients with Cognitive Impairment; and Box 39-8 Signs of Peripheral Neuropathy or Vascular Insufficiency.]

20. Bath Guidelines Provide privacy. Maintain safety. Maintain warmth.
Promote independence.
Anticipate needs.
Close the door and/or pull room curtains around the bathing area. While bathing the patient, expose only the areas being bathed by using proper draping.
Keep side rails up when away from the patient’s bedside when patients are dependent or unconscious.
Keep the room warm because the patient is partially uncovered and easily chilled. Wet skin causes an excess loss of heat through evaporation.
Keep patient covered, exposing only the body part being washed during the bath.
Encourage the patient to participate in as many of the bathing activities as possible. Offer assistance when needed.
Bring a new set of clothing and hygiene products to the bedside or bathroom.
Teach patients to follow a few general rules for skin health. Encourage them to routinely inspect their skin for changes in color or texture and to report abnormalities to their health care provider.
Instruct patients to handle the skin gently, avoiding excessive rubbing.
Stress safety concerns such as failing to adjust or check the water temperature, cutting nails too close to the skin, and slipping on wet surfaces.
Ensure that patients understand that healthy and intact skin and tissues protect them from infection. Reinforce infection control practice, including proper hand hygiene.

21. Implementation Oral hygiene
Brushing removes particles, plaque, and bacteria; massages the gums; and relieves unpleasant odors and tastes.
Flossing removes tartar at the gum line.
Rinsing removes particles and excess toothpaste.
Patients with special needs: diabetes, artificial airways, unconscious, chemotherapy
Regular oral hygiene (taught in the skills lab), including brushing, flossing, and rinsing, prevents and controls plaque-associated oral diseases.
Complete oral hygiene enhances well-being and comfort and stimulates the appetite.
The American Dental Association guidelines for effective oral hygiene include brushing the teeth at least twice a day with American Dental Association–approved fluoride toothpaste.
Education about common gum and tooth disorders and methods of prevention may motivate patients to follow good oral hygiene practices.
To prevent cross-contamination, teach patients to avoid sharing toothbrushes with family members or drinking directly from a bottle of mouthwash.
Instruct patients to obtain a new toothbrush every 3 months or following a cold or upper respiratory infection to minimize growth of microorganisms.
According to American Dental Association recommendations, flossing once a day is sufficient.
Some patients require special oral hygiene methods. Patients with diabetes mellitus frequently experience periodontal disease. Patients with decreased levels of consciousness need special attention because they often do not have a gag reflex. Proper oral hygiene requires keeping the mucosa moist and removing secretions that contribute to infection. When providing oral hygiene to an unconscious patient, you need to protect him or her from choking and aspiration.
Some treatments such as chemotherapy, immunosuppressive agents, head and neck radiation, and nasogastric intubation place patients at higher risk of experiencing stomatitis or inflammation of the oral mucosa.
Stomatitis causes burning, pain, and change in food and fluid tolerance. When caring for patients with stomatitis, brush with a soft toothbrush and floss gently to prevent bleeding of the gums. Advise patients to avoid alcohol and commercial mouthwash and to stop smoking. Normal saline rinses on awakening in the morning, after each meal, and at bedtime help clean the oral cavity. Patients can increase the rinses to every 2 hours if necessary. Consult with the health care provider to obtain topical or oral analgesics for pain control.
[See also Box 39-9 on text p. 786 Focus on Older Adults: Oral Health.]

22. Care of Dentures
Encourage patients to clean their dentures on a regular basis to avoid gingival infection and irritation.
Dentures are the patient’s personal property and must be handled with care because they break easily.
They must be removed at night to rest the gums and prevent bacterial buildup.
To prevent warping, keep dentures covered in water when they are not worn, and always store them in an enclosed, labeled cup with the cup placed on the patient’s bedside stand.
Discourage patients from removing their dentures and placing them on a napkin or tissue because they could easily be thrown away.
Signs and symptoms of denture-induced stomatitis range from redness and swelling under the dentures to painful red sores on the roof of the mouth and infection with the yeast Candida albicans.
To prevent denture-induced stomatitis, rinse the mouth and dentures after meals, clean them carefully and regularly, remove and soak them overnight, brush and floss any remaining teeth, and visit a dentist regularly for examination.
The skill of denture care can be delegated to nursing assistive personnel (NAP). Instruct the NAP to:
• Inform the nurse of any cracks in dentures.
• Inform the nurse if the patient complains of oral discomfort.
• Inform the nurse of any lesions in the mouth.
Equipment needed includes a soft-bristle toothbrush or denture toothbrush, a denture-cleaning agent or toothpaste, denture adhesive (optional), a glass of water, an emesis basin or sink, a washcloth, clean gloves, and a denture cup (if dentures are to be stored after cleaning).
[Images shows brushing dentures = Step 6 on text p. 787 Box Procedural Guidelines: Care of Dentures.]

23. Prevent: Aspiration Implementation Oral hygiene – Unconscious Patient
Turn patient’s head towards you
Place patient in semi-fowler’s
Oral air way can be used to hold mouth open
Use a small brush or swab to clean the mucous membranes and teeth
Use suctions to remove secretions and fluid
Use chap stick or lip moisturizer
Implementation
Patients with decreased levels of consciousness need special attention because they often do not have a gag reflex. Proper oral hygiene requires keeping the mucosa moist and removing secretions that contribute to infection. When providing oral hygiene to an unconscious patient, you need to protect him or her from choking and aspiration.
Prevent: Aspiration

24. Implementation Hair and scalp care Brushing and combing Shampooing
Distributes oil
Prevents tangling, as does braiding
Obtain permission before braiding or cutting.
Procedures for head lice
Shampooing
Shaving
Mustache and beard care
A person’s appearance and feeling of well-being often depend on the way the hair looks and feels.
Frequent brushing helps keep hair clean and distributes oil evenly along hair shafts. Combing prevents hair from tangling. Encourage patients to maintain routine hair care and provide help for patients with limited mobility or weakness and those who are confused or weakened by illness.
When caring for patients from different cultures, learn as much as possible from them or their family about preferred hair care practices.
Long hair easily becomes matted when a patient is confined to bed, even for a short period. When lacerations or incisions involve the scalp, blood and topical medications also cause tangling. Frequent brushing and combing keep long hair neatly groomed.
Braiding helps to avoid repeated tangles; however, patients need to unbraid hair periodically and comb it to ensure good hygiene.
Patients who develop head lice require special considerations. The lice are small, about the size of a sesame seed; thus you need bright light or natural sunlight to see them. Thorough combing is more effective than use of pediculicidal shampoos, which are often toxic and ineffective against resistant lice. Steps are shown in the text to rid the patient of head lice.
[Shampooing, shaving, and mustache and beard care are discussed on the next slides.]

25. Shampooing Hair of Patient Who Is Bed-Bound
Frequency of shampooing depends on a person’s daily routines and the condition of the hair.
Remind patients in hospitals or extended care facilities that staying in bed, excess perspiration, or treatments that leave blood or solutions in the hair require more frequent shampooing.
A shower or tub chair facilitates shampooing for patients who are ambulatory and weight bearing and become tired or faint. Handheld shower nozzles allow patients to easily wash the hair in the tub or shower.
Some patients allowed to sit in a chair choose to be shampooed in front of a sink or over a wash basin; however, certain conditions (e.g., eye surgery, neck injury) limit bending. In these situations, teach the patient and family the degree of bending allowed.
The skill of shampooing hair can be delegated to nursing assistive personnel (NAP). Instruct the NAP:
• About any precautions needed in positioning the patient.
• To inform the nurse if the patient reports neck pain.
• To inform the nurse of any new skin lesions.
Equipment needed includes a brush, comb, shampoo board, conditioner (optional), hydrogen peroxide (optional), towels (two or more), hair dryer, and a basin of very warm water.
[Review Box Procedural Guidelines: Shampooing Hair of Patient Who Is Bed-Bound.]
[Images are from text p. 788.]

26. Implementation Care of the eyes, ears, and nose: Basic eye care
Eyeglasses
Contact lenses
Artificial eyes
Ear care
Hearing aid care
Nasal care
Give special attention to cleaning the eyes, ears, and nose during a routine bath and when drainage or discharge accumulates. Care focuses on preventing infection and maintaining normal sensory function.
Cleaning the eyes involves simply washing with a clean washcloth moistened in water; this will be learned in the skills lab.
Because of the cost, be careful when cleaning glasses, and protect them from breakage or other damage when they are not worn.
Pain, tearing, discomfort, and redness of the conjunctivae indicate lens overwear. Report persistence of these manifestations even after lens removal to the patient’s vision health care provider.
Care of contact lenses includes proper cleaning and disinfection, insertion and removal, and storage. When patients require help to clean their contact lenses, first perform hand hygiene, and then clean and disinfect the lenses with appropriate contact lens solution.
[See Box on text p. 790 Patient Teaching Contact Lens Care.]
(Artificial eyes are discussed on the next slide.)
Routine ear care involves cleaning the ear with the end of a moistened washcloth rotated gently into the ear canal. Gentle, downward retraction at the entrance of the ear canal usually causes visible cerumen to loosen and slip out. You can usually remove excessive or impacted cerumen by irrigation, which requires a health care provider’s order.
A hearing aid amplifies sounds in a controlled manner; the aid receives normal low-intensity sound inputs and delivers them to the patient’s ear as louder output.
The new class of hearing aids reduces background noise interference. Computer chips placed in the aids allow for fine adjustments to the specific patient’s hearing needs. (Types of hearing aids are discussed on subsequent slides.)
The patient usually removes secretions from the nose by gently blowing into a soft tissue. If the patient is unable to remove nasal secretions, help by using a wet washcloth or a cotton-tipped applicator moistened in water or saline. Never insert the applicator beyond the length of the cotton tip.
When nasogastric, feeding, or endotracheal tubes are inserted through a patient’s nose, change the tape anchoring the tube at least once a day.

27. Shaving
Shave facial hair after the bath or shampoo. When using a razor blade for shaving, the skin must be softened to prevent pulling, scraping, or cuts. Shave in the direction of hair growth. Use longer strokes on the larger areas of the face. Use short strokes around the chin and lips.
Patients prone to bleeding need to use an electric razor. Facial hair of African Americans tends to be curly and becomes ingrown unless shaved close to the skin.
Mustaches and beards require daily grooming. Grooming keeps food particles and mucus from collecting in the hair. Comb out beards gently, and obtain the patient’s permission before trimming or shaving off a mustache or beard.
[Image is Figure 39-5 from text p. 788.]

28. Implementation Care of the genitalia:
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.”
Give special attention to cleaning the eyes, ears, and nose during a routine bath and when drainage or discharge accumulates. Care focuses on preventing infection and maintaining normal sensory function.
Cleaning the eyes involves simply washing with a clean washcloth moistened in water; this will be learned in the skills lab.
Because of the cost, be careful when cleaning glasses, and protect them from breakage or other damage when they are not worn.
Pain, tearing, discomfort, and redness of the conjunctivae indicate lens overwear. Report persistence of these manifestations even after lens removal to the patient’s vision health care provider.
Care of contact lenses includes proper cleaning and disinfection, insertion and removal, and storage. When patients require help to clean their contact lenses, first perform hand hygiene, and then clean and disinfect the lenses with appropriate contact lens solution.
[See Box on text p. 790 Patient Teaching Contact Lens Care.]
(Artificial eyes are discussed on the next slide.)
Routine ear care involves cleaning the ear with the end of a moistened washcloth rotated gently into the ear canal. Gentle, downward retraction at the entrance of the ear canal usually causes visible cerumen to loosen and slip out. You can usually remove excessive or impacted cerumen by irrigation, which requires a health care provider’s order.
A hearing aid amplifies sounds in a controlled manner; the aid receives normal low-intensity sound inputs and delivers them to the patient’s ear as louder output.
The new class of hearing aids reduces background noise interference. Computer chips placed in the aids allow for fine adjustments to the specific patient’s hearing needs. (Types of hearing aids are discussed on subsequent slides.)
The patient usually removes secretions from the nose by gently blowing into a soft tissue. If the patient is unable to remove nasal secretions, help by using a wet washcloth or a cotton-tipped applicator moistened in water or saline. Never insert the applicator beyond the length of the cotton tip.
When nasogastric, feeding, or endotracheal tubes are inserted through a patient’s nose, change the tape anchoring the tube at least once a day.

29. Peri-care Those patients who may need the nurses assistance:
Vaginal or urethral discharge
Skin irritation
Catheter
Surgical dressings
Incontinent of urine or feces

30. Peri-care: Female
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

31. Peri-care: Female
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

32. Peri-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

33. Peri-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

34. Perineal Care with Catheter
Start at the urethra
opening and clean
outward

35. 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 feel 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

36. Implementation Patient’s room environment
Maintaining comfort: temperature, noise, lighting, ventilation, odors
Beds
Features: raising, adjusting, side rails
Clean, comfortable, and safe
Bed making
Occupied
Unoccupied
What makes a comfortable environment depends on a patient’s age, severity of illness, and level of normal daily activity. Keeping the room neat and orderly contributes to the patient’s sense of well-being.
Ill patients seem to be more sensitive to noises and lighting commonly found in health care settings.
[Ask the class: What are some sources of unpleasant odors in patient rooms? How can they be managed?]
(Room equipment is discussed on the next slide.)
The typical hospital bed has a firm mattress on a metal frame that you can raise and lower horizontally. More and more hospitals are converting the standard hospital bed to one in which the mattress surface can be electronically adjusted for patient safety and comfort. Different bed positions promote patient comfort, minimize symptoms, promote lung expansion, and improve access during certain procedures.
Beds contain safety features such as locks on the wheels or casters. Lock wheels when the bed is stationary to prevent accidental movement. Side rails allow patients to move more easily in bed and prevent accidents. Do not use side rails to restrict a patient from moving in bed. When using side rails as a restraint, you need a health care provider’s order.
Keeping a patient’s bed clean and comfortable requires frequent inspection to be sure that linen is clean, dry, and free of wrinkles. When patients are diaphoretic, have draining wounds, or are incontinent, check more frequently for wet or soiled linen.
Usually you make the bed in the morning after the patient’s bath or while he or she is bathing, in a shower, sitting in a chair eating, or out of the room for procedures or tests. Change any linen that becomes soiled or wet.
Before making a bed, collect necessary bed linens and the patient’s personal items. In this way, all equipment is accessible to prepare the bed and room.
During bed making, use safe patient handling procedures and proper body mechanics. Always raise the bed to the appropriate height before changing linen, so you do not have to bend or stretch over the mattress. You move back and forth to opposite sides of the bed while applying new linen. Body mechanics and safe handling are important when turning or repositioning the patient in bed.
The patient’s privacy, comfort, and safety are all important when making a bed. Using side rails to aid positioning and turning, keeping call lights within the patient’s reach, and maintaining the proper bed position help promote comfort and safety. After making a bed, return it to the lowest horizontal position, and verify that the wheels are locked to prevent accidental falls when the patient gets in and out alone.
When possible, make the bed while it is unoccupied (see Box on text p. 795 Procedural Guidelines: Making an Unoccupied Bed).
An unoccupied bed can be made as an open or closed bed. In an open bed, the top covers are folded back, so it is easy for a patient to get into bed. In a closed bed, the top sheet, blanket, and bedspread are drawn up to the head of the mattress and under the pillows. A closed bed is prepared in a hospital room before a new patient is admitted to that room.
(Linens are discussed on a later slide.)
[See also Table 39-6 on text p. 794 Common Bed Positions.]

37. Room Equipment
A patient’s room needs to be comfortable, safe, and large enough to allow the patient and visitors to move about freely.
Shown is a typical hospital room. [Ask the class what features they note.]
Although variations are found across health care settings, a typical hospital room contains the following basic pieces of furniture: over-bed table, bedside stand, chairs, lamp, and bed (shown).
Clean the top of the over-bed table with an antiseptic cleaner before using it for meals. Do not place the bed pan or urinal on the over-bed table.
Most hospital rooms contain an armless straight-backed chair or an upholstered lounge chair with arms.
Each room usually has an over-bed light and floor level night lighting.
Other equipment usually found in a patient’s room includes a call light, a television set, a wall-mounted blood pressure gauge, oxygen and vacuum wall outlets, and personal care items.
[Image is Figure 39-8 from text p. 792.]

38. Communication
Nurse instructing patient in use of call light and bed controls.
You change the position of a bed usually by using electrical controls incorporated into the patient’s call light and in a panel on the side or foot of the bed. Be familiar with use of the bed controls.
Ease in raising and lowering a bed and changing position of the head and foot eliminates undue musculoskeletal strain on a nurse.
Instruct patients in the proper use of controls, and caution them against raising the bed to a position that causes harm.
Maintain the bed height at the lowest horizontal position when the patient is unattended.
[Image is Figure on text p. 793.]

39. Linen Care
Because of the importance of cost control in health care, avoid bringing excess linen into a patient’s room. Once you bring the linen into a patient’s room, if unused, it must be laundered before it is used.
When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform. Place soiled linen in special linen bags before placing in a hamper. To avoid air currents that spread microorganisms, never shake the linen. To avoid transmitting infection, do not place soiled linen on the floor. If clean linen touches the floor or any unclean surface, immediately place it in the dirty linen container.
After a patient is discharged, all bed linen goes to the laundry, and housekeeping cleans the mattress and bed before clean linen is applied.
[Image is Figure from text p. 794.]

40. Evaluation Evaluate during and after each intervention.
Observe for changes in patient’s behavior.
Consider the patient’s perspective.
Often it takes time, repeated measures, and a combination of interventions for improvement.
Expected outcomes met?
Patient’s expectations met?
Ask questions to determine appropriate changes to interventions.
Evaluation of hygiene care is based on a patient’s sense of comfort, relaxation, and well-being, and understanding of hygiene techniques.
Evaluate patient responses to nursing interventions to determine whether goals and outcome criteria have been met.
Critical thinking ensures that the nurse considers the patient’s perspectives and applies what is known about hygiene to the patient’s unique situation.
You need to feel comfortable in addressing the patient’s concerns and expectations. A caring approach facilitates discussion of these issues.
Evaluate patient responses to hygiene measures both during and after each particular hygiene intervention.
When evaluating for the effectiveness of hygiene measures, observe for changes in his or her behavior. Does the patient assume a more relaxed position? Is he or she free of body odor? Is he or she able to fall asleep? Does his or her facial expression convey a sense of comfort?
The nurse’s knowledge base and experience provide important perspectives when analyzing assessment data about a patient.
The standards for evaluation are the expected outcomes established in the planning stage of the patient’s care. If outcomes are not met, you need to revise the care plan.
The final aspect of evaluation determines whether or not the patient’s expectations for hygiene were met.
When outcomes are not met, ask questions to determine appropriate changes in interventions. [Ask the class: What are some examples of questions to ask to determine whether expectations were met? After discussion, offer the following as examples:
• Did your bath and back rub help make you comfortable?
• Are there ways we can do a better job with your foot care?
• Which things are preventing you from being able to perform your foot care at home?
• Which further measures do you think are necessary to keep your mouth clean and refreshed?
• What do you think would help you be more independent with your hygiene care?]
[See also Figure on text p. 796 Critical thinking model for hygiene evaluation.]

41. Safety Guidelines Communicate clearly with team members.
Incorporate patient’s priorities.
Move from the cleanest to less clean areas.
Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood.
Test the temperature of water or solutions.
Use principles of body mechanics and safe patient handling.
Be sensitive to the invasion of privacy.
Ensuring patient safety is an essential role of the professional nurse. Use the best evidence when making decisions about your patient’s care.
When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care.
Always perform hygiene measures moving from the cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities.
Use clean gloves when you anticipate contact with nonintact skin or mucous membranes, or when there will be or may likely be contact with drainage, secretions, excretions, or blood during hygiene care.
When using water or solutions for hygiene care, be sure to test the temperature to prevent burn injury.
To avoid injury when performing hygiene care, use principles of body mechanics and safe patient handling.
When giving or assisting with hygiene care, be sensitive to the invasion of privacy and possible loss of self-esteem associated with these procedures. Foster acceptance and comfort by using therapeutic communication techniques, draping and providing privacy, and informing the patient before touching sensitive or private body parts.
Remember that you are responsible and accountable for assessing the patient both before and after care to detect unexpected outcomes, and give proper direction to nursing assistive personnel when delegating hygiene care.