1. Chapter 18 Hygiene and Care of the Patient’s Environment
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2. 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.
Why are nurses role models regarding hygiene?
What personal hygiene practices should nurses practice every day?

3. 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?
How does culture affect personal hygiene?

4. 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
Why is it important to consider the room temperature?
Why is it important to rinse bedpans and urinals?
How does proper lighting affect the patient’s comfort?

5. 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.

6. 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
What items might you expect to find in the patient’s bedside table? What items would you hope not to find? Wallets, large sums of money.
What is the purpose of the overbed table?
Why is it beneficial to have straight chairs available at the bedside?

7. 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.
What is the purpose of the call light?
How should nursing staff respond to the patient’s call light?
Why is it important to make sure the patient’s call light is within reach?
What safety features would you find on a hospital bed?

8. 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?
How long should the patient sit in the sitz bath?
How can the nurse prevent hypothermia when the patient is taking a tepid bath?

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

10. Bathing Warm Water Tub Bath Hot Water Tub Bath
Given to reduce muscle tension
Water temperature 109.4° F
Observe s/s of dizziness/fainting
Hot Water Tub Bath
Given to assist in relieving muscle soreness and muscle spasms
Water temperature 113° to 115° F
How does a warm water tub bath relieve muscle tension?
How does a hot water tub bath relieve muscle soreness and spasm?

12. 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
What is the difference between a complete bed bath and a tepid sponge bath?
What is the benefit to a medicated bath?

13. 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.

14. 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.

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

16. 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.

17. 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
What is an assessment benefit for the nurse when giving a massage?
Why are massages contraindicated in patients with pulmonary embolism?

18. 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.

19. 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.
Describe how the skin might appear when the patient is dehydrated, cyanotic, and hyperthermic.
What is the skin’s physiologic function?

21. 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?

22. 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.
How does lying in one position increase a patient’s chances to develop a pressure sore?
What is the rationale that supports that these patients are at increased risk for pressure sores?
Why is the incontinent patient at an increased risk of developing a pressure sore?

23. Pressure sore staging

24. 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.

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

26. 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.
What causes blood vessels to collapse when a patient is lying in the same position for a prolonged period of time?
Why is decreased blood flow to the area a concern?
Where is pressure most severe on the patient’s body?

28. 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.
What mechanical factors can result in pressure ulcers?
When might friction occur?

30. 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.

31. 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
What is erythema?
What is partial-thickness skin loss?
What is full-thickness skin loss?
What is necrosis?

32. 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.

33. 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.

34. 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 .

35. 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 .

36. Stable eschar of heelS

37. 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.
Why is healing a long-term process?
What nursing interventions would be appropriate for the care of a pressure ulcer?
What nutritional support promotes healing of pressure ulcers?
What other devices might a nurse utilize to relieve pressure on ulcerated areas?

38. 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.
What types of patients are at risk for oral disorders?
Why is it important to maintain a healthy mouth?
How does proper oral hygiene stimulate appetite?

39. 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.

40. 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
Why should dentures not be worn during surgery and other procedures?
Why is it important to provide oral care on a regular basis?

41. 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.

42. 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.
How might hair care be important to the patient?
How often should hair care be performed?
Why is it important to use an electric razor when shaving a patient prone to bleeding?
Why is it important for the nurse to shave, or not allow a depressed or disoriented patient to shave, with a razor blade?

43. 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.

44. 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.
Why should patients with diabetes and/or peripheral vascular disease be observed for circulation of the feet?
Why are the elderly at risk for foot disorders?

45. 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.
What is the circumorbital area?
Why is the eye cleansed from the inner to outer canthus?
Why is a separate section of the washcloth used to clean the other eye?

47. 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.
Why is the patient instructed not to use items such as bobby pins, toothpicks, or other sharp objects?
What is cerumen?

48. 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.
Why is it important for the nurse to talk clearly and slowly to a patient who wears hearing aids?

49. 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.

50. 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.
How can the nurse assist the patient with excessive nasal secretions?
How often should the nurse cleanse the nares of the patient?

51. 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
Why is a patient with an indwelling catheter at risk for infection?
What signs and symptoms indicate infection of the perineum, vagina, or urethra?
Why is catheter care required twice a day?

52. 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.

53. 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.

54. 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.

55. 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.
How does the nurse make an occupied bed?
How does the nurse maintain safety when changing the linen of an occupied bed?
How does the nurse maintain privacy while changing the bed linen on an occupied bed?

56. 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.

57. 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.

58. 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.

59. 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.

60. 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.

61. 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.

62. 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.
Why is it important to inspect the patient’s bed linen frequently?
Describe methods to maintain medical asepsis when changing bed linen.
How does raising the level of the bed to a working position limit injury to the nurse?

63. 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.

64. 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.

65. 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.

66. 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.
How do you place a patient on a bedpan?
What can assist in removing the bedpan from a patient? Prior to placing a patient on a bedpan, the application of powder to the flat surface will assist in removing the bedpan by reducing friction. Note: do not apply powder to the bedpan when obtaining a urine or stool specimen.

67. 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.
What might hinder a patient from using a bedpan? The patient might procrastinate from requesting a bedpan because of discomfort and embarrassment issues.
Describe a flow sheet that would record elimination.

68. 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.

69. 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.
How might the nurse manage this patient?
What nursing staff might assist the nurse in assessing incontinence?
Why would coughing, laughing, or lifting cause incontinence in the female patient?
What type of exercises might help in minimizing incontinence in the female patient?

70. 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.
What happens to the patient’s skin that is exposed to urine for a long time?
What is bladder training?

71. Nursing Process Nursing Diagnoses Oral mucous membranes, impaired
Mobility, impaired physical
Skin integrity, impaired
Self-care deficit—bathing/hygiene, dressing/grooming
Provide an example of a patient situation in which these nursing diagnoses would be appropriate.
Provide a goal for each of the nursing diagnoses.