1. HYGIENE

2. Six Functions of the Skin  Protection of other organs from injury  Body temperature regulation  Sensation transmission through preceptors  Excretion  Maintenance of water and electrolyte balance  Vitamin D production and absorption

3. Factors affecting the Skin  Unbroken and healthy skin and mucous membranes defend against harmful agents.  Resistance to injury is affected by age, amount of underlying tissues, and illness.  Adequately nourished and hydrated body cells are resistant to injury.  Adequate circulation is necessary to maintain cell life.

4. Developmental Considerations  Infant’s skin and mucous membranes are easily injured and subject to infection.  Child’s skin becomes increasingly resistant to injury and infection. –Requires special care because of toilet and play habits  Adolescent has enlarged sebaceous glands and increased secretions.  Adult’s tissue becomes thinner and wrinkles appear; liver spots occur.

5. Causes of Skin Alterations  Very thin and very obese people are more susceptible to skin injury. –Fluid loss during illness causes dehydration. –Skin appears loose and flabby.  Excessive perspiration during illness predisposes skin to breakdown.  Jaundice causes yellowish, itchy skin.  Diseases of the skin cause lesions that require care.

6. Factors Influencing Personal Hygiene  Culture  Socioeconomic class  Spiritual practices (religion)  Developmental and knowledge level  Health status & energy level  Personal preferences

7. Interview Questions/Skin Alterations  How long have you had this problem?  Does it bother you?  How does it bother you (itching)?  Have you found anything helpful in relieving these symptoms?

8. Copyright 2008 by Pearson Education, Inc. Nursing Process: Assessment  Nursing history to determine: –Self care practices –Self-care abilities –Past or current problems –Identification of clients at risk for developing impairment  Physical assessment

9. Factors to Consider When Examining Skin  Cleanliness  Color  Temperature  Turgor  Moisture  Sensation  Evidence of lesions

10. Patient’s At Risk for Skin Alteration  Lifestyle variables  Changes in health state  Illness  Diagnostic measures  Therapeutic measures

11. Copyright 2008 by Pearson Education, Inc. Abnormal Findings of the Skin  Abrasion  Excessive dryness  Ammonia dermatitis (diaper rash)  Acne  Erythema  Hirsutism

12. Focus of Self-Care Deficit Diagnoses  Self-Care Deficit : Bathing/Hygiene  Self-Care Deficit : Dressing/Grooming  Self-Care Deficit : Toileting  Self-Care Deficit : Feeding

13. Types of Hygienic care  Early Morning Care  Morning Care (AM Care)  Afternoon Care (PM Care)  Hours of Sleep Care (HS Care)  As needed (p.r.n Care)

14. Early Morning Care  Assist patient with toileting.  Provide comfort measure to refresh patient to prepare for day.  Wash face and hands.  Provide mouth care.

15. Morning Care (AM Care) After breakfast, nurse completes morning care:  Toileting  Oral care  Bathing  Back massage  Special skin measures  Hair care, cosmetics

16. Morning Care (AM Care) (continued)  Dressing  Positioning for comfort  Refreshing or changing bed linens  Tidying up bedside

17. Afternoon Care (PM Care) Ensure patient’s comfort after lunch:  Offer assistance with toileting, handwashing, oral care  Straighten bed linens  Help patients with mobility to reposition themselves

18. Hours of Sleep Care (hs Care) Before patient retires:  Offer assistance with toileting, washing, and oral care  Offer a back massage  Change any soiled bed linens or clothing  Position patient comfortably  Ensure that call light and other objects patient requires are within reach

19. As Needed Care (prn Care)  Offer individual hygiene measure as needed  Change clothing and bed linens of diaphoretic patients  Provide oral care every two hours if indicated

20. Reasons for Providing Back Massage  Acts as a general body conditioner  Relieves muscle tension and promotes relaxation  Provides opportunity for nurse to assess the skin for signs of breakdowns  Promotes circulation  May decrease pain, distress, and anxiety  May improve sleep quality

21. Purposes of Bathing  Cleanses the skin  Acts as a skin conditioner  Helps to relax a person  Promotes circulation  Serves as musculoskeletal exercise  Stimulates the rate and depth of respirations

22. Purposes of Bathing (continued)  Promotes comfort through muscle relaxation and skin stimulation  Provides person with sensory input  Helps improve self-image  Strengthens nurse patient relationship

23. Providing a Bed Bath  Provide articles for bathing on over-bed table or bedside stand.  Provide privacy for patient.  Remove top linens and replace with bath blanket.  Place cosmetics in convenient place.  Assist patients who cannot bathe themselves completely.

24. Physical Assessment of Oral Cavity  Observe for oral problems. –Dental caries –Periodontal disease –Other oral problems  Identify actual or potential oral problems that nurses can treat.  Identify appropriate nursing measures.  Carry out the plan of care.

25. Copyright 2008 by Pearson Education, Inc. Abnormal Findings of the Mouth  Glossitis  Gingivitis  Periodontal disease  Reddened or excoriated mucosa  Excessive dryness of the buccal mucosa  Cheilosis  Dental caries  Stomatitis  Parotitis

26. Administering Oral Hygiene  Moistening the mouth  Cleaning the mouth  Caring for dentures  Toothbrushing and flossing  Using mouthwashes

27. Care of Eyes  Clean from inner to outer canthus with wet, warm cloth, cotton ball or compress.  Use artificial tear solution or normal saline every 4 hours if blink reflex is absent.  Care for eyeglasses, contact lens, or artificial eye if indicated.

28. Copyright 2008 by Pearson Education, Inc. Abnormal Findings of Eyes  Loss of hair, scaling, flaky eyebrows  Redness, swelling, flaking, crusting, discharge, asymmetrical closing, ptosis of eyelids  Jaundiced sclera  Unequal pupils  Pupils fail to dilate or constrict  Inability to see

29. Ear and Nose Care  Wash external ear with washcloth-covered finger; do not use cotton-tipped swabs.  Perform hearing aid teaching and care if indicated.  Clean nose by having patient blow it if both nares are patent.  If indicated, use nasal suctioning with bulb syringe.  Remove crusted secretions around nose and apply petroleum jelly.

30. Providing Hair Care  Identify patient’s usual hair and scalp care practices and styling preferences.  Note any history of hair or scalp problems, such as dandruff, hair loss, or baldness.  Treat any infestations, such as pediculosis and ticks.  Groom and shampoo hair.  Care for beards and mustaches.  Assist with unwanted hair removal.

31. Copyright 2008 by Pearson Education, Inc. Abnormal Findings of the Hair  Dandruff  Hair loss  Ticks  Pediculosis (Lice)  Hirsutism

32. Nail and Foot Care  Assess nails for color and shape, intactness and cleanness, and tenderness.  Check for history of nail or foot problems.  Soak nails and feet and assist with cleaning and trimming nails (if not contraindicated).  Massage the feet to promote relaxation and comfort.  Provide diabetic foot care if indicated.

33. Copyright 2008 by Pearson Education, Inc. Abnormal Findings of the Nails  Spoon nails  Excessive thickness or clubbing  Grooves or furrows  Discolored or detached  Bluish or purplish tint or pallor  Hangnails or paronychia  Delayed capillary refilling time

34. Copyright 2008 by Pearson Education, Inc. Abnormal Findings of the Feet  Excessive dryness  Areas of inflammation or swelling  Fissures  Scaling and cracking of skin  Swelling and pitting edema  Weak or absent pulses  Cool skin temperature in one or both feet

35. Ensuring Bedside Safety  Patient call light is functioning and within reach  Bed is positioned properly, at appropriate height, wheels locked  Side rails are safely used when indicated  Principle of medical asepsis are followed  Electrical equipment is safely grounded  Walk space is uncluttered

36. Patient Outcome Achievement  Level of patient participation in hygiene program  Elimination of, reduction in, or compensation for factors interfering with independent execution of hygiene measures  Changes related to specific skin problems