1. Lesson number 8 SUBJECT: Care of the critically ill patient

2. Skincare by critically ill patients Careful skin care is important. Especially for seriously ill patient. Seriously ill patient have to a long time to be on "bed rest." Contamination of the skin by sweat, urine and other secretions leads to itching, scratching, inflammation in certain areas, the appearance of bedsores. Patients on the " general regime" can independently take hygienic shower or bath ones every 7 days. At the intensive care unit the bed linen has to be changed every day.

3. Conducting hygienic bath Purpose: maintenance purity of the skin. Equipment: watertight apron, washcloth, soap, shampoo, towel, clean underwear, clothing, gloves, a thermometer to measure the water temperature. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Fill the bath half full with water, measure temperature (37-38 ̊ C). 3.Conduct hygienic washing hand and processing hand. Put the gloves on. 4.Put the patient into the bath. Water level should be up to the xiphoid process of the sternum of the patient. 5.Put an apron on. 6.Help the patient to wash the hair. 7.Wash the trunk, arms, legs and crotch. If conditions allow, the patient washes independently. 8.Help the patient out of the bath. 9.Wipe the patient. 10.Help the patient to comb hair. 11.Cut the nails ( on hands and feet). Put on clothes. 12.Go with the patient to the hospital ward. 13.Remove the apron. 14.Conduct disinfection used material. 15.Take off the gloves and put them in the container for disinfection. 16.Wash hands hygienic way. 17.Make a record of results in a medical documentation. Remember ! The duration of the bath should not exceed 25 minutes.

4. Wiping the skin Patients on "bed rest" can not take hygienic bath independently. But they also need skin care daily. Сare of the critically ill patient is hard work. Modern technological products lighten the work of the nurse. For example, napkin for body wash. These wipes cleanse, moisturize, deodorize the skin. You do not need water. Wipes impregnated with antibacterial agents effective against E. coli, staphylococcus, streptococcus, salmonella.

5. Wiping the skin Purpose: maintain the purity of the skin, prevention of bedsore (pressure sores). Equipment: oilcloth, diaper, two capacity with warm water and soap, cream, towel, clean undergarments and bed linen, waterproof apron, soft cloth for washing (or cloth napkin), gloves, a container for dirty linen. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Close windows, doors. 3.Put a screen. Wear apron. 4.Conduct hygienic washing hand and processing hand. Put the gloves on. Prepare the equipment. 5.Put under the patient an oilcloth and diaper. (Turn the patient on side. Put the oilcloth and diaper under his back. Turn the patient on the other side. Straighten out the oilcloth and diaper. Put patient on his back) 6.Moisten the soft cloth with warm soapy water, slightly squeeze out. 7.Wipe consistently by massaging movement:: eyelids, forehead, nose, ears, chin, neck. 8.Wash off the soap solution with the other soft napkin in the same order. Wipe with a towel dry. 9.Wipe the patient's arm from fingers to axilla. Then carefully wipe the skin dry. 10.Consistently wipe chest, abdomen, back. Wipe the skin dry. 11.Cover the upper body with diaper, so that to patient was not cold. 12.Wipe both legs from the hips to the soles. Wash between fingers. Wipe dry. 13.Smear the skin folds with a cream. 14.Remove oilcloth and diaper in a container for dirty laundry. 15.Change bed linen and underwear. 16.Give the patient a comfortable position. Cover blanket. 17.Remove the apron. 18.Conduct disinfection used material. 19.Take off the gloves and put them in the container for disinfection. 20.Wash hands hygienic way. 21.Make a record of results in a medical documentation.

6. Hair wash in bed Patients require constant observing for their hair. Seriously ill head washed in bed. Remember ! Long hair is better to braid in two plaits. To make it comfortable to lie. To fix the hair do not use metal clips. Purpose: personal hygiene of the patient. Equipment: capacity with warm water, a basin, a headrest, oilcloth, towel, shampoo, individual comb, gloves, waterproof apron, a container for dirty linen. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Close windows, doors. Put a screen. 3.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. Prepare the equipment. 4.Inspect the patient 's head. 5.Lay down the patient on his back. 6.Remove the pillow. 7.Put under the head an oilcloth. 8.Put the headrest under the shoulders of the patient. 9.Put the basin near the head. Put the hair into the basin. 10.Moisten the hair with warm water. Pour water from a jug on the head. 11.Apply shampoo. 12.Well rinse out the shampoo of the hair. Wipe the hair. 13.Gently comb the hair, well dry. 14.Remove the apron. 15.Conduct disinfection used material. 16.Take the gloves off and put them in the container for disinfection. 17.Wash hands hygienic way. 18.Make a record of results in a medical documentation.

7. Caring for perineum of seriously ill man Purpose: personal hygiene, patient, prevention of urinary tract infection. Equipment. Sterile: gauze napkin (10 - 15 pieces), forceps. Jug of warm water (37-38 ̊ ° C), screen, oilcloth, bedpan, gloves, oilcloth apron, a container for disinfection. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Put a screen. 3.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. Prepare the equipment. 4.Turn patient on side. 5.Put under the patient an oilcloth. 6.Put the bedpan under sacrum. 7.Lay down the patient on his back. 8.Bend the knees and spread them in the hip joints. 9.Stand at the side of the patient. 10.In the left hand to take the jug with warm water. 11.In the right hand to take the forceps with gauze napkin. 12.Gently pull with your fingers of the left hand the prepuce of penis, so that uncover the balanus (glans of the penis). 13.Slowly pour water from a jug with water at the perineum. 14.Consistently wash: the balanus, the skin of the penis, scrotum, inguinal folds, the area of the anus. 15.Change napkins depending on pollution. All movements should be directed top-down. 16.Dry perineum. 17.Turn patient on side. Remove the bedpan. Lay down the patient on his back. 18.Conduct disinfection used material. 19.Take off the gloves and put them in the container for disinfection. 20.Wash hands hygienic way. 21.Make a record of results in a medical documentation.

8. Caring for perineum of seriously ill woman Purpose: personal hygiene, patient, prevention of urinary tract infection. Equipment. Sterile: gauze napkin (10 - 15 pieces), forceps. Jug of warm water (37-38 ̊ ° C), screen, oilcloth, bedpan, gloves, oilcloth apron, a container for disinfection. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Put a screen. 3.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. Prepare the equipment. 4.Turn patient on side. 5.Put under the patient an oilcloth. 6.Put the bedpan under sacrum. 7.Lay down the patient on his back. 8.Bend the knees and spread them in the hip joints. 9.Stand at the side of the patient. 10.In the left hand to take the jug with warm water. 11.In the right hand to take the forceps with gauze napkin. 12.Slowly pour water from a jug with water at the perineum. 13.Consistently wash: labia minora, labia majora, inguinal folds, the area of the anus. 14.Change napkins depending on pollution. All movements should be directed top-down. 15.Dry perineum. 16. Turn patient on side. Remove the bedpan. Lay down the patient on his back. 17.Remove the apron. 18.Conduct disinfection used material. 19.Take off the gloves and put them in the container for disinfection. 20.Wash hands hygienic way. 21.Make a record of results in a medical documentation.

9. Washing the feet in bed Purpose: prevention of diaper rash between the toes. Equipment: a basin of warm water, oilcloth, apron, towel, soap, sponge, gloves, scissors, cream, container for disinfection. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Put a screen. Prepare the equipment. 3.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. 4.Lay down the patient on his back. Bend patients knees. 5.Remove the mattress from under the feet. 6.Put under the feet an oilcloth. Put at the oilcloth a basin with warm water. 7.Put the patient's feet in the basin with water. 8.Wash the feet with a sponge and soap. 9.Wash in the following order: shin, foot, between the toes, sole. 10.Remove the basin. 11.Dry feet. Cut nails. Lubricate with cream. 12.Remove oilcloth, put in order the bed. 13.Disinfect used material. 14.Remove gloves, put them in a container for disinfection. 15.Wash hands hygienic way. 16.Make a record of results in a medical documentation.

10. Change of bed and underwear The main place patients at the hospital is bed. Change of bed and underwear is carried out: once a week according to plan, after taking a bath or shower, in the case of dirtying of bed linen. Seriously ill patients during the change of bed linen is in bed. Change of linens a seriously ill can be made in two ways. Change linens by a seriously ill can be made in two ways.

11. Seriously ill on bedrest change of bed linen by longitudinal method (2 nurses perform manipulation) Purpose: maintain cleanliness, comfort and well-feeling of the patient. Equipment: gloves, clean bed linen (pillowcase, 2 bed-sheets), container for dirty linen. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. 3.Prepare clean bed linen, roll up a clean bed-sheet longwise to half. 4.Remove the blanket. Remove the bed-sheet from blanket. 5.A first the nurse lifts the head and shoulders of the patient. 6.A second nurse remove the pillow. Lower the patient's head. 7.Turn the patient on his side faced to you (1 nurse). 8.A second nurse rolls up a dirty sheet longwise to back of the patient. 9.A second nurse puts clean sheet on the bed with side of a patient's back (roller to roller). 10.Carefully move the patient on the clean bed-sheet. 11.Remove a dirty bed-sheet. Straighten out the clean bed-sheet at the other side. 12.Turn patient on his back. 13.Change pillowcase. Carefully lift the head and shoulders of the patient. Put the pillow under his head. Put patient. 14.Tuck in the bed-sheets under the mattress. 15.Cover the a clean bed-sheet over the blanket. 16.Cover of patient by blanket. 17.Put the dirty bed linen in the container. 18.Remove gloves, put them in a container for disinfection. 19.Wash hands hygienic way. 20.Make a note of the results in a medical documentation.

12. Seriously ill on strict bedrest; change of bed linen by cross method (2 nurses perform manipulation) Purpose: maintain cleanliness and good health of the patient. Equipment: gloves, clean bed linen (pillowcase, 2 bed-sheets), container for dirty linen. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. 3.Prepare clean bed linen. Rolls up a clean sheet transverse to half. 4.Remove the blanket. Remove the bed-sheet from blanket. 5.First the nurse lifts the head and shoulders of the patient. 6.A second nurse remove the pillow. 7.A second nurse rolls up dirty bed-sheet to loin (lumbus). 8.Put the clean bed-sheet on bed with side of a patient's head (roller to roller). 9.Put patient. 10.Change the pillowcase. First the nurse lifts the head and shoulders of the patient. 11.A second nurse put the pillow under head. Put head of patient. 12.First the nurse lifts the pelvis of the patient, then the legs. 13.Remove the a dirty bed-sheet. Straighten out the clean sheet at the other side. 14.Lower legs. 15.Tuck in the bed-sheets under the mattress. 16.Cover the a clean bed-sheet over the blanket. 17.Cover of patient by blanket. 18.Put the dirty bed linen in the container. 19.Remove gloves, put them in a container for disinfection. 20.Wash hands hygienic way. 21.Make a note of the results in a medical documentation.

13. Change of underwear Underwear is changed once in 3-4 days. Seriously ill with urinary and fecal incontinence under the gluteal region enclose oilcloth. At the top a diaper. Such patients should be changed daily or after every hygienic treatment. Every seriously ill should have an individual urinal. Change of underwear Purpose: maintain cleanliness and good health of the patient. Equipment: shirt, gloves, a container for dirty linen.

14. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. 3.Prepare clean bed linen. 4.Seat down the patient. 5.Move the shirt from the loin to the neck. Remove the shirt from head, then from hands. 6.Wear the shirt in the following sequence: hands in the sleeves, head, straighten out on the back. 7.Place the patient in a comfortable position. 8.If one arm of the patient is damaged: first, remove the sleeve from the healthy hand, then from the damaged hand. Put on the shirt: first on the damaged hand, then on the good arm. 9.Put the used shirt in the a container for dirty linen. 10.Remove gloves, put them in a container for disinfection. 11.Wash hands hygienic way. 12.Make a note of the results in a medical documentation.

15. «lying-down» patient dressing diaper (diaper adult) Disposable diapers for adults (adult diapers). Used at home and in the hospitals. This is an object for individual care and care for immobile patients. There are adult diapers in form of pants. They are used mobile patients with incontinence. There are different sizes of adult diapers. Consider when selecting a diaper: - day or night; - degree of physical activity; - duration; - costs.

16. «lying-down» patient dressing diaper (diaper adult) Purpose: personal hygiene, cleanliness of the skin, underwear and bed linen. Equipment: diapers, gloves. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Prepare equipment. Pick the type and size of diapers for the given patient. Check the expiration date of the package. 3.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. 4.Perform wash the perineum in accordance with the algorithm. 5.Inspect the patient's skin of the perineum. 6.Turn the patient on his side. 7.Take out the diaper out of the package. Uncover it. 8.Put the diaper under the buttocks of the patient. 9.Turn the patient on his back, then turn on the other side. 10.Straighten the diaper. 11.The front part of the diaper to place between his legs and up. 12.Straighten the diaper on the body, fasten the Velcro. 13.Instruct the patient or relatives on the rules applying diapers. 14.Remove gloves, put them in a container for disinfection. 15.Wash hands hygienic way. 16.Make a note of the results in a medical documentation.

17. The use bedpan to patients in bed If patient is on bedrest regime, he performs urination and defecation in bed. These patients needs in the help of medical personnel. In this case the patient gets bedpan in bed. Types urinal: - Plastic - Rubber. The rubber container is used by patients having bedsores. Rubber container for urine should not be greatly inflated. - Glass. Only for men, only for urine.

18. The use bedpan to patients in bed Seriously ill on bedrest; ( child or light patient) Purpose: bladder emptying, individual hygiene, cleanliness of bed and underwear. Equipment: bedpan, oilcloth cover, sterile gloves. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Put a screen. 3.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. Prepare the equipment. 4.Rinse the bedpan with warm water. Leave a little water in the bedpan. 5.Stand up with right side of the patient. Put the patient on his back. The patient's legs bent at the knees. 6.Put the left hand under the sacrum. Raise the patient's pelvis. 7.With the right hand put an oilcloth under the sacrum. Put the bedpan under the sacrum with right hand. 8.To cover patient with blanket. Leave the patient alone. 9.After defecation or urination put the left hand under the sacrum, raise the patient's pelvis, remove bedpan. 10.Inspect the urine or feces (can be blood, mucus, etc.). 11.Perform wash the perineum in accordance with the algorithm. 12. Remove the bedpan, oilcloth, screen. 13.Give the patient comfortable position. 14.Disinfect used material. 15.Remove gloves, put them in a container for disinfection. 16.Wash hands hygienic way. 17.Make a note of the results in a medical documentation.

19. The use bedpan to patients in bed Seriously ill on strict bedrest; ( heavy patient) Purpose: bladder emptying, individual hygiene, cleanliness of bed and underwear. Equipment: bedpan, oilcloth cover, sterile gloves. Algorithm: 1.Explain to the patient the purpose and procedure course. Obtain patient’s consent. 2.Put a screen. 3.Conduct hygienic washing hand and processing hand. Put the gloves on. Wear apron. Prepare the equipment. 4.Rinse the bedpan with warm water. Leave a little water in the bedpan. 5.Stand up with right side of the patient. Turn patient on side. 6.Put an oilcloth under the sacrum. Put the bedpan under the sacrum with right hand. 7.Put the patient on his back. The patient's legs bent at the knees. 8.To cover patient with blanket. Leave the patient alone. 9.After defecation or urination turn patient on side. Remove the bedpan, oilcloth. 10.Inspect the urine or feces (can be blood, mucus, etc.). 11.Perform wash the perineum in accordance with the algorithm. 12.Remove the bedpan, oilcloth, screen. 13.Give the patient comfortable position. 14.Disinfect used material. 15.Remove gloves, put them in a container for disinfection. 16.Wash hands hygienic way. 17.Make a note of the results in a medical documentation.

20. PREVENTION OF bedsores Bedsores - dystrophic, ulcerative necrotic lesions of the skin, subcutaneous fat and other soft tissues. At the debilitated patient with poor care often appear bedsores. They are formed where the soft tissues are compressed between the bone and a bed.

21. Assessment of risk of development of bedsores Purpose: identify patients at high risk of developing bedsores Equipment: mask, gloves. Care Pathway Explain the purpose and progress of the procedure, obtain consent. Conduct hygienic washing hands and handling, wear gloves. Determine the degree of risk of developing bedsores on the scale of Waterloo or Norton. Record results in medical records. Familiarize the patient and his relatives with the result.

22. Prevention of bedsores Purpose: Prevention of bedsores Algorithm: 1.Explain the purpose and progress of the procedure, obtain consent. 2.Conduct hygienic washing and hand washing. 3.Wear gloves. 4.Daily inspect the skin in places where bedsores often develop: sacrum, heels, ankles, shoulders, elbows, neck, greater trochanter. 5.By detecting pale skin and red patches - inform the doctor. 6.Linens should be clean and dry. 7.Linens should not have rough seams. 8.Contain the body of the patient and the bed clean and dry. 9.Wash 2 times a day ( morning, evening ) places where bedsores appear with warm soapy water. Dry the skin very well. 10.Edit the place of formation of bedsores with warm camphor or ethyl alcohol. 11.Change the position of the patient in bed every 2 hours. Move the patient carefully. 12.Massage to improve circulation. 13.Use anti-bedsores mattress. Remember! prerequisite for this algorithm is the integrity of the skin ; bedsores prevention is better than cure ; if the patient has bedsores - the care was poor.

23. Оценка степени тяжести пролежней The assessment of the severity of bedsores Purpose: determine the degree of pressure sores. Equipment: Sterile gloves, tray, gauze, tweezers. 70% solution of ethyl alcohol for disinfection container. Algorithm: 1.Explain the purpose and progress of the procedure, obtain consent. 2.Conduct hygienic hand washing, wear gloves. 3.Inspect the site of injury (bedsores). Is it - the sacrum, heels, ankles, shoulders, elbows, neck, greater trochanter. 4.On examination evaluate: the localization of damage, skin coloration, the presence of odor and pain, depth and area of ​​lesion, presence of exudate, edema. 5.Wash hands 6.Make an entry in the medical records.

24. WATERLOW PRESSURE ULCER PREVENTION/TREATMENT POLICY