FACILITATING HYGIENEFALL, 2010

What is Hygiene?Why is it Important?

Science of the establishment and maintenance of health

Contributes to psychological and physiological well-being

Promotes comfort, improves self-image and decreases infection and disease

ASSESSMENT FACTORS INFLUENCING HYGIENE PRACTICE

Personal preferences-normal routine-assistive devices needed

Culture and religion or spirituality

Economic status or living environment

Developmental level Knowledge level Allergies

ASSESSMENT OF SELF-CARE ABILITIES

Bathing/Hygiene Dressing/Grooming Toileting

Pain? Limited mobility? Sensory deficits? Cognitive impairment? Emotional disturbances?

CLASSIFICATION OF SELF-CARE ABILITIES

Completely independent 0 Requires use of assistive device 1 Requires help from 1 person 2 Requires help from 1 person and

equipment 3

Totally dependent 4

NURSING DIAGNOSIS SELF-CARE DEFICITS

Bathing/Hygiene Self-Care Deficit Dressing/Grooming Self-Care Deficit Toileting Self-Care Deficit Total Self-Care Deficit

RELATED TO: (Examples) Decreased or lack of motivation Weakness and/or fatigue Impaired transfer ability Perceptual or cognitive ability

DELEGATION

Instruct UAP regarding:Patient’s limitations and restrictionsUse of assistive devicesSpecific safety precautions to followMaintenance of tubes and bandagesRequired observations during bathingNeed to collect a specimen?

ABOUT SKIN

Protective Barrier Regulates Body

Temperature Secretes Sebum Excretes Sweat Transmits sensations Facilitates absorption of

Vitamin D

FACTORS AFFECTING THE SKIN Health Status

DampnessDehydration Insufficient circulationNutritional statusSkin diseases Jaundice (itchy and dry skin) Immobility

Nursing Diagnosis: Risk for impaired skin integrity

FACTORS AFFECTING THE SKIN

Developmental Stage Infants

Fragile, easily injured Children

Need adults to provide or supervise Adolescents

Oily skin/acne Older adult

Thinner, more fragile skin Drier, scaly, itchy skin Impaired temperature regulation Hair and nails grow more slowly

IMPORTANT SKIN TERMINOLOGY

Pallor Erythema Jaundice Cyanosis

Pruritis Dry skin Maceration Excoriation Abrasion Pressure

Ulcers Acne

HYGIENE INTERVENTIONS

BATHINGRemoves perspiration and

bacteria, increases circulation, stimulates depth of respirations, provides sensory input, strengthens nurse-patient relationship, promotes relaxation and comfort, provides opportunity for assessment

HYGIENE INTERVENTIONS

Cleaning Baths OPPORTUNIY FOR Shower Tub Self/Help Partial Bed Bath Assisted Bed Bath Complete Bed Bath

Therapeutic Baths Sitz Soaks Cool or tepid water baths

HYGIENE INTERVENTIONS

Oral Care-Halitosis, Dental caries, Gingivitis, Periodontal disease, Stomatitis, Glossitis, Cheilosis, Oral Malignancies

Hair Care-Dandruff, Pediculosis, Alopecia

Eye, Ear and Nose Care

Perineal Care

Unconscious clients

Dementia clients

**See page 451-452 Wilkinson and Van Leuven text for more details

HYGIENE INTERVENTIONS

Foot and Nail Care OPPORTUNITY FOR Corns Calluses Tinea pedis Ingrown toenail Foot odor Plantar wart Pressure ulcers Color, drainage, edema, cracks, capillary

refill?

WHAT ABOUT A BACKRUB?

BEFORE YOU LEAVE

Room temperature comfortable? Siderails up as indicated? Bed

position? Bed wheels locked? Bed linens clean and free of

wrinkles? Patient’s call device within reach? Overbed table clean and

uncluttered? Uncluttered walking space? Unpleasant odors? What else may I do for you?

A PICTURE’S WORTH A THOUSAND WORDS

http://www.youtube.com/watch?v=hYXYcOHT6aE