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35 Cards in this Set
- Front
- Back
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scientific knowledge base |
physical hygiene is necessary for comfort, safety, and well-being ill patients require assistance with personal hygiene good hygiene techniques promote normal structure and function of tissues apply knowledge of pathophysiology to provide preventive hygiene care |
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nursing knowledge base |
factors influence a patients personal hygeine use communication skills to promote the therapeutic relationship hygiene care is never routine assess - emotional status, health promotion practices, healthcare education needs. |
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factors influencing hygeine |
social patterns- ethnic, social, and family influences on hygiene patterns body image- a person's subjective concept of his or her body appearance personal preferences- dictate hygiene practices socioeconomic status- influences the type and extent of hygiene practices used |
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factors influencing hygine contd. |
health beliefs and motivation- motivation is key factor in hygiene developmental stage- affects the patients ability to perform hygiene care cultural variables- people from diverse culture practice different hygiene rituals physical condition - may lack physical energy and dexterity to perform self care |
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developmental stage |
skin- sensitive neonate skin, active glands in puberty, thinning and drying with age feet and nails- dry skin, systemic disease mouth- teething caries gum disease hair- shaving, puberty, aging eyes, ears, nose |
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nursing process - assessment |
explore patients view point assess: self-care ability, skin, feet and nails, oral cavity, hair and hair care, eyes, ears, nose,, use of sensory aids, hygiene care practices, cultural influences |
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assessment |
the nurse must assess the current hygiene practice of the individual and determine if its adequate before providing care |
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problems concerning deficient hygiene are: self care deficits |
activity intolerance bathing self-care deficits dressing self-care deficits impair physical mobility impaired oral mucus membrane risk for infection innefective health maintenance. |
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outcomes personal hygiene |
verbalize feeling clean and comfortable participate in hygiene measures to ability maintain intact integument goals and outcomes- partner with patient and family, measureable, achievable, individualized set priorities based on assistance required, extent of problems, nature of diagnosis teamwork and collaboration- healthcare team members, family, community agencies |
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implementing |
be respectful of patients preferences! encourage self-care include teaching about skin and footcare assist and prepare patients to perform hygiene as independently as possible teach techniques and signs of problems inform patients about community resources |
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implementation |
consider normal grooming routines and individualized care bathing and skin care - therapeutic - siz, medicated complete bed bath, shower partial bed bath - bag baths , perineal care back rub root and nail care |
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implementation |
oral hygiene- brushing removes particles, plaque, and bacteria, massages the gums and relieves unpleasant odors and taste. flossing removes tartar at the gum line rinsing removes particples and excess tooth paste patient with special needs: diabetes, artificial airways, unconscious, chemotherapy |
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implementation |
hair and scalp care brushing and combing- distributes oils, prevents tangling as does braiding, obtain permission before braiding or cutting, procedures for head lice shampooing, shaving, mustache and beard care |
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implementation |
basic eye care eye glasses contact lenses artificial eyes ear care hearing aid care nasal care |
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safety guidelines |
communicate clearly with team members incorporate patient priorities move from cleanest to less clean areas use clean gloves for contact with nonintact skin, mucus membranes, secretions, excretions, or blood. test temp of water or solutions use principles of body mechanics and safe patient handling be sensitive to the invasion of privacy |
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skin assessment |
techniques: inspection- look, listen, smell palpation- touch |
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function of skin |
protection temp regulation psychosocial sensation vitamin d production immunological absorption elimination |
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skin assesment |
color- age, culture, ethnicity, Mongolian spots, capillary hemangiomas characterisitcs- temp, moisture, texture, turgor, edema lesions- normal variations, primary/secondary |
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skin assessment |
color observe for uniformity, increased pigmentation on exposed surfaces palms, soles, nail beds less pigmented interview q's- self care products, exposure to weather/environment. teaching- protective clothing, skin care products, observation of lesions |
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hair assessment |
inspection- color, natural vs. enhanced distribution- face, extremities, scalp, alopecia, hirsutism palpation- texture fine-coarse debris- cradle cap, dandruff, pediculosis |
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nail assessment |
inspection- level and similar in color to skin clubbing- hypoxic state spoon shape- iron deficiency paronychia- skin surrounding nail inflamed, callused * nail picking/biting palpation- smooth and firm. thickened- poor circulation. thick and yellow- fungal infection interview- biting? salon treatment? |
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nursing assessment : skin and wounds |
focused skin assessment braden scale - numeric value for 6 risk factors related to impaired skin integrity total score < 18 = risk |
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wound assessment |
location size appearance drainage |
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pressure ulcers |
nursing play a major role in prevention and treatment affect 15 % of hospitalized clients cost of treatment 5-8.5 billion/year caused by unrelieved pressure to an area resulting in ischemia |
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pressure ulcer |
pressure intensity tissue ischemia blanching pressure duration tissue tolerance intrinsic factors- immobility, impaired sensation, malnourishment, aging, fever extrinsic factors: friction, shearing, exposure to moisture |
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risk factors for pressure ulcer development |
impaired sensory preception alterations In LOC impaired mobility shear friction moisture |
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interventions/rationales |
post and implement a turning schedule -redistributes pressure obtain and place over the patients mattress- redistributes the amount of pressure on the bony prominences clean wound and periwound skin; dry periwound skin- removes debris and old drainage from wound site, preventing further wound progression/skin breakdown apply a hydrocolloid dressing to the wound- support moist wound healing and will protect the wound determine and collab with dietician- aid in wound healing |
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nursing interventions |
prevention meticulous skin care adequate nutrition/hydration frequent repositioning therapeutic mattress client/family teaching |
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older adult considerations |
skin more easily injured has less capacity to insulate wrinkles more easily sensation of pressure and pain is reduced skin becomes dryer pruritus *itching may occur healing time is delayed |
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nursing strategies for older adult |
do not apply tape to skin unless necessary check skin frequently to observe for any signs of a pressure ulcer pad bony prominences if necessary assess pressure tolderance by checking pressure points for redness after 30 mins clean perineal area daily but do not bath full body on a daily basis apply lotion as needed encourage hydration perform skin assessments assist patient with skin checks- cancer check for tears, irriation, breakdown |
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nursing diagnosis |
disturbed body image deficient knowledge related to wound care acute pain chronic pain impaired skin integrity self-care deficit risk for trauma risk for impaired skin integrity |
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functions of the skin |
protection sensation temp regulation excretion and secretion |
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complete bed bath |
bath administered to totally dependent patient in bed |
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partial bed bath |
bed bath that consist of bathing only body parts that would cause discomfort only body parts that would cause discomfort if left unbathed, such as hands, face, axillae, and perineal care. partial bath also includes washing back and providing back rub. dependent patients in need of partial hygiene or self-sufficient bedridden patients who are unable to reach all body parts receive a partial bath. |
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bag bath |
contains a no-rinse surfactant, a humectant to trap moisture and an emollient |
